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1 ROYAL ALBERT EDWARD INFIRMARY, WIGAN LANE, WIGAN, WN1 2NN Telephone: 01942 822027 Fax: 01942 822158 Email: [email protected] Our Ref: LH/HH 24 th July 2013 Dear Colleague Public Meeting of Wrightington Wigan and Leigh NHS Foundation Trust Board I am writing to confirm that the next meeting of the Foundation Trust Board will be in the Trust Board Room, Trust Headquarters, Wigan Infirmary on Wednesday 31 st July 2013 at 9.45am. Yours sincerely For L Higgins Chairman AGENDA Timings Presentations: No formal presentations this meeting 1. Chairman’s opening remarks - LH Verbal Report 2 2. Apologies Silas Nicholls 1 3. Declaration of interests - ALL 1 4. Patient story case study A patient story will be read to Board members 5 Strategy & Planning 5. Chief Executive’s report & matters for board to note - AF Verbal report 5 6. ‘Healthier Together – AF/SN Verbal report 5 Quality & Performance Monitoring 7. Performance report month 3 – FN / PJ a. BAF objective – successfully build effective stakeholder relationships (esp. GP consortia) current score 16 Trust_Performance Report_June 1314_Fi For discussion 10 5

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Page 1: ROYAL ALBERT EDWARD INFIRMARY, WIGAN LANE, WIGAN, WN1 … · A female doctor came who didn’t have any information, she hadn’t even been given my husband’s name or file. My husband

1

ROYAL ALBERT EDWARD INFIRMARY, WIGAN LANE, WIGAN, WN1 2NN Telephone: 01942 822027 Fax: 01942 822158 Email: [email protected] Our Ref: LH/HH 24th July 2013 Dear Colleague

Public Meeting of Wrightington Wigan and Leigh NHS Foundation Trust Board

I am writing to confirm that the next meeting of the Foundation Trust Board will be in the Trust Board

Room, Trust Headquarters, Wigan Infirmary on Wednesday 31st July 2013 at 9.45am. Yours sincerely

For L Higgins Chairman

AGENDA Timings

Presentations: No formal presentations this meeting

1. Chairman’s opening remarks - LH Verbal Report

2

2. Apologies

Silas Nicholls 1

3. Declaration of interests - ALL

1

4. Patient story case study A patient story will be read to Board members

5

Strategy & Planning 5. Chief Executive’s report & matters for

board to note - AF

Verbal report 5

6. ‘Healthier Together – AF/SN

Verbal report 5

Quality & Performance Monitoring 7. Performance report month 3 – FN /

PJ a. BAF objective – successfully

build effective stakeholder relationships (esp. GP consortia) – current score 16

Trust_Performance Report_June 1314_Fi For discussion

10 5

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2

b. Negotiate a successful service

model with neighbouring Trusts for Healthier Together by Summer 2013 – current score 15

c. Stakeholder relationship update (by exception)

For discussion

8. Finance report month 3 - RF

Jun 2013 Board Report Final PUBLIC.p

10

Governance & Administration 9. Minutes of the last public meeting

held on 26.06.13– ALL TB Minutes 26 06

13_PART 1_APPLB.pd

2

10. Matters arising

a) Action sheet 26.06.13

b) Update on progress with bereavement team business case and improvements to facilities – PJ (verbal)

Action Log 26.06 P1.pdf

5

Matters for Report The following items are for information and require formal Board approval. Board members requiring further information on any of the items for Board approval are requested to contact the items sponsor for further information in advance of the Board meeting. 11. Pathology ESL / Cancer Care Unit

Business Case – Ian Bradley BC1314-0018 -

Cancer Care ESL Ser

10

12. Monitor Q1 return – HH

Monitor Q1 Declaration FINAL.pd

10

13. R&D at Wrightington reporting – RF

Verbal update and for discussion 10

For Information Only. All items are to be taken by exception. Board members requiring further information on any of the items below are requested to contact the item’s sponsor for further information in advance of the Board meeting.

Total time for items 10 14. Minutes of the Finance & Investment

Committee - RA FI mins_19.06.pdf

15. Minutes of the Audit Committee - GB

AUDIT COMM MINUTES - 22 05 13 A

16. Minutes of the Quality & Safety Committee - LB QS MINS_12 06

13_APPLB.pdf

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3

17. Minutes of the Shared Services Board– RA

Next meeting scheduled for 30th July 2013

18. Minutes of the HR Committee –- RC

Next meeting scheduled for the 12th August 2013

19. Minutes of the IM&T Strategy Committee - CPS

IMT MINS CPS approved 20 05 13.pd

20. NHS Constitution Q1 – HH

NHS Constitution Patients and public se

21. Use of company seal Q1 – HH

COMPANY SEAL Q1.pdf

22. Safeguarding children / vulnerable adults annual reports – PJ/UP

TB Front Sheet Safeguarding children

Safeguarding Vulnerable Adults & C

23. Key successes / risks as discussed at the meeting - ALL

For discussion 5

24. Exclusion of the Public: The following motion will be proposed: RESOLVED: That representatives of the press and other members of the public, be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.”

25. Date of Next Meeting: The next public meeting is to be held on 28.08.13

Total 96 mins

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Trust Board

Agenda Item 7. Date: 31.07.13

Title of Report Performance Exception Report Month 3

Purpose of the report and the key issues for consideration/decision

Assure the Board of Compliance to key standards Produce exception reports for assurance that areas of concern are under

close scrutiny with interventions in place

Prepared by: Name & Title

Business Intelligence

Presented by: Fiona Noden, Director of Performance Pauline Jones, Director of Nursing

Action Required (please X)

Approve Adopt Receive for information

x

Strategic/Corporate Objective(s) supported by this paper

1. Performance – zero points on the MCF 3.1. Maintain CQC registration without conditions.

Is this on the Trust’s risk register?

No

Yes

x If Yes, Score

20/15

Which Standards apply to this report?

CQC all NHSLA all BAF Objectives As above WWL wheel Performance

Have all implications related to this report been considered?

Finance Revenue & Capital x Equality & Diversity x National Policy/Legislation x Patient Experience x NHS Contract x Governance & Risk

Management x

Human Resources x Terms of Authorisation x Consultation/Communication x Human Rights x Other: Carbon Reduction x

Previous Meetings

Please insert the date the paper was presented next to the relevant group

Meeting Point

Audit Committee

Quality & Safety

Committee

Finance & Investment Committee

IM&T Strategy

Committee

HR Committee

Management Board

NED Other

N/A N/A N/A 24.07.13 N/A N/A N/A N/A N/A

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Trust BoardPerformance Report 2013/14

June (M3)

Final_Version 1.0

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Patient Story:We wish to complain about the way we were treated on coming into Wigan Hospital on the 29 April 2013.We received a phone call about 12:30 lunch time from the Bed Manager, asking for my husband to come to the ward at 4:30pm to be admitted. We arrived at the help desk in the front foyer at about 4:15-4:20pm and asked where we had to go as we had never visited the hospital before. The lady came with us and on arriving on the ward we were greeted with staff who knew nothing about my husband; they were unaware of who had asked him to come and what he was there for. There was no Bed. We were taken to the Discharge Lounge and deposited with nothing communicated to the staff there. We were then asked by the staff on the Discharge Lounge what time we were being picked up and by whom. We explained we had been sent from the ward to wait for a bed and were then asked why, we explained that it was because my husband would be given food here. We remained in the Discharge Lounge until 8:30pm when the staff nurse went off duty, but she did escort us back to the ward to make sure that they were ready for us. We were taken to a room that was being cleaned, the previous patient having only just gone. The nurse was washing the bed as required and while the bed was still wet she put on the clean bedding.We were still at the bed at 9:30pm, nobody had been to speak to us, nobody taking the medication we had brought in and nobody booking in my husband. We were completely ignored. Eventually a male member of staff asked why we were still there at this time of night and we explained what had happened. When the senior nurse came to see us she was not happy as she knew nothing about my husband waiting to be booked in. As for the medication she would have to bleep a doctor as the nursing staff couldn’t book them in.A female doctor came who didn’t have any information, she hadn’t even been given my husband’s name or file. My husband is a diabetic and this could have caused a lot of other problems. The doctor did take the medications and the list we provided, when they are taken and the dosage.The following day the Consultant was informed by his secretary that my husband had been at the hospital the previous day, as arranged, but he had not been informed and was not very happy as he just thought that my husband had not kept the arrangements for the admission.My husband did not receive a wrist band until the afternoon of the following day, so I also wish to know how they gave him medication without this fail safe check.

Our Response/Action taken – taking into account what we didn’t do and what we are doing about it:Apologies were offered for the failure in communication, as a catalogue of unacceptable failures in communication have been recognised. It was acknowledged that this has given a poor impression of this hospital to the patient and his family. An explanation should have been given to keep the patient informed at each stage. An explanation was given regarding the changing of the bed. Communication between the wards and staff will be highlighted within the 5 Point Communication File on the ward, which each member of staff signing this off to confirm they have read this. Name Bands should be issued at the start of the admission process and spot audits will be undertaken by the Matrons and Head of Nursing to check name band compliance.

What we should have done:Communicated the correct information to the appropriate staff to ensure that there was a seamless admission process. Even if there was no immediate bed to allocate to the patient, he should have been kept informed throughout this time. After being placed in the Discharge Lounge, contact should have been made with the medical staff to ensure the patient was seen whilst on the Discharge Lounge. This would have ensured that medications were checked promptly and ordered if necessary to avoid any delay. The Consultant should have been informed that the patient had been admitted. A wrist band should have been issued as soon as possible.

What we didn’t do:There was a complete breakdown in communication that had a knock on effect. The ward sister did not inform the other staff of the planned admission. This communication failure continued to the Discharge Lounge, to the Medical staff and the Consultant in charge of care. Hospital Policy for the issuing of medication was not followed.

Patient Story

Final_Version 1.0

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Final_Version 1.0

Page 1 Executive Dashboard 1-22 Executive Headlines 33 Board Assurance Framework 44 Monitor Dashboard 510 NHS Outcomes Framework 65 Safe 7-136 Effective 14-217 Caring 22-248 HR 25-28

Performance Performance

The graphs on Pages 15 & 16 have been re-ordered to reflect Patent Flows.

NHS Outcomes Framework has been added, and will be reported at the end of each Quarter.

The Outpatient Dashboard has been removed pending being re-designed.The Data Quality Dashboard has been removed pending being re-designed.

A new page showing compliance with NRLS reporting has been added to the Safe section.

The Monitor Compliance Framework has been re-designed. Please note that this is not final and may change following clarification with the Monitor Compliance Team.

Contents

Key Changes:

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Indicator Trend Indicator Trend Indicator Trend

Infection Control: CDT - Threshold 25 Cases

4 in-month, 14 ytd

Total time in A&E: Less Than 4 Hours (Threshold - Monitor 95%, Internal 98%)

96.85% Hospital Outpatient Cancellations (Threshold 5%) 6.59%

Infection Control: MRSA - Threshold 0 Cases

0 in-month, 1 ytd

Financial Risk Rating - (Each Quarter\Cumulative Year End Threshold 3)

4 in-month, 3 ytd

Cancelled Operations (Threshold <=0.8%) 1.35%

HSMR (Threshold <=90, Internal 83) 81.5

Monitor Compliance Framework Risk Rating (Cumulative Year End threshold 0)

2.0 Feedback Scores - Real Time Patient Survey (Threshold >=90%) 84.04%

Never Events (Threshold = 0) 0 Maximum time of 18 weeks from point of referral to treatment - admitted (Threshold 90%)

91.88% Feedback Scores - Real Time Patient Survey: Availability of Healthy Food (Threshold >=90%)

89.27%

HR: Temporary Staffing (Threshold £825,696) £974,987

Patients on an 18 week pathway waiting 26-35 weeks from point of referral to treatment

391 Feedback Scores - Real Time Patient Survey: Staff Introducing Themselves (Threshold >=90%)

87.01%

HR: % Sickness Absence (Threshold for May 13 - 3.83%) 4.23%

Patients on an 18 week pathway waiting 36-52 weeks from point of referral to treatment

186 Complaints: Attitude of Staff (Threshold = 0)

4 in-month, 10 ytd

HR: Vacancy Position - Clinical (Threshold 3.99%) 5.71%

Patients on an 18 week pathway waiting over 52 weeks from point of referral to treatment

0 Friends & Family: A&E (Threshold 15%) 10.59%

HR: Vacancy Position - Non-clinical (Threshold 4.99%) 7.50%

HR: Total Pay Expenditure (Over/Under Budget) (Threshold £13,602,000)

£13,375,000 Friends & Family: Inpatients (Threshold 15%) 22.49%

Friends & Family: Trust (Threshold 15%) 13.73%

CQUIN: Improvement on 12/13 Performance (Threshold = 72% of total Cquin financial opportunity)

90.88%

Achieved Borderline Not Met

Notes:The metrics within this dashboard are reported by exception, any metric which achieves the relevant threshold for 3 or more consecutive months may be removed from this section.Trend Graphs are based on activity over the latest available 12 months.

No MovementDeteriorating Trend

StatusStatus

Improving Trend

Status

Executive Dashboard - June (M3) 2013/14Safe Effective Caring

Page 1

Final_Version 1.0

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HR - Total Pay Expenditure:Pay Expenditure is £13,375k against a target of £13,602k. There has been an in month decrease in pay expenditure from £14,121 in May 13.

HR - % Sickness Absence:

No Never Events reported or identified.

Complaints - Attitude of Staff: There were 32 new complaints received in the Trust during the month of June. This is a 26% decrease from June 2012 (43). This also give the 1st quarter of the year a 33% decrease in the number of complaints received. 23 contacts have been recorded and dealt with as concerns. 5 complaints were the subject of Attitude of Staff.

Cancelled Operations: The overall number of cancellations rose by 21 compared to May, across all specalities and sites [increase of 67%].Total Cancellations for June: 52 [31 in May].

Hospital Outpatient Cancellations:Hospital Outpatient cancellations remain above target in June, mitigated by an increase in the number of administrative cancellations to support the relocation of services into the Hanover Building. It is possible this trend may continue short term with a number of planned service changes in Orthopaedics and clinic cancellations in Medicine to support patient flow, in addition to seasonal variation. The divisions are aware and continue to take action to minimise cancellations where possible.

Clostridium Difficile Toxin (CDT):There were 4 cases in June against a monthly threshold of 2. Year to Date there has been 14 cases against a Threshold of 25. However the Trust has exceeded the Monitor annual de minimis of 12 cases.Methicillin-Resistant Staphylococcus Aureus (MRSA):There were no hospital onset cases in June. Year to Date there has been 1 case against a Zero Tolerance Threshold. However this is well within the Monitor annual de minimis of 6 cases.

HR - Vacancy Position:The Clinical vacancy rate is 5.71% with Non-Clinical vacancies running at 7.5%. There has been an in month decrease in vacancy rates from 8.1% for both Clinical and Non-Clinical. (N.B. Clinical vacancies have reduced as a result of an adjustment to Month 3 Nursing establishment figures.)

Never Events:

HR - Temporary Staffing:Temporary spend is £975k against a target of £825k. This is an in month increase from £910k in May 2013. Year to date spend is £2,725k which is a £897k reduction on the same period in 2012 which was £3,622k.

May 13 sickness absence is 4.23% against a target of 3.83%. There has been an in month increase from 3.92% in April 13. However, there has been a slight reduction on the rolling 12 month figure at 4.45% for June 12 - May 13 which is a reduction in comparison with the period May 12 - April 13 at 4.48%. (N.B. Sickness absence figures for June 13 are not yet available.)

Executive Dashboard Headlines - June (M3) 2013/14Page 2

Safe Effective Caring

Final_Version 1.0

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Falls: Surgery:Cancer:

There were 2 new StEIS reportable SUI's identified and submitted to StEIS during 2013/14 M3.

18 weeks:Specialist Services:The modular theatres are now operational and the Division have produced a trajectory for the reduction of the backlog in line with CCG targets, utilising the increased capacity and revised booking processes.

Cancelled Operations: Specialist Services:

Reduction in number of falls to 86 in M3 (from 93 in M2).

The Trust failed to meet the target for for M2, but is on course to achieve the Quarter.

In June there were 328 patients requiring a bed on the RAEI site [compared to 304 in May] - of which 112 were taken back and discharged through SAL, this equates to 34% [29% in May] of all elective admissions on the RAEI site.Surgical Trajectory:

Complaints:

Ombudsman:There were no new requests for files from the PHSO during the month of June.

Clinical Incidents:

The Division continues to improve on the number of cancellations on day for theatre. Actions are being put in place to reduce this further.

Ward to Board Audits:Maternity:Midwifery and Nursing staff are working to support the delivery of safe and effective care, creating positive patient and staff experiences.

The overall cancellation rate for May was 1.3%. The projection for June indicates the Trust is above the 0.8% threshold at 1.4%. However this can not be confirmed at this point as there is still a large volume of coding outstanding.

There has been an increase in the time taken to CARP to Treating Trusts.

There has been a 33% decrease in Quarter 1, against Quarter 1 2012/13. This is due to improved processes within the Complaints Department facilitating more Complaints being handled as Concerns.

