council of governors agenda - wrightington, wigan and ... · minutes of a meeting of the council of...

Council of Governors

22 January 2019, 17:30 to 19:30Trust HQ Boardroom, Royal Albert Edward

Infirmary, Wigan Lane, Wigan, WN1 2NN

Agenda1. Chair and quorum

Information

Robert Armstrong

2. Apologies for absenceInformation

Robert Armstrong

3. Declarations of interestInformation

Robert Armstrong

4. Minutes of previous meetingApproval

Robert Armstrong

Minutes - CoG - 15 Oct 2018.pdf (8 pages)

5. Chair and Deputy Chief Executive's report

(Presentation) Discussion

R Armstrong/R Forster

Strategy and planning6. Development of WWL strategy

(Presentation) Discussion

Richard Mundon

7. Council of Governors' cycle of businessApproval

Paul Howard

CoG cycle of business.pdf (3 pages)

Holding to account

8. Non-Executive Directors' updatesDiscussion

NEDs

9. Board assurance frameworkInformation

Robert Armstrong

BAF - Patients - Dec 2018.pdf (2 pages)

BAF - People - Dec 2018.pdf (3 pages)

BAF - Performance - Dec 2018.pdf (2 pages)

BAF - Partnerships - Dec 2018.pdf (2 pages)

10. Leadership safety walkaround reportInformation

Paul Howard

Leadership Safety COG Quarterly Report.pdf (7 pages)

Other items11. Items requested by governors

11.1. Governors volunteering on wardsDiscussion

Bill Anderton

11.2. Progress with addressing nursing vacanciesDiscussion

Alan Baybutt

11.3. Staff engagement updateDiscussion

Mustapha Koriba

11.4. Update on fundingDiscussion

Rob Forster

12. Resolution to exclude press and public

Approval

Robert Armstrong

13. Date, time and venue of next meeting30 January 2019, 5.00pm for 5.30pm, MacDonald Kilhey CourtHotel

Information

Robert Armstrong

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WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST

MINUTES OF A MEETING OF THE COUNCIL OF GOVERNORS

HELD AT 5.30PM ON 15 OCTOBER 2018

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

Members’ attendance record 2018-19:

16 A

pr 2

018

16 J

ul 2

018

15 O

ct 2

018

22 J

an 2

019

30 J

an 2

019

Atte

ndan

ce

Robert Armstrong Chair (in the Chair)

Imran Alam Staff Governor, Medical and Dental --- --- A

Bill Anderton Public Governor, Wigan

Helen Ash Public Governor, Makerfield ---

Alan Baybutt Public Governor, Wigan --- ---

Tim Board Staff Governor, Medical and Dental A ---

John Cavanagh Appointed Governor, FT volunteers --- --- ---

Les Chamberlain Public Governor, Makerfield

Jean Coates-Topping Public Governor, Makerfield --- ---

Kathryn Drury Public Governor, Makerfield A ✗ ---

Tom Frost Public Governor, Rest of England and Wales A ---

Howard Gallimore Public Governor, Makerfield

Bill Greenwood Public Governor, Wigan A A ---

Pauline Gregory Public Governor, Wigan

Dawne Gurbutt Appointed Governor, UCLAN A

Marie Hart Staff Governor, Nursing and Midwifery A ✗ ---

Andrew Haworth Public Governor, Leigh

Jean Heyes Appointed Governor, Staff Side A ✗ ---

Alex Hilton Staff Governor, Other staff A

Sarah Howard Staff Governor, Nursing and Midwifery --- ---

Jackie Hylton Staff Governor, Nursing and Midwifery --- ---

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

Hazel Leatherbarrow Staff Governor, Other staff --- ---

James Lee Public Governor, Makerfield A

Lisa Lymath Public Governor, Rest of England and Wales A

Renée Mellis Public Governor, Rest of England and Wales --- ---

Reg Nash Appointed Governor, Age UK

Syed Shah Appointed Governor, Local Medical Committee

Maggie Skilling Public Governor, Wigan

Veronika Stevens Public Governor, Rest of England and Wales --- ---

Linda Sykes Public Governor, Leigh

Corinne Taylor-Smith Public Governor, Leigh A A A

David Thompson Public Governor, Rest of England and Wales ---

Fred Walker Appointed Governor, Wigan Council

Mavis Welsh Public Governor, Leigh

Gen Wong Appointed Governor, Wigan Borough CCG A ✗ ---

James Yates Staff Governor, Other Staff A ✗ ---

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Wrightington, Wigan and Leigh NHS Foundation Trust Minutes of a meeting of the Council of Governors held on 15 October 2018

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In attendance: Steven Elliot Non-Executive Director Andrew Foster Chief Executive Mick Guymer Non-Executive Director Ian Haythornthwaite Non-Executive Director Carole Hudson Non-Executive Director Paul Howard Company Secretary and Data Protection Officer Tony Warne Non-Executive Director Julie Critchley Integration Programme Director (to item 55/18 only) Jo Goodfellow Bolton, Salford and Wigan Partnership (for item 56/18 only) One member of the public was also in attendance. 50/18 Chair and quorum

Robert Armstrong took the chair and noted that due notice had been given to all governors and that a quorum was present. He therefore declared the meeting duly convened and constituted.

51/18 Apologies

Apologies for absence were received as shown in the members’ attendance record, above.

52/18 Declarations of interest

Prof T Warne declared an interest in minute reference 59/18 (Proposal to extend non-executive director term of office) and 60/18 (Appointment of Senior Independent Director).

