bolton nhs foundation trust – board meeting november 27th 2014 · bolton nhs foundation trust –...

Bolton NHS Foundation Trust – Board Meeting November 27th 2014

Location: Boardroom Time: 0900 – 1230 hrs

Time Topic Lead Process Expected Outcome

0900 1. Patient Story Verbal Patient story and learning points noted

2. Apologies for Absence – Trust Sec. Verbal Apologies noted (G Ashworth,

3. Declarations of Interest Chairman Verbal To note any declarations of interest in relation to items on the agenda

4. Minutes of meeting held 30th October 2014 Chairman Minutes To approve the previous minutes

5. Action sheet Chairman Action log To note progress on agreed actions

6. Matters arising Chairman Verbal To address any matters arising not covered on the agenda

7 Chairman’s Report Chairman Verbal To receive a report on current issues

7.1 CEO Report including reportable issues CEO Report To receive a report on any reportable issues including but not limited to SUIs, never events, coroner reports and serious complaints

Safety Quality and Effectiveness

0930 8 Integrated Performance Report Exec team Report To note and receive the integrated performance report

10.15 9. Nurse staffing report DoN Report To receive the report on staffing and acuity

10.40 10. Emergency Department Action Plan COO Report To receive the action plan to address and sustain Emergency Department performance

Governance

11.30 11. Audit Committee Annual Report CD Report To receive the Annual Report of the Audit Committee

Finance and Strategy

11.40 12. People Strategy D Strat & OD Report To approve the People Strategy

1

Time Topic Lead Process Expected Outcome

12.00 13. Planning for 2015/16 and beyond D Strat & OD Report To receive a briefing on the planning process for 2015/16 and beyond

For Information

Chair reports of the following sub-committees will be noted – if any member of the Board wishes to raise a question regarding one of these items they should indicate this before the start of the meeting.

12.15 14. Finance and Investment Committee – 18th November 2014

14.1 Amendment to Finance & Investment Committee’s Terms of Reference

15. Quality Assurance Committee – 12th November 2014

16. Audit Committee – 17th November 2014

17. Charitable Funds – 6th November 2014

17.1 Charitable Funds Annual Report

18. Any other business

Questions from Members of the Public

19. To respond to any questions from members of the public that had been received in writing 24 hours in advance of the meeting.

Resolution to Exclude the Press and Public

12.30 To consider a resolution to exclude the press and public from the remainder of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted

20. Review of meeting

Trust Secretary

discussion To identify KLOEs for visits to wards and departments

2

Board of Directors minutes – October 30th 2014 Page 1 of 10

Meeting Board of Directors Meeting

Time 09.30 a.m.

Date 30th October 2014

Venue Boardroom

Present:- Abbv.

Mr D Wakefield Chair DW

Dr J Bene Chief Executive JB

Mr N Chamberlain Non-Executive Director NC

Mrs C Davies Non-Executive Director CD

Mr A Duckworth Non-Executive Director AD

Mr A Ennis Chief Operating Officer AE

Mr S Hodgson Medical Director SH

Mr A Thornton Non-Executive Director (interim) AT

Mr S Worthington Director of Finance SCW

In attendance:-

Mrs E Steel Trust Secretary ES

Ms B Tabernacle Deputy Dir Nursing (deputising for Mrs T Armstrong Child) BT

Ms S Woolridge Head of HR (deputising for Mr M Wilkinson) SW

Mrs H Edwards Head of Communications HE

Two members of the Council of Governors, and a representative of the local media in

attendance as observers.

1. Patient Story

MO, a patient who had undergone a bilateral mastectomy for the treatment of breast

cancer attended the meeting to share her story with the Board. Although MO had praise

for the care she had received from nursing and clinical staff she felt let down by the

facilities, structures and processes.

In describing her experience as a patient MO identified the following issues:

Having been told she was in remission there did not appear to be a process for

regular checks - closer monitoring could possibly have picked up secondary

growths sooner.

Communication between different organisations and between the GP and the Trust

needs to be improved - more joined up services are needed

Early screening may have helped

Women in Bolton would benefit from presentations similar to those offered at

Wythenshawe Hospital

Traveling for radiotherapy treatment at the Christie was an additional burden; a

recent journey took two hours.

Patients need to be considered as individuals with different needs to ensure

pathways are adapted for each person.


Board members thanked MO for her courage in coming forward to share her story and

apologised for the failures she had experienced. Board members asked MO further

questions about her experiences and commended her analytical approach to identifying

the issues with her care. MO was asked if she would be prepared to give some thought to

enable the Trust to capture her ideal process

FT/14/70 report/plan to capture the ideal process and consider the strategic approach to addressing

the issues raised - report back to QA Committee BT/TAC

Board members repeated their thanks to MO for her courage in attending the meeting

2. Apologies

G Ashworth, M Harrison, T Armstrong-Child, M Wilkinson

3. Declarations of Interest

None

The Chairman welcomed attendees to the meeting, - Neal Chamberlain ne Non-Executive

Director was formally welcomed to his first meeting of the Board

4. Minutes of The Board Of Directors Meeting Held on 25th September 2014

The minutes of the meeting held on 25th September 2014 were approved as an accurate

record.

5. Action Sheet

The action sheet was updated to reflect progress on agreed actions.

14/64 The Medical Director advised that in response to the concerns raised at the

previous meeting, he had discussed the Trust’s revalidation response with

the GMC liaison and the responsible officer for NHS North. They have

confirmed that our process is good and not overly optimistic - they would

therefore recommend leaving as submitted.

The Board noted this recommendation.

6. Matters Arising

No matters arising not covered by the agenda.

7.1 Chairman’s Report

Staff awards - the awards held on October 23rd 2014 were felt to be a significant success.

The venue has now been booked for next year with the aim of doubling the attendance.

The Trust Secretary and her team were thanked for their work in co-ordinating the event.

Healthier Together - the amended response was submitted as agreed at the previous

Board meeting.


Performance - A&E is under immense pressure at the moment, this should be discussed

further after lunchtime visits to wards and departments.

Monitor - Members of the Board attended a review meeting with Monitor on 20th October,

it is hoped that the enforcement undertakings and discretionary requirements will soon be

lifted.

Annual Members Meeting - The trust’s Annual Members’ Meeting is on Thursday

November 6th at 6.00 pm in the Education Centre.

7.2 CEO report

Healthier Together The Chairs and CEOs of the three trusts, the three CCGs and the

three Councils met on Friday 24th October to discuss the sector plans for the emergency

surgery stream and the options for the three Trusts, there were also early discussions on

A&E and acute medicine. Now the Healthier Together consultation has finished, the CCGs

will take the lead to develop this further.

CQC - the Trust are not in the next tranche of trusts for inspection in Q4 of 2014/15 but will

be inspected before the end of 2015.

Ebola - the Trust have all the necessary protective clothing although have not yet

undertaken all the necessary training for the use of this equipment. Plans have been made

to isolate any suspected patients. Preparation is being overseen through emergency

planning. There are currently no financial implications to this.

Reportable issues There has been one never event which is currently being investigated,

this concerns the removal of the wrong lesion on a patients face - a full report will be

presented on completion of the investigation.

Accident and Emergency there has been an increase in A&E incident reports highlighting

pressure and congestion in the department, this has been raised as an issue by staff

because of the impact on patient and staff experience.

BAF - scores have been reviewed and remain unchanged, the full BAF will be reviewed in

the November Audit Committee meeting.

8 Integrated Performance Report

Quality

BT highlighted the month’s results in providing harm free care:

There have been no grade 3 or 4 pressure ulcers

Infection control performance remains good with no cases of C Difficile or MRSA

reported.

The total number of incidents reported has increased, highlighting the work done on

reporting near misses.

The QA Committee received an update on falls showing that the harm from falls

has reduced.

Board members discussed the metrics in the quality quadrant of the report. The following

points were noted:

Complaints - Board members expressed concern that the backlog of complaints had not

yet been addressed and asked for assurance that performance would be back on track.

The divisions are addressing this and have assured the Executive team through the


performance management meeting that this will be back on track in November.

There is no evidence to suggest that there has been an increase in complexity of

complaint, there has, however been a clamp down on the application of an extension to the

timeline with equal importance given to timeliness and quality of response.

Board members discussed initiatives that could be employed to achieve the target for flu

vaccinations. A campaign is underway to ensure vaccination is accessible for all staff with

sessions in the staff restaurant and in clinical areas in the hospital and the community.

The Board asked that their congratulation on the reduction in harm from falls and the

achievement of no cases of C difficile be noted.

Operational

A & E Performance against the four hour target in September was two breaches off the

95% threshold at 94.98%. As highlighted earlier, this has been more challenging in

October; the pressures will be discussed later on the agenda.

Cancer performance targets achieved and anticipated to achieve going forward.

Diagnostic waits - performance back on track following cancellations due to failed

endoscopy washers

Readmissions - a date has now been arranged for the audit of readmissions to be

undertaken jointly by consultants and GPs, it is hoped that “as part of the better care fund

work patients who are readmitted frequently as a result of a long term condition will be

identified and offered more appropriate treatment to avoid frequent admissions.

Stroke - the four hour target for admission to a stroke unit was not achieved, this failure

was related to the pathway to admit patients directly to a stroke unit.

Workforce

Although there has been a reduction in the number of vacancies, there are still significant

staffing pressures and the impact of the new staff has not yet been seen, many are still

supernumerary and continued use of bank and agency staff is impacting on budgets.

Mandatory training small improvement made but still below target. All staff should now

have access to the new e-learning package and it is hoped this will increase the uptake of

training.

Sickness absence - has remained stable at 4.57%, although this remains below target, it

is an improvement on September 2013 (4.95%) and there has not been the usual seasonal

increase seen at this time of year.

Board members discussed the use of alternative metrics to monitor sickness absence and

agreed that Neal Chamberlain would work with the head of HR to consider other

multifactorial methods of monitoring on behalf of the Board.

Appraisals performance remains just behind target, the Trust are about to approve a

policy to link pay progression to performance review. Board members discussed the

linking of pay review to appraisal and agreed that this would require a robust system to

support including a review mechanism for all referral for no pay progression.

FT/14/71 NC to work with SW to consider alternative approaches to the monitoring and management

of sickness absence NC/SW

Finance

The Trust is still forecasting delivery of the target surplus of £1.6m however the challenge


is increasing as a result of overspending on staff and the risks in regard of a range of

contracting issues. The Director of Finance asked Board members to note the following:

The risk range as debated at the Finance Committee is between a surplus of £1.6m

and a deficit of £3.8m.

At the end of month 6 the adverse variance to plan is £0.42m with a year to date

deficit of £0.66m.

A total of £2.1m non-recurrent income and expenditure is within the position

reported at month 6.

Weekly monitoring of bank and agency staff are showing some improvement

The cash balance remains healthy.

The Capital programme has been re-profiled for expenditure to be in Q4.

The Director of Finance was challenged as to how much recovery could be realistically

expected in light of the overspend on staff, the anticipated winter pressures and the use of

risk reserves. The range of risks is provided in a paper for further discussion during the

afternoon meeting, this was also discussed in detail in the Finance Committee. With

regard to the specific issue of winter wards, non-recurrent funding will be available for this.

In discussions with Monitor, the risks had been highlighted with the acknowledgement from

the Trust that things may get worse before they get better depending on the outcome of

contract discussions with the CCG.

Board members discussed the current financial performance in the context of the

performance of the Foundation Trust sector as a whole with many other trusts now in

deficit. The importance of maintaining a CSR Rating of at least 2 was acknowledged and

while the surplus may be achieved through different means to the original plan the team

have demonstrated the level of savings that can be achieved.

Concern was expressed regarding the challenge facing the Trust in 2015/16 particularly in

relation to the recurrent position. Board members asked for assurance with regard to the

planned delivery of financial targets in 2015/16 and acknowledged that the challenge will

continue.

FT/14/72 Financial report to contain outline plans for achieving savings in 2015/16 in light of non-

recurrent aspect of 2014/15 savings SW

Resolved: The Board noted the integrated performance report

9. ECIST Actions and System Resilience

The Chief Operating Officer updated the Board on recent performance against the four

hour A&E target. At the time of reporting there had been 723 breaches in the month, by

month end this is expected to be over 800, double that expected in a normal month and a

significant challenge in terms of the target. Attendances are up but only slightly, the rapid

deterioration of performance is believed to be multifactorial but significant improvement in

patient flow is considered critical to addressing the issue.

Using the graphs provided in the report circulated with Board papers, the COO highlighted

the following points.

Midnight bed occupancy is around 95%, during the day occupancy peaks at well


over 100% - beds are not vacated early enough to ensure flow through the A&E

department

The planned closure of beds was predicated on reducing length of stay, although

the length of stay is reducing the number of admissions is increasing.

11 elective cases were cancelled the day prior to the Board meeting to create

capacity.

The issue is multi-factorial, for optimum performance a number of factors must be

aligned.

Poor performance over the weekend could challenge the year to date target and

put the quarter at risk.

Community interventions are not having the desired impact for admissions

avoidance, rapid discharge or the avoidance of readmissions

It will not be possible to open an additional ward until December, the staff are not

yet available and the empty wards are either in use as decant wards or need work

to bring on line.

BCU is currently in use as a discharge lounge with 9 beds.

Interviews are scheduled in the next few weeks for staff nurses and hcas to staff

the additional capacity.

Delay in discharge medication is often cited as causing delay to discharge; to

address this it has been agreed that dedicated time will be set aside for junior

doctors to process prescriptions for the patients due for discharge the following day.

The CHC process which takes a minimum of 21 days requires review.

A recent deep dive to look at every patient on every ward to mitigate issues with

discharge identified process issues some of which were outside our control but

others including pressure on the wards which could be addressed. The wards

found the process helpful - the aim is to repeat this bi-weekly to build capacity.

Additional support from matrons and managers is being made available between 7

pm and 9pm - this time frame has been identified as a time of pressure.

The A&E team have reported a significant number of incidents relating to

overcrowding and the impact on care, privacy and dignity - the operational team are

meeting to discuss how to address these issues.

Some patients are still being transferred at night, although of the 10 patients on

average move between 11pm and 6am the majority are from assessment units to a

ward, one or two patients are move each night to make space for other patients.

This is a symptom of poor flow and is a poor patient experience.

Board members discussed the information presented and other anecdotal points which

might contribute to the multifactorial issues. The Chief Operating Officer confirmed that

addressing the current performance was a key priority.

Resolved: The Board noted the update on A&E performance and asked for a further

update to be provided to the November Board meeting

FT/14/73 briefing report back on actions taken and progress achieved AE


10. Mortality Report

The Medical Director presented the routine six monthly update on mortality. The following

points were highlighted:

Crude mortality has continued to improve, the Trust is currently second best in the

North West

While other indicators have remained stable the Trust has not yet achieved its goal

of performance in the top 50% for HSMR and SHMI

For weekend mortality performance is in the best 25% with a relatively small gap

between weekend and mid-week mortality rates - weekend mortality is expected to

be slightly higher because of the different mix of patients.

In answer to a question in the discussion following the presentation of the report, the

Medical Director confirmed that he was confident that the Trust was on track to achieve the

ambition of top 10% performance by the end of 2016.

Board members asked for further information to be provided in the next report to identify

the key risks to achieving the stated goal of top 50% performance by the end of 2014 and

top 10% by the end of 2016.

On a related matter, the Chairman advised following on from the Dr Foster ethics

committee findings of mis management in relation to the Dr Foster handling of the sepsis

audit a response from Professor Sir Bruce Keogh contained the following quote:

“Having said this, the local mechanisms in place in Bolton for validation of coding

on the case notes of patients who have died appears to be an example of good

practice, and is perhaps something that can be spread through mechanisms such

as the forthcoming patient safety collaborative...”

Resolved: board members noted the update on mortality and agreed that the quoted letter

provided a final validation of the approach the Trust took to this issue.

FT/14/74 next report to include more detail on risks to achieving the goals for mortality SH

11 Q2 Compliance Declaration

The Trust Secretary introduced the report to support the Q2 compliance declaration before

handing over to the Chairman to lead a discussion on the declaration with regard to on-

going compliance with all exiting targets and indicators.

Board members debated whether, in light of the earlier discussion on A&E performance the

statement of compliance could be confirmed. After some debate, Board members agreed

unanimously by a show of hands that the declaration should be “not confirmed”

All other aspect of the declaration were approved as proposed in the paper.

Resolved: The Board approved the Q2 declaration and agreed that in view of A&E

performance they could not confirm on-going performance with all targets and indicators

12 Request for Certification of Compliance

The Trust Secretary presented the proposed applications for certification of compliance

with the enforcement undertakings and discretionary requirements. Significant progress

has been made to address the recommendations made in reports following the breach of


authorisation and subsequent regulatory action. The application for certification of

compliance is a significant milestone in the journey to full compliance with the provider

licence and a “green” rating for governance.

Resolved: Board members approved the proposed application and delegated authority for

the final sign off to the Chair and CEO. This will be completed on receipt of the final follow

up report from PwC.

The Director of Finance advised that the following three items which are key to the

strategic direction of the Trust, fall within the portfolio of the Director of Strategic and

Organisational Development, however in his absence would be dealt with by the Director of

Finance and the chief Executive.

13 Healthier Together update

The consultation has now closed, the final position will be considered by the Committee in

Common. Although a decision is not expected it is important that the Trust continue to

participate in the North West sector collaborative work which will be important whatever the

final outcome from the central team.

Resolved: Board members agreed that although there are frustrations that the central

decision will take time, progress can be made with the sector to find the right path between

developing our own strengths and collaborating with our neighbours. The importance of

continued commissioner involvement was also recognised.

14 Community Services

The director of Finance spoke to the report to highlight the key points and focus on the

plans to take forward the leadership of community services.

Board members discussed the continuing concerns that income received for community

services does not match the costs incurred in providing the service. In addition to this the

CCG have indicated that they are not willing to support the necessary investment in IT.

Board members discussed the concerns with regard to the material deficit for community

services:

The CCG have expressed a view that the overheads are too high - the reality is that

fewer overheads are charged to community than to other services; benchmarking

also shows that the overheads are lower than other community providers.

The CCG perceive inefficiency in the service citing the high sickness rate as an

example of this.

Although in the medium term the Trust’s financial position could be improved by not

having community services there is still a strong belief that it is good to be an

integrated care organisation.

The potential to address though arbitration was discussed however with the

majority of the services on a block contract it would be difficult to go to arbitration

Costs have reduced since transfer through the cost reduction programme,

benchmarking shows the Trust corporate costs to be among the lowest.

Although strategically it is important to have an integrated organisation, thought

must be given to the other options. The five year NHS view sets out a vision for

organisations the size of the Trust to be part of integrated care or accountable care


organisations or to be part of a chain with a big hospital - continuing as an

integrated care organisation is therefore a better option to maintain independence.

Resolved: Board members gave the Executive team the mandate to continue with

discussions and negotiations providing regular updates to the Board and if absolutely

necessary the freedom to return to reconsider the position on the level of loss that can be

tolerated by community services.

15 Better Care Fund

The Director of Finance spoke to the paper providing a briefing on the development of the

Better Care Fund to provide Board members with an idea of the schemes and a flavour of

the scale of the work.

The Trust has the following implications for the Trust:

Risk management is led by the CCG and Local Authority.

Governance is through the Health and Wellbeing Board, this is not a corporate

entity - the financial risks sit with the partner organisations.

The Trust is currently paid for activity under PbR - it is important that this remains

the basis of payment

Resolved: Board members noted the report and the implications for the Trust and

supported the on-going engagement in the Bolton health and care system.

16. Finance and Investment Committee Chair report (16/10/14)

Board members noted the report from the Finance and Investment Committee as

discussed earlier during the update on the current financial position.

17. Quality Assurance Committee Chair report (08/10/14)

The meeting which was not quorate received and endorsed the new uniform policy - this

will now be presented for approval at the Exec team meeting in accordance with the

document control policy. The Chairman asked the Exec team to confirm when the policy

has been published and to empower all staff to challenge breaches of the policy for

example the wearing of theatre masks in the canteen.

The Committee received and rejected a second draft of the complaints report - this will be

presented again at the next meeting.

18. Health and Wellbeing Board minutes

Noted

19. Audit Committee

No meeting held during the reporting period

20. Charitable Funds Chair report

No meeting held during the reporting period


21 Any other business

None

21. Questions From Members of the Public

No questions were submitted.

Date And Time Of Next Meeting

27th November 2014

Resolved: to exclude the press and public from the remainder of the meeting because

publicity would be prejudicial to the public interest by reason of the confidential nature of

the business to be transacted.

22. Review of Meeting

Meeting to be reviewed using survey monkey

October Board actionsCode Date Context Action Who Due CommentsFT/14/61 25/09/2014 performance report Medication incidents to be added to front page TAC Oct-14 verbal update

FT/14/53 26/06/2014 reward and recognition reports to be provided on engagement, behaviours and standards

SW Nov-14 to be incorporated in Workforce Strategy paper - Nov 2014

FT/14/57 31/07/2014 performance report Proposal regarding adjustment to the threshold for the appraisal target to be included when workforce strategy presented

MW Nov-14 agenda item

FT/14/73 30/10/2014 ECIST/A&E briefing report back on actions taken and progress achieved AE Nov-14 agenda item

FT/14/75 30/10/2014 ward visits change to mortuary signage outside breast unit AE Nov-14 verbal update

FT/14/76 30/10/2014 ward visits report to Board on acuity and staffing levels BT/TAC Nov-14 agenda item

FT/14/77 30/10/2014 A&E/flow JB to discuss CHC process and allocation of winter funding with CCG

JB Nov-14 verbal update

FT/14/78 30/10/2014 SUI report to be redrafted as discussed and presented for approval at next meeting

BT/TAC Nov-14 agenda item

FT/14/72 30/10/2014 performance report Financial report to contain outline plans for achieving savings in 2015/16 in light of non recurrent aspect of 2014/15 savings

SCW Dec-14

FT/14/60 25/09/2014 CEO report Board development session on risk management to include BAF ES Jan-15

FT/14/42 29/05/2014 committee reports review of Board and committee effectiveness as part of wider governance review

ES Jan-15 item deferred Board development sessions for 2015 agreed, proposed schedule for governance review

FT/14/17 27/03/2014 performance report TAC to provide update to QA Committee on proposals for volunteers

TAC Jan-15 action deferred

FT/14/58 25/09/2014 patient story Exec team to consider actions to take to improve communication between clinicians and patients

TAC/SH Jan-15 actions to be incorporated into a report on you said we did in relation to patient stories to be presented

FT/14/70 30/10/2014 Patient Story report/plan to capture the ideal process and consider the strategic approach to addressing the issues raised - report back

Jan-15 report to Jan QA committee

FT/14/71 30/10/2014 performance report NC to work with SW to consider alternative approaches to the monitoring and management of sickness absence

SW/NC Jan-15

FT/14/49 26/06/2014 CEO report Board development session on incident and risk reporting ES Feb-15 incorporated in Board Development programme - redated to ensure session completed by end of

FT/14/65 25/09/2014 Board development Training session on infection control to be added to development programme

ES/TAC Mar-15 session added to plan - to be scheduled before end of financial year

FT/14/74 30/10/2014 Mortality report next report to include more detail on risks to achieving the goals for mortality

SH Apr-15

All information provided in this written report was correct at the close of play 19/11/2014 a verbal update will be provided during the meeting if required

Agenda Item No: 7.1

Meeting Board of Directors

Date 27th November 2014

Title Chief Executive Update

Executive Summary

The Chief Executive update includes a summary of key issues since the previous Board meeting, including but not limited to:

Monitor update

Stakeholder update

Reportable issues log

o Coroner communications

o Never events

o SUIs

o Red complaints

Board Assurance Framework summary

Next steps/future actions

Clearly identify what will follow i.e. future KPI’s, assurance requirements

The Board are asked to note this update

Discuss Receive

Approve Note

This Report Covers (please tick relevant boxes)

Strategy Financial Implications

Performance Legal Implications

Quality Regulatory

Workforce Stakeholder implications

NHS constitution rights and pledges Equality Impact Assessed

For Information Confidential

Prepared by Esther Steel Trust Secretary

Presented by Dr J Bene Chief Executive


Chief Executive Update

1. Stakeholders

2.1 Monitor

The Trust submitted an application for a certificate of compliance with the enforcement

undertakings and discretionary requirements. Monitor have acknowledged receipt of this

submission and have indicated that we should receive a response by December 3rd 2014.

2.2 Healthier Together

The Trust continues to work closely with partner organisations to ensure the best possible

care is provided to our patients.

2.3 Care Quality Commission

The Trust remains in band 4 of the CQC intelligent reporting. The Trust are not on the

recently announced list of planned inspections between December 2014 and March 2015.

The CQC are still aiming to have completed inspections at all Foundation Trusts and NHS

Trusts by December 2015.

3. Reportable Issues Log

Issues occurring between 30th October 2014 and 19th November 2014

3.1 Serious Untoward Incidents

There have been no SUIs since the last Board meeting.

3.2 Never Events

There have been no never events since the last Board meeting.

3.3 Coroner Prevention of future Deaths (PFD) reports

There have been no coroner notices issued since the last report

3.4 Red Complaints

There has been one red rated complaint since the last Board meeting.

3.5 Reputational Issues

None of significance

3.6 Whistleblowing

There have been no concerns raised by whistle-blowers


4 Board Assurance Framework

4.1. Introduction

The BAF is the framework setting out how the Board are assured that the Trust will achieve

its strategic objectives.

The BAF is used by the Board of Directors to ensure that all significant risks have been

identified; information on control, performance and assurance is timely and relevant; and to

provide leadership on risk management.

The BAF is reviewed on a monthly basis by the Executive team who finalise the list of

strategic risks, confirm actions being taken and check assurances

The full BAF was shared with the Audit Committee on November 17th 2014; the Director of

Nursing and the Chief Operating Officer attended to provide additional assurance and to

respond to challenge with regard to the risks on which they lead.

Changes to the BAF

A&E performance - the risk of failing to achieve the A&E target has increased - Board

members should be aware of this increased risk which was discussed at the October Board

and will be discussed further during the November Board meeting.

RTT performance - The risk of achieving the 18 week target was reduced prior to the

November Audit Committee meeting. However, in view of the challenges to A&E and the

reduction in elective ward capacity consideration is being given to increasing the score

recognising that the likelihood of failing to achieve the target has increased.

Integrated Care - The specific risk relating to the failure to achieve integrated care will be

addressed strategically in risk 11 - future scope of services and operationally as an integral

part of the Trust’s day to day business in the other areas of the BAF. Risk 14 has therefore

been removed from the BAF.