31 Days - Subsequent Treatment: Chemotherapy

62 Days - GP Referral to First Treatment

Executive Key Headlines - June (M3) 2013/14 Page 3

Safe Effective Caring

Final_Version 1.0

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Summary; risk of failure (in relation to the board objective) to:

CORPORATE OBJECTIVES 2013-14

Apr

-13

May

-13

Jun-

13

Jul-1

3

Aug

-13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Performance (E) Zero points on MCF FN F&I CO 20 20 20Performance (E) Quarterly and full year FRR of 3 RF F&I CO 20 20 15Innovation (SEC) £300k investment with 2:1 payback RF F&I CO 9 9 9

Leadership (E) Develop a leadership action plan with measureable outcomes by March 2014 JL HR CO 8 12 12

Information (E) Complete the procurement of a new HIS and commence implementation RF IM&T CO 10 8 8

Staff Eng (EC) Design and implement an Organsational Development (OD) plan by 31.10.13 JL HR CO 8 12 12

Investment (SE) To maintain a financially balanced 10 year investment plan and meet milestones for 2013/14 SN F&I CO 10 12 12

Partnership (SEC) To lead the local QUIPP plan to achieve 20% admission reduction for LTC by March 2014 SN MB CO 16 16 20

1.1 (E) Achieve HSMR max 90 and stretch 83 UP Q&S CF 20 20 152.1 (C) Implement Board objective: Healthy Nutrition AF Q&S CF 9 9 93.1 (C) Implement Board objective: Staff Introductions AF Q&S CF 12 12 124.1 (S) Maintain CQC registration without conditions PJ Q&S CF 15 15 155.1 (P) Build stakeholder relationships AF / UP TB CF 8 8 166.1 (P) Achieve Service Transformation (CIP) targets SN F&I CF 20 20 15

Partnership (SEC) Negotiate a successful service model with neighbouring Trusts for Healthier Together by Summer 2013 AF TB AO 15 15 15

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar0 0 00 0 08 8 77 7 8

15 15 15

CIP Targets: Good progress being made and on track for the quarter. Agreed to reduce this to 15 (3x5).

Local QUIPP Plan: Given the recent pressures in the hospital system, it was agreed that the 20% admission reduction was a challenge.

Issues

HSMR: Recent HSMR data showed an 18% reduction on last year. Agreed to reduce this to 15 (3x5).Agreed to increase the score to 16 (4x4).

Management ActionsRisks

Stakeholder Relationships: There have been some tensions with HT team, Healthwatch and Salford.

Extreme Risk 15-25

Risk Banding

Moderate Risk 4-6High Risk 8-12

The above table summarises and tracks the movement of BAF risks by risk banding

Low Risk 1-3

Agreed to increase the score to 20.

Total No. of BAF Risks

The above table summarises the month on month mitigated risk scores for all BAF risks including "carry forward" of BAF risks from 2012/13.

OBJECTIVES RETAINED FROM 2012-13

ADDITIONAL OBJECTIVES

Mitigated Monthly Scores (Consequence / Impact x Likelihood)

Com

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Sub

Ref

No.

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D

omai

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&

Car

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Board Assurance Framework - June (M3) 2013/14 Page 4

Final_Version 1.0

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YTD Performance

Quarter 1

MCF Points

Maximum time of 18 weeks from point of referral to treatment in aggregate - admitted 90% 91.13% 0.0Maximum time of 18 weeks from point of referral to treatment in aggregate - non-admitted 95% 97.92% 0.0

Maximum time of 18 weeks from point of referral to treatment in aggregate - incomplete pathway 92% 93.24% 0.0

A&E: Maximum waiting time of four hours from arrival\admission\transfer\discharge 95% 95.28% 0.0All cancers: 62 day wait for first treatment from urgent GP referral to treatment 85% 92.71% 0.0All cancers: 62 day wait for first treatment from consultant screening service referral 90% 100.00% 0.0All cancers: 31 day wait for second or subsequent treatment: surgery 94% 100.00% 0.0All cancers:31 day wait for second or subsequent treatment: anti cancer drug treatments 98% 98.61% 0.0All cancers: 31 day wait for second or subsequent treatment: radiotherapy 94% No patients 0.0All cancers: 31 day wait for diagnosis to first treatment 96% 99.59% 0.0Two week wait from referral to date first seen: all urgent cancer referrals (cancer suspected) 93% 98.67% 0.0Two week wait from referral to date first seen: symptomatic breast patients (cancer not initially suspected) 93% 96.57% 0.0

Clostridium Difficile Toxin (CDT) - Cumulative Monitoring. Monitor de minimus 12 cases. 25 Full Year 14 1.0 yes See Note 1Methicillin-Resistant Staphylococcus Aureus (MRSA) - Cumulative Monitoring. Monitor de minimus 6 cases. 0 Full Year 1 0.0

Self-certification against compliance with requirements regarding access to healthcare for people with a learning disability N\A Achieved 0.0

Data completeness: Community Services, comprising - Referral to treatment information 50% 66.68% 0.0Data completeness: Community Services, comprising - Referral information 50% 91.15% 0.0Data completeness: Community Services, comprising - Treatment activity information 50% 99.31% 0.0Third Parties (CQC actions/notifications anticipate resolution in July) warning letter 2.0Commissioner Requested Services 0.0Other Board Statement Failures 0.0Other Factors 0.0

3.0 yes

Acc

ess

Governance Rating

Indicator Thresholds

Note 2: 18 weeks:

234

Monitor guidance for Referral to treatment states any failure in one month is considered to be a quarterly failure for the purposes of the Compliance Framework.Note 3: Cancer:

Note 4: Methicillin-Resistant Staphylococcus Aureus (MRSA)

Total Governance Risk Rating

Monitor have confirmed that although the Trust has had a case of MRSA and has therefore breached the national zero tolerance target, unless the Trust exceeds the Monitor annual de minimis of 6 cases, a score is not incurred. As such, the above table shows a risk to the monitor annual plan, but shows achievement of MRSA for year to date and current quarter.

Note 1: Clostridium Difficile Toxin (CDT):The Trust has exceeded the Quarter 1 Target for C-Diff; the red risk override applies where the Trust has more than 12 cases year to date, and either breaches the year to date trajectory for 3 successive quarters, or breaches it's full year objective.

5

Year End Projection

Red Override Applies

All cancer treatment figures are draft until the freeze date has passed.

Out

com

es

Area

1

Compliance - Monitor Compliance Framework Performance: June (M3) 2013/14 Page 5

Final_Version 1.0

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1 Preventing people from dying prematurely 4 Ensuring people have a positve experience of careImprovement areas Period Status Trend Overarching indicators Period Trend

4b

1.1 4c Friends and family test (Trust Level) 13.73%

1.2 Improvement areasImproving people’s experience of outpatient care

1.3 4.1

1.4

Reducing deaths in babies and young children 4.2

1.6 i

ii 4.3

2 Enhancing quality of life for people with long-term conditions 4.5Improvement areas Period Status Trend

2.3 i 4.6

ii

4.8 An indicator is under development

3 Helping people to recover from episodes of ill health or following injuryOverarching indicators Period Status Trend3a 5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators Period Trend3b 5a Patient safety incidents reported

Improvement areas 5b Safety incidents involving severe harm or deathImproving outcomes from planned treatments3.1 5c

i Hip replacement Improvement areasii Knee replacement Reducing the incidence of avoidable harmiii Groin hernia 5.1iv Varicose veinsv Psychological therapies 5.2 Incidence of healthcare associated infection (HCAI)

i MRSA

3.2 ii C. difficile

Improving recovery from injuries and trauma 5.3

3.3 5.4

Improving the safety of maternity services5.5 Admission of full-term babies to neonatal care

* Delivering safe care to children in acute settings** 5.6 0 Incidents*******

Indicator complementary with Adult Social Care Outcomes Framework (ASCOF)Indicator shared with Adult Social Care Outomes FrameworkIndicator complementary with Adult Social Care Outomes Framework and Public Health Outomes Framework

Dr Foster: Data for indicative use only; as relates to deaths in hospital.

Status

Key for status:

July 12 ‐ June 13

May 12 - April 13

Achieved Borderline Deteriorating Trend Not Met No Movement

Notes:

Data Gaps: We are awaiting the CQC publication of the Section 4 Improvement Areas data.

4 in-month, 14 ytd

July 12 ‐ June 13

14 in month 44 YTD

0 in-month, 1 ytd

Incidence of newly-acquired category 2, 3 and 4 pressure ulcers

July 12 ‐ June 13July 12 ‐ June 13

May‐13

July 12 ‐ June 13

Status

Improving Trend

Incidence of hospital-related venous thromboembolism (VTE)

Incidence of medication errors causing serious harm

Incidence of harm to children due to ‘failure to monitor’

Preventing lower respiratory tract infections (LRTI) in children from becoming serious

Emergency admissions for children with LRTI. (Specific patient numbers not rate)

Proportion of people who recover from major trauma. Indicator in development. (Specific patient numbers not rate)

Alignment across the Health and Social Care SystemIndicator shared with Public Health Outcomes Framework (PHOF)

Emergency admissions for acute conditions that should not usually require hospital admission. (Specific patient numbers not rate )Emergency readmissions within 30 days of discharge from hospital* (PHOF 4.11). (Specific patient numbers not rate )

Reducing time spent in hospital by people with long-term conditions

Unplanned hospitalisation for chronic ambulatory care sensitiveconditions (adults). (Specific patient numbers not rate )Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s. (Specific patient numbers not rate )

July 12 ‐ June 13

July 12 ‐ June 13

Reducing premature mortality from the major causes of death

Under 75 mortality rate from cardiovascular disease* (PHOF 4.4). Indicative - Dr Foster. (Specific patient numbers not rate )

Under 75 mortality rate from respiratory disease* (PHOF 4.7). Indicative - Dr Foster. (Specific patient numbers not rate )

Under 75 mortality rate from liver disease* (PHOF 4.6). Indicative - Dr Foster. (Specific patient numbers not rate )

Under 75 mortality rate from cancer* (PHOF 4.5). Indicative - Dr Foster. (Specific patient numbers not rate )

Infant mortality* (PHOF 4.1). Indicative - Dr Foster. ONS Mortality statistics. (Specific patient numbers not rate )

April 12 ‐ March 13April 12 ‐ March 13

Jun‐13

0 in month 0 YTD

Responsiveness to in-patients’ personal needs. Data published nationally

Improving people’s experience of accident and emergency services

Patient experience of A&E services. Data published nationally

Improving women and their families’ experience of maternity services

Improving the experience of care for people at the end of their lives

Improving children and young people’s experience of healthcare

Hospital deaths attributable to problems in care. Indicator in development.

Women’s experience of maternity services. Data published nationally

2 in month 6 YTD

Neonatal mortality and stillbirths. Indicative - Dr Foster. ONS Mortality statistics. (Specific patient numbers not rate )

Total health gain as assessed by patients for elective procedures. (Data published nationally)

Bereaved carers’ views on the quality of care in the last 3 months of life. Data published nationally

191 in month 780 YTD

June 12 ‐ May 13

July 12 ‐ June 13

14 in month 54 YTD

1 in month , 17 YTD

14 in month 54 YTD

April ‐ June 

13April 12 ‐ March 13

April 12 ‐ March 13

April 12 ‐ March 13

April 12 ‐ March 13

Patient experience of hospital care. Data published nationally

Patient experience of outpatient services. Data published nationally

Improving hospital's responsiveness to personal needs

April 12 - March 13

April 12 - March 13

April 12 - March 13

April 12 - March 13

5 in month 31 ytd

NHS Outcomes Framework 2013/14 : Indicators applicable to WWL Page 6

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Trend (Month) Expected

Relative Risk (RR)

RR Rolling 12 Mths

RR Rolling 12 Mths prior to rebase

May-2012 101.3 89.8 94.0 85.9Jun-2012 91.3 95.3 94.5Jul-2012 88.9 87.7 94.4Aug-2012 93.3 89.0 94.4Sep-2012 78.5 91.7 94.4Oct-2012 103.3 85.2 92.5Nov-2012 93.5 93.1 92.2Dec-2012 112.1 91.9 92.4Jan-2013 118.9 102.6 92.3Feb-2013 104.1 99.9 94.2Mar-2013 102 120.6 96.5Apr-2013 99.3 81.5 94.0

Notes:Key to Dr Foster weekend deaths chart: Green (statistically significantly better than England), red (statistically significantly worse than England) or blue (no statistical significance).

HSMR: Diagnoses - HSMR Groups

Data Source: Dr Foster IntelligenceRed = > 92

Green = <= 83

SummaryThe HSMR for March was 120.6. The Trust has examined the reasons for this in detail, and this was discussed at CAB and at Q&S. There are a number of factors that have been identified, the most marked being the breakdown of patient flows through our unscheduled care pathway. There was an increase in demand through the Unscheduled Care system, with more admissions than discharges, which placed services under pressure. The Trust's Escalation Policy is to be reviewed, with work focusing on the Trust's bed stock, and how this can be flexed in times of pressure. Please Note: April's HSMR is 81.5.

Amber = <= 92 and >= 84Internal Stretch Target 83

The relative risk in Peer Analysis will be higher than Trend Month as the denominator used to calculate the relative risk will contain a lower number of superspells (i.e. patients treated at other hospitals) resulting in a higher relative risk.

Two new graphs have been provided, the first is to ensure transparency regarding the performance of the transfer of the deceased to the Mortuary within 4 hours. A considerable amount of work has been undertaken to improve the performance, as indicated from June.The second new graph indicates mortality by day of the week admission into hospital, indicating improvements in both Saturday and Sunday admissions since October 2012.

Safe - Hospital Standardised Mortality Ratio: June (M3) 2013/14

0

10

20

30

40

50

Week Commencing

Weekly Deaths in Hospital

UpperControlLimit Deaths Moving Average LowerControlLimit

Page 7

Predicted Relative Risk for 13/14 is currently 102 as at Apr 13 - indicated by the dotted line.

0

50

100

150

200 Mortality Relative Risk by Day of Admission

Monday Tuesday Wednesday Thursday

Friday Saturday Sunday

0%

20%

40%

60%

80%

0

5

10

15

20

31st May - 6thJun 13

7th - 13th Jun13

14th - 20thJun 13

21st - 27thJun 13

28th Jun - 4thJul 13

Mortuary Transfers Within 4 Hours

Within 4 Hours Over 4 Hours % Within 4 Hours

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HSMR: BenchmarkingTrust Defined Peer Group May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13ALL 99.7 99.1 98.5 97.9 98.8 98.5 98.1 98.9 98.3 96.2 96.1 94.5Salford Royal NHS Foundation Trust 74.5 74.2 74.1 72.9 75.3 75.4 74.9 76.4 75.5 75.3 76 74.1Wrightington, Wigan and Leigh NHS Foundation Trust 94.8 95.3 94.9 94.8 94.9 93 92.5 95.2 93.2 94.8 97.1 95.9St Helens and Knowsley Hospitals NHS Trust 101 98.7 96.9 95.6 95.2 94.5 99.2 98.6 98.9 95.6 96.8 95.7Bolton NHS Foundation Trust 102.4 102 101.5 100.7 102.5 103 94.4 99.4 95 93.6 94.2 94.3Lancashire Teaching Hospitals NHS Foundation Trust 102.1 101.6 98.9 97.8 99.1 99.2 99.9 101.8 101.3 100.8 100.5 100.5East Lancashire Hospitals NHS Trust 101.5 100.1 100.3 99.7 99.4 99.7 99.9 102.1 100.5 100 99.8 101.1University Hospital Of South Manchester NHS Foundation Trust 101.3 100.7 100.2 99.3 99.6 98.6 104 100.4 102.7 101.1 100.3 100Pennine Acute Hospitals NHS Trust 101.4 101.9 102 103 104.5 105.7 102.7 101.3 102.8 96.2 95.3 94.7Stockport NHS Foundation Trust 106.3 105 106.1 106.4 105.8 105.2 102.5 103.4 101.7 97.5 96.3 96.4Central Manchester University Hospitals NHS Foundation Trust 110.7 110.5 108.4 107.9 110.1 109.1 108 108.3 107.1 106.4 105 90.5

HSMR March 2013

Peer Spells Super Spells % of all Deaths % Expected % RR Low High

ALL 27616 27347 100.00% 1279 4.70% 1353.5 4.90% 94.5 89.4 99.8Salford Royal NHS Foundation Trust 2013 1976 7.20% 78 3.90% 119.9 6.10% 65.1 51.4 81.2Central Manchester University Hospitals NHS Foundation Trust 3377 3331 12.20% 96 2.90% 111 3.30% 86.5 70.1 105.6Pennine Acute Hospitals NHS Trust 5088 5058 18.50% 233 4.60% 259.5 5.10% 89.8 78.6 102.1Stockport NHS Foundation Trust 2146 2131 7.80% 116 5.40% 127.7 6.00% 90.8 75.1 109University Hospital Of South Manchester NHS Foundation Trust 2392 2350 8.60% 95 4.00% 101.9 4.30% 93.2 75.4 114Lancashire Teaching Hospitals NHS Foundation Trust 2944 2929 10.70% 144 4.90% 149.3 5.10% 96.5 81.3 113.6St Helens and Knowsley Hospitals NHS Trust 2294 2293 8.40% 123 5.40% 121.4 5.30% 101.3 84.2 120.8Bolton NHS Foundation Trust 2026 1984 7.30% 118 5.90% 114.9 5.80% 102.7 85 123East Lancashire Hospitals NHS Trust 3189 3184 11.60% 156 4.90% 148.9 4.70% 104.8 89 122.6Wrightington, Wigan and Leigh NHS Foundation Trust 2147 2111 7.70% 120 5.70% 99.1 4.70% 121.1 100.4 144.9The data shows the Relative Risk figure for a month.

Notes:The relative risk in Peer Analysis will be higher than Trend Month as the denominator used to calculate the relative risk will contain a lower number of superspells (i.e. patients treated at other hospitals) resulting in a higher relative risk.

The data has been sorted by Cumulative Relative Risk for 12 month period. The data shows the Relative Risk figure for a twelve month period leading up to the month shown.