53/18 Minutes of the previous meeting

The minutes of the previous meeting held on 16 July 2018 were agreed as a true and accurate record, subject to one minor amendment. Mr A Hilton advised that, at minute reference 41/18, his question had related to the total setup costs for WWL Solutions prior to the decision not to proceed, rather than just those paid to QE Facilities. The Chief Executive agreed to provide the revised information.

ACTION: Chief Executive

54/18 Chief Executive’s report

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

(a) a summary of his highlights and lowlights;

(b) an overview of the foundation trust’s performance across a number of metrics; and

(c) a summary of concerns and those areas of particular positivity.

Cllr F Walker noted the recent reintroduction of the Health Information System (HIS) into the Accident and Emergency Department and sought assurance that lessons had been learnt from the earlier adoption and that the reintroduction would be a smooth one. In

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response, the Chief Executive confirmed that the system had been in place within the department for around a month and that feedback from staff had been positive.

In response to a question from Mr B Anderton surrounding overseas nurses, the Chief Executive confirmed that some of the nurses in question now reside in the UK and are therefore likely to take on permanent roles within the organisation and that others will return to their home countries after a period of time, in accordance with the “learn, earn, return” model. In response to a question from Dr S Shah, the Chief Executive advised that overseas nurses from India had been targeted as a result of the strong relationship between the foundation trust and organisations in India, and the ability to provide effective pastoral care due to the size of the Indian clinical cohort within the organisation. Notwithstanding, the Chief Executive confirmed that nurses from other overseas countries would be welcomed within the foundation trust.

In response to a supplementary question from Cllr F Walker regarding nurse vacancies, the Chief Executive provided a summary of how the foundation trust seeks to address rota gaps, including the use of bank and agency staff.

In response to a question from Mr A Hilton surrounding orthopaedics, the Chief Executive noted that NHS Improvement had acknowledged that a number of procedures are loss making and wished to avoid creating a disincentive for specialist providers to undertake complicated procedures. Further information on the tariff for 2018-19 was currently awaited.

The Council received the presentation and noted the content.

55/18 Strategic item: transfer of community services

The Chief Executive delivered a presentation to update the Council of Governors on progress with the proposed transfer of Wigan-based community services from Bridgewater Community Healthcare NHS FT into the foundation trust. Confirmation was provided that commissioners had agreed to fund some of the costs of the due diligence exercise along with some of the transaction costs.

In response to a question from Mrs L Sykes, the Chief Executive advised that the potential care hotel on the Leigh Infirmary site did not fall within the scope of the project but confirmed that the proposal for an 80-bed facility is still being considered.

In response to a question from Mrs M Skilling surrounding the need for the Council of Governors to approve significant transactions, the Company Secretary reminded governors that a dedicated session run by an independent legal firm on the role of the Council of Governors in significant transactions had been scheduled as part of the North West Governors’ Forum that had been organised by the foundation trust, and confirmed that a number of governors would be attending the event. He also noted that a further update on progress would be provided to the council at its workshop on 6 December 2018.

Mr A Howarth commented that communication would be important throughout the project, to which the Chief Executive confirmed that communications were about to commence with staff and that the next step would be for information to be provided to the public, although the Chair reminded the council that, as the process is led by Wigan Borough Clinical Commissioning Group, communications would be undertaken by them rather than the through the foundation trust.

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The Chief Executive left the meeting.

56/18 Strategic item: update on Bolton, Salford and Wigan Partnership

Ms J Goodfellow joined the meeting and delivered a presentation to update the Council on the work of the Bolton, Salford and Wigan Partnership. She provided an overview of the Healthier Together programme and the proposed acute developments, as well as highlighting the intended arrangements for general surgery. She also outlined the investments that had been allocated to Bolton, Salford and Wigan and gave a summary of the key timescales associated with the transformation of services. The Council’s attention was also drawn to the key achievements to date and the plans for surgical ambulatory care and dermatology in the future.

Copies of the consultation document entitled “The development of a future, sustainable dermatology service for Bolton, Salford and Wigan” were distributed and the presentation outlined ways in which individuals can get involved.

A discussion was held around the capital investment and note was made of the increased costs associated with the building of facilities on the Salford Royal Hospital site. Confirmation was provided that the increased costs would be met by Salford Royal NHS FT and would not therefore impact on other organisations. Dr S Shah commented of the need for General Practitioners to be able to easily refer into Salford under the new model.

In response to a question from Mr A Hilton, Ms J Goodfellow summarised the work that has been undertaken to address the need for ambulance transfers between the various sites and particularly in relation to high needs patients. As a result, an additional £800k will be provided to commission additional ambulance activity from North West Ambulance Service NHS Trust.

The Chair summarised this item by thanking Ms J Goodfellow for her attendance and requested that she return at an appropriate point in time with an update, including how equity of access will be ensured, how a patient’s care record will follow them to different sites and updates on clinical leads, ambulance transfers and GP involvement.


Ms J Goodfellow left the meeting.

57/18 Holding to account: performance and finance reports

Copies of the performance and finance reports as at 31 August 2018 had been circulated with the agenda to inform the Council of the foundation trust’s current performance and to allow governors the opportunity to seek assurances from those non-executive directors present. The Chair reminded the Council of the scrutiny arrangements in place within the foundation trust, with scrutiny of clinical matters taking place at the Quality and Safety Committee, scrutiny of financial and operational matters taking place at the Finance and Performance Committee and workforce matters being scrutinised by the Workforce Committee.