3.2. 2014/15 Assurance Framework

lead May June July Sept Nov

1 Failure to control healthcare acquired infections DoN 10 10 10 10 10

2 failure to provide appropriate skill mix for “safe and suitable” staffing DoN 20 20 20 20 20

3 non-compliance with CQC standards DoN 12 16 16 16 16

4 Failure to ensure the safe management, statutory reporting, internal reporting and learning from incidents

DoN 12 12 9 9 9

5 failure to provide an adequate timely response to the deteriorating patient

MD 16 16 16 16 16

6 failure to meet the A&E target COO 12 12 12 12 16

7 failure to meet the RTT target COO 12 12 12 12 8

8 Failure to comply with standards for information governance COO 12 12 12 12 12

9 loss of IT access in community settings COO 12 12 12 12 12

10 failure to provide efficient fit for purpose estate COO 16 16 16 16 16

11 Failure to influence commissioners in shaping future scope of services Sand OD

15 15 15 15 15

12 failure to address Monitor concerns and return to green for governance CEO 10 10 10 10 10

13 To fail to achieve planned surplus of £1.6m DoF 20 20 20 20 20

14 Failure to achieve integrated care in Bolton COO 15 15 15 15

15 Low levels of staff engagement S and OD

16 16 16 16 16

Safe, High Quality Care, Fit for the Future

Quality and Safety

Valued Provider

Financially viable and sustainable

Great place to work

Fit for the future

Well Governed

Subject Integrated Performance Report – November 2014

Prepared By Performance and Information Team

Approved By Executive Management Team

Presented By Chief Executive – Bolton NHS Foundation Trust

Executive Summary

Please see the High level Executive Summary section at the beginning of the report

Key Recommendations

The Board are asked to receive the report and give approval.

Acronyms/Terms used in Report

TRUST BOARD

Trust Objectives

Purpose

This report sets out the Trust’s integrated performance against leading national and local targets and draws attention to key areas for specific review by the Trust Board. Driven by the Trust’s strategic objectives this report is underpinned by a strong platform of integrated governance and assured data quality controls allowing the Trust Board to make effective decisions and demonstrate its commitment to delivering high quality healthcare for the people of Bolton.

Report

Appendix A

Appendix B

Report change log

1 All data correct as of Thursday 20th November 2014


Executive Apex Reports High Level Executive Summary High Level Executive Dashboard High Level Executive Report • Monitor Risk Assessment Framework • Community Heat Map

Section 1 Improving the Quality of Care and Safety of our patients • Quality and Governance Scorecard • Quality and Governance Charts • Quality and Governance Report • Acquired Infection • Falls • Pressure Damage

Section 2 Valued provider of Integrated Services • Operations Scorecard

• Operations Charts • Operations Report

Contents



Section 3 Financially viable and sustainable • Finance Scorecard • Finance Report Section 4 A great place to work • Workforce Scorecard • Workforce Charts • Workforce Report Section 5 Ward to Board Heat Map

Section 6 Fit for the Future Section 7 Well Governed

Appendix A Acronyms/Terms used in Report

Appendix B Dashboard Change log - in month


There was 1 Never event reported in October.

There was an increase in reported medication incidents in month. None of these incidents resulted in severe harm or death. The rise in reporting is in compliance with the MHRA stage 3 directive.

There were no C.Diff occurrences in the Trust for the second month running.

A&E performance was at 92.3% in October, failing the target by 3.7%. Improved performance is being seen in November.

Staff Vacancies remain at a low rate due to significant recruitment.

Completion of local induction system (starters in the last 12 months) has increased for the third month in a row.

Sickness absences % increased mainly due to Gastro-related illnesses and colds.

Appraisals completed % is above target in month at 80.1%

Five Year Strategic Plan

North West SectorAll quarter 2 cancer targets have passed, although the 62 day standard % failed in month by 3.4%.

Readmissions reduced to 13.6% in October from 14.1%. This remains 1% above plan but it is the lowest re-admissions percentage for the year.

The number of Total incidents reported on Safeguard has increased for the third month, showing a corresponding increase in Insignificant (No Harm Occurred) incidents.

IT and Estates Strategy

Better Care Fund

ICIP delivery is £2.1m in month, which is £0.11m better than plan.

Year to date plan is off track by £0.31m

October's in month surplus is £0.79m and is £0.11m better than plan

Year end forecast surplus of £1.6m is on plan

RTT (admitted and non admitted clock stops) - Both achieved the targets in month.

Executive Summary

This executive summary provides an integrated overview of the Trust Board Performance Report. Supporting the Trust's Strategic Objectives it orientates executives quickly to the areas that have been escalated, are of particular note or political significance. The accompanying High-Level Dashboard and narrative gives further analyses. Compliance levels with the Monitor Risk Assessment Framework and CQC (Care Quality Commission) are also shown.

Improving the Quality of Care and Safety of our patients A great place to work

Valued provider of Integrated Services Fit for the future

Financially viable and sustainable Well GovernedOur Patients

The Trust continues to be licensed to carry out regulated activities with no conditions imposed

on our registration status

Monitor Risk Assessment Framework

CQC

Governance Finance ‐ Level 2

All data correct as of Thursday 20th November 2014

The Trust has been awarded a band 4 weighting by the CQC


Improving The Quality Of Care And Safety Of Our Patients Plan 14/15 Plan YTD

Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Financially Viable And Sustainable

Plan 14/15

Plan YTD

Plan Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Well Governed Status

Total number of new SUIs received within the month 0 0 4 0 Forecast year end deficit - FYE 1.6 1.6 1.6 0.0 0.0 0.0

Monitor Risk Assessment Framework On Plan

Total Incidents reported on Safeguard 10786 6292 6256 1201 Forecast year end income and cost improvement - FYE 22.2 22.2 22.2 0.0 0.0 0.0 CQC Intelligent Monitoring Report On Plan

Never Event 0 0 3 1 Actual position against plan - YTD 1.6 0.4 0.1 0.8 1.0 -0.3CQC Essential Healthcare Standards (5) On Plan

All Patient Falls (Safeguard) 982 574 540 72 Actual Income and Cost Improvement -YTD 22.2 11.8 11.5 2.1 0.7 -0.3CQUINS: National Clinical Quality Indicators On Plan

Acute Inpatients acquiring pressure damage (grades 2+) 27 16 31 1 Capital Expenditure YTD -7.8 -4.8 -1.4 -0.5 -0.5 3.4 Report to prevent future deaths On Plan

Community patients acquiring pressure damage 76 44 38 3 Cash Position YTD 1.1 1.1 3.2 3.2 -2.8 2.1 Litigation On Plan

VTE Assessment Compliance 95.0% 95.0% 97.1% 97.7% Continuity of services rating 2.0 2.0 2.0 2.0 0.0 0.0 Formal Contract Notices On Plan

Total number of medication incidents 636 371 708 123 Formal Performance Notices On Plan

Same sex accommodation 0 0 6 2 Contract Fines/Penalties Off Plan

C Diff Hospital acquired 48 28 10 0

CHKS RAMI (Rolling 12 months) 100 100 83 89 Staff friends and family test - Recommend treatment (Quarterly) 75.0%

SHMI 1.000 1.000 1.068 1.056Staff friends and family test - Recommend place to work (Quarterly) 59.0%

Surgical WHO Checklist compliance (Elective) 100% 100.0% 97.8% 99.0% Appraisals completed % 80% 80% 79.1% 80.1% Five Year Strategic Plan Off Plan

Surgical WHO Checklist compliance (Emergency) 100.0% 100.0% 98.9% 99.0% Sickness days % of days lost 3.75% 3.75% 4.78% 5.06% Healthier Together On Plan

Formal complaints from patients 240 140 318 33 Mandatory Training Compliance % 100% 100% 85.5% 86.5% IT and Estates Strategy On PlanComplaints responded to within the time period % 95.0% 95.0% 89.6% 91.1% Better Care Fund On Plan

Cancer Treatment Targets (7) reported 1 month retrospectivelyPlan 14/15

Plan YTD Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan

Valued Provider Of Integrated Services Plan 14/15 Plan YTDActual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Patients 2 week wait (all cancers) % 93.0% 93.0% 93.0% 97.3%

A&E 4 hour target 95.0% 95.0% 95.2% 92.64% Patients 2 week wait (breast symptomatic) % 93.0% 93.0% 93.0% 98.7%

RTT Admitted Clock Stops % 90.0% 90.0% 94.2% 93.4% 31 days to first treatment % 96.0% 96.0% 96.0% 97.0%

RTT Non-Admitted Clock Stops % 95.0% 95.0% 97.2% 96.8% 31 days subsequent treatment (surgery) % 94.0% 94.0% 94.0% 100.0%

RTT: Incomplete pathways within 18 weeks % 92.0% 92.0% 94.2% 95.8% 31 days subsequent treatment (anti cancer drugs) % 98.0% 98.0% 98.0% 100.0%

Diagnostic waits >6 weeks % 1.0% 1.0% 0.7% 0.7% 62 day standard % 85.0% 85.0% 85.0% 81.6%% of patients who spend 90% of their stay on the stroke unit 80.0% 80.0% 82.7% 83.7% 62 day screening % 90.0% 90.0% 90.0% 96.4%

% Readmissions within 30 days of discharge 12.6% 12.6% 14.2% 13.6%

The On Plan / Off Plan Columns represent a projected Year End position. The status columns represents the current status of the initiative detailed

Status

Performance improved and on target in month

Performance deteriorated but on target in month

High Level Executive Dashboard

Fit for the Future

Performance improved but off target in month

Performance deteriorated and off target in month

Monthly/ Quarterly Change

On Plan Off PlanDeveloping Our Staff

Plan 14/15

Plan YTD Actual YTD

Monthly/ Quarterly

Actual


Indicator (All measured/reported Quarterly) Threshold WeightingQuarter 1 Actual Jul-14 Aug-14 Sep-14

Quarter 2 Actual Oct-14

Referral to treatment time, 18 weeks in aggregate, admitted patients 90% 1.0 94.9% 94.7% 93.4% 93.1% 93.7% 93.4%Referral to treatment time, 18 weeks in aggregate, non-admitted patients 95% 1.0 97.5% 97.2% 96.8% 96.9% 97.0% 96.8%Referral to treatment time, 18 weeks in aggregate, incomplete pathways 92% 1.0 96.6% 95.5% 95.7% 97.0% 96.1% 95.8%A&E Clinical Quality- Total Time in A&E under 4 hours 95% 1.0 95.5% 95.4% 96.5% 94.98% 95.6% 92.6%All cancers: 62-day wait for first treatment from:

(from urgent GP referral) - post local breach re-allocation (Amended) 85% 90.7% 93.3% 96.2% 81.6% 90.4% (from NHS Cancer Screening Service referral) - post local breach re-allocation (Amended) 90% 100% 100% 100% 96% 99%

(from urgent GP referral) - pre local breach re-allocation (New) 93% 95% 95% 86% 92%(from NHS Cancer Screening Service referral) - pre local breach re-allocation (New) 100% 100% 100% 96% 99%

All cancers: 31-day wait for second or subsequent treatmentSurgery 94% 1.0 100% 100% 100% 100% 100%

Drug treatments 98% 1.0 100% 100% 100% 100% 100% From diagnosis to first treatment 96% 1.0 99% 99% 98% 97% 98%

Cancer: two week wait from referral to date first seen, comprising:Cancer 2 week (all cancers) 93% 97.5% 98.4% 96.7% 97.3% 97.5%

Cancer 2 week (breast symptoms) 93% 95.6% 97.6% 96.4% 98.7% 97.6% C.Diff due to lapses in care (Amended) 12 1.0 8 1 1 0 2 0Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) (New) 8 9 10 10 10 10C.Diff cases under review (New) 0 0 0 0 0 0Certification against compliance with requirements regarding access to health care for people with a learning disability 1.0 100% 100% 100% 100% 100% 100%Community care:

Referral to treatment information completeness 50% 99.4% 99.4% 99.4% 99.4% 99.4% 99.4%Referral information completeness 50% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Activity information completeness 50% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Risk of, or actual, failure to deliver Commissioner Requested Services No No No No No NoCQC compliance action outstanding (as at time of submission) No No No No No NoCQC enforcement action within last 12 months (as at time of submission) No No No No No NoCQC enforcement action (including notices) currently in effect (as at time of submission) No No No No No NoModerate CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) No No No No No NoMajor CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) No No No No No NoTrust unable to declare ongoing compliance with minimum standards of CQC registration No No No No No No

Monitor Risk Report 2014-15

1.0

1.0

1.0


High level Executive Report November 2014

Harm Free Care

• There was one surgical Never event reported in month. This is under investigation.

• The number of incidents reported in October increased, again achieving the target in month. This rise was reflected in an increase in reporting from the Emergency Department, and a busy month of activity. The representatives from the Emergency Department met relevant Executives and key organisational managers to discuss causes and potential solutions during the first week of November.

• Due to the recovery plan developed by the Head of Governance, October's “Performance of Complaints responded to within timescale” showed a significant upturn although, as predicted, was marginally below target due to dealing with the backlog.

• There has been a revised Falls policy published in keeping with the National Service Framework for Older People and recommendations made by the National Patient Safety Agency, with a focus on assessment and prevention including the screening of all in patients in the hospital and Darley Court. Patient falls have reduced for three consecutive months.


Pressure Damage

• In October there was one avoidable inpatient category 2 pressure ulcer and two category 2 pressure ulcers in the Community, one of these was deemed unavoidable. There was a Community based category 3 case which was avoidable, but due to patient choice was outside of our control.

Category Performance Indicator May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14

Patients acquiring pressure damage (grade 2) 3 9 2 0 3 1Patients acquiring pressure damage (grade 3) 5 0 2 1 0 0Patients acquiring pressure damage (grade 4) 0 0 0 0 0 0Patients acquiring pressure damage (Total) 8 9 4 1 3 1Patients acquiring pressure damage (grade 2) 8 5 3 1 5 2Patients acquiring pressure damage (grade 3) 3 1 1 3 0 1Patients acquiring pressure damage (grade 4) 0 1 1 0 0 0Patients acquiring pressure damage (Total) 11 7 5 4 5 3

Hos

pita

lC

omm

unity

Acquired Infection

• There were no cases of Trust apportioned CDT infections in October. There were five positive cases from GP samples processed in the Trust labs; three from Bolton patients and two from Salford patients. As of October 31st it has been 65 days since the last Trust apportioned case (28/08/14).

• There were no cases of Trust apportioned MRSA bacteraemia in October. There was one non-Trust apportioned case which is being reviewed jointly by the CCG and the Trust IPC team. As of October 31st it has been 302 days since the last Trust apportioned MRSA bacteraemia (03/01/14).

Same Sex Accommodation

• Two reported breaches in month. Both from HDU.


Valued provider of Integrated Services National Targets

• The A&E 4 hour target failed in October with a performance of 92.6% against a target of 95%. The Trust is still on track to deliver the annual target with a year-to-date performance of 95.2% however the continued pressure on A&E services means that the achievement of this target is uncertain. The Director of Operations has established an "organisational flows" group whose remit is to understand and improve the flow of patients through A&E and into acute and community services.

• Readmissions within 30 days of discharge were over target (12.6%) for the fifth consecutive month with a performance of

13.6% in August.

An audit of readmissions is scheduled to take place on 28 November; this will seek to determine what proportion of readmissions was preventable with this figure being used to drive a penalty mechanism. (Penalties are reinvested in services to prevent readmissions.) Separately, the Director of Operations is working with clinicians to ensure that readmissions figures are not being overstated though incorrect recording of activity on our patient administration systems.

• Cancer targets are reported one month in arrears. All Quarter 2 cancer targets have passed, although the 62 day standard

% failed in month by 3.4%. • All Referral to Treatment targets were achieved in September, for the sixth consecutive month. The Trust has no 52 week

waiters. However, pressure on medical beds has resulted in surgical beds being used for medical patients with elective activity being cancelled. This may impact on our ability to achieve the annual Referral to Treatment targets.


1. Executive Dashboard & Commentary


‐1

‐0.5

0

0.5

1

1.5

2

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

Surplus / (deficit) £m

Cumulative Actual Cumulative Plan

0

0.5

1

1.5

2

2.5


In month ICIP delivery £m

Acute Adult Elective Care

Family Care Trust wide contingency

Non recurrent flexibility release Plan

0

1

2

3

4

5

6

7

8


Month end cash balance £m

Actual Plan Revised Cash forecast

024681012141618


Cumulative Capital expenditure £m

Cumulative Actual Cumulative Plan Financed Capital Plan


1. Executive Dashboard & Commentary


Income & Expenditure

Overall the Trust has a year to date surplus of £0.12m; this is an adverse variance to plan of £0.31m.The October 2014 in month position shows a surplus of £0.79m against the planned surplus of £0.68m. The October position is made up of:

• Income overall is better than plan in month at £24.57m, compared to a plan of £23.83m, with clinical over achieving by £0.93m.• Pay spend is £16.83m, an over spend of £1.08m. This is a £0.3m decrease in expenditure on last month.• Non pay spend is £6.60m, an over spend of £0.20m.• The overall position is better than anticipated and the Trust has used £0.22m of Risk Reserve in month. Year to date the maximum available has been utilised.• The Trust has released, non-recurrently, £2.43m into the year to date position. • ICIPs delivered in October totals £2.1m. The year to date delivery is £11.4m, which is £0.3m behind plan.

The Trust is still forecasting to deliver the year-end target surplus of £1.6m, however this will require utilisation of the £5.9m risk reserve, £4.8m being used to mitigate financial risk and £1.4m being used to finance developments. The recurrent surplus is based on scenario D of the Finance Director's report and a minimum requirement of £3m coming from 1st October and other known income issues as yet unresolved.The Trust forecast position of £1.6m surplus is stated on the assumption that the in-year contracting issues with Bolton CCG are resolved in the Trust's favour. There are a number of liabilities that the CCG continue not to recognise. At month 7 year to date these amounted to £1.6m and would have put the Trust in a position of £1.5m deficit had we taken the CCG stated position.

There is a risk range of delivery from a deficit of £3.8m to a surplus of £1.6m and this range will narrow as we go through the year. As previously mentioned, to manage the risk within the forecast the downside risk management plan has been enacted, consequently the Corporate division has been tasked with bringing forward 2014/15 ICIP schemes to deliver an additional £1.2m and Estates has been tasked with delivering £0.25m in year.

Cash & Capital

• There was a cash balance of £3.2m at the end of the month. This is higher than the £1.1m plan. There is £1.8m of cash relating to overperformance from NHS Bolton CCG that has not yet been received but expenditure incurred (Q1 invoice raised).

• The Capital budget for the year is £6.1m plus £1.7m of financed developments. Dependent on additional finance being agreed, there is potential for a further £3.2m in developments related to the Estates & IT strategy. The remaining £6.5m of these proposed developments have now slipped into 2015/16.

• At the end of October the Capital programme has spent £1.4m and is behind the planned expenditure by £5.0m (inclusive of proposed developments).

• The Trust Continuity of Service rating remains 2 as planned for Q2.


2.1.1 Trust Income & Expenditure position

Trust SummaryAnnual budget £m Budget £m Actual £m Var £m Budget £m Actual £m Var £m

Contract income 254.3 21.4 22.3 0.9 147.7 150.7 3.0Education and Training Income 8.7 0.7 0.8 0.0 5.1 5.2 0.1Other income 17.9 1.7 1.5 (0.2) 10.5 10.8 0.3

Total Income 280.8 23.8 24.6 0.7 163.3 166.7 3.3Direct - Pay (189.4) (15.7) (16.8) (1.1) (110.9) (117.0) (6.1)Direct - Non Pay (74.5) (6.4) (6.6) (0.2) (43.5) (45.7) (2.1)Risk reserve (5.9) (0.2) 0.3 0.6 (3.0) 1.7 4.8

Total Operational Costs (269.8) (22.4) (23.1) (0.7) (157.4) (160.9) (3.5)

EBITDA 11.0 1.5 1.5 0.0 5.9 5.7 (0.2)Capital charges (9.4) (0.8) (0.7) 0.1 (5.5) (5.6) (0.1)

Total Costs (279.2) (23.1) (23.8) (0.6) (162.9) (166.5) (3.6)

Surplus / (Deficit) 1.6 0.7 0.8 0.1 0.4 0.1 (0.3)

In Month Year to Date



2.3.1 Income Summary position

Areas of DeliveryActivity Plan

Activity Actual

Activity Var

Income Plan £m

Income Actual £m

Income Var £m

Activity Plan

Activity Actual

Activity Var

Income Plan £m

Income Actual £m

Income Var £m

Unscheduled Care 15,039 15,593 554 7.1 7.7 0.6 105,474 107,576 2,102 48.7 50.8 2.0Scheduled Care 2,964 3,195 231 3.0 2.9 (0.1) 19,693 19,258 (435) 19.6 18.8 (0.8)Outpatient Care 26,999 28,362 1,363 3.4 3.7 0.3 179,055 181,307 2,251 23.2 23.4 0.2Clinical Support Services 927 772 (155) 0.6 0.6 (0.0) 5,704 5,299 (405) 4.1 4.0 (0.0)Other & Block 9.7 9.6 (0.1) 67.7 69.6 1.9

Total £m 23.8 24.6 0.7 163.3 166.7 3.3

In Month Movement Year to Date


0

10000

20000

30000

40000


Activity Actual (number) Activity Plan (number)

0

5

10

15

20

25

30


Income Actual £m Income Plan £m

Trust Income year to date• Unscheduled Care - in activity terms we have seen an increase again in month with A&E

attendances but not back to the previous highs of 10,000 a month. Non-elective admissions have also increased in month.

• Scheduled Care - financially we are still behind plan year to date and in month. All of the underperformance is within the elective point of delivery with daycases moving above plan year to date. Activity has increased in month but this is due to an increase in excess bad days mainly.

• Outpatient Care - is above plan in the month, and has moved to being above plan year to date. The two main areas of under performance is still antenatal pathways and outpatient follow-up activity. The increase has been seen in new attendances and procedures.

• Clinical Support Services - this area is slightly below plan in the month and year to date. The main area of variation is ECGs which is below plan both in month and year to date.

• Block & Other - is below plan in the month, but remains above plan year to date. The main movements are reductions in some passthrough income and a reduction in some of our smaller service level agreements.

• Penalties & CQUINS - there has been some increases in penalties but we still remain lower than last year and significant better than plan.

(more detailed information on income is available at appendix 10.03 to 10.05)


2.4.1 Pay costs position

Pay category

Annual budget £m

Budget £m

Actual £m Var £m

Budget £m

Actual £m Var £m

Senior Managers (5.2) (0.5) (0.5) (0.0) (3.1) (3.0) 0.1Medical and Dental (47.9) (4.0) (3.9) 0.1 (28.1) (27.1) 1.0Nursing, Midwifery And Health Visiting (71.4) (5.9) (6.1) (0.1) (41.7) (42.3) (0.5)Scientific, Therapeutic and Technical (23.6) (2.0) (1.9) 0.1 (13.8) (13.0) 0.8Professional and Technical (4.8) (0.4) (0.3) 0.1 (2.8) (2.7) 0.2Administrative and Clerical (21.9) (1.8) (1.7) 0.1 (12.8) (12.0) 0.7Healthcare Assistants and Other Support Staff (19.5) (1.7) (1.5) 0.1 (11.4) (10.7) 0.7Agency Staff (2.2) (0.2) (0.8) (0.7) (1.4) (5.5) (4.1)Other Pay Budgets 7.3 0.6 (0.1) (0.7) 4.1 (0.8) (4.9)

Total (189.4) (15.7) (16.8) (1.1) (110.9) (117.0) (6.1)



Pay

In total £16.83m has been spent on pay in October compared to a budget of £15.75m, an over spend of £1.08m. This is £0.3m better than September. The in-month overspend is mainly on nursing (including agency; £340k) and medical staff (including agency; £260k).

The main areas of overspend in October is the use of agency - £0.84m of spend against a budget of £0.16m. This is £0.08m less than September.

• Medical £319k – Radiology (£72k), T&O (£54k), General Surgery (£37k), Complex Care (£35k), CAMHS (£30k), Ophthalmology (£17k) and Gastroenterology (£16k)

• Nursing £198k – Acute Medicine (£59k), Complex care (£49k), General surgery (£14k), Endoscopy (£19k) and T&O (£9k)• Admin £95k • Other £64k – Blood sciences (£47k), CAMHS (£15k) and Radiology (£10k)

The Other Pay Budgets includes the cost reductions (ICIPs) monies that have all been removed from specific specialty budgets, but not yet allocated to specific staff groups on those statements.


2.5.1 Non Pay costs position

Non Pay category

Annual budget £m

Budget £m

Actual £m Var £m

Budget £m

Actual £m Var £m

Drugs (17.6) (1.5) (1.6) (0.1) (10.2) (10.9) (0.6)Medical & Surgical (10.1) (0.8) (0.9) (0.0) (5.9) (5.4) 0.5Clinical Supplies (9.1) (0.8) (0.9) (0.2) (5.3) (5.8) (0.5)

Activity Dependent (36.8) (3.1) (3.4) (0.3) (21.5) (22.1) (0.6)Establishment (11.3) (1.3) (1.0) 0.3 (6.6) (6.6) 0.0Estates & Premises (11.5) (0.8) (1.0) (0.2) (6.7) (6.4) 0.3Services from other NHS bodies (3.1) (0.2) (0.3) (0.1) (1.8) (2.1) (0.2)Other Non Pay (11.7) (1.0) (1.0) 0.0 (6.9) (8.6) (1.7)

Other Non Pay (37.7) (3.3) (3.2) 0.1 (22.1) (23.6) (1.5)

Total Non Pay (74.5) (6.4) (6.6) (0.2) (43.5) (45.7) (2.1)

Total Risk Reserve (5.9) (0.2) 0.3 0.6 (3.0) 1.7 4.8



Non Pay

The total non-pay spend at £6.6m is £0.2m worse than plan.

Non pay expenditure against activity dependant items is worse than plan by £0.31m in month. Other non-pay is on plan.

Again, there has been the release of £0.3m of non-recurrent year end flexibilities into the position.

The Trust has utilised £0.22m of the Risk reserve, which takes it to the maximum available year to date.


2.6.1 Capital Charges

Trust Position

Annual budget £m

Budget £m

Actual £m Var £m

Budget £m

Actual £m Var £m

Dividends (3.2) (0.3) (0.3) 0.0 (1.9) (1.8) 0.1Interest Paid (0.9) (0.1) (0.1) 0.0 (0.6) (0.5) 0.1Interest Received 0.0 0.0 0.0 0.0 0.0 0.0 (0.0)Depreciation (5.2) (0.4) (0.4) 0.1 (3.1) (3.3) (0.2)Profit / Loss on disposal 0.0 0.0 0.0 0.0 0.0 (0.0) (0.0)

Total (9.4) (0.8) (0.7) 0.1 (5.5) (5.6) (0.1)

£m Values Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD

Dividends (0.3) (0.3) (0.3) (0.2) (0.3) (0.3) (0.3) (1.8)Interest Paid (0.1) (0.1) (0.1) (0.1) (0.1) (0.1) (0.1) (0.5)Interest Received 0.0 0.0 (0.0) 0.0 0.0 0.0 0.0 0.0Depreciation (0.5) (0.5) (0.5) (0.5) (0.5) (0.5) (0.4) (3.3)Profit / Loss on disposal 0.0 0.0 0.0 0.0 0.0 (0.0) 0.0 (0.0)

Total (0.8) (0.8) (0.8) (0.8) (0.8) (0.8) (0.7) (5.6)

Plan (0.8) (0.8) (0.8) (0.8) (0.8) (0.8) (0.8) (5.5)Variance to Plan (0.0) (0.1) (0.1) (0.0) (0.0) (0.0) 0.1 (0.1)



Capital charges

Depreciation charges are £86k below plan in month 7. The Trust has looked at re-lifeing its assets, and thus depreciating over a more realistic life this will result in an £850k decrease in the forecast with £143k phased in the YTD position. The depreciation forecast is circa £5.3m.