Safe - Hospital Standardised Mortality Ratio: June (M3) 2013/14Page 8

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Q4 12/13 Apr May Jun Q1 Actual Q2 To Date

Q3 To Date

Q4 To Date YTD 13/14

Comparison (Same

Period) 12/13 YTD

Variance 13/14

versus 12/13

Status Trend

Number of Serious Falls By Date Reported * 4 1 2 2 5 5 4 1

Serious Falls: Indicative Financial Implication ** £14006.45 £12,550.37 £1,733.00 £25,100.74 £39,384.11 £39,384.11 £27144.78 £12239.33

Falls per 1000 Beddays *** 6.1 6.1 6.8 7.3 6.7 6.7 6.7 0.0

Number of Falls By Date Reported 246 85 93 86 264 264 282 -18

Falls 20% Reduction Target Awaiting Data

SUI's per 100 Admissions 0.01 0.03 0.00 0.03 0.02 0.02 0.19 -0.17

Hospital Acquired Pressure Ulcer Incidence 5 4 2 5 11 11 6 5

Notes:

Falls:

Issues Management ActionsRisks

Emerging trends indicate the Trust is not achieving steady and sustained improvement in managing the risk of or reducing the number of patient falls.Incorrectly scored falls risk assessments are increasing the possibility of staff then failing to recognise the need for and / or implement appropriate falls prevention care plans.

Falls Scrutiny Committee - Role and structure review is continuing.The number of patients suffering multiple falls (2 or more) has increased despite a reduction in the total number of falls. A total with 15 patients suffered a total of 33 falls (39%) of all falls during M3 representing a 6% increase since M2.

** Source: Datix / Finance combined. Figures are purely clinical costs, no staff costs are included but they do include any extended LOS costs.

Red >=2

2 Ward Managers have attended Executive Scrutiny meetings during M3 presenting RCA investigations for patient falls on their wards.Falls risk reduction is to have stronger opertaional links to Harm Free Care initiatives and involvement of Quality Champions.

Serious Falls RAG Rating Criteria

*** Beddays represent actual activity during the period. Falls Figures are by the date the incident was reported. Therefore, this is not a true like for like comaprison as not all incidents are reported in real time.

Green 0

The figures for the total number of serious falls will be subject to retrospective quarter end validation by analysis of reported incident details and confirmation of the resultant severity of patient harm following completion of diagnostic investigations and review of the incident investigation report details. The updated figures will appear in the M3, M6, M9 and M12 reports.

Amber >=1 and <2

* Moderate and severe harm - where the fall resulted in harm which extended the patient's hospital stay.

Safe - Falls and Safety Incidents: June (M3) 2013/14 Page 9

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Notes:* The details within the Circle of Harm are for those StEIS reportable SUI’s which resulted in or had the potential to cause harm to patients.** The numbers within the chart ‘Reported Serious Untoward Incidents By Reporting Quarter’ represent all SUI’s included within the Circle of Harm plus any other SUI’s meeting StEIS SUI reporting requirements but not resulting in or having the potential to cause harm to patients.

Incident referred to the nutrition clinical leads (Consultant and Nurse Specialist) and Head of Quality Improvement to identify and implement trust-wide actions to reduce risk of recurrence. The Director of Nursing & Patient Services has scheduled discussions with the Medical Director and Divisional Medical Directors. Response to actions taken is to be monitored by the Executive Scrutiny Team. Any recurring issues or concerns will be esclated to the Quality and Safety Committee.

Clinical Incidents:

Management ActionsRisksIssues

Incident related to diabetic eye screening appointments and the failure of the IT system used for this across Commissioner, PCT and Acute services. Completed investigation.

Risk that patient's clinical condition had now deteriorated and in addition would not be checked, treatment implemented and / or monitored in the future.

The reported incident highlighted the potential risk of the current trust policy not being fully understood and/or correctly applied.

All patients identified and given urgent appointments. Investigation and 12 month look back exercise completed by WWL (no harm to patients). Software changed and improved by joint across both Commissioner and Provider services involved to reduce risk of recurrence.

Incident related to patient receiving the wrong medication for 2 days, whilst an in-patient. No permanent or long term harm. Investigation underway.

This and other recent incidents demonstrate that medicines and patient identity check procedures are not being applied.

Full RCA investigation underway. Being Open/Duty of Candour initiated. Clear communication links established with family. Medicines Management being reviewed under PMO.

Never Events:

One reported incident has been investigated and considered at Executive Scrutiny Meeting as a potential StEIS SUI Never Event (Misplaced naso- or oro- gastric tube), but this was downgraded to an Adverse Event as it did not meet the DOH Never Event Criteria.

Safe - Patient Safety Incidents: June (M3) 2013/14Page 10

0 5 10 15 20

2010/11

2011/12

2012/13

2013/14

Reported Serious Untoward IncidentsBy Reporting Quarter

Quarter 1 Quarter 2 Quarter 3 Quarter 4

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Reconfiguration of the system set up and access levels is underway to create a secure shared access environment for Heads of Governance to reduce the risk of incidents being wrongly allocated and therefore not investigated.

Whilst significant improvement has been made for the reporting period 1 October 2012 to 31 March 2013 in terms of incidents reported up to the NRLS, the issue will remain a risk until the divisions resolve the ongoing and repeated delays in incidents being investigated, investigations being completed and incidents being given final approval within trust policy and/or NRLS reporting deadlines in order to enable them to be uploaded to the NRLS.

Management Actions

Situation reflected in the revised 2013/14 Q1 SEC report for discussion at the July Quality and Safety Committee.Risk to be added to the Corporate Risk Register and progress monitored in a monthly RAG rated Datix and NRLS Performance Report (by division) to the Quality and Safety Committee.Weekly and monthly Performance reports to be re-introduced and circulated to the divisional DDOP’s and Heads of Governance from week commencing 15 July 2013.Datix system upgrade will take place in September 2013 which will allow immediate quality checks and uploads to NRLS ahead of incidents being given final approval.

Risks

1509

Issues

The trust is an identified poor performer and outlier in comparison to all other large acute trusts within its NRLS reporting cluster group. This is noted on the CQC QRP.

357225255244176252

2013 012013 022013 03Totals:

Confirmed NRLS Upload Total1777 (96%)

Confirmed NRLS Upload Total832 (41%)

Confirmed NRLS Upload Total1509 (93%)

Uploads by reporting month

943

Identified as NRLS Reportable1851

Identified as NRLS Reportable2018

Identified as NRLS Reportable1624

2012 102012 112012 12

2692205692

135171

Identified as NRLS Reportable1892

Identified as NRLS Reportable1975

Identified as NRLS Reportable1555

2010 to 2013 NRLS Upload Compliance and Performance Records Following the Introduction of Datix Web 16 April 2010

Reporting Period 1 April to 30 September 2010Confirmed NRLS Upload Total

The table above summarises the trust’s performance since the introduction of the Datix web reporting system in April 2010.

This status and performance worsened during the reporting periods 1 October 2011 to 30 September 2012 when the trust registered its poorest performances.

1683 (88%)

Confirmed NRLS Upload Total1682 (85%)

Confirmed NRLS Upload Total943 (60%)

Reporting Period 1 April to 30 September 2012

2012 042012 052012 062012 072012 082012 09Totals:

Reporting Period 1 October 2010 to 31 March 2011

Reporting Period 1 October 2011 to 31 March 2012

Reporting Period 1 October 2012 to 31 March 2013

Incidents Reported to the NRLS by reporting month and NRLS 6 monthly reporting Periods 1 April 2012 to 31 March 2013

Reporting Period 1 April to 30 September 2011

Uploads by reporting month

Safe - National Reporting and Learning System (NRLS) Incidents: June (M3) 2013/14 Page 11

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Cat 2 Cat 3 Cat 4 Total

Care plan evidence of pressure area support for those 'at risk'

100%

Please note: When considering the data, it should be noted that the numbers reported for moderate and severe falls are small.

Did you have confidence and trust in the nurses treating

you?

100%

100%

100% 100%

0

Count of Indicators for This Month

Staff Experience

1

78% 99%

Trend

Overall Compliance

3

These tables automatically count the responses on each case sheet and calculate the compliance level for you.

Total Yes Responses

Falls

0

Pressure Ulcers 99% 96%

0

Total Yes Responses

3

Nursing Care Indicator - Overall Level of Compliance

Total No Responses

Risk Assessment Documentation Completed 0

* If a friend or relative needed treatment,

would you be happy with the standard of care provided on the

ward?

82%

Care plan has been implemented 1 1 50% Care plan evident for those identified 'at risk' 3

100%

Total No Responses

67%

100%00

2

2

2

3

2 1

Was the original pressure ulcer assessment correct

Tissue viability risk assessment given on admission

Care plan evident for those identified 'at risk'

0

Care plan evident for those identified 'at risk'

Further assessment for at risk patients

Was the original falls risk assessment correct

0

100%

3

100%

3

0

100%

98%

2

Risk Assessment Documentation Completed

Falls Risk assessment given on admission

2

Pressure Ulcers

Overall Compliance

I am satisfied with the quality of care I give to Patients / Service Users.

83%Average running score for each

question, from all completed cases for the month

0

Did you get enough help from staff to eat

your meals?Moderate Patient Experience

Average running score for each question, from all completed

cases for the month

Were you given enough privacy when

being examined or treated?

5

** Please note that the data within this section is published one month in arrears; and as such, is reflective of the previous month's position.

The two tables below give a running composite score of where the Trust stands in the month for Patient & Staff Experience PER QUESTION, as an

average for the whole organisation.

Trend

Death

1 1

Severe

2

90%90%

Red = <85Amber =>=85 and <90Green = >=90

0

Were you involved as much as you wanted

to be in decisions about your care and

treatment?

If you were ever in pain, do you think the

hospital staff did everything they could to help control your

pain?

Summary of Survey Scores for This Month

* On reflection, did you get the nursing

care that mattered to you?

Total measured Harms for this month

0

This table calculates the amount of Fall's & Pressure Ulcer harms checked for

compliance for the month.

Total Falls

2

FallsWhen you had

important questions to ask a nurse, did

you get answers that you could

understand?

If a friend or relative needed treatment, I would be happy with the standard of care

provided by this ward.

94%

I would recommend the ward as a place to work.

91%

Safe - Falls & Pressure Ulcer Transparency Project: May (M2) 2013/14 Page 12

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Q4 12/13

Annual Threshold

13/14Apr May Jun Q1

ActualQ2 To Date

Q3 To Date

Q4 To Date YTD Trend

Number of CDT Cases post 48 hours 8 25 6 4 4 14 14

CDT Cases post 48 hours per 1000 Beddays 0.20 n/a 0.43 0.29 0.34 0.35 0.35

Number of E.Coli Cases post 48 hours 4 n/a 3 3 1 7 7

Number of MRSA Cases post 48 Hours 0 0 0 1 0 1 1

Number of MSSA Cases post 48 Hours 1 n/a 0 0 0 0 0

Percentage MRSA Screening for Elective Admissions 113.8% 100% 111.5% 126.7% 105.2% 113.9% 113.9%

Percentage MRSA Screening for Non-Elective Admission (Emergency) 64.7% n/a 66.0% 69.6% 70.0% 68.5% 68.5%

Matching Michigan Indicators - WWL Monthly CVC BSI Rates 1 1.4 0 0 1 1 1

Ventilator Acquired Pneumonia 0 n/a 0 0 0 0 0

Reduce the Number of Hospital UTI's caused by Catheters 0.66% n/a 0.60% 0.91% 0.47% 0.66% 0.66%

Percentage Hand Hygiene Compliance 95.99 90% 97.10 95.91 96.91 96.64 96.64

Notes:

Clostridium Difficile Toxin (CDT):

The Trust has exceeded the annual target.

Matching Michigan Project:No current issues.Hand Hygiene:

Cleaning Audit:

A review of Unscheduled Care pressures is to be undertaken, and there is to be an extensive review of existing control measures. Unannounced inspections of ward clealiness standards will be carried out. The auditing of antibiotic prescribing will continue.

Methicillin-Resistant Staphylococcus Aureus (MRSA):Further cases may arise due to contamination of samples though errors in application of aseptic technique.

Clarification is being sought as to the roles of the ANTT trainers. The Divisions have been asked to provide action plans for ensuring full coverage of training.

% MRSA Screening for Elective Admissions:There are no current issues (99% coverage). There is a high levels of compliance with the screening policy for elective patients.

No current risks. Admission clinics will continue to receive monthly feedback of compliance levels.

Issues

Percentage MRSA Screening for Elective Admissions: The percentage is often over 100% due to the routine screening of Day Case patients and other low risk patients.

Management ActionsRisks

Reduce the Number of Hospital UTI's caused by Catheters: This metric is currently under review, and may be revised for Month 3.

The Trust remains well above the year to date target at month end (14 v 6).

Annual target (25) will be exceeded.

% MRSA Screening for Non-Elective Admissions:There has been a drop in complaince compared to May (71% coverage). There are persistant difficulties in maintaining higher levels of compliance.

The Trust cleaning audit score of 96% is 4% above the National Cleaning standard, this requirement has been maintained across all sites for the first time.

No current risks. Maintain high standards.

Further falls in compliance levels. The Divisions are required to produce and present action plans to the Infection Control Committee.

The Hand Hygiene audit remains above the aspirational target of 95% at 96.91%, however a small number of areas are still consistently not achieving the target.

Non-compliant areas run the risk of causing Healthcare Associated Infection.

Maintain high compliance in areas of good practice. Non-compliant areas are having targeted training in line with Divisional Action Plan for Compliancy improvement. Areas include Therapy Wrightington, Theatres Leigh.

No current risks. ICU staff are given regular feedback of infection rates.

Safe - Infection Control: June (M3) 2013/14 Page 13

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Goal Goal Red Flag Measure Frequency Data Source Jan Feb March April May June July Aug Sept Oct Nov Dec Comments/ Actions

Bookings 3250 / 250-275

>3500 / or >290<250

1st Visit Bookings Monthly ANC 308 251 253 272 293 249

Booked by 12.6 Weeks 90% <75% 1st Visit Bookings Monthly ANC 87.00% 88.44% 81.00% 84.00% 87.00% 86.0% 90.0% 90.0% 90% National Standard.

Booked after 13 weeks 10% >20% 1st Visit Bookings Monthly ANC 13.00% 12.00% 19.00% 16.00% 13.00% 14.00% 10.00% 10.00%

Births Benchmarked to 3250

3250 / 250-270

>3500 / 290 or <230 Total/ Births Monthly Euroking /

Register 252 217 217 240 262 244

Planned Home Births 2.00% <1% Total/ Births Monthly Euroking / Register 0.40% 0.46% 1.84% 1.25% 0.38% 1.64% Homebirth team in development. Team Leader

appointed.

Inductions <25% >27% No of Patients Monthly Euroking 26.90% 27.65% 37.21% 30.80% 29.16% 29.38% UK Average 25%. Care Bundle ongoing.

Induction resulting in Em C/S 20% 22% No of

Patients Monthly Euroking 12.35% 20.96% UK Average 21.7%.

Instrumental Vaginal Deliveries 10-15% >15%

Forceps/ Ventouse

BirthsMonthly Euroking 15.00% 9.22% 14.29% 13.58% 12.60% 10.64% 12.1 % National Average (UK)

Total Caesarean Sections 24% >29% C-Section

Births Monthly Euroking 28.00% 23.96% 25.81% 23.33% 23.66% 22.95% 24.6 % National Average (UK)

Elective Caesarean Sections 10% 12% C-Section

Births Monthly Euroking 10.31% 6.96%

Emergency Caesarean Sections 15% 17% C-Section

Births Monthly Euroking 13.36% 15.17%

Breast Feeding Rate 60% <50% Initiated B/Feed Monthly Euroking 58% 45% 47% 55% 57% 52% 60% 60% National Average 69% (UK). Peer support workers in

post from Nov 2012. 2 WTE for each area.Re admissions within 28 Days 0 >5 No of

Patients Monthly Orbit report 4 2 1 0 3 0 3 general admissions / 1 maternity related.

2% 3% No of Patients

No of Patients No of Patients 1.15% 0

Weekly Hour's Consultant Cover 60 hours <50 hours Prospective

Presence Monthly Con Rota 40 52 59 58 52 68 60 60 Resident Consultant on Inction period this month.

Midwife / Birth Ratio 1.28 01:33 WTE/ Births Monthly Birth Register/ Establishment 1.28 1.28 Not

available 1.29 1.29 1.29 1.28 1.28 Figures retrospectively re-calculated using actual births/ hours worked, inclusive of Bank Shifts.

Supervisor / Midwife Ratio 1.15 1.20

SOM/ Midwife Ratio

Monthly SOM Database 01:18 01:18 01:18 01:18 01:18 01:18 01:15 01:15Course Place booked for 2013. 1 midwife retired from Supervision, and new staff in post increasing midwife numbers.

Education / Training Attendance 90% <90% Training

database Monthly Training Database 6% 15% 28% 33.0% 43.0% 54.0% 65% No Training in January. (Rolling percentage of

attendance)Sickness levels Maternity Ward <4.0%. >4.9% Monthly HR 5.53% 4.85% 3.36% 2.39% 0.23% (Sickness figures 1 month behind)Delivery Suite <4.0%. >4.9% Monthly HR 2.92% 2.26% 1.90% 0.36% 2.10%Ante Natal Clinic <4.0%. >4.9% Monthly HR 3.17% 1.30% 8.76% 12.08% 12%Community <4.0%. >4.9% Monthly HR 1.70% 2.81% 1.17% 4.40% 5.85%Medical Staff <4.0%. >4.9% Monthly HR 7.14% 4.92% 6.00% 5.62% 7.69%

Target FiguresActual Figures

Clin

ical

Effe

ctiv

enes

sSa

fety

Effective - Maternity Dashboard: June (M3) 2013/14 Page 14

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Goal Goal Red Flag Measure Frequency Data Source Jan Feb March April May June July Aug Sept Oct Nov Dec Comments/ ActionsTarget FiguresActual Figures

Shoulder Dystocia <6 per month

>10 per month

No of Patients Monthly Datix 1 4 0 4 3 2

Massive PPH > 1500mls <4 >4 No of Patients Monthly Datix 3 3 5 6 1 3

Unexpected Admissions to NNU <5 >5 No of

Patients Monthly Datix 5 3 4 2 6 4 (Term infants)

High Dependency Care < 10 > 10 No of Patients Monthly Datix 8 1 3 3 7 5 (Maternity HDU)

Apgars < 6 < 10 > 10 No of babies Monthly Euroking 1 0 0 0 3 0 Changed to <6 from January 2012 in line with Euroking System.