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Mrs P Gregory suggested that it would be necessary to review the performance reports on a page-by-page basis, particularly given that there are a number of new governors now in post. The Chair commented that he felt this would be unnecessary as responsibility for performance rests with the Board of Directors and the purpose of providing the data to the Council is to allow governors to identify areas where it would wish to seek assurances from non-executive directors. It was therefore agreed that a workshop would be arranged to allow governors an opportunity to better understand the metrics used within the report.

ACTION: Company Secretary (to schedule)

It was also agreed that, for future meetings, copies of the board assurance framework would be provided rather than the detailed performance reports.

In response to a question from Mrs P Gregory surrounding the financial consequences of breaching the tumour pathway as shown on page 9 of the report, Mr M Guymer noted that financial consequences are determined based on the allocation of the breach but that the sums are minor in nature.

With regard to the wider process of holding non-executive directors to account, the Council considered it beneficial for the non-executive directors, on a rotational basis, to provide a summary of their recent activities to each meeting.

ACTION: Company Secretary (to schedule)

Mrs M Skilling noted that theatre effectiveness at Wrightington Hospital remained low, to which Mr M Guymer responded that the Finance and Performance Committee had scrutinised the Division of Specialist Services at its last meeting and confirmed that ongoing monitoring is undertaken by the committee. Mrs C Hudson also advised that work is ongoing to increase the number of cases that are undertaken on the Wrightington site.

Mrs P Gregory noted the reference in the finance report to the non-payment of fees by non-EU patients and Mr I Haythornthwaite confirmed that the matter had recently been discussed by the Audit Committee, where assurances had been provided that eligibility for treatment is being checked on arrival. The matter had been subject to internal audit and was now subject to a routine follow-up. Mr I Haythornthwaite noted that if there were a number of instances where concerns were raised, a re-audit would be arranged.

The Council received the reports and noted the content.

58/18 Non-Executive Director recruitment

The Chair noted that the recent death of Mr Neil Campbell had resulted in a non-executive director vacancy. He briefed the Council on the desire for the foundation trust to achieve University Hospital status in the future and the associated requirement for at least one non-executive director to be drawn from the faculty of an associated university. It was therefore recommended that this vacancy be filled by such a candidate.

Confirmation was provided that it was not intended for this to be an appointment by the university and that a selection process would still be undertaken, with the appointment remaining the responsibility of the Council of Governors.

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The Council of Governors APPROVED the proposal to seek candidates for the non-executive director vacancy that will satisfy the necessary requirements to enable the foundation trust to seek University Hospital status.

59/18 Proposal to extend non-executive director term of office

Prof T Warne withdrew from the meeting in light of his conflict of interest in this agenda item and in the following agenda item.

The Chair presented a report which had been circulated with the agenda to seek approval to extend the term of office of Prof T Warne by 12 months. He noted that Prof Warne would come to the end of his second term of office on 31 October 2019 and would normally not have been reappointed as he will have served six years as a non-executive director. Notwithstanding, he requested that the Council of Governors considers the exceptional nature of the presenting circumstances, as extending his term of office would facilitate stability and experience amongst the non-executive directors and allow a more progressive staggering of non-executive directors’ end dates.

Following consideration, the Council UNANIMOUSLY APPROVED the extension of Prof Warne’s appointment as non-executive director to 31 October 2020.

60/18 Appointment of Senior Independent Director

The Chair noted that the death of Mr Campbell had also left a vacancy for Senior Independent Director and recommended that Prof Warne be appointed to this role.

The Council of Governors UNANIMOUSLY APPROVED the appointment of Prof Warne as Senior Independent Director with immediate effect.

61/18 Approval of changes to the foundation trust’s constitution

The Company Secretary presented a report which had been circulated with the agenda to summarise the proposed changes to the foundation trust’s constitution. He reminded the Council that a working group had been established, comprising governors and non-executive directors, and that the group had recommended the changes.

Note was made of a typographical error within the draft constitution appended to the report and confirmation was provided that the reference at clause 11.7.2 of the constitution should be to the Local Medical Committee.

The Council of Governors UNANIMOUSLY APPROVED the amendments to the foundation trust’s constitution as presented.

62/18 Appointment of lead governor

The Company Secretary presented a report which had been circulated with the agenda to summarise the role of lead governor, which is one of being available to the regulator when the normal communication channels are not appropriate.

One nomination for the post was received from Mrs L Sykes and she was therefore ELECTED UNOPPOSED for a one-year term.

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63/18 Date, time and venue of next meeting

The next meeting of the Council of Governors will be held on 22 January 2019, 5.30pm at Royal Albert Edward Infirmary.

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Action log page 1

Action log Date of meeting

Minute ref. Item Action required Assigned to Target date Update

15 Oct 2018 53/18 Minutes of previous meeting

Provide updated information on the costs associated with WWL Solutions Chief Executive Jan 2019 A total of £300k was

paid. Action complete.

15 Oct 2018 57/18 Performance reports Arrange workshop for governors to outline the content of the performance report in more detail.

Company Secretary ASAP

Date being confirmed; update to be provided

at the meeting

15 Oct 2018 57/18 Performance reports Schedule NED updates on a rotational basis at future meetings.

Company Secretary Jan 2019 Action complete.