A proportion of the risk reserve has been set aside to cover the increased depreciation on Community IT, the budget transfer will be made in due course.

Current year-end forecasts are: net interest of £774k (£140k underspend) and dividends of £3,190k (£54k underspend).


4.1 Statement of Financial Position year to date

£m Values Mar-14OctPlan £m

OctActual

Var to plan £m

Year end Plan £m

Non-current assetsIntangible assets 0.5 0.3 0.4 0.1 0.3Property, plant & equipment 131.4 128.2 129.6 1.4 137.1Trade & other receivables >1 year 0.7 0.9 0.6 (0.3) 0.9

132.6 129.4 130.6 1.2 138.4Current assets

Inventories 1.6 1.6 2.5 0.9 1.6Trade receivables 5.4 3.1 3.0 (0.1) 2.8Other receivables 0.8 0.8 2.8 2.0 0.8Accrued income 1.8 2.8 4.3 1.5 2.8Prepayment 1.3 1.6 2.4 0.8 1.5Cash & cash equivalents 0.4 1.1 3.2 2.1 1.0

11.3 11.0 18.2 7.2 10.5Total assets 143.9 140.4 148.8 8.4 148.9

Current liabilitiesLoans due < 1 year (1.4) (2.8) (1.4) 1.4 (2.8)Trade payables (7.3) (9.2) (11.3) (2.1) (8.8)Accruals (4.6) (4.6) (5.4) (0.8) (4.6)Payments on Account (0.4) (0.6) (0.1) 0.5 (0.6)Leases due < 1 year (0.1) (0.1) (0.1) 0.0 (0.1)Other current liabilities (8.1) (8.9) (10.1) (1.2) (7.7)

(21.9) (26.2) (28.4) (2.2) (24.6)Net Current assets / (liabilities) (10.6) (15.2) (10.2) 5.0 (14.1)Non-current liabilities

Loans due > 1 year (18.5) (17.5) (17.3) 0.2 (25.5)Provisions (0.3) (0.3) (0.3) 0.0 (0.3)Leases due > 1 year (0.1) (0.2) 0.4 0.6 (0.7)

(18.9) (18.0) (17.2) 0.8 (26.5)

Total assets employed 103.1 96.2 103.2 7.0 97.7

Taxpayers Equity:Public dividend capital 102.0 102.0 102.0 0.0 102.0Retained earnings (35.3) (35.7) (36.1) (0.4) (33.3)Revaluation reserve 36.4 29.0 36.4 7.4 29.0

103.1 95.4 102.3 6.9 97.7


Summary

• As at month 7 the Trust had net current liabilities of £10.2m better than plan by £5.0m.

• The Trust's current assets are £7.2m above plan. This includes cash and cash equivalents of £2.1m and other receivables of £2.0m.

• The Trust's current liabilities of £28.4m compare with a plan of £26.2m. The variance of £2.2m relates to:-

• Accruals (0.8)• Provisions (1.6)• Trade payables (2.1)• Loans* 1.4• Other liabilities 0.9

* Loans current liability variance is offset by the non- current liabilities variance (1.5m). This is due to a change in repayable term since the plan was submitted.

• The plan was submitted prior to a revaluation of the Trust's assets therefore the property, plant and equipment variance is due to the impact of the revaluation.


5.1 Cash flow Source and Application year to date

£m Values Mar-14OctPlan £m

OctActual £m

Var to plan £m

Year end Plan £m

Income 24.4 23.4 23.9 0.5 283.0

PaymentsSalaries / Wages (10.3) (9.4) (9.0) 0.3 (110.2)Tax, NI & Superannuation (4.4) (6.2) (6.2) 0.0 (71.2)Capital (3.3) (0.7) (0.5) 0.2 (15.5)Non Pay (12.2) (6.6) (10.1) (3.5) (90.1)Loan repayment (0.1) (0.6) (0.6) 0.0 (1.4)Loan interest (0.0) (0.4) (0.3) 0.0 (0.7)PDC Dividend (1.6) 0.0 0.0 0.0 (3.2)PDC cash support 7.5 1.6 0.0 (1.6) 9.8Decrease in provision 0.0 (0.7) 0.0 0.7 0.0

Total payments (24.4) (22.8) (26.7) (3.9) (282.4)

Cashflow (0.0) 0.6 (2.8) (3.4) 0.6Opening balance 0.5 0.5 6.0 5.5 0.4

Closing balance 0.4 1.1 3.2 2.1 1.1


Summary

• In month 7 there was a cash outflow of £2.8m with a closing cash balance of £3.2m.

• Cash is above plan by £2.1m at month 7.

• All of the standard block payments relating to activity in month 7 were received in month 7. However the Trust is anticipating a payment from NHS Bolton CCG for £1.8m for overperformance in Q1 and Q2 (Q1 invoice has been raised). The corresponding expenditure has been incurred but we have not yet received payment.

• Loan interest and repayment of £878k was made in month 7.

• The Trusts plan is showing a cash inflow of £0.6m for the year with a planned balance of £1.1m at 31st March 2015 this is based on the approved Budget / Annual plan. The Trust would look to maintain an improved cash balance during the year and improve on the year end position.


6. Capital Expenditure position

Capital schemes

Annual budget £'000

Budget £'000

Actual £'000 Var £'000

Budget £'000

Actual £'000

Var £'000

Plant and Equipment 2,037 274 23 (250) 1,371 316 (1,055)Property - Maintenance 3,350 50 147 97 1,530 539 (991)Plant and Equipment - Information Technology 713 65 7 (58) 637 30 (607)Sub Total 6,100 389 177 (212) 3,538 885 (2,653)Funded Developments 1,743 229 328 0 1,285 508 0

Schemes plus funded developments 7,843 618 505 (113) 4,823 1,393 (3,431)

Other Developments 9,693 1,590 0 (1,590) 1,590 0 (1,590)GROSS CAPITAL EXPENDITURE 17,536 2,208 505 (1,704) 6,413 1,393 (5,021)



Capital Expenditure• The Trust Capital plan is £6.1m plus £1.7m of financed developments. The further developments of £9.7m relate to Estates and IT strategy and are

dependent on additional finance being agreed. Part of these strategies has now slipped into 15/16 with £3.2m remaining to be spent in 14/15.• At the end of month 7 Capital Expenditure was £5.0m underspent.• The main areas of underspend are Defibs, main walkway duct, M1 replacement windows, community IT and single sign-on with a total of £1.95m

underspend against plan to month 7. Plus £1.59m on IT and Estates strategy "other developments" as above.• The Trust has spent 22% of the year to date Capital plan, this is below the 85% Monitor threshold.• Forecast Capital Expenditure is £11.0m with £6.5m now planned for 15/16. The forecast assumes £3.2m of this years developments will be funded via

loans.

(more detailed information on planned capital spend is available at appendix 10.09)


6. Capital Expenditure run rate

Capital schemes Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD

Plant and Equipment 245 (10) 8 23 16 11 23 316Property - Maintenance 7 31 60 155 125 14 147 539Plant and Equipment - Information Technology 0 0 23 0 0 0 7 30

Sub Total 252 21 91 178 141 24 177 885Funded Developments 0 0 0 180 0 0 328 508

Schemes plus funded developments 252 21 91 358 141 24 505 1,393

Other Developments 0 0 0 0 0 0 0 0GROSS CAPITAL EXPENDITURE 252 21 91 358 141 24 505 1,393

Plan 176 568 1,259 805 714 684 2,208 2,138 2,258 2,142 2,292 2,292 6,413Variance to Plan 76 (547) (1,168) (446) (573) (659) (1,704) (5,021)



7. Income & Cost Improvement Programme

Division Savings typeFull year target £'000

Forecast £'000


Forecast £'000


Adult Acute Pay 3,646 363 135 (228) 1,831 730 (1,101)Non Pay 700 67 402 335 365 83 (282)Income 2,822 222 109 (113) 1,717 609 (1,108)Corporate share 1,394 116 116 0 814 813 (1)Contingency (1,184) (74) 0 74 (1,036) 0 1,036Benefit of Risk reserve usage 0 0 66 66 0 904 904

Total Adult Acute 7,378 694 828 134 3,691 3,139 (552)

Elective Pay 1,815 149 107 (42) 1,070 534 (536)Non Pay 1,017 85 (211) (296) 592 (1,109) (1,701)Income 4,720 393 314 (79) 2,755 1,511 (1,244)Corporate share 1,277 107 115 8 747 754 7Contingency (1,104) (69) 0 69 (966) 0 966Benefit of Risk reserve usage 0 0 60 60 0 829 829

Total Elective 7,725 665 385 (280) 4,198 2,519 (1,679)

Families Pay 3,468 288 49 (239) 2,023 340 (1,683)Non Pay 618 52 (9) (61) 358 661 303Income 2,968 248 121 (127) 1,733 709 (1,024)Corporate share 955 79 80 1 555 557 2Contingency (912) (57) 0 57 (797) 0 797Benefit of Risk reserve usage 0 0 49 49 0 677 677

Total Families 7,097 610 289 (321) 3,872 2,944 (928)

Trust wide Contingency 0 0 240 240 0 416 416Trust wide Non Recurrent 0 0 333 333 0 2,432 2,432

Total ICIP Delivery 22,200 1,969 2,075 106 11,761 11,449 (312)



Cost Improvement Programme• The Trust has released £2.4m non recurrently year to date, and with the divisions' releasing of risk reserves the overall delivery against ICIP plan is £312k

adverse year to date.• The Corporate and Estates divisions have generated a year to date surplus of £411k which is contributing to the Trust wide contingency of £416k year to date.


8. Forecast outturn for year

Trust Summary

Annual budget £m

Forecast£m

Contract income 254.3 260.2Education and Training Income 8.7 8.6Other income 17.9 17.7

Total Income 280.8 286.4Direct - Pay (189.4) (200.8)Direct - Non Pay (74.5) (77.1)Risk reserve (5.9) 2.4

Total Operational Costs (269.8) (275.4)

EBITDA 11.0 11.0Capital charges (9.4) (9.4)

Total Costs (279.2) (284.8)

Surplus / (Deficit) 1.6 1.6


Forecast outturn for year• The Trust is forecasting that the £1.6m planned surplus for 2014/15 can be delivered• Taking into account the Divisional forecast and allowing for 'optimism bias' within the Divisional Forecasts the Trust is forecasting that the £1.6m

planned surplus for 2014/15 can be delivered by fully utilising the risk reserve of £6.2m• To manage the risk within the forecast the Corporate division has been tasked with bringing forward 2014/15 ICIP schemes to deliver an additional

£1.2m and Estates has been tasked with delivering £0.25m in year.


9. Continuity of Service Risk Rating (CSRR)


Capital Service Cover rating 1 1 1 2 2 2 2Liquidity rating 1 1 1 1 1 1 1

Continuity of Service Risk Rating - Actual 1 1 1 2 2 2 2

Continuity of Service Risk Rating - Plan 1 2 2 2


Continuity of Service Risk Rating

• The Capital Service Cover rating is a 2 and the Liquidity rating 1, giving an overall Continuity of Service Risk Rating of 2.

• This is as per plan for quarter 2.


Workforce

• The Appraisals completed % met the target of 80% in October.

• Sickness absence rate increased mainly due to Gastro-related illnesses and colds. Divisions achieved the following percentages: Acute Adult 5.7%, Elective Care 5.0%, and Family Care 4.6%

• Consultant and Specialty and Associate Specialist job planning is being undertaken by clinical leads, which will lead to the compliance rate increasing over the next few months as the exercise is completed.

• Staff vacancies remain at a low rate (4.93%) due to significant in year recruitment activity.

• Bank & agency expenditure has been reduced as vacancies were filled by newly qualified staff and staff recruited in the international recruitment campaign.

In each division there are particular areas of excellent achievement across the range of workforce indicators.

The top three departments with under 1% sickness absence (and over 15 whole time equivalent people) in each Division are shown below. They are also achieving very good levels of appraisal and mandatory training compliance.

Division DepartmentSickness Absence

Mandatory Training Appraisal

Acute Adult Diabetes 0.20% 92.40% 94.90%Elective Care Therapies MSK 0.70% 97.10% 83.60%

Family CarePaediatric Nutrition & Dietetics 0.00% 95.70% 82.30%

In more acute-based environments the lowest levels of sickness absence in each Division are in A&E (3.4%), HDU (1.2%) and Maternity (3.6%).


Fit for the Future

Monitor

Monitor have assessed the Trust’s Five Year Strategic Plan and rated it as "Amber". They raised three main issues:

• The level of Cost Improvement Plans "looks exposed" compared to historical levels and delivery against plan.

• The Trust's strategies and initiatives need to have "broad acceptance across the local health economy" reflecting the "priorities and intentions of commissioners".

• The Trust's sustainability is dependent on securing DH funding for the IT and Estates Strategy.

North West Sector

The North West sector providers (Bolton FT, Salford Royal FT, Wrightington, Wigan and Leigh FT) are collaborating to propose new ways of working together which can deliver high quality standards in a sustainable way. This work will form a response to the Healthier Together proposals under development by GM commissioners. A briefing note on the North West Sector work will be included in a future report.


Better Care Fund

The Health and Care integration programme in Bolton has reached a new phase - progressing from the planning stage to the implementation stage. Four of the five operational work streams are in implementation phase (Intermediate Tier, Complex Lifestyles, Integrated Neighbourhood teams & Staying Well) and one is in planning phase (Care Co-ordination Centre). Project plans and progress monitoring are in place.

The development of phase 2 of Integration commenced in August with the second phase expected to run from September 2014 – January 2015

The enabling work streams (finance, performance, IT, workforce, communications/engagement and estates) are all established and will develop further as the requirements emerge from the design and refinement of the operational work streams.

2014 Sep Oct Nov

Complex lifestylesCare Co-ordination CentreIntegrated neighbourhood teamsIntermediate tierStaying well

Performance monitoringCommunications and engagementWorkforceFinance and contractingEstatesIM&T and IG

Service Transformation Workstreams

Enabling Workstreams


Six Better Care Fund metrics have now been agreed:

1. Total emergency admissions. [Decrease by 3.5%]. This is the sole measure on which the pay for performance element of the BCF will be assessed.

2. Permanent admissions of older people (aged 65 and over) to residential and nursing care homes. [Decrease from 380 to 378]

3. Proportion of older people (aged 65 and over) who were still at home 91 days after discharge from hospital in to reablement / rehabilitation services (effectiveness of the service). [Increase from 78.5% to 86%]

4. Delayed transfers of care (total number of delayed days) [Decrease to 311 per month]

5. Overall satisfaction of people who use services with their care and support. [Increase from 65.6% to 66.6%]

6. Referrals to home based intermediate care. [Increase from 798 to 1,36]

Future reports will show our performance against these metrics.


Well Governed

Penalties

Plan Actual£'000 £'000

Penalties (806) (139)C-Diff (9) 0TOTAL (816) (139)

At month 6 we reported we had recognised penalties for a 52 week wait which has now been removed following validation. A penalty for diagnostic waits was also reported and has been validated as correct.

• In month 7 reporting we are predicting the following penalties changes:

• The validation reduction is where we can't charge for any activities that cannot be coded by the deadline; the value for this has increased significantly in month due to higher number of uncoded spells. Actions are being taken to address this.

• Re-admission penalty is a set amount based on an audit, this value may change once we've completed an new audit of all emergency re-admissions within 30 days of original discharge. The audit looks at a sample of patients and determines how many of them could have been avoided if better primary/social care services existed, the audit will be taking place in late November.

• The 18 weeks referral to treatment penalties are estimated to continue for T&O and Plastic Surgery.

• There have been a further 2 mixed sex accommodation breaches within the month.

• The A&E four wait penalty has been applied in month due to the non-achievement of the 95% threshold. The penalty is

£200 per patient below the threshold of 95%.

• CQUINS, at month 7 we are reporting 100% achievement of the available CQUINs.


INDICATORS Acute Frailty Unit B2 B4 C1 C2 C3 C4 CCU CDU D1 (MAU1) D2 (MAU2) D3 D4 Darley

CourtH3 (Stroke

Unit) HDU ICU DCU (Daycare)

EU (Daycare) E3 E4 F3

F4/F6 (Combined wards)

G3/G3TSU G4 G5 H2 (daycare)

UU (Daycare)

E5 (Paed HDU and

Obs)

F5 (Short Stay Paed Ass Unit)

M1 and Assessme

ntEPU M2 CDS M3 (Birth

Suite) M4/M5 NICU Total

Number of Beds 22 26 26 25 26 26 27 10 14 27 22 27 27 34 24 10 8 15 15 25 25 24 22 23 25 16 10 4 38 7 16 6 26 18 5 44 38 783

Exception indicator

Friends and Family Net Promoter Score

Safety Express Programme Harm Free Care (%) NA 100.00% 80.77% 91.30% 88.46% 100.00% 92.59% 100.00% NA 100.00% 70.00% 95.24% 100.00% 92.59% 85.71% 90.00% 100.00% NA NA NA 100.00% 100.00% 100.00% 100.00% 92.00% 100.00% NA NA 100.00% NA 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 95.38%

Weekly KPI Audit % 95.00%

Hand Washing Compliance % (Self Assessed) 85.00% 100.00% 97.50% 100.00% 97.50% 97.50% 97.92% 100.00% 98.33% 98.33% 97.50% 98.33% 100.00% 100.00% 98.75% 98.75% 96.67% 95.00% 100.00% 97.50% 95.00% 97.50% 92.92% 90.56% 92.50% 98.75% 100.00% 81.67% 100.00% 100.00% 100.00% NA 97.22% 100.00% 97.22% 92.50% 100.00% 96.96%

1.60 - Monthly New pressure Ulcers (Grade 2+) 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3

1.01 - All Patient Falls (Safeguard) 9 1 5 5 6 5 4 2 0 7 8 1 1 0 3 0 0 0 0 2 0 1 3 0 2 1 0 0 0 0 0 0 0 0 0 0 0 72

1.13 - Infection Control (C. Diff) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1.39 - MRSA HA aquisitions 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1.20 - VTE Assessment Compliance (September 14) 100.00% 50.00% 50.00% 100.00% 100.00% 100.00% 100.00% 100.00% 86.61% 98.06% 9822.00% 100.00% 91.30% NA 88.46% 100.00% 100.00% 99.49% 98.42% 100.00% 87.50% 100.00% 100.00% 100.00% 98.80% 99.08% 100.00% 100.00% 99.63% 99.59% 100.00% 97.58% 86.11% 97.06%

ESSA Assessment

1.27 - Number of complaints received 1 0 0 1 0 3 0 0 0 2 1 0 0 0 1 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 1 0 1 1 0 0 0 16

Budgeted Nurse: Bed Ratio (WTE) 1.41 1.16 0.00 1.21 1.16 1.16 1.12 3.29 1.94 0.74 1.80 1.30 1.12 0.89 1.33 2.87 5.00 2.19 2.01 0.99 1.21 1.23 1.82 1.65 1.34 2.32 1.92 13.14 4.08 1.24

Actual/Current Nurse: Bed Ratio (WTE) 1.17 1.06 0.15 1.10 1.17 1.21 1.02 3.05 1.77 0.77 1.79 1.27 1.06 0.88 1.38 2.86 5.07 2.12 1.65 0.91 1.29 1.25 1.73 1.44 1.55 2.08 1.95 13.55 3.76 1.20

% Qualified Staff (Night) 98.4% 98.4% 100.1% 100.1% 100.3% 98.4% 99.7% 100.1% 94.5% 80.0% 94.8% 100.2% 98.7% 100.0% 96.7% 92.9% 100.4% 98.9% 87.2% 81.2% 98.9% 65.5% 91.0% 87.7% 100.0% 96.8% 91.1% 75.0% 96.0% 97.1%94.00%

% un-Qualified Staff (Night) 104.9% 156.4% 162.8% 108.3% 131.1% 132.3% 137.7% 103.2% 103.2% 106.5% 130.6% 136.9% 96.8% 141.9% 100.0% 0.0% 98.4% 126.9% 102.0% 60.0% 97.8% 99.6% 78.3% 35.5% 87.0% 100.0% 122.6% 100.0% 70.1% 100.0%104.35%

% Qualified Staff (Day) 112.3% 103.7% 105.2% 100.8% 98.3% 95.6% 99.9% 91.9% 116.5% 97.3% 108.7% 96.8% 101.3% 105.9% 104.8% 106.2% 108.4% 93.6% 106.3% 75.6% 112.2% 112.8% 100.5% 87.3% 84.1% 94.2% 88.7% 92.7% 88.9% 93.7%99.48%

% un-Qualified Staff (Day) 104.8% 142.3% 124.2% 103.0% 108.1% 115.6% 101.4% 131.6% 94.0% 92.3% 102.3% 110.0% 100.8% 94.6% 100.0% 100.0% 96.8% 102.7% 91.3% 52.1% 94.4% 94.0% 79.1% 64.6% 102.9% 95.2% 56.7% 100.0% 53.9% 127.9%97.88%

AUKUH Acuity/Dependancy (WTE)

1.07 - Total Incidents reported on Safeguard 15 3 14 11 11 10 24 6 8 33 35 8 6 22 6 4 13 20 12 8 10 13 22 7 13 8 5 13 17 6 13 0 6 43 7 8 39 499

SUIs in Month 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Current Budgeted WTE (From Ledger) 31.02 30.22 0.00 30.22 30.22 30.22 30.22 32.87 27.21 19.97 39.64 35.05 30.21 30.22 32.02 28.74 39.96 32.87 30.21 24.73 30.22 29.42 39.93 37.90 33.61 37.07 19.23 52.54 16.08 65.21 27.60 974.63

Actual WTE In-Post (From Ledger) 25.75 27.44 4.00 27.56 30.52 31.38 27.52 30.54 24.75 20.85 39.37 34.19 28.68 30.01 33.07 28.61 40.58 31.75 24.71 22.77 32.37 29.95 38.08 33.05 38.82 33.23 19.52 54.21 14.88 60.12 24.07 942.35

Actual Worked (From Ledger) 29.70 33.72 2.78 32.71 31.23 36.33 31.11 35.13 24.20 22.45 41.43 34.02 31.79 33.44 36.81 29.35 37.32 33.80 27.24 23.30 33.88 32.53 41.84 33.34 41.82 35.42 20.90 50.45 14.96 58.12 24.47 995.59

Pending Appointment 0

Current Budgeted Vacancies (WTE) 5.27 2.78 -4.00 2.66 -0.30 -1.16 2.70 2.33 2.46 -0.88 0.27 0.86 1.53 0.21 -1.05 0.13 -0.62 1.12 5.50 1.96 -2.15 -0.53 1.85 4.85 -5.21 3.84 -0.29 -1.67 1.20 5.09 3.53 32.28

Sickness (%) 11.51 8.22 4.75 3.54 5.76 5.63 11.41 4.56 6.03 8.85 4.27 7.65 8.96 13.83 2.39 1.28 2.36 10.67 7.56 2.33 9.86 4.53 12.41 4.22 4.66 4.79 5.02 9.44 7.05 4.67 3.79 3.79 3.79 3.79 5.31 6.25

4.02 - Substantive Staff Turnover Headcount (rolling average 12 months)

6.90% 6.45% 19.44% 3.57% 5.56% 16.13% 11.43% 6.67% 30.00% 4.88% 11.43% 15.63% 13.33% 11.11% 5.56% 4.65% 8.93% 8.70% 19.44% 2.94% 16.67% 9.52% 17.50% 4.88% 20.59% 9.52% 6.25% 12.50% 14.08% 14.08% 13.04% 7.75% 7.75% 7.75% 7.75% 11.02% 10.93%

12 month Appraisal 59.26% 55.17% 43.33% 100.00% 97.22% 73.33% 70.00% 100.00% 36.84% 47.92% 84.38% 90.32% 79.31% 51.43% 55.56% 75.61% 89.09% 100.00% 97.73% 62.86% 62.50% 48.78% 57.58% 76.74% 87.50% 73.91% 60.00% 53.85% 95.45% 95.45% 88.46% 88.82% 88.82% 88.82% 88.82% 90.29% 75.42%

12 month Mandatory Training 87.29% 66.98% 67.37% 94.94% 93.15% 90.83% 71.30% 98.42% 87.18% 75.32% 86.67% 95.83% 85.21% 83.64% 87.56% 90.60% 89.43% 94.27% 84.55% 91.41% 85.66% 87.42% 84.44% 77.40% 85.79% 83.20% 80.29% 98.68% 96.04% 96.04% 88.69% 82.88% 82.88% 82.88% 82.88% 97.59% 86.52%

Friends and Family N/A

Board Assurance Heat Map - Hospital - October 2014


INDICATORSNorth DN

TeamsAvondale Team 1

Avondale Team 2

Avondale Team 3

Breightmet Team 1

Breightmet Team 2

Crompton Team 1

Crompton Team 2

Crompton Team 3

Egerton & Dunscar Team 1

Egerton & Dunscar Team 2

Waters Meeting Team 1

Waters Meeting Team 2

South & West DN Teams

Farnworth Team 1

Farnworth Team 2

Farnworth Team 3

Great Lever

Team 1

Great Lever team 2

Horwich Team 1

Horwich Team 2

Horwich Team 3

Pikes Lane Team 1

Pikes Lane Team 2

Westhougton Team 1

Westhougton Team 2

Evening Service Total

Safety Express Programme Harm Free Care (%) *

100.00% 93.10% n/a 100.00% 100.00% 100.00% 100.00% 95.24% 100.00% 89.47% 100.00% 100.00% 100.00% 95.00% 75.00% 100.00% 92.86% 100.00% 100.00% 100.00% 100.00% 97.44% 100.00% 100.00% 97.31%

1.60 - Monthly New pressure Ulcers (Grade 2+) **

0 2

High Dependency Patients (40 Minutes >)

108 129 n/a 67 36 101 85 n/a 70 77 111 115 82 80.2 67 143 214 238 2398.2

Medium Dependency Patients (21 Mins >)

345 425 n/a 440 288 1071 633 n/a 427 351 864 516 534 317 319 302 755 885 11202

Low Dependency Patients (< 20 mins)

486 337 n/a 402 321 434 444 n/a 370 118 462 506 388 81 121 100 65 62 6768

Number of Home Visits 185 17 29 621 342 626 485 389 962 541 894 541 88 822 322 213 201 89 231 653 616 445 2902 14274

Current Budgeted WTE19.95

135.62

Actual WTE In-Post18.97

128.66

Actual WTE Worked20.06

133.16

Pending Appointment

Current Budgeted Vacancies (WTE)

0.98 6.96

Sickness (%)#DIV/0!