3rd/4th Degree Tears<3%per month

>5% per month

No of Patients Monthly Datix 0.40% 3.64% 2.48% 2.72% 1.50% 3.19%

Figure rebased to only include Vaginal deliveries. RCOG <5% of Deliveries / Local <3%. Continuous Audit in progress. Individual Staff offered support.

2.02% 2.25% 2.31% 2.02% 2.32% Rolling Percentage - Data base and continuous audit in progress.

Total Clinical Incidents <25 >60 No of Patients Monthly Datix 37 44 34 32 33 26

SUI's <1 >2 No of Patients Monthly Datix 0 0 1 0 0 0

Complaints <1 >2 No of Patients Monthly Pat Rel 3 1 1 1 2 2

Still Births <1 >2 No of babies Monthly Birth Register 1 1 2 0 0 0 National Rate 5.2 per 1000 Births or 0.52%. Local Rate 2.79 per 1000 births or 0.28%.

Page 14 Commentary

To promote Normal Vaginal Birth.Despite a high induction rate, assisted and operative delivery rates remain within the national average.

Induction of Labour Rate is above the National average of 25%Patient satisfaction is reduced when interventional measures are taken.High risk conditions and women with pre-existing medical problems will always necessitate early delivery.

A continual audit is undertaken by the Quality and Safety Midwife to ensure processes are adhered to and to assess maternal and infant outcomes. This is presented at the monthly Clinical Cabinet.

Management Actions

Patie

nt E

xper

ienc

e

Issues Risks

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62 Days - GP Referral to First TreatmentThere are delays to the Lung pathway due to Cardiothoracic Service clinic availability issues.

Patient details are not being communicated to the Chemotherapy Delivery Suite.

Oncologists are directly referring to Chemotherapy unit via e-mail to bypass the delay experienced with clinic letters.

Deterioration of Trust performance. The local Cardiothoracic service has been suspended to allow for centralisation by UHSM and the implementation of a one stop service.

Delays in communicating treatment decisions from Outpatients can delay patient treatment.

31 Days - Subsequent Treatment: Chemotherapy

StatusMay Finalised 62 day CWT (Monitor)June Provisional 62 day CWT (Monitor)Previous Quarter 62 day CWT (Monitor)Current Quarter 62 day CWT to date (Monitor)

Risks

CaRP - National Communication and Referral Protocol for Inter-Network Referrals

Management ActionsIssues

Threshold 85%

Effective - Cancer Care: June (M3) 2013/14 Page 15

0

20

40

60

80

Jul-12 Aug-12

Sep-12

Oct-12 Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13 May-13

Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13Post day 42 4 8 7 6 5 4 4 5 5 4 2 639-42 4 2 3 1 1 1 2 1 1 4 2 318-38 23 24 22 40 26 17 24 25 27 18 27 200-17 24 25 20 30 18 19 19 25 24 18 24 14

CaRP Sent to Treating CentreJuly 2012 to June 2013

0

2

4

6

8

Jul-12 Aug-12

Sep-12

Oct-12 Nov-12

Dec-12

Jan-13 Feb-13

Mar-13

Apr-13 May-13

Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13Post day 42 3 2 0 3 3 2 3 3 3 3 1 139-42 1 1 1 2 0 0 0 0 0 0 0 018-38 1 1 1 1 4 2 0 1 1 4 3 20-17 1 0 0 1 0 0 0 1 1 0 0 1

CaRP Sent Date of patients who breached 62 day pathwayJuly 2012 to June 2013

Jul-12

Aug-12

Sep-12

Q212/1

3

Oct-12

Nov-12

Dec-12

Q312/1

3

Jan-13

Feb-13

Mar-13

Q412/1

3

12/13

YTD

Apr-13

May-13

Jun-13

Q113/1

4WWL CWT 62 Day Standard 91.40% 92.59% 93.44% 92.27% 94.12% 93.98% 89.74% 92.74% 93.85% 92.54% 95.89% 94.06% 93.23% 91.04% 91.07% 97.06% 92.71%WWL 62 Day Standard with Reallocations 89.47% 92.59% 95.00% 91.88% 93.02% 92.86% 88.61% 91.63% 93.85% 91.18% 100.00 95.00% 92.39% 91.04% 91.07% 97.06% 92.71%62 Day Standard 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0%

84.00%

86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

102.00%Cancer 62 Day GP Referral to Treatment

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Notes:

Surgery:Continue to monitor cancellations on a daily basis.

Poor patient experience.

RisksIssues

Cancelled Operations:

Poor utilisation of resource.TOP 3 Cancellation Reasons: (make up 87% of all surgical cancellations)

3. 2 [9%] were due to administration errors.

The Trust has engaged with Unipart, and is beginning to see the benefits of the improved Theatre Utilisation process.

Bed Occupancy: The Data Quality team are investigating continuing issues regarding the recording of daily bed numbers on PAS in real time, especially with regard to wards on the Wrightington site.

Management Actions

The process for ensuring patients are dated with 28 days is being revised to prevent this occuring in future.

Poor data quality.Delay in patient care. Escalation to senior manager before cancellation takes place to

ensure all avenues have been explored.Continue to indentify patients clinically appropriate for recovery on SAL to avoid bed pressures in main ward cohort.

76% of the surgical cancellations were on the RAEI site [23 out of 30].

Site: RAEI - 29 (13 in May), Leigh - 15 & Wrightington - 9.

The majority of cancelled procedures took place on the RAEI site (56%).

28 Day Breaches: 1 surgical 28 day breach patients, this is an AMD patient that is done as a procedure outside of theatre.

Summary

Directorate: 30 - Surgical (12 in May), 10 - Specialist Services & 12 - Medical.

Failure to achieve standards.

2. 2 [9%] were due to equipment / K61 issues.

58% of the cancellations were within surgery [30 out of 52].

1. 16 [70%] were cancelled due to a lack of beds [1 cancellation in the previous month due to a lack of beds]. Daily 'communication cell' meetings are being held to address any

immediate concerns and learn from events from the previous day in order to make continous daily improvements.

Continue to monitor outliers and work with Divisions to ensure right patient right ward.

Administrative burden.

Effective - Elective Patient Flow (Rolling 12 Months): June (M3) 2013/14Page 16

0%2%4%6%8%10%12%14%

010203040506070

Cancelled Operations

1st Cancellation 2nd Cancellation CQC Target Cancellations

% Cumulative Cancellations CQC Target Breach % Cumulative Breaches

75%76%77%78%79%80%81%82%83%84%85%

Theatre Utilisation

Theatre Utilisation

02000400060008000

100001200014000

Occupied Bed Days & Bed Occupancy by Site

RAEI Occupied Beds RAEI Available Beds Leigh Occupied Beds

Leigh Available Beds Wrightington Occupied Beds Wrightington Available Beds

0

2000

4000

6000

8000

10000

12000

14000Referrals

GP Referrals Other Referrals

0%

2%

4%

6%

8%

10%

05000

1000015000200002500030000350004000045000

Outpatient Activity

First Attendances Subsequent Attendances Procedures

DNA % Hospital Cancellation %

020406080100120140

0500

1000150020002500300035004000

Elective Admissions(Including Day Case Admissions)

Elective Day Cases Elective Inpatients

Average Daily Day Case Admissions Average Daily Inpatient Admissions

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Notes:Daily Averages: The daily average activity figures have been calculated as a total of all activity during the month, divided by the actual number of days over which activity occurred during the month.

Summary

Bed Occupancy: The Data Quality team are investigating continuing issues regarding the recording of daily bed numbers on PAS in real time, especially with regard to wards on the Wrightington site.

The Trust is undertaking a bed base review and commissioned an external piece of work to understand the Medical, Specialist Services & Surgical bed base requirements.The Readmissions Task & Finish group contines to meet and is beginning to see some improvements in the number of readmissions.Since the Core Strategy Redesign in September 2012, it can be seen from a comparison of the 6 months January to June 2012 against the same period this year, that there have been significantly less admissions though the Trust. However the variance between admissions and discharges continues to cause issues at times of pressure.

Effective - Non-Elective Patient Flow (Rolling 12 Months): June (M3) 2013/14 Page 17

235.00

240.00

245.00

250.00

255.00

260.00

265.00

6500

7000

7500

8000

8500 A&E Attendances

Follow-Up Attendance New Attendance

Average Daily Attendances Linear (Average Daily Attendances)

0

50

100

0500

100015002000250030003500

Non-Elective Admissions

Admissions (Other)Admissions (AE & GP)Non-Elective Admissions PlanAverage Daily Admissions (AE & GP)Average Daily Admissions (Other)Linear (Average Daily Admissions (AE & GP))

2.5

3.0

3.5

4.0

4.5

5.0Length of Stay

Elective Length of Stay

6.0%

6.5%

7.0%

7.5%

8.0%Readmissions

28 Day Readmission 30 Day Readmission Linear (30 Day Readmission)

2400

2500

2600

2700

2800

2900

3000

Medical Division Admissions & DischargesJanuary - May 2012 v January - June 2013

Admissions Jan - Jun 2012 Discharges Jan - Jun 2012

Admissions Jan - Jun 2013 Discharges Jan - Jun 2013

1000011000120001300014000150001600017000

Occupied Bed Days(Trust Level)

Trust Occupied Beds Trust Available Beds

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Notes:

Summary

The conversion rate A&E Attendance to Admission via A&E has shown s a downward trend.As can be seen there was a significant increase in Delayed Discharges in April 2013, which has started to reduced to concerted efforts, and the Delayed Discharges Task & Finish Group. In June 2013, the CCG commissioned community beds to aid patient flow out of the Trust.

Delayed Discharges: These are a snapshot of the number of patients delayed divided by the total number of patients occupying an acute hospital bed as reported via Monthly Sitrep report. These figures won't correlate to the SHA report card as their methodology uses the quarterly KH03 for the occupied beds data.Right Patient Right Ward: The Audit figures do not correlate directly with the Trust Outliers as RPRW is a snapshot audit of the Inpatients on the Royal Albert Edward Infirmary (RAEI) site, undertaken on 1 day bi-monthly. The audit scheduled for the 23rd May 2013 did not take place due to workload issues.

Patient Outliers: These figures are on a divisional level basis, i.e. where a patient under the care of one division is in a bed owned by another division.Bed Occupancy: The Data Quality team are investigating continuing issues regarding the recording of daily bed numbers on PAS in real time, especially with regard to wards on the Wrightington site.

Effective - Effectiveness (Rolling 12 Months): June (M3) 2013/14Page 18

0%

5%

10%

15%

20%

25%

30%

0100020003000400050006000700080009000

Admissions Via A&E

A&E Attendances A&E Admissions (MSS figures) Conversion Rate

0%

1%

2%

3%

4%

5%

600062006400660068007000720074007600 Admissions versus Discharges

Admissions Discharges % Delayed Discharges

050

100150200250300350400 Patient Outliers

Outliers

Patient Flow Implemented November 2012.

0%

2%

4%

6%

8%

10%

12%

050

100150200250300350400450

Right Patient Right Ward

Correct Bed Outlying % Outliers

01000200030004000500060007000

100200300400500600700800900

Time to Discharge

Saturday Discharges Sunday Discharges

Discharges Before 11am Discharges After 11am

Patient Flow Implemented November 2012.

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SummaryA significant amout of work has been undertaken to reduce the Outpatient follow-up backlog by 998 cases (the T&O backlog has reduced by 519 cases). This will continue to be closely monitored.

Effective - Outpatient Follow-up Backlog: June (M3) 2013/14 Page 19

0 1000 2000 3000 4000 5000 6000 7000

General SurgeryPhysiotherapy

Speech and Language TherapyPlastic Surgery

GynaecologyEndocrinology

Chem PathologyG MedicineNephrology

Geriatric MedVascular Surgery

DermatologyOral Surgery

Community PaedsCardiology

Diabetic MedicineUrology

DieteticsRespiratory Med

ENTPain MgmtPaediatrics

OphthalmologyGastroenterology

RheumatologyT&O

Number of Patients

Spec

ialty

Number of Patients waiting for an outpatient Follow Up Appointment, by the period of time elapsed since the appointment was expected to take place

No Date Recorded

1 Month

2 Months

3 Months

4 Months

5 Months

6 Months

7-12 Months

1-2 Years

2-3 Years

3-4 Years

4-5 Years

The longest wait is 17 patients who were expected to be seen in June 2009.

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Spec

North of England

Commissioning Region

Apr May Jun Total Q1 Jul Aug Sep Total

Q2 Oct Nov Dec Total Q3 Jan Feb Mar Total

Q4 YTD

110 - Trauma & Orthopaedics 89.0 84.97 84.99 88.47 86.18 86.18Other 92.4 86.00 90.44 90.77 88.94 88.94Total 91.9 90.39 91.12 91.88 91.13 91.13

Spec

North of England

Commissioning Region

Apr May Jun Total Q1 Jul Aug Sep Total

Q2 Oct Nov Dec Total Q3 Jan Feb Mar Total

Q4 YTD

100 - General Surgery 96.5 92.19 90.41 97.06 93.17 93.17110 - Trauma & Orthopaedics 96.7 92.44 92.71 94.00 93.05 93.05160 - Plastic Surgery 96.7 95.45 95.00 92.00 94.03 94.03410 - Rheumatology 97.8 90.00 96.21 96.55 94.18 94.18Total 97.3 97.63 98.10 98.05 97.92 97.92

Spec

North of England

Commissioning Region

Apr May Jun Total Q1 Jul Aug Sep Total

Q2 Oct Nov Dec Total Q3 Jan Feb Mar Total

Q4 YTD

100 - General Surgery 92.7 86.12 88.38 89.33 87.97 87.97110 - Trauma & Orthopaedics 92.3 84.79 85.42 84.23 84.81 84.81140 - Oral Surgery 98.7 91.67 93.43 93.49 92.91 92.91Total 94.7 93.08 93.50 93.13 93.24 93.24

North of England Commissioning Region figures are as at: APRIL 2013

Specialist Services:

95% of Non-Admitted Patients to be Treated Within 18 Weeks

The referral to treatment (RTT) operational standards should be achieved in each specialty by every organisation and this will be monitored monthly.90% of Admitted Patients to be Treated Within 18 Weeks

92% of Patients on an Incomplete Pathway to be Treated Within 18 Weeks

Issues continue regarding the admitted pathway for T&O, due to the lack of capacity to meet demand.

Poor performance will provide poor patient experience and financial penalties. The Division has revised booking processes within the admissions

team, and with the additional capacity created through the two modular theatres have a planned trajectory for reduction of the backlog.

Risks Management ActionsIssues

Effective - 18 Weeks Waits By Exception: June (M3) 2013/14 Page 20

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Indicator Thresholds Q4 12/13 M1 M2 M3 Q1 Actual

Q2 To Date

Q3 To Date

Q4 To Date

YTD Performance Trend

A&E Attendances 23106 7801 7739 7423 22963 22963

Total time in A&E: 4 hour waits Monitor 95%, Internal 98% 95.88% 91.35% 97.74% 96.85% 95.28% 95.28%

A&E: Admitted Patients Total time in A&E (95th percentile) <= 4 hours 06:21:10 08:22:27 05:33:32 06:40:58 07:23:05 07:51:18

A&E: Non Admitted Patients Total time in A&E (95th percentile) <= 4 hours 03:52:46 04:16:32 03:48:11 03:49:26 03:53:31 03:55:23

A&E: Time to initial assessment (95th percentile) <= 15 minutes 00:20:59 00:20:01 00:17:58 00:18:42 00:18:54 00:19:01

A&E: Time to treatment decision (median) <= 60 minutes 00:53:31 00:54:12 00:44:58 00:47:12 00:49:09 00:49:09

A&E: Unplanned re-attendance rate <= 5% 4.3% 4.0% 3.7% 4.0% 4.0% 4.0%

A&E: Left without being seen <= 5% 3.7% 4.9% 3.8% 3.9% 4.9% 4.9%

Number of NWAS ambulances attending A&E * 7672 2504 2242 2174 6990 6990

Average NWAS Notification of Patient Arrival to Handover Time (mm:ss) * <= 15 minutes 13:33 13:53 10:03 11:15 11:43 11:43

Average NWAS Ambulance Turnaround Time at A&E (mm:ss) * <= 30 minutes 30:04 31:08 28:27 28:59 29:36 29:36

Notes:

Loss of income.Loss of reputation.Poor patient care.

Due to the reduction in discharges throughout March and April a Discharge Task & Finish group has been established in order to improve the discharge process with various actions being implemented throughout June and July.

The A&E Performance graph is based on the Greater Manchester UM Gold Performance Report, circulated by Salford Clinical Commissioning Group.* NWAS : North West Ambulance Service. Data Source: http://nww.nwas.nhs.uk. The data relates specifically to Category AS1 (999 emergency call - immediate response). Notification to Handover Time is the time taken from HAS notification to the Trust assuming ACUTE responsibility for the attendance. Handover & Turnaround times can only be calculated where all relevant timestamps are present on the NWAS Hospital Arrival Screens (HAS) system.

Issues Risks Management Actions

Failure of target.Following the significant pressures faced by A&E departments across the country during March and April, performance significantly improved during May and June to 97.74% and 96.85% respectively. This resulted in the Trust achieving the Q1 target with a performance of 95.28%.