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Approved by the Council of Governors: October 2017 (updated Jan 2019) 1

Council of Governors: cycle of business 2018-21

THE STATUTORY FUNCTIONS OF THE COUNCIL OF GOVERNORS

Under National Health Service Act 2006:

To appoint and, if appropriate, remove the Chair To appoint and, if appropriate, remove the other non-executive directors To decide the remuneration and allowances, and other terms and

conditions of office, of the Chair and other NEDs To approve the appointment of the Chief Executive To appoint and, if appropriate, remove the NHS Foundation Trust’s

external auditor To receive the NHS Foundation Trust’s annual accounts, any report of

the auditor on them and the annual report In preparing the NHS Foundation Trust’s forward plan, the board of directors must have regard to the views of the council of governors.

Under Health and Social Care Act 2012:

To hold the non-executive directors individually and collectively to account for the performance of the board of directors

To represent the interests of the members of the Trust as a whole and of the public

To approve “significant transactions” as defined within the constitution To approve any application by the Trust to enter into a merger, acquisition,

separation or dissolution To decide whether the FT’s private patient work would significantly interfere

with its principal purpose, i.e. the provision of goods and services for the health service in England or the performance of its other functions

To approve any proposed increase in private patient income of 5% or more in any financial year

Jointly with the board of directors, to approve amendments to the FT’s constitution

2018-19 2019-20 2020-21

Item Presenter Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan

GENERAL ITEMS

Apologies for absence Chair

Declaration of interests Chair

Minutes of previous meeting Chair

Review of action log Chair

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2

2018-19 2019-20 2020-21


HOLDING TO ACCOUNT

Board assurance framework (to inform discussions) Non-Executive Director

Non-Executive Director reports (on rotational basis) Non-Executive Director

Leadership safety walkabout report Non-Executive Director

Arrangements for winter Director of Ops and Performance

INFLUENCING STRATEGY

The forward plan (held as workshop) Director of Strategy and Planning

Feb

Agreement of local indicator for quality report Director of Governance

REPRESENTING THE INTERESTS OF MEMBERS AND THE PUBLIC

Approval of Membership Engagement Strategy Membership Engagement Group

Review of Membership Engagement Strategy Membership Engagement Group

RECEIVING THE ANNUAL REPORT AND ACCOUNTS

Annual report and accounts Chief Executive and auditor

APPOINTMENT, REMUNERATION AND TERMS OF SERVICE OF THE NON-EXECUTIVE DIRECTORS

Chair’s appraisal Senior Independent Director

Non-executive directors’ appraisals Chair

Review of terms and conditions of non-executive directors Company Secretary

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3

2018-19 2019-20 2020-21


Appointment of Chair Senior Independent Director

(Re)appointment of non-executive directors Chair TW

MG +3

APPOINTMENT OF EXTERNAL AUDITOR

Considering extension of contract for external auditor Chair of Sub-Group

ITEMS REQUIRED BY THE CONSTITUTION OF NHS FOUNDATION TRUST CODE OF GOVERNANCE

Review policy on the composition of the council of governors Company Secretary

Review policy on the composition of the non-executive directors Company Secretary

Review council/board engagement policy Company Secretary

Review of council effectiveness Company Secretary

Review of CoG Register of Interests Company Secretary

Appointment of lead governor Company Secretary

GOOD PRACTICE ITEMS

Review of constitution Company Secretary

Review of CoG Standing Orders Company Secretary

Review of code of conduct Company Secretary

Review of cycle of business Company Secretary

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Patients: Every patient receives the best possible care

Executive lead(s): Director of Nursing Medical Director

Reviewing committee: Quality and Safety Committee DELIVERY CONFIDENCE WEIGHTED DASHBOARD

Strategic importance: Provision of safe, effective, high-quality and evidence based care is at the heart of everything we do.

CURRENT MONTH: MONTH: YTD:

2.68

3.61

Sources of assurance: Scrutiny by Quality and Safety

Committee Scrutiny by Board of Directors Use of internal and external auditors

Escalation of emerging risks Divisional performance reviews REMC

ROLLING TREND: ROLLING TREND:

2.48

2.56

2.27

2.27

Nov 2018

Oct 2018

Sep 2018

Jul 2018

Nov 2018

Oct 2018

Sep 2018

Jul 2018

Individual risks Original

Score Mitigations Current score

Failure to document patient care through the production and maintenance of accurate and contemporaneous clinical records. 16 Risk escalated and subject to review by

REMC 16

There is a risk that patients with infectious conditions may not be able to be appropriately isolated in a timely manner due to a lack of side rooms 20 GM pipeline bid for additional beds

including side rooms 20

Inability to recruit to required staffing levels, in particular nurse staffing (numerous entries) 20 Board and Workforce Cttee briefed on this issue, various options being pursued 20

Risk of injury/equipment failure/fire cause by failure of celling pendants in ICH/HDU, as a result of excessive weight, beyond safe 16 Previously escalated to Q&S. Business

case and decant plan being prepared 20

8 out of 16 cardiac telemetry transmitters broken and out of service support period 20 Escalated to Q&S 20

Upgrade to Somerset cancer registry interface on PAS has potential to delay cancer diagnosis 20 New risk, further analysis being undertaken 20

Only 1 maternity theatre available for elective and emergency cases 20 New risk, further analysis being undertaken 20

NARRATIVE

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PATIENTS: WEIGHTED DASHBOARD

Performance Measure Result 1 (Green)

2 (Amber- Green)

3 (Amber)

4 (Amber-

Red) 5

(Red) Weight Month Year Source

Harm free care %VTE Assessments undertaken within 24 hours of admission (indicative data)