Substantive Staff Turnover Headcount (rolling average 12 months)

8.6% 12.5%

12 month Appraisal94.3% 92.0%

12 month Mandatory Training89.7% 75.9%

12 month Staff Survey/ Temp checks

Number of complaints received0

Total Incidents reported on Safeguard

2 67

* - Harm Free Care is from the Monthly Safety Thermometer showing percentage of patients with no harm recorded within District Nursing Domiciliary. ** - Pressure Ulcers are not broken down by team 1 or 2. For this reason, pressure ulcers have been recorded under the relevant Health Centre Name.

Board Assurance Heat Map - District Nursing - October 2014

1 0 0 0 0 0 0 01 0

8.65 10.5011.27 8.71

409

797

881

862

515

1071

675

2060

127 139

11.35 12.039.99

7.65

8.06

83.3% 78.8% 52.8%

1

17.42

11.74

11.72

8.72

7 15 5 0 16 7 3 4 7

17.03

10.56

10.68 16.01

15.94

78.4%

0.0% 0.0% 14.3% 16.7% 0.0%

9.50

10.08

7.57

7.46

8.99

9.64

14.87

16.41

12.08

12.18

10.81

10.84

100.0%

-3.00

79.9% 77.7% 83.2% 53.0%

100.0%91.7%83.3%76.5%

1.00 2.16 0.54 -0.05 1.001.00 0.71 1.48 1.14

83.7% 74.4%

87.5%87.5%100.0%91.7%100.0%

25.0% 0.0% 0.0% 40.0% 33.3%


Date Indicator Code Indicator Description Requested by Change Authorised by

19/11/2013Monitor Compliance Governance 1013-14

Monitor Compliance Governance 1013-14 Report Esther Steel Remove from Report. No longer used. Esther Steel

27/11/2013

1.07 - Total number of incidents (Clinical and non-clinical)

This metric is everything reported, patient, staff, visitors, contractors, non person. “Clinical & non clinical” infers just patient incidents. Eric Porter

Change to 1.07 - Total Incidents reported on Safeguard Trish Armstrong-Child

04/12/2013

4.02 - Substantive Staff Turnover Headcount (rolling average 12 months)

Labour turnover of substantive contracted employees Kelly King

This metric previously included turnover relating to contrived reductions in workforce over the course of the year, relating to Turnaround schemes, redundancies (voluntary and compulsory) etc. The data for this metric should be based on “natural” turnover in order to demonstrate a representative picture of the workforce. Retrospective figures have replaced the previously reported figures for the current year (2013/14). The 2012/13 figures have not been adjusted. The target remains at 10%. The metric definition has also been changed. Louise Ludgrove

13/12/2013 1.39 ‐ MRSA HA acquisitions N/A Julie Dziobon This is a duplicate of metric number 1.38 - MRSA Bacteraemia post-48 Hours admission Trish Armstrong-Child

13/12/20131.37 - MRSA Bacteraemia pre-48 Hours admission

No of pts identified as having MRSA presenting complaint 48 hrs before admission Julie Dziobon

All pre cases are now the responsibility of the CCG, for both CDT & MRSA bacteraemia cases, so despite having 4 pre cases of MRSA bacteraemia for the current year– none of them have been attributed to the Foundation Trust. Action: To remove this metric . Trish Armstrong-Child

17/01/2014 1.50 Infection Control Level 1 National Qualification David Wakefield Not Reportable David Wakefield17/01/2014 1.51 Infection Control Level 2 National Qualification David Wakefield Not Reportable David Wakefield

14/02/2014

1.36 Surgical WHO Checklist compliance (Emergency)

Checklist to reduce surgical morbidity and mortality Mike Steele Metric added Jill Patterson

19/02/2014

1.10 - pt incidents that resulted in severe harm or death %

Number of incidents involving pts that resulted in severe harm or death

Trish Armstrong-Child Target changed to 0%

Trish Armstrong-Child

19/02/2014 1.27 - complaints receivedTotal number of complaints received into trust


change target to 10% reduction on last years outturn


11/03/2014

1.25 - NICE Guidelines Adoption of Technology Appraisals

% of Technology appraisals applicable to the Trust that are adopted or adopted with caveat Steve Hodgson

Use the percentages based on total adopted technology appraisals Steve Hodgson

03/04/20144.13 - Qualified Nurse to bed ratio

Compares the number of contracted WTE nurses against in the number of occupied beds in the most recent month Nigel Moloney

Remove from Report. Replaced by ‘Budgeted Nurse: Bed Ratio’ and ‘Actual Nurse: Bed Ratio’ in the Board Staffing Assurance Heat Map Suzanne Woolridge

Report Change log



Report Change log

03/04/2014

1.33 - Compliance of 6 access criteria for learning disability %

to ensure equality of access and equity for all people with learning disabilities Mike Steele

After reviewing the 13-14 and 12-13 data there were incorrect figures in (83%). We were 100% compliant in year 12-13 and also in 13-14. Data changed to reflect this Bev Tabernacle

07/05/2014

2.46 - Readmissions within 30 days of discharge % - National

scorecard to have a line to show the national rate of readmissions along with the Trust’s performance. Esther Steel

Added Line to scorecard and series into 2.40 - Readmissions within 30 days of discharge % Chart Simon Worthington

14/05/20141.01, 1.02, 1.03, 1.04, 1.52, 1.56 (All falls and pressure damage grade 2)


a 5% reduction in year 2013/14 target applied to 2014/15 targets Jill Patterson

14/05/2014

2.40 - Readmissions within 30 days of discharge % Joanna Warburton

Readmission % for Feb14 reported last month has changed from 12.8% to 13.3% due to natural changes in data on LE2.2. The figure has still come within the ranges of previous month’s figures reported. Mike Steele

10/06/20141.13 - Infection Control (C. Diff) Mike Steele Metric duplicated by 1.45 Jill Patterson

13/06/2014

2.40 - Readmissions within 30 days of discharge % Simon Worthington

Target of 8% replaced by average of last years Readmission data = 12.6% Jill Patterson

02/07/2014

Total number of patient incidents (clinical and non-clinical) Total number of patient incidents

Mike Steele/Richard Sachs Number better represented by metric 1.07 Richard Sachs

15/07/2014

4.13 - Substantive Staff Turnover Headcount (Contrived) (rolling average 12 months)

This includes redundancies and MARS but still excludes junior doctors, flexi retirements and TUPE transfers Nigel Moloney New metric Suzanne Woolridge

17/07/20141.34 - No of CQUIN targets achieved in month

CQUINs are reported Quarterly to the CCG. This metric should reflect this position. Mike Steele Revise from monthly reporting to quarterly. Jill Patterson

01/08/2014 N/AAdded new metrics into Monitor Risk Report Mike Steele

New Metrics added to reflect new and amended metrics in the "Monitor Declaration of Risk" return Mike Steele



Report Change log

26/08/20141.07 - Total Incidents reported on Safeguard

Total number of all incidents, patient, staff, visitors, contractors etc


The QA committee has agreed that we need to increase our incident reporting and to get us in the top 20% of reporting nationally. New annual target of 10,786 added inorder to double our incident reporting per 100 admissions ratio from 6.26 per 100 to 12.60 per 100.


27/08/2014

1.09 - Total number of patient incidents reported per 100 admissions

Total number of patient incidents per 100 admissions within the month Richard Sachs as above


11/09/2014

4.05 - Local Induction Attendance (starters in the last 12 months)

Number of local (department) induction packs divided by the number of new starters in the most recent 12 month period Mark Wilkinson

4.05 - Completion of local induction system (starters in the last 12 months) - More accurate metric description. Suzanne Woolridge

07/10/20144.29 - FFT Recommend treatment

Implementation of staff FFT as per guidance, according to the national timetable. Suzanne Woolridge

Added metric 4.29 and 4.30 to the Workforce scorecard, to measure the National CQUIN Friends and Family Test – Implementation of staff FFT Mark Wilkinson

07/10/20144.30 - FFT Recommend place to work

Implementation of staff FFT as per guidance, according to the national timetable. Suzanne Woolridge

Added metric 4.29 and 4.30 to the Workforce scorecard, to measure the National CQUIN Friends and Family Test – Implementation of staff FFT Mark Wilkinson


1

Agenda Item No: 9



Title Staffing Paper

Executive Summary

Why is this paper going to the Board

To summarise the main points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

Introduction This report has been produced in line with the organisations requirements to provide a 6 monthly update regarding safe staffing levels across all inpatient areas. This report will also make reference to staffing levels across the District Nursing Services, who have been involved in a Greater Manchester evaluation of acuity.

Background In June 2013 the Trust Board received a report requesting additional investment into ward staffing to bring the Trust in line with the recommended nurse/patient ratios of 1:8 on day duty and 1:12 on night duty for general medical/surgical inpatient areas. This request was accepted by the Board and an additional investment was agreed.

In January 2014 the Quality Assurance Committee received a Gap Analysis report against the 10 recommendations being made by the National Quality Board (NQB), and this report outlines the actions taken to address identified gaps.

From June 2014 there was a requirement set out by NHS England to publish planned and actual staffing levels across all inpatient areas in the Trust. On the 24

th June 2014 this information was published on the NHS Choices web

pages. From June 2014 the Trust Board receives monthly updates around staffing performance which mirrors the NHS England published submissions from the Trust against planned and actual staffing numbers.

In October 2014 the Quality Assurance Committee received an update regarding the implementation of the staffing escalation process.

This paper provides an overview of recommendations and includes the latest published acuity data that was completed in October 2014.


Clearly identify what will follow a Board decision i.e. future KPI’s, assurance requirements

Discuss Receive

Approve Note

Assurance to be provided by:


Strategy * Financial Implications


Quality * Regulatory *

Workforce * Stakeholder implications

NHS constitution rights and pledges Equality Impact Assessed

For Information Confidential

Prepared by Bev Tabernacle, Deputy Director of Nursing

Presented by Trish Armstrong-Child, Director of Nursing

2

STAFFING PAPER 1 Introduction

This report has been produced in line with requirement of a 6 monthly update regarding safe staffing levels across all inpatient areas. This report will also make reference to staffing levels across the District Nursing Services, who have been involved in a Greater Manchester evaluation of acuity. In June 2013 the Trust Board received a report requesting additional information into ward staffing to bring the Trust in line with the recommended nurse/patient ratios of 1:8 on day duty and 1:12 on night duty for general medical/surgical inpatient areas. This request was accepted by the Board and an additional investment was agreed. In January 2014 the Quality Assurance Committee received a Gap Analysis report against the 10 recommendations being made by the National Quality Board (NQB), and this report outlines the actions taken to address identified gaps. From June 2014 there is a requirement set out by NHS England to publish planned and actual staffing levels across all inpatient areas in the Trust. On the 24th June 2014 this information was published on the NHS Choices Web Pages. From June 2014 the Trust Board receives monthly updates in relation to staffing performance which will mirror the NHS England published submissions from the Trust against planned and actual staffing numbers. This is represented through the Heat Map information presented to the Board. In October 2014 the Quality Assurance Committee received an update regarding the implementation of the staffing escalation process. This report will also provide an update to the Trust’s position against the 10 expectations set out by the NQB and the more recently published NICE Guidance, and includes information on staffing for inpatient areas, including Adult, Maternity and Paediatrics.

2 Bolton FT Response to the NQB 10 Recommendations

ACCOUNTABILITY & RESPONSIBILITY

Trust Progress

Expectation 1 Boards take full responsibility for the quality of care provided to patients, and as a key determinant of quality, take full and collective responsibility for nursing, midwifery and care staffing capacity and capability

All identified Actions Complete

Expectation 2 Processes are in place to enable staffing establishments to be met on a shift-to-shift basis.


3

EVIDENCE-BASED DECISION MAKING

Expectation 3 Evidence-based tools are used to inform nursing, midwifery and care staffing capacity and capability.


Expectation 4 Clinical and managerial leaders foster a culture of professionalism and responsiveness, where staff feel able to raise concerns.


Expectation 5 A multi-professional approach is taken when setting nursing, midwifery and care staffing establishments.


Expectation 6 Nurses, midwives and care staff have sufficient time to fulfil responsibilities that are additional to their direct caring duties.


OPENNESS AND TRANSPARENCY

Expectation 7 Boards receive monthly updates on workforce information, and staffing capacity and capability is discussed at a public Board meeting at least every six months on the basis of a full nursing and midwifery establishment review.

. All identified Actions Complete

Expectation 8 NHS providers clearly display information about the nurses, midwives and care staff present on each ward, clinical setting, department or service on each shift.


PLANNING FOR FUTURE WORKFORCE REQUIREMENTS

Expectation 9 Providers of NHS services take an active role in securing staff in line with their workforce requirements.


THE ROLE OF COMMISSIONING

Expectation 10 Commissioners actively seek assurance that the right people, with the right skills, are in the right place at the right time within the providers with whom they contract.


4

3 UNIFY Returns

The Trust has published its monthly UNIFY returns illustrating fill rates on a monthly basis, in line with the national guidance. Each month we have worked with the e rostering system to ensure that the overall reflection of fill rates across areas included is accurate and reflective of our current staffing position. These returns are now part of the Heat Map which is presented at Trust Board on a monthly basis. The Heat Map provides a balance of the staffing information against a number of agreed quality indicators. The information included in the return includes Supervisory staff and staff who have been employed to provide one to one supervision to a patient (Special). Following our International recruitment initiative and employment of a number of newly qualified nurses across areas, we have seen the fill rates increase for the month of October. However, it is important to understand and contextualise the actual needs of the areas in comparison to the current agreed established levels and skill mix.

4 NICE Staffing Guidance

This is the first guideline from NICE directly linked to safe staffing. It makes recommendations on safe staffing for nursing in adult inpatient wards in acute hospitals, based on the best available evidence. The guideline focuses on wards that provide overnight care for adult patients in acute hospitals. It does not cover Accident & Emergency, intensive care, high dependency, maternity, mental health, acute admission or assessment units or wards, or inpatient wards in community hospitals. In this guideline, nursing staff are referred to as registered nurses and healthcare assistants. The guideline identifies organisational and managerial factors that are required to support safe staffing for nursing, and indicators that should be used to provide information on whether safe nursing care is being provided in adult inpatient wards in acute hospitals. The guideline has been developed for NHS provider organisations and others who provide or commission services for NHS patients. It is aimed at hospital boards, hospital managers, ward managers, healthcare professionals and commissioners. It will also be of interest to regulators and the public. This guideline does not cover nursing workforce planning or recruitment at regional or national levels, although its content may inform these areas. A baseline assessment against the recommendations made by the guidance has been completed. We have also ensured that the ‘RED FLAGS’ identified within the guidance are included in the agreed staff escalation process which was agreed by the Quality Assurance Committee in October 2014. In the coming months further guidance is expected for the following areas:

A/E

Community

Midwifery Further work will be undertaken in the next month to implement the ‘RED FLAGS’ into the incident reporting process.

5

Through the staffing escalation process ward staff have been encouraged to raise staffing issues through the incident reporting process. Since the 1st August 2014 a total of 142 incidents have been raised with regard staffing. The breakdown of these incidents across the divisions is:

Acute Adult Care 57

Elective Care 50

Family Care 35

The further breakdown of this information into specific themes includes:

Acute Adult Care

Delay/Difficulty Obtaining Clinical Assist. 4

Lack of Suitably Trained / Skilled Staff 46

Mandatory Training - Non-Attendance 1

Non-Attendance for Shift 4

Training Issue for Staff 2

Elective Care

Competency of Staff Member 3

Delay/Difficulty Obtaining Clinical Assist. 4


Non-Attendance for Shift 8


Family Care

Competency of Staff Member 2



Out of 142 incidents raised 106 (75%) relate to lack of suitably trained staff being available across the wards.

5 Adult Nursing Acuity Review

Patient acuity analysis evaluates the size/mix of nursing teams to match ward activity (based on assessment of patient dependency). The AUKUH Tool is one method that can be used to assist Directors of Nursing to determine optimal nurse staffing levels. The AUKUH Tool is evidence based and fully validated. Within the tool the patient acuity descriptors have been based on 5 groups:

Level 0 Patient receiving standard level of care

Level 1a Acute care (unstable)

Level 1b Basic nursing care (significantly dependant)

Level 2 HDU Level

Level 3 ICU Level

It has to be acknowledged that all tools to measure the acuity and dependency of patients have limitations. This tool should not be used in isolation, but be used in conjunction with quantative information in relation to nursing indicators, alongside the professional judgement of clinical nursing staff working in our wards and departments. By using this triangulation we will have increase assurance in the agreed staffing levels.

6

A further review of acuity across our wards was undertaken in October 2014. The chart below outlines the increase in acuity across the organisation in recent months, which supports some of the anecdotal evidence suggesting the increased complexity of the patients we are treating on our wards.

The acuity study for October 2014 does suggest that increased nursing numbers are required. As previously highlighted this should not be viewed in isolation and further work and analysis is currently underway to consider this. Consideration for the principles set out in the NICE Guidance in terms of setting staffing levels across the acuity of a 24 hour period will also need to be considered. A presentation has been given by Allocate our provider for E Rostering, who has a Safer Care module which provides an ability to monitor Acuity and Dependency in ‘Real Time’. A business case for the purchase of this module is under development. This technology would provide a greater understanding for the orgnaisation across the board in relation to staffing and the ability to flex staff safely across areas.

6 Paediatric/Neonatal Area Staffing Assurance

Paediatric and neonatal services have produced a daily monitoring process for measuring acuity and dependency in line with the document ‘Defining staffing levels for children and young people’s services” published in August 2013. This acuity and dependency tool is updated daily by the ward manager and allows for movement against the outlined standard reporting compliance against these and flexing of staff across the service, based on the patient/service need.

7 Midwifery Staffing Assurance

National guidance in relation to midwifery staffing levels in the form of the Birth Rate Midwifery Staffing Tool. Birth rate + is a service based tool which takes into account both activity and acuity levels within the maternity service. It has been developed to monitor the delivery of 1:1 care in labour and includes time required for management, holidays, sickness and study leave. The National and Greater Manchester ratio for midwifery is 1:28. However, due to the decrease in births booking into the Bolton Maternity Services, the ratio has been 1:26. The NICE staffing guidelines for Midwifery have recently been available through the NICE consultation process. A comprehensive response to each of the elements of the guidance has been submitted by the Director of Nursing supported by the Professional Lead/ Head of Midwifery.

7

8 Community District Nursing Staffing

There has been an increase in requests for face to face District Nursing Services over the past 2 years, without the support of additional resources. Despite a commissioner led review of the service undertaken in 2008/2009 (Bolton PCT), which led to two separate service specifications; Domiciliary Nursing care and the Treatment Room Service (Ambulatory Care). In addition the increase in referral rates has led to a significant increase in workload for individuals and teams across the service, which has proved that within current funded staffing establishment is not sustainable in the long term.

There has also been a significant increase in the number of patients requiring administration of insulin, and multi administration regimes as NICE guidance, NSF and QOF promote improved management of type 2 diabetes.

Since June 2014 a situational report is produced every day with the aim of managing capacity vs. demand. The data is submitted by the teams daily and is a live indicator of the workflow across the service. The report works in the following way;

In respect of acuity, patients within the caseload are stratified on a daily basis.

There are three levels of acuity and each level has a time frame attached to it. o Low level 15 minutes o Medium level 30.5 minutes o High Level 40 minutes

Below snap shot that illustrates a typical day in October 2014. It is clear that the service is consistently showing red;

8

8.1 Acuity of caseload – Community Services

Following on from the background information relating to the acuity of the caseload, there has been a further shift, examples of this are below;

Proactive response to harm free care,

Changes in modality of health care delivery i.e. earlier discharge after reduced length of hospital stay, advancing quality etc.

Increased service provision by other community teams means that the ‘community caseloads’ have increased in volume and patients still need DN service provision in spite of specialist service provision. For example, IV therapists will provide IV treatment however the generic care assessment for such as pressure care, catheter care is undertaken by the DN service

Raising the bar for social service care has increased the sub threshold population who access still health care leading to increased health care demand

Increased dementia population –research shows that care delivery to a patient with dementia increases the time factor by 1 and ½ times e.g. patient care of 30 mins would increase by 45 mins to 1hour 15mins)

Admission avoidance: increased cohort of patients requiring intervention in order prevent hospital admission/re-admission e.g. eye drops

Preventative care e.g. public health care: Keeping Warm campaign

Continuing Health Care-restitution cases and/or nursing assessments for FNC or CHC are undertaken mainly by DN service

Increase in safeguarding incidents/assessments leading to increasing community nursing demand

Increased carers support

An acuity study was undertaken by Professor Keith Hurst in July 2014 across the GM community services. The findings highlighted that Bolton caseloads were higher than average with low acuity. A deep dive review of current case load activity is currently underway to clarify.

8.2 DN referrals

Source and number of referral for the last 12 months Sept 13 to Oct 14 inclusive is:

A&E 38

Consultant 1576

External 1205

GP 2996

Internal 155

Self 1573

Many of the self-referrals are GP referrals where the GP has advised the patient or carers to contact the DNS. The above data quality is un-validated and current methods of recording need review and revision to ensure they are fit for purpose.

9 Recruitment/Retention

The Trust Board are aware of the challenges the Trust has experienced in relation to recruitment and the retention of nurses, and alongside this issue the impact of high levels of sickness across many of our wards and departments.

There has been a tremendous focus on the management of sickness absence particularly on ward areas where absence levels were slightly higher.

9

This sustained effort has resulted in a reduction in sickness absence over recent months, although a seasonal ‘spike’ was seen in October with higher levels of coughs and colds etc. The Trust has now introduced a new attendance management policy which replaces a number of different policies in operation through various TUPE transfers. A significant number of Trust managers have been trained against the new policy and the management focus on sickness absence continues.

Overall turnover has also reduced over previous months however there has been some movement between teams which has led to an increased requirement for recruitment. Over 100 new starters have been recruited to the clinical teams over the past three months and the numbers of staff now falls within acceptable levels. However, the challenge we now face with many new starters is the impact of a much more junior skill mix, which requires careful management until the individuals are suitably oriented to take on a full workload.

10 Conclusion

The focus continues to ensure that our wards have safe and effective staffing levels across the services we deliver to our patients. A substantial amount of work has been undertaken to ensure we are recruiting to vacant posts across the divisions. However we have seen an increase in the acuity and complexity of our patients and alternative models of service delivery need to be examined to ensure we invest in the correct way to improve staffing levels going forward.

11 Recommendations The Trust Board note the content of this report and support the further work underway to review current staffing levels.

Agenda Item No: 10


Date November 2014

Title Action plan for the Improvement in performance against the four

hour target for the Emergency Department

Executive Summary

This paper is the follow up to the analysis presented in the October Board on Emergency Department performance. The purpose of this paper is to set out the actions being taken by the Trust to recover the underperformance against the 4 hour target. It will set out the actions required in the short term to quickly arrest the poor performance and those actions that will be required to sustain performance over the medium to long term.


• For the Board to receive the paper • To provide an update on the action plan at the November

Board meeting Discuss Receive Approve Note


• Four Hour target performance • Reductions in procedures cancelled on the day • Reductions in outliers • Evidence of implementation of action plans




Quality Regulatory


NHS constitution rights and pledges Equality Impact Assessed For Information Confidential

Prepared by Andy Ennis – Chief Operating Officer Presented by Andy Ennis –

Chief Operating Officer

Action plan for the Improvement in performance against the four hour target for the Emergency Department

This paper is the follow up to the analysis presented in the October Board on Emergency Department performance. The purpose of this paper is to set out the actions being taken by the Trust to recover the underperformance against the 4 hour target. It will set out the actions required in the short term to quickly arrest the poor performance and those actions that will be required to sustain performance over the medium to long term. Situation

• The Trust has been seen a deteriorating position since April 2014 against the 4 hour target. • Quarter 1 was passed at 95.7%, Quarter 2 was passed at 95.57%, Quarter 3 will fail the target at a

predicted position of 92% plus or minus 0.5%. • Significantly the year performance has moved to an overall fail at 94.86% at the time of writing the

report. This is expected to fall to 94.5% by month end. • The November position is likely to be a little over 90% • The actions taken should ensure that the December position will be over 95% • It will not be possible to recover the year position until January 2015. • The pressure on capacity has increased the number of medical patients in elective beds. The net

result of the reduction in surgical elective activity has put pressure on the 18 weeks RTT performance. • The actions taken should ensure we continue to deliver 18 weeks.

Background

• The Trust despite its deteriorating position remains one of the best performing Trusts in GM. • Only two Trusts are passing the year (95.96 and 95.15% respectively) and only 4 Trusts are passing

the quarter (of which 3 are in a declining position). • There is a reported pressure nationally on ED performance

Assessment

• The Department of Health has made funding available for winter pressures, however the ability to recruit staff has meant that many schemes have not started or are only just beginning to have an impact.

• The QUIP schemes supported by the CCG and Trust have had little or no impact on preventing admissions to date.

• Whilst the CCG dispute the increase in admissions and believe this to be an accounting error related to BCU, we have seen a 6% rise in Non elective admissions. The Trust accepts that some patients will have been admitted who were previously were in the BCU, however there is an underlying trend of an increase in admissions.

• Bed closures were predicated on a reduction of length of stay, whilst there is considerable weekly variation in length of stay the overall trend is down.

• Length of stay had shown continued improvement compared to previous year from October 2013 to April 2014 when the decision to close beds was made. It was not anticipated that length of stay would return to seasonal norms through the summer. We are awaiting the results of the acuity scoring to verify the belief that acuity had increased.

• Statistically, admissions are constant within a range over a year, what change’s is length of stay related to severity of illness in winter.

Urgent Care Programme Plan Bolton NHS Foundation Trust Page 1 of 19 Version 5

• The increase in admissions combined with the increasing acuity of patients as winter draws in has led to an increase in pressure on beds.

• The Trust has recruited 100 more nurses, but there is a skill mix issue which is affecting flow. • The Adult Acute Division at current length of stay and admissions has an occupancy of 107% at

midnight, this would be higher during the daytime. • At time of writing the report, 17 patients were medically fit but requiring 24 hour packages of care and

a further 20 were not medically fit but would be soon and require packages of care. • The continuing healthcare assessment is overly long and complicated. • The net impact is periods where over 40 medical patients are being cared for on non-medical wards • The Adult Acute Division has been under increasing pressure to deliver change across hospital and

community services at a pace that outstrips their capacity. Recommendations/Actions Short term

• Staffing • There is an urgent need to bolster the admission/assessment units to ensure a member of

staff is able to coordinate care. Action: The Executive have approved recruitment to a coordinator role for ED, and

D1/2 wards immediately. • There is an urgent need to ensure the correct skill mix on the assessment units D1 and 2.