Effective - A&E Clinical Quality Indicators : June (M3) 2013/14Page 21

90% 91% 92% 93% 94% 95% 96% 97% 98% 99% 100%

Central Manchester

Stockport

Tameside

Salford

Wigan

Pennine

South Manchester

Bolton

Greater Manchester A&E Performance by Acute Trust1st April 2013 to 30th June 2013

Please note activity for Central Manchester is Level 1 activity only.

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Vital Signs Indicator: TIA & Stroke Threshold Q4 12/13 Apr May Jun Q1 Actual

Q2 To Date

Q3 To Date

Q4 To Date YTD Trend

High Risk Transient Ischaemic Attack (TIA) Patients Treated Within 24 Hours 60.00% 92.73% 76.19% 100.00% 73.68% 83.33% 83.33%

Stroke Patients Spending 90% of Their Hospital Stay on a Stroke Unit 80.00% 65.38% 76.92% 77.78% 51.22% 68.10% 68.10%

Q4 12/13 Apr May Jun Q1 Actual

Q2 To Date

Q3 To Date

Q4 To Date YTD Trend

107 25 35 32 92 92

Q4 12/13 Avg Apr May Jun Q1 Avg Q2 Avg Q3 Avg Q4 Avg YTD

Avg Trend

N/A 87.7% 88.4% 87.0% 87.7% 87.7%

N/A 88.9% 84.4% 91.5% 88.3% 88.3%

N/A 92.0% 96.5% 93.2% 93.9% 93.9%

N/A 90.7% 91.9% 85.9% 89.5% 89.5%

N/A 84.0% 83.8% 83.1% 83.6% 83.6%

N/A 88.3% 95.4% 87.0% 90.2% 90.2%

N/A 90.1% 84.4% 89.3% 87.9% 87.9%

N/A 48.1% 59.0% 55.4% 54.2% 54.2%

97.8% 83.7% 85.5% 84.0% 84.4% 84.4%

Q4 12/13 Avg Apr May Jun Q1 Avg Q2 Avg Q3 Avg Q4 Avg YTD

Avg Trend

93.4% 96.8% 93.2% 88.6% 92.9% 92.9%

87.9% 91.7% 86.1% 89.4% 89.1% 89.1%

94.7% 97.6% 92.1% 87.5% 92.4% 92.4%

93.4% 100.0% 82.2% 81.8% 88.0% 88.0%

92.4% 96.5% 88.4% 86.8% 90.6% 90.6%

New thresholds for April'12

Stroke: 90% stay on a Stroke Unit:

Complaints:

Ombudsman:

The Divisions will be advised of the number of complaints received over the last quarter and the recognised reduction from the same quarter last year.

There is a probability that the PHSO, if they uphold a complaint, will recommend financial redress.

Divisions are to review the Ombudsman's Principles of Good Complaint Handling.

The performance against the target of 80% of stroke patients having 90% of their stay on a stroke unit was 76.92% in April and in May was 77.78%. During May there were still pressures on inpatient flow which led to a higher number of outliers, resulting in a slight under-achievement of the target.

In the month of June the highest number of complaints received were under the category of All Aspects of Clinical Care (17). The other complaints relate to Admissions, Discharge and Transfer Arrangements (2); Appointments, delay/cancellation (OPD) (2); Appointments, delay/cancellation (IP) (1); Attitude of Staff (5) and Communication (5).

We have once again received 5 complaints that are related to Attitude, 4 logged as Uncooperative and 1 as Rude. These are in respect of Nurses (2); Doctors (2); and 1 involving both nursing and medical staff. These are all related to different areas and will be taken forward with the Divisions. This month there is also a rise in Communication complaints(5).

An action plan has been developed and shared with the CCG and is currently being implemented. A daily bed state for the stroke unit is now e-mailed to the Directorate Manager and the DDOP detailing the bed position and daily action plans.

Poor patient experience.Loss of reputation.

The 3 PHSO cases that have recently been upheld have been cases that have advised financial redress.

Failure of target.

Indicator

AVERAGE

Number of complaints

INVOLVEMENT IN YOUR CARE

Outcome of "How are we Doing?" Patient discharge surveys conducted monthly:

Outcome of Real Time Patient Surveys conducted monthly: CHANGE OF QUESTIONS FROM APRIL'13Have staff treating and examining you introduced themselves?

If your family or someone else close to you wanted to talk to a doctor, did they have enough opportunity to do so?

RECOMMEND THIS HOSPITAL

Amber =>=85 and <90

Have you been involved as much as you wanted to be in decisions about your care and treatment?

Do you think the hospital staff did everything they could to help control your pain?

Have you been offered a choice of food during your stay?

Red = <85

THE CARE YOU RECEIVED

Management Actions

Green = >=90

Issues Risks

Did you find someone to talk to about your worries and fears?

CLEANLINESS AND FOOD

Has there been healthy food on the hospital menu?

Have you been involved in decisions about your discharge from hospital?

AVERAGE

Caring - Patient Experience: June (M3) 2013/14 Page 22

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Results of Monthly Ward to Board Audits

IndicatorQ4

12/13 Avg

Apr May Jun Q1 Avg Q2 Avg Q3 Avg Q4 Avg YTD Avg Trend

FALLS ASSESSMENT 98.87 97.53 99.30 100.00 98.94 98.94

FOOD AND NUTRITION 97.49 99.07 96.85 99.21 98.38 98.38

HEALTHY HOSPITALS 95.50 96.60 96.85 96.84 96.77 96.77

INFECTION PREVENTION & CONTROL 96.95 97.84 97.20 98.81 97.95 97.95

MEDICINE ADMINISTRATION 98.97 98.46 98.25 98.42 98.38 98.38

PAIN MANAGEMENT 99.17 99.07 98.95 100.00 99.34 99.34

PATIENT OBSERVATIONS 97.68 96.91 95.10 98.81 96.94 96.94

PRESSURE AREA CARE 98.72 98.77 99.65 99.60 99.34 99.34

PRIVACY AND DIGNITY 98.12 98.77 98.60 100.00 99.12 99.12

AVERAGE 97.94 98.11 97.86 99.08 98.35 98.35

RAG Rating CriteriaRed = <92Amber = >=92% and <95%Green = >=95%

Maternity:Inpatient metrics all remain within taget.

Surgery:

Medicine:

Emergency Care: All areas scored 100%.

The Nursing Quality Outcomes report consists of nine nursing care indicators which are used to assess and measure standards of clinical care and patient experience.

Issues Management Actions

Overall increase in all indicators, showing highest compliance since Decemebr 2012.

Positive feedback to staff.

Positive feedback to staff.

Risks

Maternity Services produce 5 audits from clinical areas each month.

There has been an overall increase in compliance with the exception of Healthy Hospitals.

Two wards are piloting a new IT system of audit and results are awaited.

All reports are discussed during the monthly Clinical Cabinet.

Caring - Nursing Quality Outcomes: June (M3) 2013/14 Page 23

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Areas of Quality ImprovementMetric Plan Type

Indicator Weighting Year Target Apr May Jun Q1 Actual Q1 Target Indicator Lead Divisional

Lead

GM2 - Avoidable Admissions HIGH GM2 - Avoidable Admissions 0.107 £224,725 1 1 1 1 1 Steve Aspinall / Gill Rowlands

GM3 - Transfers of Care HIGH GM3.1 - Clinical Peer Review 0.077 £161,718 1 1 1 1 1 Margaret JolleyGM3 - Transfers of Care HIGH GM3.2a - End of Life 0.031 £65,107 1 1 1 1 1GM3 - Transfers of Care HIGH GM3.2b - End of Life 0.03 £63,007 1 1 1 1 1GM3 - Transfers of Care HIGH GM3.2c - End of Life 0.03 £63,007 1 1 1 1 1GM3 - Transfers of Care HIGH GM3.3 - Homelessness 0.077 £161,718 1 1 1 1 1 Debbie HindGM4 - Alcohol HIGH GM4 - Alcohol Action Plan 0.0525 £110,262 1 1 1 1 1

GM4 - Alcohol HIGH GM4a - Alcohol Training (Cumulative Psition) 0.0245 £51,455 1.3% 4.6% 7.5% 7.5%

6 Monthly Target 40.0%

L1- 7 Day Working HIGH L1 - 7 Day Working 0.6 £1,260,143 1 1 1 1 1 Gillian Edwards Andrew Beatty / Lesley Hadley

L2 - Integrated Health System Patient Record HIGH L2.1 - Milestone Achievement in HIS

Project Plan 0.2 £420,047 1 1 1 1 1

L2 - Integrated Health System Patient Record HIGH L2.2 - Establish Data sharing across the

health economy 0.2 £420,047 1 1 1 1 1

L2 - Integrated Health System Patient Record HIGH L2.3 - Participate in the GM Electronic

Clinical Correspondence Innovation 0.2 £420,047 1 1 1 1 1

L3 - Sepsis Reduction HIGH L3a - No of Eligible Staff Trained in Sepsis Screening (Cumulative Position) 0.08 £168,019 33.7% 33.7% 36.8% 36.8% 30.0%

L3 - Sepsis Reduction HIGH L3b - Achievement of Quarterly Milestones on the Sepsis Action Plan 0.075 £157,517 1 1 1 1 1

L4 - Antimicrobial Stewardship HIGH L4a - Antibiotics Indicated on Prescription Chart 0.035 £73,920 88% End

of Oct

L4 - Antimicrobial Stewardship HIGH L4b - Antibiotic Stop Date Documented on Prescription Chart 0.035 £73,920 60% End

of OctN1- Friends and Family Test HIGH N1.1 - Phased Expansion of Survey 0.03 £63,007 1 1 1 1 1

N1- Friends and Family Test HIGH N1.2 - Increased Response Rate (Measured at Quarter End) 0.03 £63,007 9.9% 7.6% 13.7% 13.7%

15.0% as at end Qtr1

N1- Friends and Family Test HIGH N1.3 - Increase Score of Family and Friends 0.03 £63,007 0

Ray Green

Lucy Lyon

Rebecca Lyon / Joanne Hough

Dr Teo Hoon / Jackie Hylton

Pauline Jones / Andrea Arkwright

Stephen Dobson

Caring - CQUIN Quality Scheme:June (M3) 2013/14 Page 24

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Areas of Quality ImprovementMetric Plan Type

Indicator Weighting Year Target Apr May Jun Q1 Actual Q1 Target Indicator Lead Divisional

Lead

N2 - Safety Thermometer HIGH N2.1 - Safety Thermometer 0.035 £73,508 1 1 1 1 1

N2 - Safety Thermometer HIGH N2.2 - Reduction in the No of Total Trust Falls 0.035 £73,508 1 1 1 1 1

N3 - Dementia HIGH N3.1a - Dementia FAIR Case Finding Question 0.025 £52,505 53.8% 62.5% 77.7% 65.0% 90.0%

N3 - Dementia HIGHN3.1b - Dementia FAIR No of Patients with Diagnostic Assessment & Investigations

0.025 £52,505 85.7% 78.9% 75.0% 78.9% 90.0%

N3 - Dementia HIGH N3.1c - Dementia FAIR No of Patients Referred for Diagnostic Advice 0.025 £52,505 100.0% 100.0% 100.0% 100.0% 90.0%

N3 - Dementia HIGH N3.2 - Dementia - Clinical Leadership 0.0075 £15,751 1 1 1 1 1

N3 - Dementia HIGH N3.3 - Dementia - Supporting Carers and People with Dementia 0.0375 £78,758 1 1 1 1 1

N4 - VTE Risk Assessment HIGH N4 - VTE - Root Cause Analyses 0.11 £231,026 100.0% 69.2% 0.0% 47.6% 30.0%N4 - VTE Risk Assessment HIGH N4 - VTE Risk Assessment 0.11 £231,026 95.6% 95.7% 95.6% 95.0%

R1-5 - Advancing Quality HIGH R1 - AMI 0.01 £21,002 80.7% Dr Sanjay Arya / Carolyn Dereszkiewicz

R1-5 - Advancing Quality HIGH R2 - Heart Failure 0.01 £21,002 90.2% Dr Sanjay Arya / Carolyn Dereszkiewicz

R1-5 - Advancing Quality HIGH R3 - Hip & Knee 0.01 £21,002 Martyn Porter Robert Wilson

R1-5 - Advancing Quality HIGH R4 - Pneumonia 0.01 £21,002 62.9% Dr Ram Sundar / Carolyn Dereszkiewicz Simon Hill

R1-5 - Advancing Quality HIGH R5 - Stroke 0.01 £21,002 56.0% Dr Appu Suman / Lesley Hadley

SC - Neonatal HIGH SC - Breast Feeding 0.06 £126,014 0.0% 6.7% 10.0% 10.0% 58.0%

SC - Neonatal HIGH SC - Retinopathy of Prematurity Screening 0.05 £105,011 100.0% 100.0% 100.0% 100.0% 60.0%

£5,280,000

Neonatal breast feeding target is not being achieved.

VTE RCA's are not being carried out in Surgery or Specialist Services, although the target is being acheived due to Medicine Division completing them.

Friends and Family Response Rate is currently below target for end of Q1.Some dementia targets were not achieved in months 1 and 2.

All non achieving CQUIN's are discussed fortnightly at the Implementation Group and will be escalated to the new CQUIN Project Group.

A meeting has been arranged to discuss the recording of breast feeding (this is believed to be a data issue and not a service issue).

Additional support will be provided to the dementia team to improve service (and achieve the CQUIN measures).

Friends and Family will continue to receive a high profile within the Trust to encourage an increased return rate.

There is a risk that CQUIN funding will not be achieved, plus all targets have a quality impact.

Linda Smyth

Dr Arvind Kumar / Jean Ramsdale

Ian Aspinall

Management ActionsRisksIssues

Dr Christos Zipitis / Diane Swindlehurst

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Headcount WTE Headcount WTEEstates & Facilities 667 491.18 698 513.64Finance 68 62.59 84 77.12IM&T 92 87.21 86 82.72Human Resources 44 39.58 50 43.30Medicine 1054 934.18 1168 1046.75Specialist Services 1262 1073.51 1254 1071.99Surgery 957 845.35 982 865.44Small Divisions 142 130.93 153 139.89Total 4286 3664.53 4475 3840.85

Pay expenditure in June 13 is £13,375k which is £227k under the budget for June 13. All Divisions are overspent with the exception of Estates and Facilities, Finance, Medical Directorate, Dir of Strategy & Planning and Trust Exec which are underspent by £17k, £14k, £6k, £3k and £2k respectively.

Management ActionsDivisional teams (inc HR & Finance) are meeting monthly to review headcount reduction plans as part of Divisional CIP meetings and agree any headcount reduction re-forecasting.Robust vacancy control measures are in place to ensure that vacancies are made available to support re-deployment of employees where required.

Vacancy control measures have to be carefully managed to ensure that service quality is not compromised. ●If headcount reduction forecasts are not met then pay If headcount reduction forecasts are not met then pay expenditure will exceed the agreed pay budget.

The Trustwide actual headcount reduction for June 13 is 2.98 WTE against a plan of 2.25 wte for the month. The 2013-14 target is 50 wte and ytd there has been 4.49 achieved.

Total Staff in Post

Division As at 30 Jun 2012 As at 30 Jun 2013

Issues Risks

HR - Workforce in Post & Trajectory Page 25

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Target May 13

May 13 Sickness

Absence %YTD% Variance % Variance

from target

3.83% 5.32% 5.42% 1.49% 38.90%4.40% 5.04% 5.10% 0.64% 14.55%2.39% 0.00% 0.11% -2.39% -100.00%2.39% 1.04% 0.58% -1.35% -56.49%2.39% 3.01% 2.37% 0.62% 25.94%4.40% 4.12% 3.88% -0.28% -6.36%3.83% 3.74% 3.57% -0.09% -2.35%2.39% 1.45% 1.35% -0.94% -39.33%3.83% 4.23% 4.15% 0.40% 10.44%

Non achievement of sickness absence targets will impact upon our ability to reduce temporary spend and to meet our CIP temporary spend target.

Trust Sickness Absence was 4.23% for May 13 (an in month increase from 3.92% for April 13). Taking into account seasonal trends the target for May was 3.83% and this target has been exceeded. The rolling 12 month figure for June 12 - May 13 is 4.45%.

MedicineSurgery

Management ActionsIssues

Continued analysis of sickness absence reports to identify hotspots/trends and strong partnership working with Divisional managers to continue to proactively manage long & short term sickness absence cases.

The information on the Health & Wellbeing dashboard around long term sickness referral timescales has been expanded and any areas of concern are progressed by the HR Business Partners.The Health and Wellbeing Steering Group & HR Department have developed strategies to support staff health and wellbeing which should ultimately result in an absence reduction for the year 2013/14. This includes the launch of an Trust Wide EAP and a 1st day of absence service which will commence with a pilot in Specialist Services (exc SSDU) in July 13.

Risks

Labour Turnover has increased slightly to 6.17% for the period July 12 - June 13. It is noted that the labour turnover figure includes MAS leavers.

Trust Sickness Absence

Division

Specialist ServicesEstates & Facilities

OVERALL TRUST TOTAL

IM & T

Small Divisions

Finance

Human Resources

HR - Productivity: Trust Sickness Absence; Labour Turnover; Stability Page 26

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Non-compliance of medical staff PDR's could impact on revalidation.

Local Induction: Trust wide compliance for the period January 13 - March 13 is 71% for Trust employed staff; this is a significant improvement over the figure reported for October 12 - December 12 (32.5%). Local Induction for the period April 12 - March 13 is 62% for Agency staff which has increased from 55% at December 12. However, this is well under target of 95% compliance. There are two NHSLA criterion which are linked to local Induction which are local induction of temporary staff and local induction of permanent staff. The risk of failing to meet the requirements around NHSLA has been scored at 20.