96.6% M 97.2% Y ≥95% 94% -

90% 89%-85% 84%-80% <80% 1 1 x 1 = 1 1 x 1 = 1 Perf. Report (Nov 2018)

Harm free care No. Serious Falls 1 Mth 6 YTD

0 1

(MTD) 2 or 3 >3 (YTD) 2 3 x 2 = 6 5 x 2 = 10 Perf. Report

(Nov 2018)

Patient Safety % of 'red sepsis' patients receiving antibiotics within 1 hour 87.2% ≥95% 94% -

90% 89%-85% 84%-80% <80% 1 3 x 1 = 3 --- A&E Monthly Audits

Patient Safety No. of Never Events 1 Mth 5 YTD 0 1 3 5 x 3 = 15 5 x 3 = 15 Perf. Report

(Nov 2018)

Patient Safety 100% compliance with appropriate frequency of observations 92.4% 100% 99-95% 94-90% 89-80% <80% 1 3 x 1 = 3 --- CCOT quarterly

Audits

Infection Control No. of MRSA 0 Month 1 YTD

0 (MTD) 1

(YTD) 3 1 x 3 = 3 5 x 3 = 15 Perf. Report (Nov 2018)

Infection Control No. of C. diff Lapses in Care 1 month 1 year 0 1 2 3 >4 2 2 x 2 = 4 2 x 2 = 4 Perf. Report

(Nov 2018)

Patient Experience % of patients recommending WWL for care 94% ≥95% 94% - 90% 89%-85% 84%-80% <80% 2 2 x 2 = 4 --- Monthly FFT

(Oct 2018)

Patient Experience % of patients feeling involved with decisions about their discharge 88.2% ≥95% 94% -

90% 89%-85% 84%-80% <80% 1 3 x 1 = 3 --- Perf. Report (Nov 2018)

Patient Experience % of complaints responded to within the timescale agreed with the patient

72.5% M 74.9% Y ≥95% 94% -

90% 89%-85% 84%-80% <80% 1 5 x 1 = 5 5 x 1 = 5 Perf. Report (Nov 2018)

Mortality HSMR 102% M 114% Y ≤100 101-105

(MTD) 106-110 111-115 (YTD) >115 3 2 x 3 = 6 4 x 3 = 12 Perf. Report

(Aug 2018)

Mortality SHMI 111.9% ≤100 101-105 106-110 111-115 >115 1 4 x 1 = 4 1 x 1 = 1 Perf. Report (June 2018)

Mortality No. of PFDs 0 0 1 2 3 >4 2 1 x 2 = 2 1 x 2 = 2 Perf. Report (Nov 2018)

Medicines Management

% of critical medicines prescribed within 24 hours of admission or before the patient is transferred to a new area

Not avail. 100% 99-95% 94-90% 89-80% <80% --- --- --- HIS

Medicines Management

% of completed medicines reconciliation within 24 hours 87.2% 100% 99-95% 94-90% 89-80% <80% 2 4 x 2 = 8 --- Pharmacy

(Oct 2018)

Total 67(/25) 65(/18)

Average 2.68 3.61

.

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People: Everyone has the opportunity to achieve their purpose

Executive lead(s): Director of Workforce Reviewing

committee: Workforce Committee DELIVERY CONFIDENCE WEIGHTED DASHBOARD

Strategic importance:

Every member of staff has the opportunity to achieve their purpose. Safe and effective workforce to meet service needs

MONTH: YTD:

4

4

Sources of assurance:

Scrutiny by Workforce Committee

Scrutiny by Board of Directors Use of internal and external

auditors

Escalation of emerging risks Exec-to-exec meetings REMC


4

3.38

3.5

3.38

Nov 2018

Oct 2018

Sep 2018

Jul 2018

Nov 2018

Oct 2018

Sep 2018

Jul 2018



HR 84 - Ability to recruit and retain to required staffing levels for service delivery and service development plans 20 International recruitment, nursing incentive schemes, return to practice

programmes, nursing pipeline 20

HR 86 - Lack of assurance around medical job plans will lead to both negative service and financial impacts for the Trust

12 E-job planning 16

HR93 – Breaching the NHSI agency ceiling 12 Temporary staffing protocols, nursing incentive schemes, international recruitment, Steps 4 Wellness programmes, regional collaboration 16

HR101 – Access to intranet (Wally) 16 Liaison between IT, system provider and staff engagement to resolve Active Directory problems. Single sign on implementation 16

HR102 - Re-building the relationship with E&F staff, the wider organisation and the Unions following WWL Solutions

20 Development of new recognition agreement. Commitment to partnership working. Early engagement regarding E&F CIP schemes and consultations. 1:1’s with new regional officer (Unison)

20

HR80 – meeting the Government Apprenticeship targets 10 Prioritisation programme. Workforce Committee discussions and agreement around the apprenticeship strategy – target will not be delivered

15

HR06 – sickness absence above target (and not delivering 20% reduction as specified in BIG scheme) 12 Escalation from divisional to corporate risk due to be discussed at

REMC. 15

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NARRATIVE The weighted dashboard overleaf has been updated and the month to which data relates has been included.

The October Pulse survey has seen a significant deterioration across almost all engagement enablers, behaviours and feelings. The recommendation as a place to work is at its lowest ever reported rate within the Trust and recommendation for treatment has also deteriorated significantly.