Action: The Adult Acute Division have been required to demonstrate the skill mix is adequate

to meet the needs of service immediately. The Chief Nurse will attend the Divisions weekly staffing meeting to ensure that skill

and staffing fill rates are managed appropriately. • Fill rates on the bank are 60%, staff are paid at lower band 5, irrespective of band or

experience. Action: The Executive have approved that any staff doing bank work will be paid at

their substantive band and incremental point. • Beds are not being made available in a timely manner

Action: The Executive have approved the employment of a small transfer team

• Management • The Adult Acute Division do not currently have the management capacity to deliver the pace of

change required to deliver turnaround in a timely manner. Action:

• The Chief Operating Officer will take over management of the Community sub division from 17/11/14 for a period of 6 months.

• The Executive have approved the appointment of turnaround support for the ED and flow team starting 25/11/14 for a period of two months.

• Patient Flow • Challenges occur when pace is needed to clear beds in a timely manner to ensure flow.

Action: • The Executive have approved the recruitment of a transfer team for the winter

period whose job will be support wards in making beds available in a timely manner.

• There is significant delay in discharging patients who have on going care needs. Action:

• The Chief Operating Officer has requested the transfer of the professional lead from Surgery to lead the clinical flow team and work on ensuring timely discharge. They will be in post for 3 months from December.

• The Director of Nursing is leading a team with the CCG to review the CHC process.

Programme Plan Bolton NHS Foundation Trust Page 2 of 19 Version 5

• A weekly on site meeting with all representative bodies will assess patient delays at a Divisional level.

• A process has been set up to highlight patients with delays in on going care which Directors will escalate on a weekly basis to CCG and Local Authority colleagues.

• Twenty one of the medical consultants have agreed to extra sessions to ensure medical cover for the winter ward, effective immediately.

• The Executive have approved the recruitment of extra junior medical cover to support the outlying wards.

• Bed capacity

Staffing is being recruited for the winter ward but is not likely to be available until mid to late December in full, in the interim.

• Action: o The Chief Operating Officer has agreed to cohort all medical outliers on

E4. This will ensure medical capacity to meet demand. Nursing and medical support from the Acute Adult Division has been agreed.

o Surgical capacity is being managed through increased day case work and cooperation with M1.

o The former BCU (now R1) has been opened as a discharge lounge and for surge capacity beds

o GPAU hours have been extended to provide increased ambulatory care capacity, staffing will be in place by 22/11/14.


Medium and Long term actions The Chief Operating Officer has set up a senior meeting comprising the heads of Divisions, Deputy Directors of Operations and Professional leads with PMO support to monitor and drive the changes required to deliver a sustainable position. This report is an evolving plan over time.

1. Urgent care/flow plan

The plan has been developed by Divisions who will manage progress via weekly oversight project meetings reporting into the Flow Board. Recommendations from ECIST have been incorporated into the plan.

Workstreams

Workstream 1&4 – Prevention and return to independence (pre-admission and post discharge) Workstream 2 - Emergency care, assessment and decision making (Peri attendance) Workstream 3 – Inpatient Flow (Peri admission)

2. Governance

3. KPIS The following key outcome indicators will be monitored and reported to the the flow board in addition to the Quality Impact Assessment measures;

• Length of stay - aim for a reduction in length of stay across the Trust of half a day • A&E Performance • Cancelled operations due to no bed • Outliers • Critical care – delayed step downs

Board of Directors

Exec Team

Acute Adult

Elective

Families

Flow Board

HE Resilience Board


4. Risks Risks to delivery will be monitored via a risk log which will be overseen by the flow board. Risks to delivery scoring highly will be escalated to Divisional risk registers and managed through the risk management process.


Programme Plan – Workstream 2 Emergency care Assessment & Decision making (Peri-Attendance)

Last Updated 14/11/2012

Ref Intervention No. Actions to close Lead Delivery date Status Commentary Change

embedded

1

A&E Minors - Review and re-design clinical

model for minors based on 'see and treat'

clinical model. Model to ensure nursing skill mix & medical rotas aligned to case mix and patient

arrival profiles

1.1

Review minors cubicle capacity to ensure adequate capacity to meet demand RB November

2014

Number of cubicles currently matches the number of staff deployed in minor assessments. No further action required

November 2014

1.12

Analyse demand by hour, by day and case mix. Review current workforce allocation against demand profiles – Nursing and medical

RB January 2015

Mapped number of ENP staff in minors against activity. New model to commence January 2015.

1.13

Define clinical model to meet demand and associated workforce numbers and skills. Test out clinical model to confirm actual benefits will equal anticipated benefits

RB/ Clinical Lead

January 2015

Model to be defined with Business Unit Manager, Clinical Lead and minors lead in December 2014. To test ‘see and treat’ model in January when ENP staffing model in place.

1.14 Complete gap analysis for skill mix and numbers for preferred model

RB/ Minors Lead

January 2015

To be completed in line with defining the model

1.15 Complete skills assessment of current staff and training needs analysis

RB/ Matron January 2015

ENP staff up to date with injury competencies. To identify the need for minor illness competencies in line with the defined/ agreed model.

Key: R

Intervention not started or behind plan or not impacting performance A

Intervention on plan and/ or not yet impacting performance G

Intervention implemented and impacting performance B

Change embedded and sustained

Programme Plan Bolton NHS Foundation Trust Page 6 of 19

1.16

Create a workforce plan to support minors structure to ring fence staff (inc terms and conditions) and restructure

RB January 2015

?Minors delays/breaches sometimes occur due to staff being pulled to majors – there was discussion about ringfencing the staff

1.2

Reduce A&E follow up clinic to release

demand on medical staff (release time)

1.2 Conduct an audit of review clinics OM September

2014 Audit undertaken, presented at consultants meeting

1.21 Explore alternatives to AE review clinics OM November

2014

1.22 Agree if there are alternative pathways – quantify impact and trial

OM November 2014

1.3

Improve and sustain response/turnaround in diagnostics to reduce

delays to patient care in ED /Assessment and

ambulatory care

1.3 Quantify delays and reasons for delays – develop action plan to address

RB/Elective

November 2014

Known delays in CT reporting. Radiology Manager aware and developing a Business Case for additional reporting capacity. Need to set and monitor internal professional standards. Need to ensure that the same response times are available for ambulatory care.

1.31

Implement hot reporting to reduce demand on medical staff in A&E, reduce risk of missed fractures and reduce demand for clinic follow up in ED

Radiology Manager January 2015

Scope the need and benefit for ‘hot reporting’. Radiology to determine need and resource implications of ‘hot reporting’. Any resource implication would require

1.4

In line with ECIST recommendations. Develop case to

relocate GPOOH to hospital site opposite ED to support working together. Working with

CCG regarding

1.41

Develop a responsive primary care stream to manage out of hours and weekends primary care presentations

RB/ Clinical Lead

November 2014

GP stream ended August 31st 2014.

ANP agency trial Sept/ Oct, but fill rates low, trial ended.

COO sent letter (end Oct 2014) to all GP practices re: providing a primary care stream. Decision

in November 2014 to decide


appropriate consultation and strategic fit

how we are going cover the GP stream in the short term (till

March 2015) - to include BARDOC

1.42

Assess viability of service and conduct review of options. Present and agree strategic direction.

RB/ OM/ CCG

November 2014

Met with CCG commissioner August 2014, need to re-meet in

November 2014.

1.43

If OOH decision supported develop project plan to support transition of service. Move service to co-locate

RB/ OM/ CCG Await outcome of above

1.5 Reduce breaches for patients with mental health requirements

1.51

Work with RAID to ensure plan in place to support ED/ambulatory care assessment areas

RB/ RAID October 2014

Fortnightly meetings with RAID have been ongoing since July

2014.

Audit of case notes undertaken to determine main issues. Increased awareness with AE staff re: alcohol pathway

Weekly breach meetings commenced w/c 27/10/14


1.6

Ensure professional standards are in place

to support timely response to ED in line

with critical timings. Clear escalation should

be in place to avoid delays in patient flow which impacting on

accumulative numbers of patients in ED

1.61

Document and develop operational policy describing

critical timings and professional standards to support ED

Urgent Care Board

December 2014

Professional standards for each area to be agreed and publicised and monitored. Determine how often to report turnaround times.

1.62

Complete analysis of performance in relation to

response times for bed and senior review adherence, to reduce variation in response

times

BB/LZ/SM February 2015 Determining live method of capture will be challenging

1.63

Ensure internal standards are in place for ; ED to AMU/AFU/CDU/GPAU AMU to specialty ward Pathology Radiology Pharmacy Internal referrals

RB/OM/LZ February 2015 To be agreed

1.64

Ensure pathways, professional standards and response from other community teams and partners are in place

JP/SU/JS December

Work has commenced


1.65

Ensure pathways, internal professional standards and response from surgery and orthopaedics are in place

VW/ Clinical lead

1.7

Re-design clinical model for Acute Medicine to support Ambulatory care, assessment, decision making & short stay. Base on ECIST recommendations. To; • Establish an

ambulatory care unit

• Improve acute medical take

• Re-focus D1/D2 as short stay

• Additional project to right size wards

1.71

Agree model and funding/resource implications. Produce paper for sign off by Divisional Board and clinical

leads.

SM/ RB/ Dr Brian Bradley

November 2014

Presentation to Clinical leads 29/10/14, agreement of ambulatory model. Medical support to model agreed in principle. Clinical Head of the Division to establish short term medical model. Project to be split into 3 phases described on paper which has been produced for exec review and support (12/11/2014).

1.72

Develop and manage project plan for delivery of new model – develop detailed timeline and

project manage providing updates via Divisional

project meetings

SM/ RB November 2014

Project plan timescales being confirmed.

1.73 Review bleep and referral pathways for DVT & GP

JH November 2014

Discussion had with clinical leads Oct. working through options.


1.8

Re-define and document referral pathway for surgical ‘urgent care’ assessment and decision making

1.8

Review and update operational policy and review effectiveness

of pathway

Review Registrar cover on SAU

Review potential of ANP role on SAU

Potential/ Scope of SARC 7

days per week

SAU access to diagnostics

Elective Division December 2014

Elective care developing plans to support improvements in SAU N

1.9

ED staffing review – ensuring shift patterns and skill mix matches demand and that best practice models have been considered eg RATS

1.91 Review nursing skill mix and shift patterns against demand

RB January 2014

Initial reviews of skill mix taken place.

1.92 Review medical skill mix and

shift patterns

RB January 2014

1.93

Triage and RATS model review based on best practice

RB January 2014

1.10 NWAS – ambulance handovers 1.10

Ensure ambulance handover and turnaround action plan in

place with KPIs tracked against interventions. Progress to be monitored in weekly project

team meeting

RB December 2014

Meetings arranged in November, discussion with ALO


Workstream 3 – Inpatient Flow (Peri admission)

Ref Intervention No. Actions to close Lead Delivery date Status Commentary Change embedded

2

Complete analysis of medical beds required

based on trends throughout the year to ensure capacity meets demand. Ensure that

reporting supports this.

2.1 Conduct analysis of bed

capacity to meet demand using bed modelling

COO November 2014

2.12

Ensure plans in place to increase physical capacity in

winter months to allow flexible bed capacity alongside

associated workforce, reducing delays due to 'no bed'.

MR November 2014

Weekly meetings taking place to manage actions for winter plan. A winter ward will be established on A4 to increase capacity by 22 beds.

2.12

Ensure winter/resilience plan in place and managed through

weekly meetings

MR Oct 2014 Winter plan developed, latest

update being shared with Execs 13th November

2.13

Redesign flow report to support capacity and demand

management, monitoring number of bed numbers at

midnight and 7am

SM October 2014

Flow report has been redesigned to provide a more comprehensive view of demand and capacity.

October 2014

2.14

Define standards for extramed develop SOP and ensure

training available. RE-design of function to support

JH January 2015 Flow Manager has met with Extramed lead. Work continues.

2.2

Ensure robust management of

infection control issues to ensure that bed capacity is not lost.

Impacting on delays/breaches due to

'no bed'

2.21

Complete analysis of bed days lost last year to ensure ward capacity takes into account

proportion of bed days lost due to infection control

IP to lead

Infection control being managed in line with requirements,

2.22

Clear process of review to link risk assessment and bed

utilisation to infection control decisions and any escalation

IP to lead

2.23 Ensure wards are managing infection control in line with

guidance Matrons


2.3

Proactively manage LOS by working to

discharge targets, daily MDT, daily ward rounds

to reduce delayed discharges and harm. Introduce operational

standards for management.

2.31

Ensure discharge & LOS targets are set by ward, and

are managed via daily MDT on all medical wards. All wards to have EDD, PDD. Each BU to

ensure that routine audits are in place

BUMs January 2015 Challenge around measuring LOS

2.32 Increase weekend discharges –

trial of weekend discharge stickers

Matrons/ Clinical leads

TBC

2.33

Increase weekend discharges – increase nurse led discharge

by developing roll out plan and trial

Matrons/ Clinical leads

TBC

2.34

Introduce and manage daily 12 o’clock bed meeting to review LOS/discharges for same and

next day

SM Complete

Meeting has been introduced. Attendees include – Bed

Managers, Discharge coordinators and community

colleagues in attendance (Long term conditions & IV team). Operational Policy has been

developed.

Duty social worker to be based in Flow office and will be

attendance at the daily 12pm meeting from November 2014.

November 2014

2.35 Introduce in reach for IMC – monitoring LOS and delays JP/AG November

The flow team are developing visibility of the delays to flow

through the units. R&A attend the 1pm bed meeting are are aiming to have visibility on the discharges today, tomorrow or

any delays.

2.36 Ensure that weekly DTOC is managed SM December 2014

An issues list is in development. This includes all patients with a LOS>20 days plus any patients

who are medically fit but are


delayed. From this list the weekly DTOC is produced.

In development – definition of

DTOC, training for clerical officers to collect and action

appropriate delays.

2.37

Introduce weekly breach meeting to aggregate themes

and conduct deep dive for learning and actions

RB November 2014 Meeting has been introduced

2.4 Review feasibility of

discharge lounge and introduce

2.41 Review Pennine Gold Standard discharge lounge SM/JH December 2014 Visit still to be arrranged

2.42 Complete QIA and sign off SM/JH October 2014

Operational policy & QIA complete

Requires Divisional sign off.

2.44 Test out flow and resource implications SM/JH October 2014

Discharge Lounge launched in October 2014.

Consistant staffing difficult to

maintain. Reliance on bank and agency. All agency staff are swapped with Trust staff to ensure a Trust employed

individual runs the lounge. All Divisions supporting with

staff.

Daily monitoring of use is in place.

2.45 Decision to implement MR/COO Currently being tested and monitored for effectiveness

2.5

Review management of flow in and out of hours.

Ensure bed management policy is

re-designed in line with clinical pathway

changes and clear roles and responsibilities.

Escalation process to

2.51 Appoint new flow manager MR Complete New flow manager in post

2.52 NNP roles and responsibilities and line management. RB/CC

2.53

Establish flow team – office redesign, new structure for

team, Include review of discharge team review working

JH/SM Complete

Flow team formally combined and flow office operational from

27/11/2014.


be reviewed updated if required, documented

and clear

model and recruitment. Corporate Bed Meetings moved to office 03/11/2014.

New Discharge coordinators

commencing 03/11 & beginning of December.

Role of Band 3 staff under review – November 2014

24/7 bed management & site

coordinator roles under review – November 2014

2.54

Draft Trust Bed Management policy and circulate for comment incorporating

escalation protocols

JH/SM October 2014

Draft Corporate Bed Management Policy &

Procedures developed.

Comments received from Executive Sponsor incorporated.

Returned to Executive Sponsor

for Trust circulation and approval

October 2014

2.55 Communication and awareness of policy

All Trust Divisions Awaiting Policy Approval

2.56 Training for staff and launch new policy JH Awaiting Policy Approval

2.57 Review adherence JH Awaiting Policy Approval

2.58

Tier 1&2 – establish training packs, prompt questions, flow

capacity and demand templates and call logs

SM/ JH November 2014

List of suggested roles and responsibilities re: flow developed for Tier 1.

2.59

Ensure clarity of roles and responsibilities for teams to

support flow; Bed Managers

Site coordinators Shift Leaders

MOD Acute and Elective Medical Reg

Medical consultant on call Tier 1&2

Ward Managers Band 7 at weekends

JH/SM November 2014

Roles and responsibilities developed for;

Bed Managers, site coordinators, MOD Acute


Review medical working OOH Rotas

Responsibilities Model of working OOH handovers

Medical management of staff

RB/HB

2.6

Establish 7 day working to support early senior

review, admission avoidance and

consistent support for ED to reduce delays

2.61 Review workforce requirements in line with support for ED RB

2.62 Implement changes in light of workforce review RB

2.63 Model acute physician

requirements to move to 7day working

RB

2.7

Improve partnership working across Health

economy to reduce delays to care eg CHC

2.71

Working with Social Care partners review the management of the delayed discharge from the units. Implement actions to resolve top reasons for delays.

KM

2.72

Review in partnership with social care CHC process Monitoring/redesign of internal process/daily incident reporting of process delays and daily reporting to CCG

JH/SM/KM

January 2015

Need to establish clearly Trust process and monitoring of all patients in CHC process within the Trust - New discharge coordinator to commence 03/11/2014. Their primary objective for the first month is to understand the CHC process in Bolton, understand the paperwork and whats is required to achieve a decision on funding at the first panel to which the paperwork goes to and to clinically check the paperwork prior to submission to the CHC panel. Process requires full review with CCG. ECIST offered to facilitate discussions.

N


2.73

Work with the out of area social care providers and commissioners to create an agreed single referral standard with response times that is monitored and reported

TBA

TBA

What is progress on this?

N

2.8 Reducing readmissions

2.81

Develop divisional plan to include analysis of re-admissions

HODS/ clinical leads

Division was challenged at IPM to review re-admissions – work

is being carried out by the Business Unit managers and lead clinicians to review and

validate trends

2.82

Complete clinically led audit in support of COO analysis Clinical

leads/ HODS

TBC

Need to confirm dates of when audit will be completed,

2.9 Level 1 beds 2.91

Develop and confirm clinical model for level 1 beds and develop project plan

CC/MR

Level one plan being written to present to execs


Workstream 1&4 – Prevention and return to independence (pre- admissions and post discharge)

Ref Intervention No. Actions to close Lead Delivery date Status Commentary Change

embedded

3.0 Integration workstreams

3.1 IMC beds AG/JP/HC TBC

Laburnum Lodge opened in August 2014. Darley Court to be re-furbished and beds to be re-

located pending works.

3.2 IMC at home AG/JP/HC TBC

Increase capacity in home pathway to accommodate the reduction in beds from 80 down to 62. Recruitment under way and capacity of service is increasing month on month.

3.3 Community admission avoidance AG/JP/HC 1.4.2015

Recruitment to admission avoidance service

(enhancement of R & A Team) has commenced using SRG funding to bring forward April

2015 start.

3.4 Hospital admission avoidance AG/JP/HC 1.4.2015

R & Assessment Team delivering daily in-reach on hospital site. LTC Team attending daily bed meeting.

3.5 7 day discharge MR/JS 1.4.2015

BCF funding for Integrated Discharge Team available from 1.4.2015. Paper being prepared to describe service delivery model for January Integration Board

3.6 Care Home Service JP/LP/HC 1.4.2015

Provider response to service specification sent to CCG on 31.10 2014. Recruitment initiated using SRG funding. Pilot project at Farnworth Care Home and 4 Seasons continuing.

3.7 Integrated Neighbourhood Teams LP/JP/HC 1.4.2015

First co-located INT now established at Great Lever HC-starting to work through lists of

high-risk patients from 7 GP practices involved in second phase of Integration. Patients will have admission avoidance care plans and key workers.


Agenda Item No : 11



Title Audit Committee Annual Report

Executive Summary

This annual report has been prepared for the attention of the Board of Directors and reviews the work and performance of the Audit Committee in satisfying its terms of reference.

The production of an Audit Committee Annual Report represents good governance practice and ensures compliance with the Department of Health’s Audit Committee Handbook, the principles of integrated governance and Monitor’s Compliance Framework.

The report covers the period 1st October 2013 - 30th September 2014


Discuss Receive Approve Note For Information Confidential y/n


Strategy Legal Implications Performance and Quality Regulatory Financial Implications Stakeholder implications Workforce Risk

Prepared by Esther Steel Trust Secretary Presented by Carol Davies

Chair of Audit Committee

Audit Committee Annual Report

1st October 2013 – 30th September 2014

Report approved by the Audit Committee 17th November 2014

1. Introduction

The Audit Committee is established under Board delegation with approved terms of reference aligned with the Audit Committee Handbook, published by the HFMA and Department of Health. The Committee met on five occasions in the period covered by this report to discharge its responsibilities for scrutinising the risks and controls which affect all aspects of the organisation’s business.

Three of the Non-Executive Directors are members of the Committee, the Trust Chair and Chair of Finance are specifically excluded from membership. A number of “officers” are in regular attendance. These include the Director of Finance, the Trust Secretary, Internal and External Auditors, and the Local Anti-Fraud Specialist. Other Directors and Managers attend at the request of the Committee. The Audit Committee Chair provides a summary report of the Committee’s activities to the next Board meeting. The Committee believe that its members have sufficient knowledge of the organisation’s business to identify key risks

The Committee’s work predominantly focused upon the framework of risks, controls and related assurances that underpin the delivery of the organisation’s objectives (the Assurance Framework). The Committee had a pivotal role to play in reviewing the disclosure statements from the organisation’s assurance processes; in particular the Annual Governance Statement, included in the Annual Report and Accounts.

1.2 Purpose of the Report

1.2.1 This annual report has been prepared for the attention of the Board of Directors and reviews the work and performance of the Audit Committee in satisfying its terms of reference.

1.2.2 The production of an Audit Committee Annual Report represents good governance practice and ensures compliance with the Department of Health’s Audit Committee Handbook, the principles of integrated governance and Monitor’s Compliance Framework.

1.2.3 The report covers the period 1st October 2013 - 30th September 2014 (the reporting period)

1.3 Context

1.3.1 In its previous report, the Committee reflected on the challenges faced in 2012/13. The period covered by this report has been a time of development with the impact of actions taken in response to previous reviews starting to have the desired effect.

Although further development and maturation is required the general consensus is that the Trust is now in a far stronger position with improved governance arrangements and improved performance against key financial, quality and operational metrics.

2. Committee Membership

2.1 The Audit Committee membership comprised :-

Meeting Date

22/11/13 24/02/14 28/04/14 28/05/14 18/09/14

Carol Davies (chair)

Mark Harrison

Gina Ashworth* apologies apologies apologies

*Mrs Ashworth submitted apologies due to an extended period of absence for ill health

3. Compliance with the Terms of Reference

3.1 The Terms of Reference of the Audit Committee are reviewed annually.

3.2 The Audit Committee met five times during the reporting period

3.3 All meetings were quorate (quorum is defined in the terms of reference as two Non Executive Directors.

3.4 A Chair report from the Audit Committee is submitted to the next meeting of the Board of Directors.

3.5 Audit Committee members meet in private with the Internal and External Auditors prior to each Audit Committee meeting.

3.6 The Director of Finance, Deputy Director of Finance, Trust Secretary Head of Internal Audit and Internal Audit Manager, representatives of External Audit and the Local Counter Fraud Specialist have been in attendance.

3.7 Executive Directors, Corporate Directors and other members of staff have been requested to attend the Audit Committee as required.

3.8 The Terms of Reference were reviewed by the Audit Committee in September 2014 (appendix A)

4. Work and Performance of the Committee

4.1 The Audit Committee agenda is constructed in order to provide assurance to the Board of Directors across a range of activities including corporate, clinical, financial and risk governance and management.

The Audit Committee agendas in the reporting period covered the following:-

• Reviews of Board Assurance

• External Audit progress reports

• Internal Audit progress reports

• Anti-Fraud reports

• Losses and special payments reports

• Tenders waived reports

• Declarations of interest

• Register of sealings

4.2 Reviews of Board Assurance

During the year the Committee received regular updates on the Board Assurance Framework in addition to a schedule of in depth reviews of each section of the BAF with the lead director attending to respond to the Committee’s challenge and scrutiny.

The Committee have also received a first draft of the Assurance Map and have challenged the Executive team to ensure proactive ownership of a robust Board Assurance Framework.

5. Audit Provision

5.1 External Audit

External Audit during the reporting period was provided by KPMG

2013/14 Accounts and Report

5.1.1 The 2013/14 accounts were audited by KPMG and an unqualified opinion was presented to the Audit Committee in May 2014.

5.1.2 The on-going enforcement action relating primarily to financial performance resulted in a qualified use of resources opinion.

The Audit Committee considered the External Audit Annual Governance report.

The Audit Committee approved the accounts for the period 1st April 2013 to 31st March 2014.

The Council of Governors subsequently received the report on the accounts from the Independent Auditor in July 2014.

5.1.3 KPMG carried out an audit on the Quality Account 2013/14 and provided recommendations to the Audit Committee in July 2014.

5.1.4 KPMG provided regular progress reports and technical updates to the Audit Committee.

5.2 Internal Audit

5.2.1 Outsourced internal audit during the reporting period has been provided by PwC.

5.2.2 The Committee worked with Internal Audit to consider the major findings of internal audit reports and the associated management responses and monitored the implementation of recommendations through regular progress reports.

5.2.3 In September 2014 an online action monitoring system TrAction was introduced to streamline the process of updating audit actions.

5.2.3 The Head of Internal Audit Opinion 2013/14 was presented to the Audit Committee in May 2014 and at that time, it was felt that significant improvement was required to improve the adequacy and/or effectiveness of governance, risk management and control.

This opinion was based on the work completed during 2012/13 with three reports issued during the year classified as high risk plus a critical risk finding in the Service Integration review and high risk findings in the reviews for Key Financial Controls, Budgetary Controls and Cost Improvement Plans.

5.2.4 The following Internal Audit Reports were received by the Audit Committee during the reporting period

6. Anti-Fraud

6.1 Anti-Fraud services have been provided through an SLA with Wrightington, Wigan and Leigh NHS FT. A nominated Anti-Fraud specialist works with the Trust.

6.2 The Audit Committee received regular progress reports and details of investigations carried out during the year were provided to the Committee.

6.3 During the reporting period the organisation has undertaken anti-fraud work as per the “Standard for Providers” document this is set out in four sections and covers corporate responsibilities and the three key principles for action. These are:

• Strategic governance

• Inform and Involve

• Prevent and Deter

• Hold to Account

Audit Title Report

classification

Number of findings

Critical High Medium Low

Assurance Framework and risk management Medium 0 0 2 3

Key Financial Controls Medium 0 3 7 5

Financial management and reporting High 0 2 2 0

Budgetary controls Medium 0 1 1 0

IT general controls Medium Individual risk rating not assigned

IT Projects Low 0 0 0 1

Cost improvement plans Medium 0 1 1 0

Estates High 0 2 2 1

Data quality Medium 0 0 3 2

Service integration High 1 0 0 0

Financial Governance Follow up All recommendations fully implemented

Counter Fraud desk top review Low 0 0 0 1

Follow up of Deloitte and KPMG reviews Of the 110 recommendations, all but 10 have been completed or are no longer valid. Of the 10, 8 have been partially implemented with just 2 yet to be actioned.