Compulsory Training: Compulsory training for the period July 12 - June 13 is 88.3% which is a slight increase compared to the period June 12 - May 13 (86.5%). The only Divisions currently meeting the 95% compliance target are Finance, Human Resources and IM&T.PDR: Overall the Trustwide compliance rate is 79.8% for Jun 13 - a marginal decrease from 80.3% for May 13. The only Divisions currently meeting the current compliance target are Estates and Facilities, Human Resources and Specialist Services. The Division with the lowest compliance rate is Small Divisions at 55.3% (up from 54%). The Trust PDR target is 82%; therefore improvements are still required to enable the Trust to meet this target.Corporate Induction: Induction compliance has increased to 99.1% for the period July 12 - June 13 compared with 98% for the period June 12 - May 13. The target is 95% and all Divisions with the exception of IM&T are currently meeting this target.

Mandatory Training: Month 3 compliance has increased slightly to 88.3%. All Divisions/Departments falling below 95% compliance for any aspect of mandatory training are now required to submit a monthly action plan to REMEC detailing how they plan to address their compliance rates. This now requires immediate action with risk assessments from the responsible managers. From the 6th July individual e-mail alerts will be sent to staff to remind them that their training is due. It is hoped that this will support the management of compliance.PDR: Reports are now being produced on a monthly basis to aid in more effective monitoring. The HR & T & D teams are working together with the Divisions and action plans are in place to address the poor compliance rates.Local Induction: Non-compliant staff are followed up by the Training and Development department individually and via their line manager. Divisions with compliance below 95% are now required to present a risk assessment and action plan to REMEC to ensure compliance.

Non-achievement of Trust targets for Induction, PDR & E-compulsory could impact upon compliance with NHSLA and also lead to non achievement of CQUIN targets.

Issues Risks Management Actions

HR - Learning & Development Page 27

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Pay type Mar-13 Apr-13 May-13Average salary costs for employed staff £33,253 £33,134 £33,555Average salary for all staff (inc Agency) £34,200 £33,396 £34,249Average pay costs for employed staff £39,425 £39,522 £39,843Average pay costs for all staff (inc. Agency) £40,044 £39,466 £40,252

There has been an in month increase in temporary spend to £975k in June 13 from £910k in May 13. All Divisions have decreased their temp spend in June 13 with the exception of Medicine, Finance, HR and Medical Directorate which have increased by £15k, £1.5k, £3k and £1k respectively.In June 13 one category of spend has marginally decreased: Bank Internal decreased by £355. All other categories of spend have increased: Agency (from £490k to £513k), Bank NHSP (from £235k to £236k) Locum (from £31k to £59k), Overtime (from £105k to £112k) and Zero Hours Contract (from £46k to £51k).

Pressure to maximise income opportunities will increase pressure on agency and medical locum costs.

Temporary Spend reporting has been improved and divisional spending is scrutinised and challenged at Management Board and Temporary Spend group meetings.A VAT reduction scheme for Locum bookings will reduce the overall cost of Locum temporary spend within 2013/14.

The introduction of a new type of temporary spend 'Cost per case' should help contribute to a reduction in temporary spend within 2013/14. If Trust staff undertake additional activity under the 'Cost per case' payment framework this is a lower cost than other types of temporary spend such as Agency or Locum spend.

Risks

Average Salary Paid & Total Employment Costs by Month

Management ActionsIssues

The temporary spend figure for June 13 is £975k which is £150k over the forecast for June 13. YTD temp spend is £2,725k which represents a £897k reduction on the same period last year.

Shortages in some medical specialties will continue to make it very difficult to fill certain medical vacancies resulting in increased agency locum expenditure.

HR - Productivity: Staffing Costs Page 28

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Trust Board

Agenda Item 8. Date: 31.07.13

Title of Report Finance Report M3

Purpose of the report and the key issues for consideration/decision

To inform the Board of financial performance during Month 3.

Prepared by: Name & Title

David Hughes, Associate Director of Finance

Presented by: Rob Forster, Director of Finance

Action Required (please X)

Approve Adopt Receive for information

x

Strategic/Corporate Objective(s) supported by this paper

Performance: quarterly and full year FRR of 3

Is this on the Trust’s risk register?

No

Yes

x If Yes, Score

20

Which Standards apply to this report?

CQC Finance NHSLA Governance BAF Objectives As above WWL Wheel Performance

Have all implications related to this report been considered?

Finance Revenue & Capital x Equality & Diversity National Policy/Legislation Patient Experience NHS Contract Governance & Risk

Management

Human Resources Terms of Authorisation Consultation/Communication Human Rights Other: Carbon Reduction

Previous Meetings

Please insert the date the paper was presented next to the relevant group

Meeting Point

Audit Committee

Quality & Safety

Committee

Finance & Investment Committee

Management Board

IM&T Strategy

Committee

HR Committee

NED Other

N/A N/A N/A 24.07.13 N/A N/A N/A N/A N/A

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.

Wrightington, Wigan and Leigh NHS Foundation Trust

Financial Board Report

As at Month 03

30th June 2013

Date of Issue: 12

th July 2013

(Working day 10)

Robert Forster DIRECTOR OF FINANCE AND INFORMATICS

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1 Contents

1 Contents ................................................................................................................ 2

2 Executive Summary .............................................................................................. 3

3 Executive Summary – Part 2 ................................................................................ 4

4 Statement of Financial Position ........................................................................... 5

5 Cash Flow .............................................................................................................. 6

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2 Executive Summary

The Trust is reporting a £0.6m surplus in month 03, a favourable variance of £0.7m versus plan. The overall cumulative position is a deficit of £0.1m which is £0.1m better than plan and £0.2m better than the position this time last year.

Income in month 03, is £20.6m versus a plan of £19.2 recovering versus plan compared to the opening two months of the year. Cumulatively income is now £1.2m ahead of plan

Divisional expenditure is £18.9m in month 03 which is £0.7m more than planned. Year to date the Trust overspend is £1.1m

The Trust has spent £5.3m versus a plan of £5.5m.

The cash balance in month 03 is £16.8m, versus plan of £18.4m.

The Trust has achieved a FRR of 3 year to date versus a plan of 3.

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3 Executive Summary – Part 2

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4 Statement of Financial Position

Headlines:

Non-current assets have moved by £3.3m this includes capital additions in the programme of

£5.3m, £0.1m donated assets, offset by (£1.8m) depreciation and amortisation, and the

impairment of the accommodation block at RAEI (£0.3m).

Trade and other receivables have seen an increase of £3.1m in relation to an increase in NHS

balances.

The assets held for sale continues to include land for Billinge and the Ashton Stores.

The final cash position is lower than planned due to the FTFF loan being planned to be

drawndown in Q1 and actually received July 1st plus movement in working capital.

Current liabilities have increased due to accruals in the quarter.

Reserve movement is in line with Trust deficit and includes £0.2m adjustment to revaluation

reserves to I&E reserves for the impairment of the accommodation block described above.

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5 Cash Flow

Headlines:

Technical operating deficit equates to I&E performance

Cash paid on capital expenditure is overspent by £0.3m in month 03. This is different from

capital program expenditure due to capital creditors.

Working capital movement in the month reflects movement in accruals and an increase in NHS

receivables.

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Chairman: Les Higgins Chief Executive: Andrew Foster CBE Template Version 2 – reviewed June 2011, next review June 2012

your hospitals, your health, our priority

1

Trust Board Chairpersons Name Louise Barnes (for Les Higgins) Committee Name Trust Board Date of Meeting 26th June 2013 Name of Receiving Committee N/A Date of Receiving Committee meeting N/A

Please detail a key success or achievement of the committee discussed at the meeting 1. Improvements to the bereavement service 2. Improvement in workforce metrics 3. The Wrightington design proposals 4. Investment plans 5.

Details of the top three risks identified during the course of the meeting and initials of primary member of staff actioning 1. Challenges around the C Diff trajectory 2. Emergency bed pressures 3. FRR 2 in M2 4. 5. Attendance at the meeting (please highlight):

Excellent (well attended)

Acceptable (some apologies)

X

Unacceptable (quorate)

Unacceptable(not quorate)

Was the agenda fit for purpose and reflective of the Committees terms of reference?

Yes

Narrative report of the key issues of the meeting

The Trust Board received a powerful presentation on the Bereavement Service, and an outline of improvements the service hopes to take forward. Metrics to monitor performance will be included in the Performance Report. The TB noted the significant operational pressures that may impact on green rating on the Monitor Compliance Framework, including CDiff, A&E, bed pressures and financial performance. It was agreed to notify Monitor that the Trust has breached the de minimus figure for Qs 1 and 2 for CDiff . The impact on patients was a key part of the discussion. The implementation of step-down community beds was welcomed. An update on Healthier Together and governance arrangements to expedite work with Bolton was received. Increases in car parking charges were agreed under AOB. It was noted this had previously gone to the Council of Governors and had been approved. Some further amendments were proposed at the Board, and these will be investigated.

Key actions Name of primary lead for the actions F Murphy to liaise with U Prabhu for dates to deliver the Bereavement presentation to doctors

F Murphy / U Prabhu

F Murphy to liaise with E Kerr to discuss a communications programme to publicise the bereavement work and logo

F Murphy / E Kerr

An update to come to next month’s Trust Board on the BC for specialist nurses, private areas on wards and improvements

P Jones

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Chairman: Les Higgins Chief Executive: Andrew Foster CBE Template Version 2 – reviewed June 2011, next review June 2012

your hospitals, your health, our priority

2

to mortuary viewing facilities Time to mortuary under 4 hours to be added as an Always Event and to be added to the performance report for monitoring

P Jones / F Noden

A high level briefing to be provided to the Board that will look to give an analysis of the issues such as weekend discharges, acuity of patients and bed base and how these are being addressed. It will also advise what mitigations can be put in place including work with the CCG to prevent the system falling over again

Exec directors

H Hand to arrange for the next full board away day at SSDU H Hand P Jones to ensure amendments are made to the risk management strategy in line with Board comments

P Jones

S Nicholls to look at the possibility of a parking season ticket and the first 30 minutes of parking being free of charge

S Nicholls

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TRUST BOARD AGENDA ITEM: MINUTES OF A PUBLIC MEETING OF THE WRIGHTINGTON WIGAN AND LEIGH NHS FOUNDATION TRUST BOARD HELD ON WEDNESDAY 26 JUNE 2013 IN THE BOARDROOM, TRUST HEADQUARTERS, RAEI

PRESENT 2012 2013

28 03

25 04

30 05

27 06

25 07

29 08

26 09

31 10

28 11

19 12

30 01

27 02

27 03

24 04

29 05

26 06

Mr L Higgins, Chairman C A A Mr R Armstrong, NED A A Mrs L Barnes, Deputy Chair/SID C A A Mr G Bean, NED E A Mr R Collinson, NED L Mr R Forster, Director of Finance & IM&T L Mr A Foster, Chief Executive A E A Mr J Lenney, Director of Human Resources

- A

Mr S Nicholls, Deputy CEO / Director of Strategy & Planning

-

Dr U Prabhu, Medical Director - A Mr N Turner, NED A - Mrs C Parker Stubbs, NED - A A Ms F Noden, Director of Performance A - A Mrs P Jones, Director of Nursing - A A IN ATTENDANCE Mrs L Hancock, Acting Corporate Services Administrator

- -

Mrs H Hand, Trust Board Secretary - A Mr E Kerr, Head of Corporate Communications

A - A

2 members of the public - - - - - - - - Mr J Husain, DMD Surgery - - A - - - A - - A - A Dr S Arya, DMD Medicine - - - - A - A - - - A Mrs P Law, Deputy Director of Nuring - - - - - - - - - - - - - - - Mr T Clayson, DMD SS - - - A Mr I Bett, DDoP SS (for FN) A Mr D Pearce, Directorate Manager for MSK - Dr A Wardman, Responsible Officer (for UP)

-

FT239/13 CHAIRMAN’S OPENING REMARKS L Barnes welcomed all to the meeting, particularly the members of the public that were in attendance. She noted the challenges of the agenda and asked that it was assumed that all present had fully read the papers. She welcomed Fiona Murphy to the meeting who would be presenting to the Board on the improvement work that had been undertaken around bereavement. FT240/13 BEREAVEMENT PRESENTATION: FIONA MURPHY P Jones introduced F Murphy to the Board. F Murphy currently provides support across 3 Trusts / communities: Wigan, Bolton and Salford, and has received many plaudits for her work in this area. F Murphy thanked the Board for the opportunity to present and began by noting that grief and bereavement touched everybody at some time. She noted that a death was a major event in the lives of families and how vitally important it was that the process was handled correctly and with care every time, regardless of the place of death. She noted that since her arrival at WWL in November, massive improvements have been made. However, she noted that WWL

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2

had sometimes been careless in its treatment of the dying and their families and related some examples of this. However, positively, the time from ward to mortuary has reduced dramatically, dedicated parking has been made available to families and beds have been made available for relatives who want to stay with their loved ones. Access to the mortuary is now unrestricted for relatives wishing to see their loved ones and F Murphy has close links with PALs to assist with complaints that stem from the bereavement process. F Murphy advised that all staff had embraced these changes and that a real culture change had been made although there were still improvements to be made. The Board thanked F Murphy for her presentation and it was agreed that this should be delivered to doctors as well. E Kerr will liaise with F Murphy and give support to the plans to publicise the bereavement work and logo. F Murphy noted that a business case was going to be put forward to recruit some specialist nurses to assist with the work, particularly around deaths that are in sudden and tragic circumstances. This was noted and it was also suggested that the Board should look at the provision of private areas on wards for use by bereaved families and the improvement of the viewing facilities available in the mortuary. It was further agreed that time to mortuary under 4 hours should be an ‘Always Event’ and F Noden will add this indicator to the performance report for monthly monitoring. ACTION: F Murphy to liaise with U Prabhu for dates to deliver the presentation to doctors F Murphy to liaise with E Kerr to discuss a communications programme to publicise the bereavement work and logo An update to come to next month’s Trust Board on the BC for specialist nurses, private areas on wards and improvements to mortuary viewing facilities Time to mortuary under 4 hours to be added as an Always Event and to be added to the performance report for monitoring FT241/13 APOLOGIES As noted in the table above. FT242/13 DECLARATION OF INTERESTS None declared. FT243/13 PATIENT STORY R Forster read the patient story to those present. The Board were pleased to note the positive content of this. FT244/13 CHIEF EXECUTIVES REPORT AND MATTERS FOR THE BOARD TO NOTE Performance / C Diff S Nicholls noted the continued pressures in terms of A&E and beds. C Diff cases have risen to 13 and F Noden advised that the Monitor de-minimus had been breached for Q1 and Q2. If a further 6 cases occur before the end of December, WWL will go to a red rating for governance. It was agreed that Monitor should be notified of this in the Q1 return. The Board noted the continued efforts made to minimise cases of C Diff, the forward planning and investment that was put in place at the very start of the year and that, despite analysis, no trend could be found for the increase in cases although it was felt likely to be linked to increased A&E / hospital pressures. It was noted that an external infection control inspector had been invited in to review WWL practices. He found that WWL had good infection control practices in place and the only recommendations made were with regard to changing pillows and cleaning audits. Both of

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these recommendations are being taken forward. It was supported by the Board to inform Monitor of the Q1, Q2 and possible Q3 failure for C Diff. Healthier Together / media coverage With regard to Healthier Together, S Nicholls noted that discussion continued although there are mixed messages with regard to timescales. There had been significant press coverage yesterday in the Borough about Healthier Together and WWL. He further noted the recent press coverage with regard to Healthwatch and the CoG agreement to defer inviting them to sit on the CoG for 6 months. The Board noted the press interest but felt that it wasn’t necessary at this time to respond. H Hand confirmed that Healthwatch had been notified that all Board meetings were held in public and that they were welcome to attend. Bolton S Nicholls advised that governance arrangements are being looked at and more detail around this will be brought to the next meeting.