Sickness absence remains over the Trust target of 4% and bank / agency expenditure has increased significantly in October. Nursing vacancies within medicine are now 5% higher than 12 month ago.

Confidence in delivery has deteriorated to amber-red. A workforce summit has been proposed to help facilitate actions in response.

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PEOPLE: WEIGHTED DASHBOARD


2 (Amber- Green)

3 (Amber)

4 (Amber-

Red) 5


Go Engage Friends and family test (work) 63.25% ≥95% 72-94% 68-71% 64-67% ≤63% 2 5 x 2 = 10 5 x 2 = 10 Workforce team

Employment Essentials Turnover 8.72% ≤8% 8.01-

8.5% 8.51-9% 9.01-9.9% ≥10% 1 2 x 1 = 2 2 x 1 = 2 Workforce team

Employment Essentials Leavers with less than 12 months’ service 17.12% ≤10% 11-14% 15-20% 21-24% ≥25% 1 3 x 1 = 3 3 x 1 = 3 Workforce team

Route Planner PDR completion 88.2% ≥95% 86-94% 78-85% 73-77% ≤72% 1 2 x 1 = 2 2 x 1 = 2 Workforce team

Steps 4 Wellness Energy levels 3.39 ≥4.00 3.7-3.99 3.61-3.69 3.47-3.6 ≤3.46 1 5 x 1 = 5 5 x 1 = 5 Workforce team

Go Engage Cultural enabler score 32.41 ≥36 35.01-35.9 34.01-35 33.61-34 ≤33.6 2 5 x 2 = 10 5 x 2 = 10 Workforce team

Total 8 32 32

Average 4 4

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Performance data as at 30 November 2018

Performance: We aim to be in the top 10%

Executive lead(s):

Director of Ops & Performance Director of Finance & Informatics

Reviewing committee:

Finance and Performance Committee DELIVERY CONFIDENCE WEIGHTED DASHBOARD

Strategic importance:

Delivery of operational and finance performance underpins clinical care, facilitates the patient journey and enhances the patient experience, and affects the organisation’s financial performance.

MONTH: YTD:

2.63

2.30

--Sources of assurance:

Scrutiny by Finance and Performance Committee

Scrutiny by Board of Directors Use of internal and external

auditors

Escalation of emerging risks Divisional performance reviews REMC


2.20

2.09

2.61

2.79

Oct 2018

Sep 2018

Jul 2018

Jun 2018

Oct 2018

Sep 2018

Jul 2018

Jun 2018



Risk of failure/vulnerability of back-end infrastructure resulting in no access to IT systems 20 Reviewed by REMC. Business case to be considered by F&P committee 20

Delivery of cost improvement programme 20 Reviewed by F&P committee regularly, focus on transformation programme 20

Risk of forecast and recurrent plans for 2018/19 not being achieved 20 Reviewed by F&P on a monthly basis. 20

Numerous IT-related risks 16 Reviewed by REMC. 16

Corroded copper pipe to water system 16 Reviewed by REMC 16

NARRATIVE **Please note that the weightings allocated to the metrics in the weighted dashboard were reviewed in September 2018 and therefore direct comparison with earlier periods is not possible. An additional metric relating to CIP performance was added to the dashboard in October 2018**

For the IT metric, this has been carried forward from November’s BAF due to the close proximity of the meetings. It should be noted that many of the projects not delivered on time were due to awaiting input from suppliers or input/authorisation from internal departments. All have been re-planned and there are only 2 projects in amber and one in red.

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PERFORMANCE: WEIGHTED DASHBOARD Performance data as at: 30 NOVEMBER 2018


2 (Amber- Green)

3 (Amber)

4 (Amber-

Red) 5


4-hour standard 95% of patients should be admitted, transferred or discharged within 4 hours of arrival at A&E

80.80% Mth 87.13% YTD ≥95% 94.9-90% 89.9-80%

Mth & YTD 79.9-70% ≤70% 2 3 x 2 = 6 3 x 2 = 6 BI (Nov 2018)

12-hour operational standard

No patient requiring emergency admission will wait 12 hours in A&E

0 Mth 0 YTD

0 Mth & YTD 1 2 1 x 2 = 2 1 x 2 = 2 BI (Nov 2018)

Ambulance handover standard

All handovers between ambulance and A&E must take place within 15 mins with none waiting >60m

61 >60m Mth 623 >60m

YTD ≤ 15 mins 15-30

mins 30-59 mins

>60 mins mth & YTD 1 5 x 1 = 5 5 x 1 = 5 BI (Nov 2018)

Cancer treatment times

85% should wait no more than 62 days from urgent referrer to first definitive treatment

89.17% Mth 89.11% YTD

≥85% Mth & YTD ≤84.9% 2 1 x 2 = 2 1 x 2 = 2 BI (Nov 2018)

18-week RTT 92% on incomplete RTT pathways (yet to start treatment) should wait no more than 18 weeks

93.18% Mth 93.75% YTD

≥92% Mth & YTD ≤91.9% 1 1 x 1 = 1 1 x 1 = 1 BI (Nov 2018)

52-week RTT Zero tolerance for patient waits over 52 weeks on an incomplete pathway

0 Mth 0 YTD

0 Mth & YTD 1 2 1 x 2 = 2 1 x 2 = 2 BI (Nov 2018)

Diagnostic waiting times

99% of service users waiting for a diagnostic test should receive it within 6 weeks of referral