6.4 An Anti-Fraud annual report was presented to the Audit Committee in September 2014 and provided a summary of the Anti-Fraud work undertaken based upon the annual work plan.

7 Losses and Special Payments

The Audit Committee was provided with information regarding the levels and values of losses and compensation payments within the Trust at each meeting

8. Tenders Waived

A summary of all tenders waived above a £50k value was presented at each meeting

9. Priorities for 2015

The workplan for 2015 is attached (appendix B)

One of the key corporate objectives for the organisation is “to be well governed. Having overseen the actions to address issues identified in earlier governance reports the Audit Committee’s aim is to drive improvement further moving from adequate/good to good/excellent.

10. Effectiveness of the Audit Committee

The committee undertook a review of its effectiveness the results of which were reported to the committee in September 2014. While the review found the work of the Committee was broadly in line with recognised good practice as recommended in the HFMA Audit Committee handbook areas were identified for further improvement:

• Training for Audit Committee members

• integration with other committees

• Integration with performance management framework and data quality

• Review of length of papers

Actions will be implemented to address these areas.

11. Cost of the Audit Committee

A paper was presented to the Audit Committee in November 2014 outlining the costs incurred by the Committee. Committee members noted that the costs of approximately £34,000 per year or £6,000 per meeting provide assurance that the Committee is providing value for money.

12. Conclusion

The audit committee has an important role in delivering good governance, providing challenge and oversight and in advising senior management on the effectiveness of risk management processes.

Committee members have expressed their resolve to address areas identified for development in a timely manner.

During 2012/13 the Trust faced significant challenges, 2013/14 saw a rapid improvement in governance and risk management across the Trust with the development and introduction of new effective systems and processes of control. During the current year these processes are being embedded and enhanced, for example a new format of the Board Assurance Framework (BAF) was introduced last year. Since its introduction this has been further developed to become an effective tool which provides clarity around the management of current and emerging strategic risks and outlines a clear structure of accountability.

Esther Steel Carol Davies Trust Secretary Chair of Audit Committee

27nd November 2014 27nd November 2014

of 26

Agenda Item No: 12


Date 27 November 2014

Title People Strategy 2014 to 2019

Executive Summary

This paper proposes a People Strategy for the next five years. As importantly it articulates the next steps required for the successful implementation of the strategy and specifically the board level commitment that will needed.

There are four priorities:

Ensuring we are fit for the future.

Engagement and experience.

Managing an efficient workforce.

Developing capabilities in management and leadership.


Discuss X Receive

Approve X Note

For Information Confidential y/n N


Strategy X Legal Implications

Performance and Quality X Regulatory

Financial Implications X Stakeholder implications X

Workforce X Risk X

Prepared by Suzanne Woolridge, Head of Human Resources

Presented by Mark Wilkinson, Director of Strategic and Organisational Development

of 26

PEOPLE STRATEGY 2014 TO 2019 1. PURPOSE

The purpose of this paper is to propose a People Strategy to the Board, to explain how the strategy has been developed, and to articulate the next steps to implementation including the required board level commitment. This paper builds on the workforce strategy 2012 to 2017 approved by the Board in June 2013.

2. BACKGROUND

Strategies for NHS employees have received increasing intention in the NHS over the last few years:

Professor Michael West has carried out well publicised work demonstrating the connection between levels of employee engagement and important patient outcomes including mortality.

Sir Robert Francis‟s reports on Mid Staffordshire NHS Foundation Trust have led to a significant expansion in nurse staffing, the setting out (by NICE) of minimum staffing levels. Sir Robert‟s reports also called for changes in NHS culture.

As the financial, workload and recruitment pressures build across the NHS, attention has turned to maximising the value secured from the current NHS workforce. Pay, at almost 70% of total NHS expenditure, makes all other areas of NHS expenditure look relatively minor.

Appendix 2 sets out the relevant NHS policy context to this strategy.

3. CURRENT POSITION

Appendix 3 sets out key workforce information and has been used to identify the principal people challenges facing the Trust.

The strategy has been developed by the Workforce Team with engagement from the following stakeholders:

The Workforce Committee which brings together managers, clinicians and governors from across the Trust.

The Divisional Executive (Trust executive directors and divisional leadership teams) have discussed the principal workforce challenges and supported the strategy as set out here.

The CCG‟s Executive have commented on the strategy supporting the broad intent and wanting to see greater staff engagement in its production and also more stretching and defined measures of success.

of 26

Defining and then measuring successful implementation is clearly crucial. We have looked at performance across our peer group of NHS Trusts with a similar profile to ourselves. Detailed information is provided in Appendix 4, and that has been used to underpin our proposed success measures.

4. PROPOSAL

Appendix 1 sets out the proposed People Strategy for 2014 to 2019. It is proposed that a two part approach is taken to it‟s approval.

Part 1 – this paper – defines the challenges and outlines the high level approach to be taken to meet these challenges. In response to specific board concerns about current performance reporting, some new performance thresholds are proposed.

It is proposed that as part of some strategy development sessions to take place over the next few months, the Board reflects on how it wishes to commit to this strategy. This will inform Part 2.

Part 2 – to be presented in February 15 – will set out costed high level implementation plans for the strategic priority areas.

The people strategy should become wholly aligned to the organisational plans and priorities for the Trust. It should be reviewed annually commencing in Spring 2016.

5. RECOMMENDATIONS

It is therefore recommended that the Board:

i. Approves the strategy for the people in this organisation.

ii. Supports the success measures outlined within and that the board and divisional level performance reporting moves to this new basis as soon as possible.

iii. Approves the timescales outlined above.

of 26

Appendix 1 People Strategy

2014 to 2019 SUMMARY

This organisation can only ever be as good as the people who work in it. Our goal for Bolton people is therefore simple: The team should feel fully engaged in their work, well recognised and fairly rewarded. Only as we achieve this can the Trust achieve its goals of delivering excellent integrated care to Bolton and beyond. We need to fully align the people and their skills and efforts to our objectives. There are real areas of current strength – particularly given the recent organisational history of financial, governance and operational failure. It has been a really tough couple of years. We now need to turn our efforts to those areas that will yield the biggest benefits over the next few years. 1. Ensuring we are fit for the future – implementing new workforce models,

responding to the ageing workforce and working across organisational boundaries.

2. Engagement and experience - maximising commitment and effort through

open communication, ample recognition and evident connection to our values i.e. the way we do things round here.

3. Managing an efficient workforce – fairly rewarded and flexible staff fully

aligned to demand for our services and deployed in agile ways. 4. Developing capabilities in management and leadership – the three priority

areas above require strong management and leadership at all levels across the organisation.

Progress will be conditional upon investment in terms of time and money; it also relies on a robust partnership between the Workforce Directorate and the Divisions / Corporate Functions. The implementation of this strategy will deliver tangible results – the scale of our ambition is to achieve current upper quartile performance within three years.

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INTRODUCTION This strategy aims to ensure the workforce is fully aligned to the strategic direction of the Trust. The strategy has been developed in the following way:

Consideration of the strategic plans of the organisation.

Identification of the drivers for change from our current performance.

Agreeing areas for continuous improvement and priorities for change.

Defining responsibilities for implementation.

Setting out measurable success criteria.

Engagement with a variety of stakeholders AS A TRUST WHERE DO WE WANT TO BE? Each year the Trust reviews and then publishes its strategic direction1 which answers this question. The vision of the Trust is to be an excellent integrated care provider within the district of Bolton and beyond, delivering patient centred, efficient and safe services. The services we plan to provide can be summarised as follows:

Integrated care for the Bolton community

Services which keep people healthy and which intervene early

Major provider of A&E and medical and surgical emergency access services

Centre of excellence for women‟s and children‟s services

Range of planned diagnostic and treatment services Our immediate objectives for the year 2014/2015 are to:

Improve care; outcomes, experience, effectiveness and safety

Be well governed; better governance

Be financially viable; financial stability

Be a great place to work; Bolton as the best place to work and train

Be fit for the future

1 http://www.boltonft.nhs.uk/wp-content/uploads/2012/10/Strategic-Direction-2013-14-to-2018-19-

Final-version.pdf

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FOR OUR PEOPLE WHERE ARE WE NOW?

2013 Staff survey results Every year a sample of our employees are invited to respond to a detailed survey. This survey is carried out on a consistent basis nationally and the results are then published2. Compared to all acute trusts we scored relatively well against the following indicators:

The percentage of our employees who reported having been appraised in the last 12 months, although we scored much less well if the question was „have you had a well structured appraisal?‟

The percentage of staff having equality and diversity, and health and safety training in the last 12 months.

The percentage of staff agreeing that their role makes a difference to patients.

Relatively low numbers of staff reported experiencing harassment, bullying or abuse from staff in the last 12 months

We scored much less well in the following areas:

People suffering work related stress in last 12 months and feeling under work pressure

The percentage of staff reporting good communication between senior management and staff

Perhaps overall findings are captured in these questions about whether our people would recommend the trust as a place to work or receive treatment.

Staff friends and family test We are now two quarters into the „friends and family‟ test which asks staff two simple questions:

How likely are you to recommend this organisation to friends and family if they needed care or treatment?

How likely are you to recommend this organisation to friends and family as a place to work?

Although slightly behind the NHS average, we have seen improvements in the first half of 2014/15. The survey narrative results point to the legacy of turnaround

2 http://www.nhsstaffsurveys.com/Caches/Files/NHS_staff_survey_2013_RMC_sum.pdf

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and a feeling that community teams have not been fully integrated or understood. The divisional leadership teams are working to address these issues and we anticipate seeing the impact of this work over the coming quarters.

Values Our values were „launched‟ in April 2012 following extensive consultation with our staff, patients and other stakeholders. They are: We put patients and staff at the heart of everything we do – how we behave, our attitudes and behaviour towards our patients and each other.

To be respected – treating everyone as we would want to be treated with dignity courtesy and respect.

To be valued – striving to provide a quality service and taking responsibility for making improvements.

To be proud – showing appreciation to one another and positively promoting the reputation of the Trust as the place to receive care and to work in.

From discussions with senior clinical and managerial leaders across the Trust, whilst these values command a measure of support there is concern about how „embedded‟ they are across the Trust. They also perhaps cut across the values set out in the Trust‟s Quality Improvement Strategy and its „strapline‟: Caring Safe and Effective.

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WHAT ARE OUR PRINCIPAL WORKFORCE CHALLENGES?

Challenge Focus for Change

1. Maximising discretionary effort through an engaged and committed workforce. Staff should feel engaged, recognised and rewarded.

En

gag

em

en

t an

d

Exp

erie

nce

2. Embedding our organisational values

3. Staff are ambassadors for the Trust – making them into great ambassadors. Staff should be proud of the work they do

4. Ensure our workforce reflects Bolton people / our role in Bolton‟s future. Optimising our use of apprenticeships to „grow our own‟ future workforce.

5. Implement new service and staffing models for example around advanced nurse practitioners to alleviate recruitment challenges in key specialties for example A&E medical staff, radiology, and geriatricians

Fit fo

r th

e f

utu

re

6. Respond to „the greying workforce‟ workforce with innovative workforce solutions that value experience particularly for health visitors and midwives. How to support our staff to work for longer in new roles but perhaps in roles of less „intensity‟.

7. Develop new roles and staffing models encouraging our current and future staff to work flexibly across hospital and community settings, and also across current hospital provider footprints.

8. Fully aligning workforce to demand for our services - teams need to be appropriately staffed and flexible

Effic

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Wo

rkfo

rce

9. Recruitment in a competitive market by setting appropriate levels of remuneration.

10. Develop management and leadership capability across the trust particularly focusing on first line and middle managers. Leaders should be visible, communicate with their teams and deal with issues effectively

Ma

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d

Le

ad

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hip

Above all, staff engagement is crucial. It fosters

Increased commitment

A belief in our organisation

A desire to work to make things better

Suggesting improvements

Working well in a team

Helping colleagues

A likelihood to “go the extra mile”

Greater work satisfaction

A desire to deliver safe, high quality and compassionate care to patients

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WHAT ARE WE GOING TO DO? We will use the model below: There are two tiers of activity, all built on our Trust values, continuous improvement and focus for change:

Continuous improvement looks at those essential practices that are often prescribed by national guidelines and can be refined and improved to ensure that our managers practice excellence in all aspects of staff management.

Focus for change looks at those areas where more innovative solutions can be explored to achieve our aspirations.

Continuous improvement Effective recruitment and induction All recruitment undertaken by the Trust to be done in a timely fashion, safely and

TRUST VALUES

L

Engagement & Experience

Mgmt.&Leadership Efficient Workforce

Fit for the future

FOC

US

FOR

CH

AN

GE

CO

NTI

NIO

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IMP

RO

VEM

ENT

Effective Recruitment

Induction

Workforce Wellbeing

Clear about

Objectives

Workforce Trained

Appropriately

Performance

Management

ENGAGED PEOPLE, RIGHT SKILLS,

RIGHT PLACE

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in line with both NHS and Statutory regulations. We will attract quality candidates to our vacancies by recruiting against the Trust values, and by making sure candidates are clear about the roles they apply for and what is expected of them in those roles. Achieving caring safe and effective care begins with corporate induction and robust local induction practices. New employees; students; temporary staff; volunteers and people on work experience will attend corporate induction. Clinical staff will attend departmental clinical induction. A robust local induction specific to their work area is required for all new employees; students; temporary staff and volunteers. Clear about objectives, performance management and appraisal Good quality appraisals will ensure that our staff receive feedback on their performance and behaviour with a clear development plan agreed with them to support their motivation, engagement levels and future development and career aspirations. The medical workforce comprises of Trust employees – consultants, staff, associate specialist and specialty (SAS) doctors and year 1 foundation doctors, and doctors in training from Health Education Northwest (HENW). The Trust is responsible for the revalidation of its own employees and contributes to the revalidation of doctors in training by HENW. Doctors are contractually required to have a yearly appraisal which is used to support their five yearly GMC revalidation; requiring sign off from the responsible officer, the Medical Director of the Trust. In support of this process the Trust has acquired an electronic system for appraisal, has appointed a consultant as Appraisal Lead and has invested in administrative and managerial support. Workforce trained appropriately As a large, complex organisation we have a duty to ensure our staff receive training at a number of levels, these are summarised below:

Statutory - where there is a requirement in law that staff need training on a certain topic, for example, fire training

Mandatory - where there is a contractual or regulatory requirement for training, the organisation would deem this to be mandatory

Best practice - best practice training either by professional group or external guidance eg. NICE

Clinical skills - technical training which impacts on clinical outcomes in a measurable way

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Leadership and management - development for staff with responsibility for the leadership and/or management of staff

Development of all staff to enable leadership at all levels, essentially within roles where there is leadership and/ or management of staff

Continued Professional Development - An on-going process for improving and increasing capabilities of staff through access to education and training opportunities.

The following programmes represent the current offers from the Trust: Medical continued professional development – A personal study leave budget is available linked to the individual‟s appraisal. Junior doctors training – The Trust is responsible for providing an environment conducive to work based training and providing adequate consultant supervision and support to allow trainee doctors to work within their competencies. Non-Medical continued professional development – Effective use of the Multi-Professional Education and Training (MPET) monies from Health Education Northwest and partnership working with Higher Education Institutes and external training bodies mean we are shaping the workforce to meet the challenges of the changing healthcare environment, ensuring our staff have the right skills, in the right place, at the right time. Leadership and management - a suite of generic leadership and management programmes and master classes have been planned along with targeted course for nurse leaders, medical leaders and general managers. Bands 1-4 –Focussed programmes to include apprenticeships, basic skills, and the care certificate for Health Care Assistants and widening access routes for pre registration training. Medical students - The Trust is funded to provide education and training for undergraduate medical students from Manchester University. Non-medical students - We liaise closely with Higher Education Institutes for placement provision on non-medical pre-registration healthcare programmes and the Practice Education Facilitators (PEF) team support all pre-registration healthcare professional students within the trust. An external review of this service recently deemed the quality to be excellent. Education Governance is the framework to ensure that the education activity we undertake produces the right outcomes. Workforce wellbeing Proactive interventions will help improve attendance, for example, stress

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management and access to a dedicated physiotherapy service as these two conditions (stress/anxiety & MSK) continue to be our two highest reasons for employee absence. We will seek to encourage take up of our existing proactive wellbeing services (e.g. mental wellbeing, smoking cessation, holistic therapy) and introduce more offers in future to complement NHS England‟s intention that the NHS workforce serve as „health ambassadors‟ in their local communities.3 Focus for Change Workforce fit for the future Healthier Together, our work in the North West Sector and Community Integration are examples of large scale changes which will require our workforce to do things differently. Consideration of more generic, flexible roles will be important in these exercises, especially in areas such as urgent care and community teams where traditional recruitment has not been as successful. Certain staff groups have an age profile which makes planning the future workforce a more urgent task; we will work alongside managers to understand their workforce issues and develop solutions by accessing the case studies of the innovative practice that has been applied elsewhere. For example today one in seven of our district nurses are over the age of 60. Efficient use of the workforce We will understand staffing establishments for each ward and department creating a set of clear rules for our clinical areas with regards to the rostering of our clinical workforce, and this will support the wellbeing of our staff, and the care our patients receive. We will make the best use of our rostering IT software to support our clinical managers and reduce the amount of administration they are required to perform. We will provide a proactive and effective temporary staffing service but will ensure that, through strong roster management, bank and agency use and spend is only utilised when appropriate. Staff engagement and experience As our values are the foundation of all our efforts, it is now time to revisit them to ensure that they are relevant, easily understood and above all owned by our people. This work will be completed in the first part of 2015.

3 http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

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We firmly believe that engaged members of staff will give more discretionary effort and will act as ambassadors for the Trust. We can regularly test this using the friends and family score. To help facilitate this, organisational leaders should commit to being personally and visibly committed to engaging and working with staff, investing in leadership development and devolving decision making within their structures. Reward and recognition is essential both at a team level where a simple thank you for a job well done should never be missed The Trust will maintain and develop its annual programme culminating in an awards evening where teams and individuals will receive awards across a number of categories during an evening of celebration. It is also important that staff are able to contribute regardless of any protected characteristic. Equality and diversity is a fundamental principle for our workforce. We will regularly check the profile of the workforce to ensure we reflect the Bolton demographic and that no group is under represented or disadvantaged, and where anomalies exist, take action to address the issue. Good two way communication and access to information are vital in developing a valued, engaged and productive workforce. We will continue to review and refresh our communication channels. The Trust‟s team briefing process has been revised and a new policy will be implemented at the start of 2015 in order to support managers and team leaders to communicate better with their staff. It will also facilitate more opportunities for discussion and feedback. The Trust is investing in a new staff intranet which will go live in April 2015 and reflect better the needs of staff throughout the organisation. We will explore the potential to better equip people for change and ambiguity. Leadership and management of the workforce Leadership and management development is a core component of the training provision we have planned following a period when little activity has taken place. First line and middle managers will be a priority. We have a comprehensive programme for nurse leaders from ward managers to matrons to professional leads. A complementary programme has also been developed for clinical leads to ensure our clinical leadership development is aligned across professionals. Our leaders should also expect to be held to account for what they deliver in their role against their objectives and the standards of behaviour against our values (in other words, the „what‟ and „how‟ of performance). The framework for objective

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setting and appraisal should be used for this purpose. Spotting emerging talent and planning how individuals will reach their next role is essential if we want to ensure we continue to have the best people in key positions. The approach is also essential if we want to motivate and keep well performing individuals within the Trust. WHO IS RESPONSIBLE FOR IMPLEMENTATION? Board level responsibility for implementation rests with the Director of Strategic and Organisational Development. The Workforce Committee will oversee the actions to ensure progress is being made and provide the assurance to the Board of Directors via the Quality Assurance Committee. More practically, success will call for the robust efforts both of the Workforce Directorate and the Divisions / Corporate Teams. We will only succeed by working together. Our respective roles are set out in the table below:

Workforce Directorate Divisions and Corporate Teams

Establishing an appropriate policy framework.

Training and supporting managers in policy implementation

Day to day operational support to managers

Workforce information

Manage staff side relationships

Timely recruitment, temporary staffing, and health and wellbeing services

Ensure managers and team leaders implement policies, including holding people to account as appropriate.

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HOW WILL WE MEASURE OUR SUCCESS? Our goal is to be at the current average level of performance by for similar NHS providers by March 2016 and to have reached current upper quartile performance by March 2018. We will use the following overarching indicators:

Staff feel engaged, recognised and rewarded

Staff are proud of the work they do

Staff are clear about their objectives and development needs

Teams are appropriately staffed and flexible

Leaders are visible, communicate with their teams and deal with issues effectively

These targets will be annually reviewed to ensure that they are adjusted to reflect the improvements made by our peers and remain relevant. CONCLUSION This document describes what we need to do to sustain and develop the workforce we require over the next five years to provide our patients with the best levels of care. We have tested out the principles of the strategy with stakeholders and any future review will be undertaken in consultation with those groups in recognition of a changing internal or external environment. A complementary communication strategy should now be undertaken to ensure our staff and managers understand our direction with regards to our people over the coming years.

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Appendix 2 NHS POLICY CONTEXT A number of national strategy and policy drivers influence workforce matters across our organisation and there is a need to ensure that workforce matters are fully considered in an ever-changing landscape of service improvement. The key policy drivers impacting on the workforce include: Leadership and Engagement for Improvement in the NHS - Together we can - A report from the Kings Fund Leadership Review 2012.

The Francis Report (2013) which made a number of recommendations in relation to the causes of the failings at Mid Staffordshire, many of which are relevant to a people strategy.

Public Health Responsibility Deal (2012): Health at Work pledge embeds principles of the chronic conditions guide to ensure workforce is managed with reasonable flexibility and workforce adjustments staff sickness absence should be reduced.

The known constraints on public sector spending over this planning period, involving an end to a decade of growth and inevitable pressures on all areas of service at a time when the demand for services is likely to grow. NHS England‟s Operating Framework – which reflects the national financial position and is focused on the third stage of NHS-wide reform through ensuring high quality care for all using the additional capacity and reform levers introduced in previous years. High Quality Care for All – sets out a vision for an NHS that is fair, personal, effective and safe. Develops improved models of care that are up to date with latest clinical developments and in line with changing needs and expectations. Emphasises the importance of staff having the freedom to focus on quality. Assuring the Quality of Medical Appraisal for Revalidation (AQMAR) – sets out the revalidation requirements for medical staff and the role of appraisal as a cornerstone to assure patients, the public, employers and other healthcare professionals that licensed doctors are up to date and are practising to the appropriate professional standards. A High Quality Workforce: NHS Next Stage Review – outlines how three complementary priorities will be taken forward – ensuring workforce planning reflects service planning, ensuring effective partnership working and strong professional voices, and improving the quality of education and training.

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Appendix 3 WHERE ARE WE NOW?

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0

100

200

300

400

500

600

700

2012/13 2013/14 2014/15

Leadership & Management Development attendence (numbers)

Leadership & Management Development

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10

30

50

70

90

110

130

2012/13 2013/14

Leadership Programmes (numbers)

Leadership Programmes

0

10

20

30

40

50

60

70

80

2013 2014

Bands 1-4 Development (numbers)

Bands 1-4 Development

0

5

10

15

20

25

30

35

40

2013 2014

Apprenticeship/ Cadets (numbers)

Apprenticeship/ Cadets

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Trust workforce profile compared to aggregated peer workforce profile

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Current medical vacancies in hard to recruit to clinical teams: 2 x Middle Grade in Gastroenterology 1 x Consultant in Elderly Medicine 1 x Consultant in Acute Medicine 1 x Consultant in Radiology 4 x Middle Grade Doctors in Emergency Medicine Our current organisational values

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Appendix 4

Measuring Success

WHAT

OUTCOME MEASURE CRITERIA Mar 15 %

Mar 16 %

Mar 17 %

Mar 18 %

Mar 19 %

Staff feel engaged, recognised and rewarded

Our staff tell us they would recommend the Trust as a place to work

Sickness absence levels are appropriately managed

Current NHS average by March 16, upper quartile two years later

65 4.2

65 4.1

75 4.0

75 4.0

Turnover is within reasonable levels

8% to 10% 8 to 10

8 to 10

8 to 10

8 to 10

8 to 10

Staff are proud of the work they do

Our staff tell us they would recommend the Trust for treatment

Current average by March 16, upper quartile two years later

75 80 85 85

Staff are clear about their objectives and development needs

Increased staff with a quality appraisal

Staff attending statutory training

Staff attending mandatory training

Genuinely statutory training is a „stop the line issue‟.

80 98 80

85 98 80

90 98 85

95 98 90

95 98 90

Teams are appropriately staffed and flexible

Vacancies filled in timely manner

Better rostering practices

Reduced levels of bank and agency usage

TBC 100

TBC 100

TBC 100

TBC 100 5

TBC 100 4

Leaders are visible, communicate, and deal with issues effectively

% of staff reporting good Comms between management and staff

Leadership and management development

29 250

30 350

31 450

32 550

33 650

Agenda Item No: 13



Title Planning for 2015/16 and beyond

Executive Summary

Strategy is about making choices to deliver the long- term goals of an organisation in the face of uncertainty. It is a key role for the Board. Our strategy and plan is chiefly for the organisation and our local partners.

The overall direction for the Trust is the right one – and we need to recommit to the delivery of it – there are areas where it needs refreshing: developing a service strategy, embedding our organisational values, reviewing stakeholder engagement, recreating an informatics strategy and planning for innovation.


Discuss Receive

Approve Note

For Information Confidential y/n n



Strategy

Legal Implications

Performance & Quality

Regulatory

Financial Implications

Stakeholder implications

Workforce

Risk

Prepared by Mark Wilkinson Director of Strategic and Organisational Development

Presented by Mark Wilkinson Director of Strategic and Organisational Development

PLANNING FOR 2015/16 AND BEYOND 1. PURPOSE

The purpose of this paper is to secure the approval of the Board to the timescales and approach to be followed as the Trust plans for 2015/16.

2. BACKGROUND

Trust strategies and plans exist principally for our benefit (i.e. the board, our leaders and staff). They also help us with external partnerships i.e. commissioners, the council, patient and public, and regulators. For all those different groups they help to understand our priorities, and inspire confidence that we will deliver. In short they are our ‘ambitions, expressed’. Appendix 3 sets out Monitor’s likely expectations of us in terms of planning requirements.

3. CURRENT POSITION

The Trust’s current operational plan1 and strategic plan2 were adopted in April and June 14 respectively. Recent Monitor publications have sought to strengthen Foundation Trust capabilities in strategic and business planning:

What board members should focus on3

How strategic planning in Foundation Trusts needs to improve4

A strategy development toolkit for NHS providers5 Reading these publications it can be seen that the best Trusts are:

Building their strategies from the bottom up. The best are strategic at individual service level with plans supported by detailed external forecasts and commissioning insights.