FT245/13 ‘HEALTHIER TOGETHER’ This was covered under the CEO’s update. FT246/13 PERFORMANCE REPORT M2 F Noden reported a significant reduction in cancelled ops. She noted that the A&E target had been achieved in May and was achieving in June but it was tight for the quarter. She and S Arya have been looking at measures to be put in place over the coming days to support achievement. P Jones noted that there had been one instance of MRSA which had been found to be a contaminated sample. A sweep of training has been undertaken to refresh sample taking skills. Two new patient experience measures are in place, staff introductions are improving but healthy nutrition has been struggling. Complaints have improved and the Friends and Family test remains a challenging target to meet. J Lenney advised that sickness absence levels had reduced in M2, temp spend was on a downward trend. Recruitment to vacancies remained a challenge and all possible was being done. G Bean expressed concern at the continued challenges of A&E and requested that the Board have some analysis on these issues. It was agreed that a high level briefing would be provided to the Board around issue analysis that would look at discharge, acuity of patients and bed base. The paper will include how these issues are being addressed and what mitigations can be put in place should the system fall over again. ACTION: A high level briefing to be provided to the Board that will look to give an analysis of the issues such as weekend discharges, acuity of patients

and bed base and how these are being addressed. It will also advise what mitigations can be put in place including work with the CCG to prevent the system falling over again

FT247/13 BAF SCORING BUILD STAKEHOLDER RELATIONSHIPS Resolved: It was agreed to increase the score to 12 The recent issues with Healthwatch were noted and considered in the scoring of this objective. Taking this into consideration it was agreed to increase the score to 12. H Hand will circulate a brief to Board members on the role and remit of Healthwatch. NEGOTIATE A SUCCESSFUL SERVICE MODEL WITH NEIGHBOURING TRUSTS FOR HEALTHIER TOGETHER BY SUMMER 2013 Resolved: It was agreed to retain this score at 15

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S Nicholls felt that good progress was being made. Therefore it was agreed to retain the score for this at 15. FT 248/13 FINANCE REPORT M2 R Forster reported that it had been a disappointing month 2 with Trust falling behind plan by £600k. Income was down on plan, particularly in T&O, and expenditure was overspent. This overspend was primarily in non-pay and the reasons for this are being investigated. Capital expenditure is ahead of plan with £4.1m spend to date. It was emphasised that this was due to phasing and that all spend had been on agreed projects but would need to be brought back within the 15/% margin. The cash position is strong and the Trust achieved FRR 2 in month. The importance of getting back on track was emphasised. R Armstrong noted the key risks on revenue, and assurance had been received at F&I committee that Specialist Services would hit budget in June. Assurance had also been given on cappex and achievement of an FRR3 by the end of the quarter. G Bean asked about confidence levels on maintaining sufficient reserves and R Forster advised that it was likely that reserves would be needed to support CIP performance again this year. FT249/13 7 DAY WORKING R Forster gave a brief update on the 7 day working project. Work progresses well and it is anticipated that a final business case will be ready by the end of September. FT250/13 MINUTES FROM THE MEETING HELD ON 29.05.13 These were agreed as accurate. FT251/13 ACTION SHEET FROM THE MEETING HELD ON 29.05.13 All actions were noted as completed. G Bean advised that he had met with P Law to discuss patient property and he feels that good progress is now being made. L Barnes suggested that the next Full Board Away Day was held at the SSDU. H Hand will look at making the arrangements for this. ACTION: HH to arrange for next full board away day at SSDU FT252/13 RISK MANAGEMENT STRATEGY ANNUAL REVIEW H Hand advised that this was a routine update completed yearly. It had been discussed and approved at Q&S Committee. It was noted however that further amends were being made to the document. The Board also agreed that reference to the responsibilities of sub committees and risk appetite needed to be added. P Jones will ensure these amendments are made. ACTION: P Jones to ensure amendments are made to the Risk Management Strategy in line with Board comments FT253/13 BI-ANNUAL REPORT ON SERVICE CHANGE DRIVEN BY PATIENT FEEDBACK The Trust Board received and noted the report. FT254/13 DIPC ANNUAL REPORT Resolved: The Trust Board approved the DIPC Annual report It was noted that this had been discussed at Q&S Committee. The Board approved the report. FT255/13 NHSLA REPORT Resolved: The Trust Board approved the decision to defer assessment It was noted that agreement had been reached at F&I Committee to recommend that assessment was deferred. This was due to the proposed changes to NHSLA assessment

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arrangements. It had been agreed however to continue to pursue the NHSLA level 3 work streams to drive through quality improvements. The Board approved the decision to defer assessment. FT256/13 ITEMS RECEIVED BY THE BOARD FOR INFORMATION The Board received and noted the following items for information:

F&I Committee minutes Q&S Committee minutes Shared Services Board minutes HR Committee minutes SEC Q3 report Wrightington Phase 1 designs

FT258/13 ANY OTHER BUSINESS Car parking charges Resolved: The Board approved the proposed increases to staff charges and the use of salary sacrifice Resolved: The Board approved the proposed increases to patient parking charges subject to the outlined stipulations S Nicholls presented the paper to the Board which proposed increases to parking charges for both staff and public. He noted that this had been discussed at the CoG and amended in line with recommendations made there. Staff increases have been discussed with and received support from LNC and staff side. S Nicholls asked the Board for approval to proceed with the increases. Mixed feelings were expressed around the table with some Board members expressing concern that the increases and new grouping of charges were unfair to patients and families. However, it was noted that the proposed parking increases were as equitable as possible and that this was an important income stream to support CIP and future investment. Following discussion, the Board fully supported the increases to staff charges and the use of salary sacrifice. The Board also accepted the proposed increases to patient parking on the proviso that S Nicholls looked at a ‘season’ ticket for parking and the possibility of the first 30 mins being free. ACTION: S Nicholls to look at the possibility of a parking ‘season’ ticket and the first 30 mins of parking being free of charge Carbon Energy Fund Resolved: The Trust Board approved the proposal to procure energy infrastructure plan via the CEF S Nicholls advised the Trust Board that this paper was seeking Board approval for the Estates team to procure energy infrastructure plant via the CEF. The Board approved this. FT259/13 KEY SUCCESSES / RISKS The key successes were agreed as:

Improvements to the bereavement service Improvement in workforce metrics The Wrightington design proposals Investment plans

The key risks were agreed as:

C Diff Emergency bed pressures FRR 2

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FT260/13 EXCLUSION OF THE PUBLIC Resolved:

That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

FT261/13 DATE OF THE NEXT MEETING This was noted as taking place on 31st July 2013 from 9.45am.

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TRUST BOARD 26.06.13 (Part 1)

ACTION LOG Trust Board Agenda Item:

Date of Meeting

Minute Ref No.

Item Action Required Assigned to

Target Date

Date completed

Actions Carried Forward from previous Meetings

Actions from this meeting Date of Meeting

Minute Ref No.

Item Action Required Assigned to

Target Date

Date completed

26.06.13 FT240/13 BEREAVEMENT PRESENTATION

F Murphy to liaise with U Prabhu for dates to deliver the presentation to doctors F Murphy to liaise with E Kerr to discuss a communications programme to publicise the bereavement work and logo An update to come to next month’s Trust Board on the BC for specialist nurses, private areas on wards and improvements to mortuary viewing facilities Time to mortuary under 4 hours to be added as an Always Event and to be added to the performance report for monitoring

F Murphy / U Prabhu

F Murphy / E Kerr

P Jones

P Jones / F Noden

31.07.13

31.07.13

31.07.13

31.07.13

Completed Completed On the agenda for TB 31.07.13 FN met with FM 8.7.13 to be inserted into PR ASAP

26.06.13 FT246/13 PERFORMANCE REPORT M2

A high level briefing to be provided to the Board that will look to give an analysis of the issues such as weekend discharges, acuity of patients and bed base and how these are being addressed. It will also advise what mitigations can be put in place including work with the CCG to prevent the system from falling over again

Exec team 31.07.13 On-going due to bed base analysis. Report to F&I Committee in September

26.06.13 FT251/13 ACTION SHEET FROM THE MEETING HELD ON 29.05.13

H Hand to arrange for the next Full Board Away Day to take place at SSDU

H Hand 31.07.13 Completed

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Committee Action Log SOP Version: 1

Author: Board Secretary Approved: Meeting Point/ 15.11.10

Next review date: 19.11.12

1

26.06.13 FT252/13 RISK MANAGEMENT STRATEGY ANNUAL REVIEW

P Jones to ensure amendments are made to the Risk Management Strategy in line with Board comments

P Jones 31.07.13 Completed

26.06.13 FT258/13 ANY OTHER BUSINESS S Nicholls to look at the possibility of a parking ‘season’ ticket and the first 30 minutes of parking being free of charge

S Nicholls 31.07.13 Completed

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From: Kerr Eric  Sent: 22 July 2013 17:31 To: Hand Helen; Hancock Lynda Cc: Hesketh Lorraine Subject: Update on Trust Board Action  Hi Helen and Lynda  Here is an update for the action assigned to Fiona Murphy and me at the last Trust Board.  Fiona met with me and Lorraine on 15/07/13 to discuss communications actions to support bereavement care.   We agreed a number of actions to publicise bereavement care including:  •  Members article – complete •  Article in Focus •  Press release(s) – topics tbc •  Fiona is the keynote speaker at the National Coroner’s Conference on 04/10/13 •  Fiona is liaising with Rachel Pugh (freelance writer for national newspapers) on article of 

bereavement work at Bolton, Salford and WWL (Heather Edwards, Head of Communications at Bolton is supporting this) 

•  Nursing Standard are going to get a writer to contact Fiona to write an article  •  Fiona is in contact with Sean Linton at HSJ who is also interested in writing an article  •  Trust News – regular updates on progress e.g. swan logo entered for awards (and 

shortlisted), bereavement nurses to be available 7 days, request donations of any free toiletries from staff 

•  The Trust’s bereavement Booklet is currently being updated  Fiona was already active on some of these actions with support being provided by communications colleagues at either Bolton, Salford or WWL.  Kind regards Eric   

       

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Trust Board

Agenda Item 11. Date: 31.07.13

Title of Report Pathology ESL / Cancer Care Unit Business Case

Purpose of the report and the key issues for consideration/decision

The Board are asked to approve the attached business case.

Prepared by: Name & Title

Various

Presented by: Silas Nicholls, Director of Strategy & Deputy CEO

Action Required (please X)

Approve x Adopt Receive for information

Strategic/Corporate Objective(s) supported by this paper

Maintain a financially balanced 10 year investment plan and meet milestones in 2013/14

Is this on the Trust’s risk register?

No

Yes

X (BAF) If Yes, Score

12

Which Standards apply to this report?

CQC Safety and suitability of premises NHSLA Safe environment / clinical care BAF Objectives As above WWL Wheel Investment

Have all implications related to this report been considered?

Finance Revenue & Capital x Equality & Diversity National Policy/Legislation x Patient Experience x NHS Contract Governance & Risk

Management x

Human Resources Terms of Authorisation Consultation/Communication Human Rights Other: Carbon Reduction

Previous Meetings

Please insert the date the paper was presented next to the relevant group

Meeting Point

Audit Committee

Quality & Safety

Committee

Finance & Investment Committee

Management Board

IM&T Strategy

Committee

HR Committee

NED Other

15.07.13 N/A N/A 24.07.13 N/A N/A N/A N/A Deputies11.07.13 STB 17.07.13

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CANCER CARE UNIT/ESSENTIAL SERVICE LABORATORY DEVELOPMENT - BUSINESS CASE

TRUST BOARD 31 JULY 2013 - FOR APPROVAL

1. EXECUTIVE SUMMARY

The provision of a new Cancer Care Unit and Essential Services Laboratory at RAEI is a key part of the Service and Site Investment strategy in providing the very latest facilities for the treatment of our patients and for our staff to work in, whilst also supporting the rationalisation of older parts of the estate which creates development zones for the future.

The Trust Board is requested to approve this business case, which is included for your review, in line with the recommendation.

2. BACKGROUND

The development of a new Cancer Care Unit and Essential Services Laboratory at RAEI is one of the high priority major projects which were approved by the Trust Board in April 2011 as part of the Trusts Service and Site Investment Strategy.

3. CURRENT POSITION

The Cancer Care Unit is currently located at first floor level in what was the former children's ward in the oldest Victorian part of the hospital. The facilities are poor in many respects and are not suitable for expansion or modernisation to meet the current and planned service needs for the delivery of cancer care. In addition, the Trusts strategy for the RAEI will require the demolition of this part of the site to create space for future clinical developments.

The Pathology Essential Services Laboratory is currently located in the old Laboratory on the RAEI site. The facilities are not fit for purpose and the building is due for demolition to create space for future clinical developments.

4. PROPOSED DEVELOPMENT

The proposed development will see the construction of a totally new two storey build on the site of the former South Ward at the southern end of the RAEI site. This will accommodate a new Cancer Care Unit with the latest treatment facilities at ground floor level with dedicated access direct from the visitor car parking area. This has been developed in partnership with both the Christie and MacMillan.

The new Essential Services Laboratory will be located at first floor level and has been developed in partnership with our colleagues at Salford as part of the PAWS service.

Both departments will be linked to the main hospital streets which are being extended as part of this scheme.

5. CONCLUSION AND RECOMMENDATION

This development forms a key part of the Service and Site Investments and will provide new facilities which will significantly improve our patients experience, reduce the number of Wigan patients travelling to Christie for oncology and provide a laboratory service which can support and enhance the clinical activity on site.

As part of the Trusts Business Case process this case has already been approved at Deputies Forum, Executive Meeting Point, Management Board and the Finance and Investment Committee and therefore it is recommended that the Trust Board formally approve this business case.

David Evans, Associate Director of Estates and Facilities, 22 July 2013.

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WWL FT Business Case Template Version April 13 Page 1 of 21

12/07/2013

New Build- Cancer Care Centre and Pathology Essential Services Laboratory Ref Number BC1314-0018

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WWL FT Business Case Template Version April 13 Page 2 of 21

12/07/2013

BUSINESS CASE TEMPLATE – CASES OVER £50,000 SUMMARY INFORMATION

Scheme Title New Build – Cancer Care Centre and Pathology Essential Services Laboratory

Division

Specialist Clinical Services

Executive Sponsor

Silas Nicholls

Project Owner Ian Bett

Type of Case Service & Site Investment

Executive Summary

The proposal identified within this Business Case is to construct a two storey new build on the RAEI site, which will provide purpose designed accommodation for the following services:

Cancer Care Pathology Essential Services Laboratory.

This build will be constructed on the site of the former South Ward, which was vacated in 2012 and will be demolished shortly following completion of services diversion and minor enabling works which formed part of the previously approved separate Business Case. The proposed new build locates the Cancer Care Centre at ground floor level, where it will benefit from a dedicated entrance with access directly from the adjacent car park and a landscaped external area. The Pathology Essential Services laboratory is located at first floor level and both departments will have direct access internally onto a newly constructed extension of the main hospital street. An important part of this development has been the partnership working with both the Christie and Macmillan. Both of these services currently occupy poor quality accommodation on the RAEI site with neither being considered fit for purpose to provide the latest healthcare. The new facilities are purposed designed to provide a greatly improved patient experience, improved clinical activity, flexibility to support service growth and also enables the demolition of the current Laboratory the create a development zone for the future and a reduction in the estate condition backlog.

Planned implementation date

The building will become operational September 2014.

Summary finance

The project is anticipated to cost £5.060M in capital expenditure, split £2.893 relating to the Cancer Care Suite and £2.167 relating to the ESL. The model below shows the position for the development, if we enter into partnership with Christies. The majority of the costs in year 1 relate to asset impairments. (Detailed analysis of the costs is provided in Appendix 2)

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WWL FT Business Case Template Version April 13 Page 3 of 21

12/07/2013

Financial Summary 2013-14 2014-15 2015-16 2016-17 10 YearYear 0 Year 1 Year 2 Year 3 Total(£'000) (£'000) (£'000) (£'000) (£'000)

Total Capital Expenditure (0.0) (5,060.0) - - (5,060.0)

ESL Incremental Income - - - - - Cancer Care Incremental Income - 221.1 393.6 408.9 3,870.4Total Incremental Income - 221.1 393.6 408.9 3,870.4

ESL Incremental costs - (1,987.3) (138.8) (125.8) (2,951.9)Cancer Care Incremental costs - (1,233.6) (561.6) (555.2) (5,818.1)Total Incremental Costs - (3,220.9) (700.3) (681.0) (8,770.0)

ESL Contribution to Surplus / (Deficit) - (1,987.3) (138.8) (125.8) (2,951.9)Cancer Care Contrib. to Surplus / (Deficit) - (1,012.5) (168.0) (146.4) (1,947.7)Contribution to Surplus / (Deficit) - (2,999.8) (306.8) (272.1) (4,899.6)

Memorandum - Capital Related Costs included above

Depreciation - (92.7) (185.4) (185.4) (1,576.0)Dividends - (175.5) (170.6) (164.1) (1,358.7)Asset Impairment/Disposal (2,773.0) - - (2,773.0)PDC Saving - 43.9 43.9 43.9 395.3Depreciation Savings (0.0) 37.0 37.0 37.0 332.9Total Capital Related Costs (0.0) (2,960.3) (275.1) (268.6) (4,979.4)

Impairment £000

30% of Capital Costs (1,518.0)Lab ‐ full impairment (1,255.0)Total (2,773.0)

ESL and Cancer suite Business Case (Cancer includes the Christie agreement)

               

Expenditure to be Funded By

The capital cost of £5.060M is included in the capital programme. The recurrent revenue costs will be included in the 2014-15 budget setting process for the relevant divisions - Specialist Services, Medicine, Estates and Facilities and IT. The case makes a contribution after overheads in 2016-17. The capital charges are sought from the Trust capital charge budget, including the £2,773M impairment. There will be funding from Macmillan for 1 year for 2.8 posts. After 1 year, it is intended that these posts will be funded through a contract variation with the

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WWL FT Business Case Template Version April 13 Page 4 of 21

12/07/2013

commissioner. This has yet to be confirmed with the commissioners. Some external capital funding is anticipated, but not yet confirmed and as such is not in this financial model.

Year to date Approvals

Is the Capital requested part of the approved capital programme – YES Are the revenue implications part of the approved budget – NO

Quality Impact Pathology ESL The purposed designed environment will enable the service to operate more efficiently and effectively, and consequently improve the quality of the service for patients. This plan supports the vision for Pathology at Wigan and Salford (PAWS) previously agreed Business Case 2011. Cancer Care Centre The purposed designed environment will improve the patient experience and streamline their pathway by co-location of outpatient and chemotherapy delivery services. In addition the unit will offer dedicated complimentary therapy facilities for patients receiving chemotherapy to provide a fully holistic patient experience. The establishment of the Macmillan Information and Support Service will directly benefit patients and the public by providing on site support and information. As part of the Trust’s strategic priority to improve partnership working the Trust are currently in discussion with The Christie to bring chemotherapy treatment currently undertaken at their main site to be delivered at WWL. The Cancer Care Centre acts as an enabler to this by ensuring WWL have a suitable environment for treating the more complex cancer patients that at present are not able to access chemotherapy closer to home.

Workforce Impact

Pathology This will be managed within the current establishment for PAWS. Cancer Care Centre The scheme enables the Trust to set up a Macmillan Information and Support Centre, the following establishment will be required: Nurse Band 7 – 1 wte.

YTD £000

Post Approval £000

Capital requested (492) (5,552)Already approved in capital programme (447) (5,507)Increase to captial programme (45) (45)

Reccurent RevenueIncome generated 194 588Expenditure required (498) (923)(Increase) / Improvement to revenue budget (304) (335)

Non Recurrent Revenue (49) (43)

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WWL FT Business Case Template Version April 13 Page 5 of 21

12/07/2013

Nurse Band 4 - 1.8wte. The centre staffing is funded in 2013/14 through a charge back arrangement with Macmillan and from 2014/15 funding is anticipated from the CCG via a contract variation. In addition the centre will benefit from partnership arrangements with the Christie to provide staffing for additional activity that is delivered locally currently under the Christie.