99.18% Mth 99.15% YTD

≥99% (mth) ≤98.9% 1 1 x 1 = 1 1 x 1 = 1 BI (Nov 2018)

Paper switch off programme

By 1 Oct 2018, NHS E-referral will be used for all relevant consultant-led first OPD appointments All using 100% ≤99.9% 1 1 x 1 = 1 1 x 1 = 1 Complete

Control total achievement

Forecast position: Achieve finance control total before STP

Forecast 3 quarters

Achieve 4 quarters

3 quarters

2 quarters 1 quarter 0

quarters 4 2 x 4 = 8 2 x 4 = 8 Forecast

Control total achievement

Forecast position: Achieve A&E control total trajectory

Forecast 2 quarters

Achieve 4 quarters

3 quarters



Use of resources risk rating

Forecast position: Achieve use of resources risk rating as per plan

Forecast 2 quarters

Achieve 4 quarters

3 quarters



Transformation CIP delivery against target >30% Mth 7% YTD

Achieved (YTD)

Fail by <10%

Fail by 10-20%

Fail by 20-30%

Fail by >30% 3 5 x 3 = 15 2 x 3 = 6 Finance report

IT Completion of agreed IT priorities in line with plan 62% 100% 90-99% 80-89% 70-79% ≤70% 2 5 x 2 = 10 5 x 2 = 10 IT department

Total 27 71 62

Average 2.63 2.30

2/2 18/27

Partnerships: We work together for the best patient outcomes

Executive lead(s): Director of Strategy and Planning Reviewing

committee: Board of Directors DELIVERY CONFIDENCE WEIGHTED DASHBOARD

Strategic importance: Effective partnership working underpins our strategic direction

MONTH: YTD:

3.08

2.95

Sources of assurance:

Scrutiny by committee Scrutiny by Board of Directors Use of internal and external

auditors

Escalation of emerging risks Exec-to-exec meetings REMC


2.92

2.58

3.00

2.91

Nov 2018

Oct 2018

Sep 2018

Jul 2018

Oct 2018

Sep 2018

Jul 2018

Jun 2018



Lack of Tier 4 CAMHS beds 16 Escalated to Q&S 20

Transfer of community services from Bridgewater NHS FT to WWL 20 Risk assessment discussed and risk score agreed. Included on risk register 20

Non-achievement of KPIs relating to cellular pathology 16 Shared services board to be re-established 16

NARRATIVE Delivery confidence has reduced as a result of board discussions on Healthier Together and the potential consequences of this, together with the temporary suspension of the orthopaedic pilot with Bolton NHS FT.

1/2 19/27

PARTNERSHIPS: WEIGHTED DASHBOARD


2 (Amber- Green)

3 (Amber)

4 (Amber-

Red) 5


Transformation Support to BIG projects Mild problems Fully provided

Mostly provided

Mild problems

Moderate problems

Major problems 2 3 x 2 = 6 3 x 2 = 6 Self-assessment

Research Numbers recruited against target Ahead of target Target complete

Ahead of target On track Off target Way off

target 1 1 x 1 = 1 1 x 1 = 1 R&D report

Bolton partnership Progress on 8 key projects Mod. concern M Mild concerns Yr

Fully on track

Almost on track

Mild concerns

Moderate concerns

Major concerns 3 4 x 3 = 12 3 x 3 = 9 Self-assessment

Locality partnership Locality plan performance matrix Mild concerns Fully on track

Almost on track

Mild concerns

Moderate concerns


Locality partnership Transformation of hospital care Mild concerns Fully on track

Almost on track

Mild concerns

Moderate concerns


Locality partnership Healthier Wigan partnership score Almost on track Fully on track

Almost on track

Mild concerns

Moderate concerns


Locality partnership Community services transfer Moderate concerns

Fully on track

Almost on track

Mild concerns

Moderate concerns


NW Sector p/ship Highlight report for NWSP Moderate concerns

Fully on track

Almost on track

Mild concerns

Moderate concerns


GM partnership Combined theme 3 status Mild concerns Fully on track

Almost on track

Mild concerns

Moderate concerns


GM partnership Orthopaedic theme 3 status Almost on track Fully on track

Almost on track

Mild concerns

Moderate concerns


GM partnership Cardiology theme 3 status Almost on track Fully on track

Almost on track

Mild concerns

Moderate concerns


Total 24 74 71

Average 3.08 2.95

2/2 20/27

Leadership Safety Walkround

Quarterly Report Council of Governors Meeting

Carrie McManus - Patient Safety Manager

1/7 21/27

Introduction

Visible leadership is an essential part of an engaged organisation. It allows frontline staff to

see and interact with, executive and non-executive directors on a regular basis, therefore

breaking down those barriers to good communication including hierarchy and promoting an

open and honest culture. It is essential to walk the walk as well as talk the talk if culture is to

change.

Leadership safety walkrounds were first introduced in the USA and have proved to be a

useful tool in promoting a more proactive safety culture. They allow frontline staff access to

executives and it allows executives, non-executive directors and governors to experience

first-hand the safety concerns that staff have. They promote a culture of openness and

trust. Opportunities to improve safety will be identified and staff will be empowered to take

these opportunities and make them reality if this is possible, where it is not then an

explanation will be given and reasons as to why therefore creating a trusting and open

relationship. It will also signal to staff the importance that the senior team place on safety.

The walkrounds can take place in any area that impacts on patient care either directly or

indirectly, in other words any area of the hospital or outpatients sites.