Devising strategies and plans that set specific and stretching ambitions that address commercial, quality and financial aspects – with a clear prioritisation applied.

Implementing formal processes for reviewing strategy / responding to any areas of underperformance.

Monitor has recently written to the Trust following their review of the strategic plan we submitted at the end of June 14. The Trust has received an amber rating which is defined as marginal sustainability. Specific feedback centred on:

High level of planned cost savings included in comparison with others and our

historic track record of achievement.

1 http://www.boltonft.nhs.uk/about-us/trust-publications-and-declarations/annual-plan/

2 http://www.boltonft.nhs.uk/about-us/trust-publications-and-declarations/strategic-direction/

3 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/363273/Monitor_-_Developing_Strategy_-_a_guide_for_board_members.pdf 4.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/286327/Meeting_the_needs_of_patients_-_Improving_strategic_planning_in_NHS_foundation_trusts.pdf 5. https://www.gov.uk/government/publications/strategy-development-a-toolkit-for-nhs-providers

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/363273/Monitor_-_Developing_Strategy_-_a_guide_for_board_members.pdf


The importance of broad acceptance across the local health economy for our plans

and therefore the need for us to continue to engage with our local partners.

Finally it was noted that future sustainability is dependent on funding of IT and estates business cases.

Monitor recommends following a seven stage approach to strategic planning. It is presented in more detail at Appendix 1 and in essence involves:

Framing the strategic questions.

Understanding the issues.

Generating options and prioritising.

Implementing and then starting again.

One of the earliest stages is to review our current strategy and decide to what extent do we need to recommit, refresh or recreate? This is part of Stage 1: Frame. A plan on a page view of the current strategy is shown in Appendix 4. Recommit if the underpinning assumptions are still accurate and implementation is on track. The focus will be on delivering and also evolving the strategy. Refresh if we are happy with it but the external environment has changed. The focus will be on answering questions such as:

Has anything changed in the local health economy or internally?

Has our view of the future changed? What new options are available?

How do we implement the adjusted strategy and what are our success measures?

Recreate if we do not have a strategy to meet our goals. This would be a ‘root and branch’ review of the Trust’s strategy. The Divisional Executive i.e. some executive directors and divisional leadership teams reviewed the Trust’s current strategy. The broad view was to recommit ourselves to the strategy and then focus on implementing it. There was however some areas where a refresh was considered appropriate.

What is our clinical services core offer? We need to understand clinical dependencies and align our work with the North West sector and commissioner preferences.

Define what is meant by integration for this organisation and then work to make it a reality.

Develop more effective partnerships with the CCG and local authority.

Revisit our commitment to the 'digital trust' and refresh our IT strategies accordingly.

Improve our strategic and operational planning processes to take account of the considerable uncertainty in the external environment.

4. PROPOSAL It is essential that the Trust’s five year strategy and two year plan both inform, and are informed by other strategies and plans. Our current approach is set out pictorially below in Appendix 3. Over the coming period it is proposed to strengthen this in the following areas:

a. A Service Strategy (May 15) defines the services we wish to provide and the rationale for these choices. It will be driven by:

a. Continuing need to identify savings to support re-investment across the Trust. b. Changes in demand for our services including greater patient acuity. c. CCG review of community services that both support strategic objectives and

are sustainable.

d. Prospective insights on workforce, finance, quality (including seven day working).

b. The People Strategy has proposed a review of our organisational values and

consideration given to how they are promoted across the organisation (April 15)

c. Review of external stakeholder engagement (June 15) seeking to build better relationships with health and care commissioners, and to form new partnerships where appropriate.

d. Recreate an Informatics strategy (June 15) with the aim of supporting care

professionals to make the best use of data and technology so that all patient and care records will be digital, real-time and interoperable.

e. Innovation Planning (July 15) to generate ideas and ensure that best practice is

rapidly adopted across the organisation.

Where the Trust develops new strategies it will demonstrably follow the Monitor recommended strategic planning process as set out in Appendix 1.

Given the Trust’s reliance on a Divisional Delivery System, much of the above work, particularly the service strategy, will need strong divisional ownership and engagement. This will be secured through the IPM process between the executives and the divisions. Board members have the central role in leading the strategy-making process6. The Board should therefore set aside some time to explore the strategic issues identified in this paper.

5. CONCLUSION

Strategy is a set of choices designed to work together to deliver the long- term goals of an organisation in the face of uncertainty. Whilst the Trust’s strategy and plan must satisfy Monitor’s requirements, they are fundamentally for the organisation and our local partners. It is essential that the Trust’s five year strategy and two year plan both inform, and are informed by other strategies and plans. Although the overall direction is the right one – and we need to recommit to the delivery of it – there are areas where it needs refreshing: developing a service strategy, embedding our organisational values, reviewing stakeholder engagement, recreating an informatics strategy and planning for innovation.

6. RECOMMENDATIONS

It is therefore recommended that the Board approves the way forward and timescales outlined above.

6 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/363273/Monitor_-

_Developing_Strategy_-_a_guide_for_board_members.pdf Page 7



Appendix 1

Appendix 2

Expected Monitor Planning Expectations of Foundation Trusts

The annual plan review (APR) process is designed to identify short term risks (quality, financial and operational) and longer term risks to the sustainability of high quality healthcare services.

Operational review

We will submit a two year plan narrative and supporting two year financial return to Monitor in April 2015. These will set out how the board intends to ensure high quality and cost-effective services for patients over the next two years.

Monitor will review the plan and assess:

Understanding of the challenges over the next two years. Level of engagement with stakeholders in your local health economy. How well commissioner and provider activity and revenue assumptions match

up. How reasonable our assumptions are. The level of capacity we are planning compared with likely demand. Plans for ensuring that high quality services continue to be provided over the

next two years.

Strategic review

We will submit a strategic plan and supporting five year financial return to Monitor in June 2015. These will set out how the board intends to ensure appropriate, high quality and cost-effective services for patients on a sustainable basis.

Monitor will review the plan assess our sustainability by considering:

The outcome of the first phase of the review and our response. The robustness of our strategic planning process. Understanding of the local health economy and any likely financial gap based on

its current configuration. Alignment between five year commissioner and provider activity and revenue

assumptions. The strategic options we believe are available to ensure the sustainability of high

quality services for patients. the schemes we plans to use to secure our long term sustainability Engagement and alignment with key stakeholders. Our self-assessment of longer term sustainability and the key points supporting

the conclusions.

Appendix 3 Pictorial Representation of Strategies and Plans

People

Services Quality Improvement

Appendix 4

Our Objectives• Improved care

o Improved outcomes for patientso Improved patient experienceo Better integrated careo Safer care across patient

pathways, in hospital and community

• To be financially strong• To be well governed• To be a great place to work• To be fit for the future

• We will build on the advantages of being an integrated provider of local hospital and community based health services

• Prevention, early intervention and keeping people healthy is central to why we are here

• Royal Bolton Hospital will remain a major provider of A & E services

• The Trust will continue to develop as a centre of excellence for Women’s and Children’s services

• We will retain and develop a range of planned diagnostic and treatment services

• We will act in partnership with other organisations when this is the most appropriate solution

The services we plan to provide

A Strategy for High Quality Care

Priorities

• Reduce mortality

• Prevent infection and harm

• Respond and learn

• Better patient experience

Achieving and Maintaining Financial Health

Priorities

• Return to surplus in 2014/15• Achieve a Monitor rating of 2 in 2014/15 rising

to 3 in 2016/17• Achieve sufficient surplus to finance the Estates

and IT strategiesTo do this the Trust will deliver income and cost improvements of £73.1m over five years

EstatePriorities• Supporting the Clinical Service Strategy

• More ambulatory care access in the community• Improved facilities for urgent and emergency care• Relocate more children’s services to the

community• Expand Endoscopy capacity

• Improving Quality and Safety• Reducing Costs/Generating Income

Informatics

Priorities

• Supporting the Clinical Service Strategy

• Integration of hospital and community IT

• Develop electronic patient records

• Improving Quality and Safety

• Electronic access to records

• Improved information governance

• Reducing Costs

Workforce

Priorities

• Improved leadership

• Appropriate staffing levels

• Cultural integration

• Development of the unqualified workforce

Supporting Strategies

Good Governance

• Board development and management team stability• Governor development• Leadership development

• Strengthened risk management systems• Integrated performance reporting

• External assurance and audit• Working in partnership• Systematic project management

Committee Chair Report

Name of Committee: Finance & Investment Committee Date of Meeting: 18th November 2014 Report to: Board of Directors Chair: Mark Harrison Key Issues Discussed • Month 7 financial performance including Divisional Financial Management

Framework update • 2015/16 Income and Cost Improvement Update

• Healthier Together Impact Review • Procurement KPIs • Cash and Working Capital Update Risks Identified/Further Assurance • The work being undertaken in relation to the North West Sector and in particular

the Trust's strategies - the Director of Strategy & Workforce will present a related paper to November’s Board of Directors’ meeting;

• Organisational Development – the Director of Strategy & Workforce will present

a paper on this to include an assessment of capabilities for the managerial cohort;

• delivery of the in-year financial position; • the scale of CIPs required in 2015/16; and, • contracting issues and risks into next year. Apologies received from: Allan Duckworth Date of next meeting Tuesday 16th December at 9.30am in the Boardroom

Executive Summary

Why is this paper going to theFinance & Investment Committee

To summarise the main pointsand key issues that the Finance &Investment Committee shouldfocus on including risk,compliance priorities, cost andpenalty implications, KPI’s,Trends and Projections,conclusions and proposals

This paper proposes an addition to the Finance & Investment Committee’s terms of reference to give it oversight of the implementation of the Trust’s procurement strategy.


Clearly identify what will follow a Finance & Investment Committee decision i.e. future KPI’s, assurance requirements Discuss Receive

Approve Note





Quality Regulatory



Prepared by Simon Worthington Finance Director Presented by Simon Worthington

Finance Director

Agenda Item No: 14.1



Title Amendment to Finance & Investment Committee’s Terms of Reference

Finance & Investment Committee Terms of Reference Update - Procurement Strategy 1. Introduction 1.1 In response to Better Procurement, Better Value, Better Care issued August 2013, this paper proposes an addition to the Finance & Investment Committee’s terms of reference to give it oversight of the implementation of the Trust’s procurement strategy. 2. Background 2.1 Since 1st April 2013 the Trust has had a procurement improvement plan

which forms part of the overall finance improvement plan. 2.2 A key output of this improvement plan was the Trust’s Procurement

Strategy. 2.3 In August 2013 the DH published Better Procurement, Better Value,

Better Care which is an attempt to drive improvement in procurement practice across the NHS as a whole.

2.4 One of the requirements of Better Procurement, Better Value, Better Care policy is that the Trust should have a lead Non-Executive Director with a special interest in procurement. The Board has previously agreed that the Chair of the Finance and Investment Committee should take on this role.

2.5 The Trust has a contract with NHS Shared Business Services (SBS) for procurement support. SBS provided consultancy support to ensure that the strategy covered all the relevant aspects of the Better Procurement, Better Value, Better Care policy.

2.6 The procurement team held a briefing with the Chair of the Finance and Investment Committee on the 08/05/2014.

3. Proposal 3.1 To allow ongoing Non-Executive oversight of the Procurement Strategy

the Finance & Investment Committee proposes that its terms of reference should have the following added:

“On behalf of the Board the committee shall

Approve the Trust’s procurement strategy Monitor the delivery of the procurement strategy Obtain external assurance that the procurement strategy remains

fit for purpose”

4. Recommendation 4.1 It is recommended that the Board agree

i) The addition to its terms of reference set out in paragraph 3.1


Name of Committee: Quality Assurance Committee

Date of Meeting: 12th November 2014

Report to: Board of Directors

Chair: David Wakefield

Key Issues Discussed

The Committee received reports from the three clinical divisions. Reports were presented

using CQC key lines of enquiry (KLOE) to review all areas of the service in terms of

providing a service that is safe, effective, caring, responsive and well led. Areas for

improvement have been identified and will be addressed.

Committee members discussed the new format of the reports and agreed that although it

provided a useful baseline the format should be reviewed for future reports.

The committee reviewed and approved the annual Complaints report noting the

improvements made in line with discussions in previous meetings.

Committee members received the proposed workplan for the Clinical Governance and

Quality Committee (CG&Q) (2015) The revised meeting schedule will allow for effective

escalation and reporting between the QA Committee and the CG&Q Committee.

Committee members also received routine reports from the following reporting committees:

Workforce Committee

Clinical Governance and Quality Committee

Mortality Reduction Group

Risk Management Committee

For Escalation to the Board: no items identified for escalation to the Board

Date of next meeting – 10th December 2014


Name of Committee: Audit Committee

Date of Meeting: 17th November 2014

Report to: Board of Directors

Chair: Carol Davies

Key Issues Discussed

Audit Committee Draft Annual Report

Draft annual report approved – agenda item at Board meeting

Update on Accounting Policies and Accounting Reporting Requirements

Received an update on accounting policies and reporting requirements

Internal Audit update and reports

Internal audit presented their update, good progress made on addressing actions; received reports on the Governance review and procurement review no significant concerns identified

Counter Fraud update Good practice work continues

External Audit update Noted the Technology update from the External Auditors

Board Assurance Framework Progress made with the BAF, COO and DoN attended to provide additional insight into the risks within their Directorates. A&E remains a significant risk - potential impact on RTT noted – the previous decision to reduce the RTT risk will be reconsidered in light of operational pressures.

Meeting in February will receive focus on the risks led by the Medical Director and the Director of Strategic and Organisational Development

Review SFIs approved

Risks Identified/Further Assurance

The meeting to agree the terms of reference and scope of the Medicine Management review is scheduled for December 3rd 2014

Apologies received from

Gina Ashworth

Date of next meeting – February 24th 2014


Name of Committee: Charitable Fund Committee Date of Meeting: 6th November 2014 Report to: Board of Directors Chair: David Wakefield Key Issues Discussed Audit of Charitable Funds - KPMG's executive summary of audit conclusions

following their audit of the Bolton NHS Charitable Fund indicated that an unqualified audit opinion was proposed on the financial statements, that no significant accounting issues had arisen during the course of the audit and that no major weaknesses in the financial systems had been identified.

Expenditure – more money had been spent in the last year than had been

received.

Governance relating to funding requests – process to be reviewed to ensure that the Divisions are meeting the objectives of the charity in relation to the items they are purchasing and also that they are not purchasing items which should be funded by the Trust.

Bank Account - a review of possible options for the Charitable Fund's bank

account will be undertaken to ensure the Charity is receiving the best available interest rate but without putting the funds at risk.

Charitable Fundraiser – the Trust's Charitable Fundraiser has now commenced in

post and a report relating to his work will be requested for each future meeting.

Funding request for My Life Software – the Committee agreed that this software would enhance the care of dementia patients across the Trust but requested assurance from IT that it provided good value for money and could not be provided in another way; assurance would also be sought from the Chief Executive that she was in agreement with the purchase of this software following evaluation on the wards.

SLA – the Committee approved the SLA between the Charity and the Trust.

Legacy – a legacy for £95k to be split between Acute Medicine and Cardiology had

been received.

Apologies received from: Allan Duckworth, Gillian Halstead, Steve Tyldsley, Heather Edwards Date of next meeting To be arranged – January/February 2015

Agenda Item No: 17.1

Meeting Board of Directors Date 27th November 2014 Title NHS Charitable Fund Annual Report 2013/14

Executive Summary

• Why is this paper going to the Board

• To summarise the main points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

To receive the Bolton NHS Charitable Fund Annual Report 2013/14

Next steps/future actions Clearly identify what will follow a Board decision i.e. future KPI’s, assurance requirements

Discuss Receive x Approve Note





Quality Regulatory



Prepared by Alison Tilley, Finance Manager Presented by David Wakefield, Chairman

BOLTON NHS CHARITABLE FUND

ANNUAL REPORT

For the Year Ended

31

st March 2014

Bolton NHS Charitable Fund Annual Report for the Year Ended 31 March 2014 Index Page Chairman’s Statement 1 Foreword to the accounts 2 Reference and Administrative Details 2 & 3 Principal Professional Advisers 3 Structure, Governance & Management 4 Risk Management 5

Investment Policy 5

Reserves Policy 5 Objectives & Strategy 5 Charities Objectives and Achievements for 2013/14 6 to 14 Objectives for 2014/15 14 Statement of Trustees Responsibilities 15 Independent Auditor’s Report 16 to 17 Statement of Financial Activities 18 Balance Sheet 19

Notes to the Accounts Note 1 Accounting Policies 20 to 22 Note 2 Related Party Transactions 22 Note 3 Analysis of Voluntary Income 23 Note 4 Analysis of Investment Income 23 Note 5 Investment Management Fee 24 Note 6 Allocation of Support Costs and Overheads 24 Note 7 Analysis of Charitable Expenditure 24 Note 8 Analysis of Grants 25 Note 9 Transfers between Funds 25 Note 10 Analysis of Staff Costs 25 Note 11 Fixed Asset Investments 25 Note 12 Analysis of Current Assets 26 Note 13 Analysis of Current Liabilities and Long Term Creditors 26 Note 14 Contingencies 26 Note 15 Commitments 26 Note 16 Analysis of Charitable Funds 27 Note 17 Post Balance Sheet Events 27

1

BOLTON NHS CHARITABLE FUND ANNUAL REPORT 2013/14 Chairman’s Statement The Bolton NHS Charitable Fund received significant sums of money in the form of donations, legacies and the proceeds of fundraising, which assist the Foundation Trust in providing better services for patients, visitors and staff. In summary, during 2013/14 £179,000 was received in donations and other income and £393,000 was spent in accordance with fund purposes. The Trustees of the funds have a duty to ensure that funds, which are kindly donated to the Charitable Fund, are used in an appropriate manner. The following report outlines the main activities of the Fund during the year ended 31

st March 2014.

The Trustees are extremely grateful for all the support the Foundation Trust receives from the local business community, staff, patients and the general public of Bolton and surrounding areas. I would like to take this opportunity to thank all of the trustees, staff, volunteers, supporters, fundraisers and everyone else concerned for all their help and support during 2013/14 and hope that their valuable and much appreciated work will continue in the future.

Mr David Wakefield Chairman

2

Trustee’s Annual Accounts for Bolton NHS Charitable Fund For the Year Ending 31st March 2014

Foreword The Charity has a corporate trustee - the Bolton NHS Foundation Trust. The members of the NHS Foundation Trust Board who served during the financial year were as follows: Mr D Wakefield Chairman Mr A Sumara Acting Chief Executive (until 21/6/13) Mrs J Bene Acting Chief Executive (22/6/13 to 21/1/14) Mrs J Bene Chief Executive (from 22/1/14) Mr S Worthington Director of Finance Mrs D Sissons Director of Nursing (until 30/6/13) Mrs T Armstrong-Child Director of Nursing (from 13/5/13) Mrs A Schenk Director of Strategy & Improvement (until 31/12/13) Mrs N Ingham Director of Workforce & Organisational Development (until 31/10/13) Mrs L Ludgrove Interim Director of Workforce & Organisational Development (1/11/13

to 2/12/13) Mrs S Woolridge Acting Director of Workforce & Organisational Development (3/12/13) Dr J Bene Medical Director (until 21/06/2013) Mr S Hodgson Acting Medical Director (01/09/2013 to 20/03/2014) Mr S Hodgson Medical Director (from 21/03/2014) Mr J Scott Interim Chief Operating Officer (until 31/10/13) Mrs S Roberts Interim Chief Operating Officer (1/11/13 to 23/12/13) Mr A Ennis Chief Operating Officer (from 1/1/14) Mrs C Davies Non-Executive Director Dr E Adia Non-Executive Director Mrs G Ashworth Non-Executive Director Dr M Harrison Non-Executive Director Mr A Duckworth Non-Executive Director The Corporate Trustee presents the Bolton NHS Charitable Funds Annual Report for the year ended 31

st March 2014.

The Charity’s annual accounts for the year ended 31

st March 2014 have been prepared by the

Corporate Trustee in accordance with the Charities Act 2011 and the Statement of Recommended Practice (SORP): Accounting and Reporting by Charities published in 2005. The Charity’s accounts include all the separately established funds for which the Bolton NHS Foundation Trust is the sole beneficiary. The Charitable Funds are registered with the Charity Commission (No.1050488) in accordance with the Charities Act 2011. Reference and Administrative Details The main Charity the Bolton NHS Charitable Fund was entered on the central register of Charity’s on 20

th October 1995, as Bolton Hospitals NHS Trust Endowment Fund and

renamed by supplemental deeds on 5th October 2005, 5

th June 2009 and 13

th September

2011. The Charity comprises of 115 individual funds (2013-127) as at 31st March 2014 and

the notes to the accounts distinguish the types of fund held and disclose separately all material funds. Charitable funds received by the Charity are accepted, held and administered as funds and property held on trust for purposes relating to the health service in accordance with the National Health Service Act 1977 and the National Health Service and Community Care Act 1990 and these funds are held on trust by the corporate body.

3

Trustee The Bolton NHS Foundation Trust is the Corporate Trustee of the Charitable Funds governed by the law applicable to Trust, principally the Trustee Act 2000 and the Charities Act 2011. The NHS Foundation Trust Board has delegated responsibility for the on-going management of funds to the Charitable Funds Committee which administers the funds on behalf of the corporate trustee. The names of those people who served as agents for the corporate trustee, as permitted under regulation 16 of the NHS Trusts (Membership and Procedures) Regulations 1990 were as follows:- Charitable Funds Committee Mr E Adia Chair Non-Executive Director Mrs G Ashworth Non-Executive Director Mr A Duckworth Non-Executive Director Mrs C Davies Non-Executive Director Mr S Worthington Director of Finance Mrs P Lee Governor Mr J Ramsay Governor Mrs J Roberts Staff Governor Mrs A Tilley Finance Manager Dr G Halstead Consultant- Acute Adult Care Division Mrs L Woods Professional Lead- Elective Care Division Mr S Tyldesley D.D.O.-Family Care Division and Estates & Facilities

Principal Office The principal office for the Charity is:- Finance Department Dowling House The Royal Bolton Hospital Minerva Road Farnworth Bolton BL4 0JR Tel: 01204 390184 Principal Professional Advisers:- Bankers Solicitors Royal Bank of Scotland Hempsons Solicitors Bolton Central Branch Portland Tower 46 – 48 Deansgate Portland Street Bolton Manchester BL1 1BH M1 3LF Auditor Statutory Auditor-Trevor Rees KPMG LLP Statutory Auditor Chartered Accountants St James’ Square Manchester M2 6DS

4

Structure, Governance and Management The Charity changed its name from the Royal Bolton Hospital Charitable Fund to the Bolton NHS Charitable Fund on the 13

th September 2011 using a supplemental deed. This was to

reflect the change of the Foundation Trusts name with the transformation of community services. The Charity currently has 3 special purpose trusts and they are:- The Royal Bolton Hospital The Arts Project The Student Nurse Education Fund During the financial year funds were donated to specific wards or departments in line with the donor’s wishes. Ward or departmental heads manage funds at a local level and all expenditure is authorised according to the Trusts Standing Financial Instructions, Standing Orders and Charitable Fund Procedures that also comply with Charity Law. Acting for the Corporate Trustee, The Charitable Fund Committee is responsible for the overall management of the Charitable Fund. The Committee is required to:-

Control, manage and monitor the use of the funds resources

Provide support, guidance and encouragement for all its income raising activities whilst managing and monitoring the receipt of all income

Ensure that ‘best practice’ is followed in the conduct of all its affairs fulfilling all of its legal responsibilities

Ensure that the approved Investment Policy is adhered to and that performance is continually reviewed whilst being aware of ethical considerations

Keep the Foundation Trust Board fully informed on the activity, performance and risks of the Charity

The accounting records and the day to day administration of the funds are dealt with by the Finance Department located at Dowling House, Royal Bolton Hospital, Minerva Road, Farnworth, Bolton BL4 0JR. The Trustees of the Charity are Executive and Non-Executive Directors of the Foundation Trust. Non-Executive Directors are appointed by the Foundation Trust Board of Governors, and once appointed they receive their initial induction training, all relevant on-going training is provided by both the Foundation Trust and the Charity. As at 31

st March 2014, the Charity had 115 individual funds that relate to various wards and

departments. Each fund manager ensures that donations are spent in accordance with the wishes of the donor and of purpose(s) that relate to the Charity. New Funds Structure A new funds structure commenced on 1

st April 2012, from this date each division now has

speciality funds which reflect the services provided to patients at the Royal Bolton Hospital and within the Community. All current fund balances will be spent in accordance with the donor’s wishes and the individual ward and departmental funds will close once funds have been spent.

5

Risk Management The major risks to which the Charity is exposed have been identified and considered. They have been reviewed and systems established to mitigate those risks. The most significant risks identified were possible losses from a fall in the value of the investment and the level of reserves to mitigate the impact of such loss. These have been carefully considered and there are procedures in place to review the investment policy and to ensure that both spending and firm financial commitments remain in line with income. All expenditure is committed against funds by the Charitable Funds Accountant and this expenditure is applied in line with the objects of the Charity. This expenditure is then authorised according to the Trusts Standing financial Instructions, Standing Orders and Charitable Fund Procedures that also comply with Charity Law. Investment Policy Since the financial crisis of 2008, the funds of the Charity were invested in a Government Banking Service (GBS) Account in order to protect these funds from market volatility. The Charitable Funds Committee met in December 2012 and they made a decision to transfer the funds from the G.B.S. Account with an interest rate of 0.25% to the Royal Bank of Scotland Special Interest Bearing Account with an interest rate of 0.5%. The Charitable Funds Committee reviewed the options for investment and decided that the funds should remain with the Royal Bank of Scotland.

While the majority of funds are held in a Royal Bank of Scotland- Special Interest Bearing Account (SIBA), a Royal Bank of Scotland- Current Account continues to meet its daily banking needs. Reserves Policy The policy of the Charity is to ensure that all fund holders spend donations as they are received and not to build up fund balances unless funds are being accumulated for a specific purpose e.g. the purchase of a more expensive piece of equipment. A review is undertaken of fund balances on a regular basis and a report is presented to the committee detailing the expenditure plans of funds with balances in excess of £5,000.

Objectives & Activities The objects of the Charity are that the Trustee being the Bolton NHS Foundation Trust are to apply the income and, at their discretion so far as may be permissible, the capital for any charitable purpose or purposes relating to the National Health Service. The Charity’s Mission Statement is:- ‘Through the receipt of donations, legacies, fundraising activities and appeals the Bolton NHS Charitable Fund will further improve the provision of high quality patient care, specialist training and education for staff and the provision of amenities for both patients and staff which are not fully covered by or supported by central NHS funds’. Income has continued to be applied as per the Charity’s objectives and funds have been received for medical and surgical items, patient’s amenities, staff welfare and for education and training.

6

The Charity’s Objectives for 2013/14

The Charity’s objectives for the year are:-

To provide patients amenities and extras to enhance and improve the patient experience

To provide additional and up to date medical and surgical equipment

To enhance the knowledge of staff through the provision of training and education The foundation trust treats patients from all areas of the local community and also people who may fall ill whilst visiting the area. All equipment and resources purchased by the Charity are available for all of the general public who need the benefit of such items and no one is excluded from their use. In total the Charity received £179,000 worth of donations and other income; the funds received have allowed the Charity to meet its objectives for the year.

The chart below details the different types of income that the Charity has received.

Types of Charitable Fund Income

Donations- £108,000

Legacies- £63,000

Investment Income- £8,000

7

Achievements for 2013/14 The structure of the Foundation Trust is divided into three Clinical Divisions plus Corporate Services. The Clinical Divisions are Elective Care, Acute Adult Care and Family Care. The following pages describe some of the major achievements made in the year by the charity. Acute Adult Care Division Specialities within this division include:-

Emergency Care

Acute Medicine

Cancer Services

Cardiology

Dermatology

Diabetes & Endocrinology

Elderly Medicine

Gastroenterology

Haematology

Palliative Care (Non-Cancer)

Respiratory Medicine

Stroke The division have invested in a variety of items of medical equipment which has included the purchase of 10 new beds for the Coronary Care Unit, 19 Resuscitation trollies, 6 ABP Blood Pressure monitors, 3 ABP Recorders and a Data Capture Stroke System. Data Capture Stroke System –Stroke services are governed nationally to ensure that the service and treatment provided are in line with best practice. As part of this governance every hospital with a stroke service needs to audit each patient’s treatment to ensure they received best possible care, this information is then analysed at national level. Previously this information was collected by the stroke team on paper after the patient had been discharged, this was an extremely time consuming, laborious exercise. Since the introduction of the Data Capture Stroke computerised system, this process is now be faster, the information is taken at the point of care and stored ready for submission, meaning the stroke team spends less time collecting information and more time with the patient.

The Data Capture Stroke System

8

The Ambulatory blood pressure monitor is used to provide a 24 hour blood pressure profile for patients with suspected high blood pressure (hypertension). The patient visits the hospital to have a monitor fitted and will then go home to carry on with their daily activities. The patient returns to the hospital the next day to have the monitor removed. The results are downloaded and used to decide if a patient needs medication for blood pressure control. The purchase of these monitors has allowed the department to set up a new service for GP’s to refer their patients direct to the Cardiology/Lung Function department for a 24 hour blood pressure monitor. This service enables a faster diagnosis of hypertension and early initiation of treatment.

The Ambulatory blood pressure monitor

Education and continuing professional development has also been at the forefront to the division in ensuring patients receive up to date diagnosis, treatment and care, courses have been attended and subscriptions have been purchased for the following:-

An Introduction to Conscious Sedation

Delivering Safe and Effective Practice in the Operating Theatre

Myelodysplasia and Myeloproliferative Neoplasms

Launch of the National IBD Standards

Leadership & Exemplar Course

Cancer Nursing Practice Subscription

9

Elective Care Division Specialities within this Division include:-

Breast Services

Critical Care

Endoscopy

General Surgery

ENT, Audiology & Oral Surgery

Laboratory Medicine

MSK

Ophthalmology

Pharmacy

Pathology

Radiology

Therapies

Theatres & Anaesthetics

Urology The Elective Care division have purchased an Omnitract System for use in Theatre at a cost of £11,559, 7 Resuscitation trollies, smaller pieces of medical equipment and they have completed works on a multidisciplinary meeting room for the Breast team. The Omnitract System was purchased to facilitate major open surgical procedures. It is primarily used in colorectal surgery in large bowel resection cases for benign and malignant disease. It is particularly helpful for pelvic cases i.e., rectal cancer surgery. The system fixes to the operating table providing a constant, fixed retraction that is easily adjustable. This enables the surgeon and the assistants to focus on the procedure without the need for constant retraction and optimises the view of the surgical field. Additionally the system is incredibly helpful in patients with a high body mass index where standard retraction can be extremely difficult. The Urologists are also making use of the system for their open nephrectomy cases. The Breast Unit have completed works on a multidisciplinary meeting room this is with grateful thanks to a patient who left a legacy to the unit when she passed away. Discussing patients with all the Breast team is necessary in making the right decisions with regards to their diagnosis and treatment. A room which was big enough for the purpose was found in a neighbouring department, this room can house large screens for the whole team to be able to view images and validate patient data. The room is set to be furnished and IT equipment will be installed in 2014/15. There are many Resuscitation trollies throughout the Trust and a decision was made by the Resuscitation Committee to standardise all of the trollies. This was to ensure that every trolley looked the same, was easily recognisable and was stocked with exactly the same equipment. This is vital during emergencies and cardiac arrest situations so the users are familiar with the lay out and have easy access to emergency equipment no matter where they are within the Trust.

10

Resuscitation Trolley

Family Care Division Specialities within this Division include:-

Neonatal & Paediatric Services

Women’s Health Care

Sexual Health

The division have made a number of larger purchases this year which include; an Ultrasound Machine, 7 K2 Guardian Software Units and 4 Foetal Monitors. The Ultrasound Machine was purchased for use in the Delivery Suite. The Royal Bolton Hospital is a tertiary unit providing care to over 6,000 mums and babies a year, many of whom will have complex needs. This new machine has provided the accessibility for midwives and doctors to have further detailed information in clinical situations, particularly where an immediate diagnosis is needed. For example in the event of a mum presenting in labour and her baby is clinically felt to be breach, utilising the scan machine gives an accurate diagnosis and then a plan of care can be made. This is crucial during the night and at weekends when scan availability is very limited. Having this machine has facilitated efficient care planning and this in turn has helped deliver babies safely and given parents the information they need to make an informed choice regarding their care.

11

The Ultrasound Machine 7 x K2 Guardian Software Units were purchased. This system has the ability to archive babies heart traces, previously these have been paper copies, liable to be lost or damaged. The system also enables continuity of recording as the system is also in place on delivery suite. This is particularly important when there are concerns over a baby’s wellbeing, as all the information is stored on the system clinicians can assess improvement and deterioration in the baby’s condition. This system has ensured the safe delivery of babies, from mothers who have had a high risk pregnancy, for example mothers with medical conditions such as diabetes or babies with problems, such as those who haven’t grown as well as expected. The maternity service has been enhanced greatly by the purchase of this system and it is used 24 hours a day.

K2 Guardian Software Unit

12

Patient Safety & Experience Departments within this Division include:-

Chaplaincy

Bereavement Services

The Chaplaincy Department funded a Ulysses modular software system in 2011/12 which links in with other modules already in use across the Trust, as there were several modules in use the cost to purchase this by the department was considerably cheaper. The purpose of this module is to enable the department to record religious and spiritual input to patients and staff. Previously the Chaplains did not have access to patient notes in order to record such input, such recording is required by NICE guidelines with regard to religious and spiritual care. It was decided that the Chaplaincy Department would pay for extra training on the system and also train new members of staff. General Purpose Funds The Manual Handling Advisor asked the Charitable Funds Committee for monies to fund the purchase of an Orthopaedic Bariatric Bed, mattress and traction kit for use on the Orthopaedic wards. The Contoura 1080 bariatric bed has been specifically designed to cater for patients who exceed the safe working load of a standard bed. It has a maximum patient weight limit of 450kg (71stone). Bariatric patients are defined as anyone regardless of age, who have limitations in health and social care due to their weight, physical size, shape, width, health, mobility, tissue, viability and environmental access with one or more of the following:- A Body Mass Index (BMI) greater than 40kg/m2 Weight greater than 152kg (24 stone) Exceeds the safe Working Load and/or dimension of standard hospital equipment

The Bariatric Bed

13

The Infection Control department received funding of £4,509 to fund the purchase of 6 EXATP Machines, these machines use ATP testing (Adenosine Tri-Phosphate), the test indicates levels of ATP in the environment which is an indicator of organic matter. The hand held machine and swabs can be used as a training tool for monitoring cleanliness of all clinical areas as when surfaces are clean bacteria and viruses can still be present. Visual assessment of cleaning is often subjective and can be unreliable, ATP testing provides objective measurements and evidence that cleaning has been effective. Results of how clean or dirty surfaces are available in seconds and enables the board to monitor the cleaning effectiveness of both the hospital environment and of patient equipment. The system comes with data management software that will provide the Trust with trend graphs and records improvements for feedback to clinical areas.

The EXATP Machine

14

The Radiology department applied for funds to purchase a PACS CD production unit. This new CD unit allows automatic encryption and production of CDs with secure password creation and storage and the ability to produce multi-examination disk encryption. This leads to increased data security and a huge reduction in time spent manually encrypting disks and troubleshooting issues, meaning the team are able to turn around image transfers between hospitals and clinicians in a much shorter timeframe. When a patient is referred to a different hospital for further treatment clinicians are able to access the patient data in a timely manner.

The PACS CD Production Unit Objectives for 2014/15

The Charity will continue to spend donations in the areas that are specified by the donor, and that are in harmony with the objects of the Charity. The Charity will endeavour to support the Foundation Trust with the provision of education and training, the purchase of additional and up to date medical and surgical equipment and the provision of patient’s amenities and extras to make the patients hospital stay and community based care a better experience. A Charitable Funds leaflet has been produced and is available to all, they can be found on every ward and department and are also available from the Charitable Funds Department on 01204 390184. A special note of thanks is given to all those who have given their consent to have their photographs taken for this year’s Annual Report and to the Medical Illustration Department for taking the photographs.

15

Statement of Trustees Responsibilities

Under the trust deed of the Charity and Charity Law, the trustees are required to prepare financial statements for each financial year which show a true and fair view of the state of affairs of the Charity and the excess of income over expenditure. In preparing these financial statements, the trustees are required to:-

select suitable accounting policies and then apply them consistently

make judgements and estimates that are reasonable and prudent

state whether the recommendations of the Statement of Recommended Practice (‘Accounting and Reporting by Charities : Recommended Practice (Feb 2005)’) have been followed, subject to any material departures disclosed and explained in the financial statements

state whether the financial statements comply with the trust deed, subject to any material departures disclosed and explained in the financial statements

prepare the financial statement on the going concern basis unless it is inappropriate to presume that the Charity will continue its activities

ensure the accounts comply with current statutory requirements, the requirements of the Charity’s governing document and the requirements of the charity SORP

The trustees are required to act in accordance with the trust deed of the Charity, within the framework of Trust Law. They are responsible for keeping proper accounting records, sufficient to disclose at any time, with reasonable accuracy, the financial position of the Charity at that time, and enable the trustees to ensure that any statements of accounts comply with the requirements of regulations under that provision. They have general responsibility for taking such steps as are reasonably open to them to safeguard the assets of the Charity and to prevent and detect fraud and other irregularities. These financial statements were approved by the trustees on 06/11/2014 and were signed on its behalf by:- Chairman Director of Finance

16

Independent auditor’s report to the Trustee of Bolton NHS Charitable Fund

We have audited the financial statements of Bolton NHS Charitable Fund for the year ended

31 March 2014 set out on pages 12 to 24. The financial reporting framework that has been

applied in their preparation is applicable law and UK Accounting Standards (UK Generally

Accepted Accounting Practice).

This report is made solely to the charity’s trustee as a body, in accordance with section 145 of

the Charities Act 2011 (or its predecessors) and regulations made under section 154 of that

Act. Our audit work has been undertaken so that we might state to the charity’s trustee those

matters we are required to state in an auditor’s report and for no other purpose. To the fullest

extent permitted by law, we do not accept or assume responsibility to anyone other than the

charity and its trustee as a body, for our audit work, for this report, or for the opinions we

have formed.

Respective responsibilities of trustee and auditor

As explained more fully in the Statement of Trustee’s Responsibilities set out on page 10 the

trustee is responsible for the preparation of financial statements which give a true and fair

view.

We have been appointed as auditor under section 145 of the Charities Act 2011 (or its

predecessors) and report in accordance with regulations made under section 154 of that Act.

Our responsibility is to audit, and express an opinion on, the financial statements in

accordance with applicable law and International Standards on Auditing (UK and Ireland).

Those standards require us to comply with the Auditing Practices Board’s Ethical Standards

for Auditors.

Scope of the audit of the financial statements

A description of the scope of an audit of financial statements is provided on the Financial

Reporting Council’s website at www.frc.org.uk/auditscopeukprivate.

Opinion on financial statements

In our opinion the financial statements:

give a true and fair view of the state of the charity’s affairs as at 31 March 2014 and of its

incoming resources and application of resources for the year then ended;

have been properly prepared in accordance with UK Generally Accepted Accounting

Practice; and

have been properly prepared in accordance with the requirements of the Charities Act

2011.

http://www.frc.org.uk/auditscopeukprivate

17

Matters on which we are required to report by exception

We have nothing to report in respect of the following matters where the Charities Act 2011

requires us to report to you if, in our opinion:

the information given in the Trustee’s Annual Report is inconsistent in any material

respect with the financial statements; or

the charity has not kept sufficient accounting records; or

the financial statements are not in agreement with the accounting records and returns; or

we have not received all the information and explanations we require for our audit.

Trevor Rees

for and on behalf of KPMG LLP, Statutory Auditor

Chartered Accountants

St James’ Square

Manchester

M2 2DS

KPMG LLP is eligible to act as an auditor in terms of section 1212 of the Companies Act

2006

Bolton NHS Charitable Fund

Statement of Financial Activities for the year ended 31st March 2014

Note Restricted Un-Restricted Endowment Total Total

Funds Funds Funds Funds Funds

2014 2013

£000 £000 £000 £000 £000

Incoming Resources:

Incoming resources from generated funds:

Voluntary income: 3

Donations 8 100 0 108 154

Legacies 36 27 0 63 630

Sub total voluntary income 44 127 0 171 784

Activities for generating funds:

Fundraising events 0 0 0 0 1

Investment income 4 7 1 0 8 5

Incoming resources from charitable activities:

Income from provision of education & training 0 0 0 0 0

Transfer from NHS bodies 0 0 0 0 23

Other Incoming Resources 0 0 0 0 0

Total incoming resources 51 128 0 179 813

Resources Expended

Costs of generating funds:

Fundraising Cost 10 0 0 0 0 0

Investment Management 5 0 0 0 0 0

Sub total cost of generating funds 0 0 0 0 0

Charitable activities: 7

Purchase of new equipment 245 32 0 277 472

New building, refurbishment & care 39 2 0 41 40

Staff education & welfare 27 6 0 33 55

Patient welfare & amenities 6 10 0 16 78

Research 7 0 0 7 1

Sub total direct charitable expenditure 324 50 0 374 646

Other resources expended

Miscellaneous 1 0 0 1 10

Governance Costs 6 18 0 0 18 17

Total resources expended 343 50 0 393 673

Net incoming/(outgoing) resources before transfers (292) 78 0 (214) 140

Gross transfer between funds

Net incoming/(outgoing) resources before other (292) 78 0 (214) 140

recognised gains and losses

Realised and unrealised gains/(losses) on (1) 0 0 (1) 0

investment assets

Net movement in funds (293) 78 0 (215) 140

Reconciliation of Funds

Total Funds brought forward 1,268 149 109 1,526 1,386

Total Funds carried forward 975 227 109 1,311 1,526

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Bolton NHS Charitable Fund

Balance Sheet for the year ended 31st March 2014

Note Restricted Un-Restricted Endowment Total Total


2014 2013

£000 £000 £000 £000

Fixed Assets:

Investments 11 16 0 0 16 18

Total Fixed Assets 16 0 0 16 18

Current assets: 12

Debtors 21 26 0 47 3

Short Term Investments & deposits 952 228 109 1,289 1,547

Cash at bank and in hand 10 0 0 10 10

Total Current Assets 983 254 109 1,346 1,560

Liabilities 13

Creditors falling due within one year (24) (27) 0 (51) (52)

Net current assets or liabilities 959 227 109 1,295 1,508

Total assets less current liabilities 975 227 109 1,311 1,526

Net assets or liabilities 975 227 109 1,311 1,526

The funds of the charity:

Endowment funds 0 0 109 109 109

Un Restricted funds 0 227 0 227 149

Restricted income funds 975 0 0 975 1,268

Total charity funds 975 227 109 1,311 1,526

The notes at pages 20 to 27 form part of these accounts

Signed:

Name: Simon Worthington

Date: 06/11/2014

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Notes on the accounts

1. Accounting Policies

(a) Basis of preparation

The financial statements have been prepared under the historic cost convention, with the

exception of investments which are included at market value. The financial statements have

been prepared in accordance with Accounting and Reporting by Charities: Statement of

Recommended Practice (SORP 2005) and applicable UK Accounting Standards and the

Charities Act 2011.

(b) Funds structure

Where there is a legal restriction on the purpose to which a fund may be put, the fund is

classified as an endowment fund, where the donor has expressly provided that only the

income of the fund may be applied, or as a restricted income fund where the donor has

provided for the donation to be spent in furtherance of a specified charitable purpose.

The major funds held within these categories are disclosed in note 16.

(c) Incoming resources

All incoming resources are recognised once the charity has entitlement to the resources, it is

certain that the resources will be received and the monetary value of incoming resources can

be measured with sufficient reliability.

(d) Incoming resources from legacies

Legacies are accounted for as incoming resources either upon receipt or where the receipt

of the legacy is virtually certain; this will be once confirmation has been received from the

representatives of the estate (s) that payment of the legacy will be made or property transferred

and once all conditions attached to the legacy have been fulfilled and the amount of the

incoming resources can be measured with sufficient reliability.

(e) Incoming resources from endowment funds

The incoming resources received from the invested endowment fund is wholly restricted.

(f) Resources expended

All expenditure is accounted for on an accruals basis and has been classified under headings

that aggregate all costs related to the category. All expenditure is recognised once there is a

legal or constructive obligation committing the charity to the expenditure.

Grants are only made to related or third party NHS bodies and non NHS bodies in

furtherance of the charitable objects of the funds. A liability for such grants is recognised

when approval has been given by the Trustee. The NHS Foundation Trust has full knowledge

of the plans of the Trustee, therefore a grant approval is taken to constitute a firm intention

of payment which has been communicated to the NHS Foundation Trust, and so a liability

is recognised.

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(g) Irrecoverable VAT

Irrecoverable VAT is charged against the category of resources expended for

which it is incurred.

(h) Allocation of overhead and support costs

Overhead and support costs have been allocated as a direct cost or apportioned

on an appropriate basis (see note 7) between Charitable Activities and Governance

Costs. Once allocation and/or apportionment of overhead and support costs has

been made the remainder is apportioned to funds on a transactional basis.

(i) Costs of generating funds

The costs of generating funds are those costs attributable to generating income for

the charity, other than those costs incurred in undertaking charitable activities or the

costs incurred in undertaking trading activities in furtherance of the charity's objects.

The cost of generating funds represent fundraising costs together with investment

management fees. Fundraising costs include expenses for events and the costs

for the fundraiser's salary, this is recharged to the charity by the Foundation Trust.

(j) Charitable Activities

Costs of charitable activities comprise of all costs incurred in pursuit of the charitable

objects of the charity. These costs comprise of direct costs and an apportionment of

overhead and support costs as shown in note 7.

(k) Governance Costs

Governance costs comprise of all costs incurred in the governance of the charity.

These costs include costs related to statutory audit together with an apportionment

of overhead and support costs.

(l) Fixed asset investments

Investments are stated at market value as at the balance sheet date. The statement

of financial activities includes the net gains and losses arising on revaluation and

disposals throughout the year.

Quoted stocks and shares are included in the balance sheet at mid-market price,

excluding dividend.

Other investments are included at the trustees' best estimate of market value.

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(m) Realised and Unrealised gains and losses

All gains and losses are taken to the Statement of Financial Activities as they

arise. Realised gains and losses on investments are calculated as the difference

between sales proceeds and opening market value (purchase date if later).

Unrealised gains and losses are calculated as the difference between the market

value at the year end and opening market value (or purchase date if later).

(n) Going Concern

In preparing these accounts the Corporate Trustee has considered the future

activities of the Charity and consider it to be a going concern.

(o)Transfer of Funds from NHS Bodies

There have been no transfers in 13/14 from NHS bodies.

Note 2. Related party transactions

The Bolton NHS Foundation Trust receives grants from Bolton NHS Charitable Fund,

the Foundation Trust is the Corporate Trustee of the Charity (note 8).

The members of the Charitable Funds Committee are detailed below :-

Mr Ebrahim Adia -Chair -Non-Executive Director of the Bolton NHS Foundation Trust

Mrs Gina Ashworth -Non-Executive Director of the Bolton NHS Foundation Trust

Mr Allan Duckworth -Non-Executive Director of the Bolton NHS Foundation Trust

Mr Simon Worthington -Director of Finance of the Bolton NHS Foundation Trust

Mrs Pauline Lee -Governor of the Bolton NHS Foundation Trust

Mr Jack Ramsay -Governor of the Bolton NHS Foundation Trust

Mrs Janet Roberts -Staff Governor of the Bolton NHS Foundation Trust

Mrs Alison Tilley -Finance Manager, Finance Department, Bolton NHS Foundation Trust

Dr Gillian Halstead -Consultant, Acute Adult Care Division, Bolton NHS Foundation Trust

Mrs Linda Woods -Professional Lead, Elective Care Division, Bolton NHS Foudation Trust

Mr Stephen Tyldesley -DDO, Family Care and Estates & Facilities Division, Bolton NHS

Foundation Trust

None of the above have received honoraria, emoluments or expenses from the charity

for the year ended 31st March 2014.

During the year none of the Trustees or members of the key management staff or parties

related to them has undertaken any material transactions with the Bolton NHS

Charitable Fund.

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3. Analysis of voluntary income

Restricted Un-Restricted Endowment Total Total


2014 2013

£000 £000 £000 £000 £000

Donations

Breast Fund 0 14 0 14 23

Neonatal & Paediatric Services Fund 0 16 0 16 21

General Purposes Fund 0 11 0 11 11

Other Funds (112) 8 59 0 67 99

Sub total 8 100 0 108 154

All funds with donation income received over £10,000 are listed individually.

Legacies

RBH General Purposes 6 0 0 6 350

Coronary Care Unit Fund 29 0 0 29 72

Respiratory Medicine 0 14 0 14 0

Stroke 0 9 0 9 0

Other Funds (111) 1 4 0 5 208

Sub total 36 27 0 63 630

Total 44 127 0 171 784

All funds with legacy income received over £6,000 are listed individually.

4. Analysis of Investment income

Gross income earned from: 2014 2013

Held in UK Held in UK

£000 £000

Dividend income from Stocks & Shares 1 1

Income from Investments 0 2

Interest from Bank Account 7 2

Total 8 5

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5. Investment management fee

There are no cost's for managing the investment portfolio in 2013 or 2014.

6. Allocation of support costs and overheads

Allocation and 2014 Allocated Residual Basis

apportionment to Total to for of

Governance Costs Governance Apportionment Apportionment

£'000 £'000 £'000

Salaries & related costs 31 12 19 Fixed and

transactional

Bank Charges 0 0 0

External Audit Fee 6 6 0 Governance

Total 37 18 19

7. Analysis of charitable expenditure

The charity undertook direct charitable activities and made available grant support to the

Bolton Hospital NHS Foundation Trust in support of donated assets.

Activities Grant Support 2014

undertaken Funded Costs Total

directly activity

£'000 £'000 £'000 £'000

Purchase of new equipment 192 79 6 277

New building, refurbishment & care 0 40 1 41

Staff education & welfare 26 0 7 33

Patient welfare & amenities 12 0 4 16

Research 7 0 0 7

Total 237 119 18 374

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8. Analysis of grants

The charity does not make grants to individuals. All grants are made to the

Bolton NHS Foundation Trust in the form of donated assets.

9. Transfers between funds

No transfers were made between restricted, un-restricted and endowment funds.

10. Analysis of fundraising events

There have been no fundraising events.

11. Fixed asset investments

Movement in fixed asset investment 2014 2013

Total Total

£000 £000

Market value brought forward 18 1,360

Add: additions to investments at cost 0 3

Less disposals at carrying value (1) (1,345)

Add net gain (loss) on revaluation (1) 0

Market value as at 31st March 16 18

Historic cost as at 31st March 11 11

In 2012/13 an amount of £1,345 was transferred from the GBS Account to the

SIBA Account.

2014 2013

Total Total

£000 £000

UK equity funds 0 0

Government gilts 16 17

Investments held in Citi Account 0 1

16 18

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12. Analysis of current assets

Debtors under 1 year 2014 2013

Total Total

£000 £000

Accrued Income & Aged Debt 47 3

Total 47 3

Analysis of cash and deposits 2014 2013

Total Total

£000 £000

R.B.S. Special Interest Bearing Account 1,289 1,547

Royal Bank of Scotland -Current Account 10 10

Total 1,299 1,557

Total Current Assets 1,346 1,560

13. Analysis of current liabilities and long term creditors

Creditors under 1 year 2014 2013

Total Total

£000 £000

Other creditors 40 48

Accruals 11 4

Total 51 52

14. Contingencies

The Trust has no contingent liabilities or assets.

15. Commitments

The trustees recognise that they have commitments for goods or services that

have yet to be received for £75,693.79.

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16. Analysis of charitable funds

Material Funds Balance Income Resources Gains & Fund

b/fwd Expended Losses c/fwd

£000 £000 £000 £000 £000

RBH General Purposes 504 9 (103) 0 410

Coronary Care Fund 109 30 (23) 0 116

Thoracic Medicine Fund 82 0 0 0 82

Bolton Rectal Fund 60 1 (12) 0 49

Other Funds (111) 662 139 (255) (1) 545

1,417 179 (393) (1) 1,202

The funds listed above all have an individual closing fund balance of £40,000 or above.

The General Purposes Fund receives donations from donors who have not expressed a preference as

to how the funds should be spent, these funds are used by the trustees for any charitable purposes(s)

related to the Royal Bolton Hospital. This year the General Purposes Fund has purchased a Bariatric

Bed, a PACS CD Production System, Arm Chairs for Patients and 6 EXATP Machines.

The Coronary Care Unit receives many donations from grateful patients and also from

legacies, funds are mainly used to purchase medical equipment for the unit.

The Thoracic Medicine department treats and cares for adult patients with respiratory disease. This

includes rapid diagnosis of conditions such as lung cancer, treatment and care of long term conditions

such as Chronic Obstructive Pulomonary Disease and Asthma, public health management of T.B. and

palliative care of patients at the end of their disease. The department is a busy area with a strong multi-

disciplinary team that aims to continue to develop respiratory services to meet the needs of the people

in Bolton and lead in respiratory care.

The Bolton Rectal Fund received a rather large legacy in 12/13 and have used part of this legacy to

purchase an Omnitract Retractor System.

17. Post balance sheet events

There have been no post balance sheet events that require disclosure.

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