Dates & Areas of Visit:

• 14 September Wrightington Main Theatres

• 16 October 2018 ICU

• 5 November 2018 Orrell Ward

Overall Summary

Wrightington Theatres

The tour of the Department was led by Theatre Matron, Wendy McNair and she provided

the team with an excellent walk through on the journey of a patient attending theatre.

During the interaction with staff there was a general consensus that they felt listened to and

well supported by senior staff and they would be happy for themselves or any member of

their family to be treated at Wrightington Hospital. The staff appeared to work well

together and communicated well within their team and within the division more widely.

They came across as energised, passionate and although they felt pressured due to the

2/7 22/27

operational demands this did not appear to faze them; they gave the impression that they

deal with pressures calmly and do not allow things to have too much of an effect on the

team dynamics.

Actions to take away:-

1. The first impression of the department was that aesthetically the department was

lacklustre and in need of some maintenance/redecoration (holes in doors & chipped

paint). – This action is currently still outstanding but will be addressed by the Estates

Walkaround that is scheduled to take place on the 14 January 2019.

2. The staff discussed the new Health Information System (HIS) and although it is now

integrated across the Trust and provides real time information across teams and

services, within theatre the system is only utilised for the prescribing and

administration of medication. The team have explained that HIS does have the

functionality to be able to improve theatre effectiveness yet currently they are

required to duplicate information on several systems which is proving time

consuming and non-productive. The team have highlighted that currently the

systems that are in theatre cannot be integrated which results in duplication and

unnecessary time spent by staff inputting this information into several systems. This

action has currently not been resolved.

ICU

The tour of the Department was led by Rebecca Worthington, ICU Quality Lead and she

provided an excellent explanation of a patient’s journey on ICU. The team observed

effective team working with clear visible leadership within the unit. Staff spoke positively

about the care and treatment provided, with all staff stating they would be happy for

themselves or a family member to be treated on the unit. The team were particularly

impressed with the cascade of information to staff working across the unit. Rebecca

explained the electronic screen in the staff room which delivers subtle key messages to

staff. Reassuringly, the most recent Internal Patient Safety Notice relating to the Air Flow

Never Event was clearly displayed, providing the appropriate information for staff without it

being overwhelming and losing the key message.

3/7 23/27


1. One area of concern that was highlighted by the visiting team was the current

progression with the replacement of the HDU ceiling pendants. The team were

aware of the current risk assessment and requested an update on the progress of

the business case for replacement of this equipment. – This actions is still

outstanding, update still awaitied

2. ITU staff were asked what would be on their ‘wish list’. The general consensus was

for the Visitors Room to be more spacious with more amenities available for

relatives and also for their staff room to be redecorated with the old shabby chairs

replaced. – Chairs purchased through 3 wishes for the visitors room have been

replaced allowing some of the older furniture to be relocated to the staff room

3. The team found the role of Quality Lead very interesting and a role that was

proactive and not reactive in addressing concerns so to prevent errors/harm to

patients before they occurred. Tony (Non-Executive Director) asked Rebecca would

she present at a future Q&S meeting to share what her role entails within ITU. –

Rebecca presented at Q&S on 12 December 2018

4. The bitesize training facilitated by the Practice Educator was commended by the

team and the Company Secretary agreed to provide training for staff in relation to

GDPR. – This training has been scheduledto take place on the 15 January 2019

Orrell Ward

The tour of the Department was led by Kay MacDonald, Deputy Ward Manager and she

provided the team with an excellent explanation of the speciality of the patients nursed

here, she provided us with a commendable explanation of the patient flow process and how

this works effectively when the ward is being utilised as it was intended.

The team observed effective team working with clear visible leadership on the ward. Staff

spoke positively about the care and treatment provided, with all staff stating they would be

happy for themselves or a family member to be treated on the ward.


1. The Ward staff were asked what would be on their ‘wish list’. There was general

consensus that since the introduction of the Trainee Nursing Associates (TNA) there

has been depletion in the wards establishment for Health Care Assistants. The staff

4/7 24/27

therefore, would like additional HCA for the ward to support the patient

dependency. – An update on progress is only due for February 2019

2. The staff explained that at times the job can be very emotional especially and can be

hard to stand back from the situation. All staff were interested to take part in the

current ongoing ‘Power Pause and Power to Recover’ pilot. This is an application that

gives staff permission to step away from what is going on and press the reset button.

– Staff Engagement have advised that if the pilot is to continue then Orrell Ward will

be contacted and involved. An update will be provided on progress in February

All actions identified via these visits are monitored via CQEC. The action plans developed for

ICU and Wrightingon Theatres are due to be tabled in January 2019 and the action plan for

Orrell will be discussed at CQEC in February 2019.

5/7 25/27

6/7 26/27

Issue Owner Feedback method Progress to date Completed

• Business case progress for replacement of HDU Pendants

• Sean Curran

DDOP Surgery

• Discussion at Risk

Management Group and feedback to CQEC in February 2019

• Feasibility for

replacement of staff chairs for staff room on ICU

• Sean Curran

DDOP Surgery

• For consideration

and update at CQEC in February 2019

• Quality Lead ICU to

attend Q&S to discuss role and current initiatives in ICU

• Rebecca

Worthington Quality Lead ICU

• To schedule

meeting with Nina Guymer (Deputy Company Secretary)

• Company Secretary to arrange training session on GDPR for staff on ITU

• Paul Howard

Company Secretary

• Training session to

be scheduled with Janet Enston (Practice Educator)

7/7 27/27

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