Activity Impact

Cancer Care Centre The current activity for chemotherapy within WWL is expected to grow at a rate of 5% per annum. This may increase over time and once the first phase of the Christie partnership working is implemented and further activity is currently being identified by Christie that would benefit from the new facility. Pathology There is no anticipated increase in activity relating to Pathology

Links to Corporate objectives

Investment – This development meets the Trusts objective of investment. The creation of a new build facility to accommodate the Cancer Care and the Pathology ESL services is an important scheme in the overall 2013-14 investment programme. Partnership – This project involves partnership working with other healthcare organisation, The Christie, Macmillan Charitable Trust and Salford Foundation Trust.

Risks mitigated

Cancer Care There are currently no risks identified on the Divisional Risk register relating to Cancer Care. Pathology This business case provides an opportunity to replace the out-dated pathology facilities. The building had been timed to co-incidence with the end of the current Managed Equipment Service, with equipment replacement forming part of the combined MES for PAWS. With some slippage of the original timeframes, there is an element within this business case that will accommodate the relocation of new equipment once the ESL had been handed over.

Benefits KPI’s for Post Project Evaluation

Cancer Care Suite Benefit April 2014 April 2015 April 2016 April 2019

Quality Decrease in number of negative comments regarding the environment

Baseline Assessment

10% reduction from baseline

25% reduction from baseline

75% reduction from baseline

Reduction in waiting time for treatment

Baseline Assessment

10% reduction from baseline

25% reduction from baseline

75% reduction from baseline

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WWL FT Business Case Template Version April 13 Page 6 of 21

12/07/2013

caused by logistical issues Improvement in results from National Chemotherapy Survey

Baseline Results

10% Improvement on identified areas

25% Improvement on identified areas

50% Improvement on identified areas

Pathology ESL Benefit April 2014 April 2015 April 2016 April 2019

Quality Provides a purpose designed modern laboratory facility, which will ensure that the service is able to deliver 20% efficiency savings and improved quality

Approvals

See below the intended approval process and planned / actual dates FORUM DATE Deputies Forum 11 July 13 Meeting Point 15 July 13 Management Board 17 July 13 F&I Committee 24 July 13 Trust Board 31 July 13

Divisional Medical Director of Sponsoring Division

See below the Divisional Medical Director sign off email confirming approval of the business case and recommendation for approval.

Div Med Dir Sign off V.17 Final.doc

Divisional Director of Performance of Sponsoring Division

See below the Divisional Director of Performance sign off email confirming approval of the business case and recommendation for approval.

DDP Sign off V. 17 Final.htm

Deputy Director of Human

See below the Deputy Director or Human Resources sign off email confirming approval of the business case and recommendation for approval.

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Resources sign off

HR Sign off V. 17 Final.htm

Associate Director of Estates & Facilities sign off

See below the Divisional Director of Performance Sign off email confirming approval of the business case and recommendation for approval.

ADEstates Sign off V. 17 Final.htm

Head of IM&T sign off

See below the Divisional Director of Performance Sign off email confirming approval of the business case and recommendation for approval John Hunt obtaining

Divisional Finance Managers sign off

See below the Divisional Accountants Sign off email confirming approval of the business case and recommendation for approval

DA Sign off V. 17 Final.htm

It is essential to attach e-mail confirmation from these 6 signatories even if there is “no impact”

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WRIGHINGTON, WIGAN & LEIGH NHS FOUNDATION TRUST BUSINESS CASE PROFORMA

BUSINESS CASE DETAIL: to include the following

1 Introduction This business case has been developed to gain approval for the development of a two storey building to provide accommodation for the following services: A new dedicated Cancer Care Centre on the RAEI site with the transfer of Chemotherapy delivery to the new unit. The aim is to design an Oncology department which delivers the key components of quality healthcare; Effective, safe, efficient, timely, equitable and patient centred care by creating an environment which is able to respond to differing demands in activity including one stop chemotherapy review and delivery services ensuring quicker access, reduced travel and an overall streamlined quality service. The new environment will act as an enabler for the repatriation of local patients, which is a key driver as it has a major impact on the patient experience. The development will also act as an enabler to joint working with Macmillan and the Christie to create an Oncology service that provides comprehensive care for patients within the Wigan borough, bring more chemotherapy delivery closer to home with the associated outpatient review activity and supportive therapies and access to information. An ESL in line with the Royal Alliance Business Case proposal approved in October 2011(Royal Alliance became PAWS) The development of a purpose built ESL provides the opportunity to improve quality and deliver a more consistent Pathology service across Wigan and Salford. As part of the QIPP agenda both Trusts have already reduced Pathology prices to commissioners by 20%. The ESL will allow the Trust to operate in a more efficient manner meaning current Pathology costs can be maintained in line with the 20% price reduction. 2 Current Service Profile and Case for Change

2.1 The Cancer Care Unit serves the WWL catchment population of 300,000 and is currently based on the acute Royal Albert Edward Infirmary site. The department is located in a former Paediatric ward area, which had minor modifications prior to the service moving in over four years ago. The clinical area is poorly laid out and supporting accommodation is very poor. Despite the excellent care and professional approach of the staff on the unit, the environment is not ideal and provides a poor patient experience in that respect. The service provides chemotherapy treatments to patients who attend as day cases in the department. Neither the accommodation or staff resources allow the service to increase patient activity or the range of treatments provided.

The unit is mainly nurse led and has the following establishment:

o 1.0wte band 7 chemotherapy nurse/ward manager o 3.6 wte band 6 chemotherapy nurses o 1.0wte health care assistant o 0.8 wte receptionist.

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There is also a visiting oncologist from the Christie and a staff grade who is based on the unit, the service delivers chemotherapy and supportive treatments to patients within the Wigan Borough.

The unit is not able to provide all chemotherapy treatments due to insufficient accommodation and resources and consequently WWL patients have to travel to Christie for their treatments. The following treatments are provided:

o Chemotherapy for adjuvant breast and bowel patients, o a small minority of metastatic breast treatments. o Haematology treatments, namely in the form of treatments for lymphoma o a small amount of treatments for patients with leukaemia. o Supportive treatments such as bisphosphonate treatments and blood products.

The service completed approximately1,500attendances for chemotherapy treatments in 2012/13 as follows:

Treatment Type Number of patients Breast 72 Bowel 25 Haematology 40

The service also provided a further 1,500 attendances for supportive treatments and interventions for this patient group. Currently many Wigan patients have to travel to Manchester for their chemotherapy treatment; there is a call nationally for chemotherapy patients to receive their chemotherapy closer to home, documents such as Chemotherapy Services in England (NCAG 2009) and Chemotherapy Services in the Community (DOH 2010) highlight this. Having treatment locally means that patients do not have far to travel, which is extremely beneficial as many patients feel unwell or are suffering from symptoms of their disease/chemotherapy treatment. The Trust is committed to improving the quality and functionality of the Cancer Care Department accommodation and to the repatriation of local cancer patients to enable them to receive care and treatment in the Wigan borough. Discussions have taken place with the Christie hospital and an agreement to repatriation of our patients has been made. To do this, the Trust plans needs to provide additional accommodation for the unit to deliver these additional services. In addition, it is acknowledged that the current environment is not purposed designed or suited to provision of cancer care services. It is proposed that a new unit be built on the RAEI site, which will re-provide the current accommodation: provide additional clinical treatment facilities and an outpatient clinic area along side. The new facility will provide a modern, purpose design clinical environment, where patients can both be seen by Consultants in clinic and receive treatments. In addition, valuable supporting services will be provided from the Macmillan Information & Support Facilities, which will be provided in the department and from the TLC and Leigh sites. The Cancer Care Centre will provide services to the residents of the Boroughs of Wrightington, Wigan and Leigh, and these will consist of the following three main elements:

Cancer Care Centre Macmillan Information and Support Facility Oncology Outpatient Clinics

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The diagram below shows WWL’s proposed Outpatient Cancer Care delivery model.

The main benefits of this development are detailed below:

o The additional accommodation will enable the service to respond to the increase demand anticipated.

o Enables the Trust to repatriated patients and provide care closer to home. o The purpose-designed environment will greatly enhance the patient experience & the

working environment for staff. o Partnership with Macmillan in establishing the Macmillan Information & Support

facilities in the centre and across the Trust will provide a broader more extensive support network and information hub for patients, public and visitors to the Trust.

o The Macmillan Information & Support service is a new venture for the Trust and will enable us to organise events promoting the service, its facilities and working with the community and other agencies to improve and enhance the services for the WWL residents.

o Increased number of outpatient clinics will be held in the centre ensuring that patients are not travelling long distances for treatment

2.2 Pathology – ESL In February 2010, the Department of Health endorsed the recommendations of the Independent Review of NHS Pathology Services in England, 2008 (Carter Report) which required SHA’s and PCT’s to take forward the reconfiguration of Pathology Services. Pathology is one of the work-streams within the QIPP programme in which service transformation is expected in order to respond to the removal of £500 million from pathology funding in England. This challenges pathology services to achieve a 20% cost saving. WWL under PAWS is seeking to make these savings by working with SRFT and centralising its services at Salford. These central services should enable economies of scales and efficiencies which will enable the 20% savings to be made. It is essential that GP work is retained by Trusts as if it were lost would result in a significant deterioration in income (of the between £5-10 million for SRFT and WWL) due to the reduced efficiency and utilisation of only providing both internally referred tests within an infrastructure that currently also supports GP work. As part of the Greater Manchester Pathology network a vision of collaborative working to achieve the savings, rather than Trusts attempting to achieve this saving in isolation. This brought together Salford Royal Foundation Trust (SRFT) and Wrightington, Wigan and Leigh NHS Foundation Trust (WWL) as a shared service, now referred to as Pathology at Wigan and Salford (PAWS).The agreed PAWS model of delivery is reliant on a Central Services Laboratory (CSL) based at SRFT, and an Essential Services Laboratory (ESL) for WWL based at the acute Wigan site.

WWL CANCER CARE SERVICES

TREATMENTSOUTPATIENT CLINICS OUTPATIENT 

CLINICSOUTPATIENT 

CLINICS

CANCER CARE CENTRERAEI

LEIGH INFIRMARY SITE

THOMAS LINACRE CENTRELOCATION

CARE DELIVERED

LEVEL 1,2,3,4 SUPPORT LEVEL 1 & 2 SUPPORT LEVEL1, 2 & 3 SUPPORT

LEVEL OF SUPPORT 

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The upgrading of the CSL at SRFT nears completion and non essential services are progressively transferring. This Business Case considers the local requirement for ESL based at the Wigan site, as a replacement for the outdated equipment and resultant inefficient processes, as previously agreed within the original PAWS Business Case 2011, and support the original drivers for change. Benefits of the Essential Service Laboratory Move

o Enable the Trust to implement the recommendations in the Royal Alliance Business Case approved in October 2011, which was to create an Essential Services laboratory on the RAEI site.

o Provides a purpose designed modern laboratory facility, which will ensure that the service is able to maintain costs and continue to comply with the QIPP agenda offering prices which include a 20% reduction from those which were charged pre PAWS/

o Allows vacation the current Pathology accommodation, thereby allowing the Trust to demolish the building in readiness for the planned future development.

3. List of Options. 3.1 Cancer Care Centre Option 1 Do Nothing -In this option, there would be no capital investment and improvements to the estate and the Cancer service would be unable to extend its range of treatments and outpatient services to enable us to repatriate the WWL catchment area patients. The patients in the borough would not benefit from care closer to home and the continuity of care. Additionally without improvement to the current department, patients will continue to have a poor experience due to the poor layout & non-purpose designed clinical accommodation.

Option 2 - Capital investment on the RAEI site to provide a new Cancer Care Centre This option provides a new build development with the Cancer Care Centre located on the ground floor. The build will provide the following accommodation:

A chemotherapy treatment area with 12 clinical patient areas An Outpatient area Counselling Facilities Complimentary Therapy Room Macmillan Information & Support Facility

The service will be able to support the repatriation of WWL patients and provide continuity of care, which will be closer to home. The repatriation of patients will enable the service to increase activity and corresponding income. 3.2 Essential Services Laboratory Option 1 Do nothing. In this option, the department would remain in its current location. This is not acceptable as it would prevent the trust demolishing the accommodation and prevent the planned development of the site. Additionally the Pathology Royal Alliance projects success relies on the relocation of this service into new purpose designed accommodation to ensure that it is able to provide an efficient and effective service. Option 2 Capital investment to enable the move the ESL into a new accommodation. This option meets the requirements of the Trusts site development of the RAEI site and the Royal Alliance Project for the delivery of Pathology services.

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In summary - Preferred Option

Option 2 is the preferred option for both of the services for the following reasons:

Cancer Care Centre - it will provide a functional purpose designed environment, which will support current patient activity and future service growth. In addition, it enables the Trust to move the Cancer Care Service out of the current poor Victorian accommodation, which supports the sites future development plan. Pathology ESL – Meets the requirements of the Royal Alliance Project to provide an ESL on the RAEI site and frees up buildings, which need to be demolished as part of the future phased development of the site. The move of the services from their current locations supports the overall site development plan by vacating the old Victorian buildings in readiness for future site development. More importantly, the creation of purpose designed modern facilities for both services will enable the services to operate more efficiently and effectively and provide a better service to patients and other service users. The overall patient experience will be greatly enhanced by the new facilities and projected clinical activity growth increases can be met.

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4 Finance Summary of Each Option The financial mode below reflects the overall financial model for the business case, including the ESL and the Cancer Care Suite and including partnership working with the Christie.

In year Part year Full Year 10 Year2013/14 2014/15 2015/16 Total£000's £000's £000's £000's

Capital Expenditure (0) (5,060) 0 (5,060)

Additional Income 0 221 394 3,870Additional Expenditure 0 (169) (268) (2,441)Contribution 0 52 126 1,429Contribution Margin % N/A 23.6% 31.9% 36.9%

Overheads 0 (92) (157) (1,350)EBITDA 0 (40) (32) 80EBITDA Margin % N/A -17.9% -8.0% 2.1%

Capital Charges (0) (2,960) (275) (4,979)

Net Surplus / (Loss) (0) (3,000) (307) (4,900)I&E Surplus Margin % N/A -1356.8% -77.9% -126.6%

NPV (£5,999,902)Payback Period (years) >10

ESL and Cancer suite Business Case (Cancer includes the Christie agreement at Christie Prices)

The negative NPV indicates that the project costs exceed the revenue, this can also be seen from the table above. However, it should be noted that the business case makes a positive EBITDA from 2017-18 onwards. The costing’s have been prepared using the unit costs calculated by the Divisional Finance Manager and the Cancer Services Manager and projected forward to reflect the anticipated 5% growth in activity forecast by the Cancer Services Manager. The current activity and income streams are subject to negotiations between WWL and Christies. The current thinking is that the existing WWL profit will be ring fenced and a further agreement will be reached around future profits. Negotiations are currently taking between the two Trusts and the financial arrangements are outside the scope of this document. Potentially there will be 3 external funding sources for the capital spend from Christies, Macmillan and Three Wishes Charity. At this stage, there is no written confirmation of the provision of this funding, and as such it is not included in the financial model. There is also potential for a one off payment from Christie to cover branding and associated costs. This again is outside the scope of this business case. The main consideration regarding the Cancer Care Suite and its financial projections is the uncertainty around its future operation. WWL and Christies are currently negotiating a new

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operating framework for the unit which includes issues around profit sharing and funding. Until this position is finalised and agreed by both parties, the financial performance of the WWL aspect cannot be fully quantified. It is anticipated that this project will receive additional revenue funding from Macmillan Cancer to pay for 2.8 staff manning information points for 1 year only. After the 1 year period, these additional staff will be funded through a contract variation with the commissioners. This has yet to be confirmed by the commissioner. The costs and the income stream relating to these 2.8 staff are incorporated into the model. In Appendix 2, there is an additional financial model / tables that shows the financial position without working with Christie’s. This model is included for information only, as it is expected that the partnership working will be agreed in the near future.The main differential between the two models of working (one with Christies and one without) is that the WWL income for procurement and delivery is currently at a more beneficial rate than the Christies local tariff. It is expected that this inequality will be corrected over time, as national tariffs are agreed. To recognise this, the tariff in the WWL only model has been reduced by 5% pa. Regarding the model that includes the partnership working with the Christie, it is important to reiterate that WWL and the Christie are currently negotiating a joint working arrangement, with the Christie delivering increased chemotherapy in Wigan. Until an agreement with Christies has been formally approved, the actual anticipated financial position will be unknown. The Board received an update on the latest position in May. The activity included in the model is Christie activity and as such the income is calculated using the Christie tariff. (Christie and WWL are paid differing local tariffs for this activity.) The current plan is to arrange a financial model that ring fences WWL’s current profit levels but allows a profit share agreement with them that will enable an equitable split of profit. This model does not factor in any profit share, but shows a holistic view of the whole business case. The model shows only the 5% gain in activity predicted by the Cancer Services Manager and does not include any further potential gains through future marketing or by repatriated patients. The Pathology ESL construction and relocation is a consequence of the reorganisation of the Pathology service under the Royal Alliance Pathology Review. The financial model does not contain any anticipated increase in income or Pathology expenditure. The increased costs in the model are driven primarily by Estates and Facilities Department and also some elements of IT. Following the construction of the new facility and the demolition of the existing floor space, Estates and Facilities will be able to offer up additional revenue savings on top of those incorporated in this business case that will in part offset the additional costs included in this Business Case. Those savings will be quantified in future Business Case associated with the demolitions of those buildings. Appendix 1 shows the E&F position in more detail. Appendix 2 also contains more detail around the costs in the model. 5 Proposed recommendation The recommendation is for the construction of the new facility for ESL and Oncology. It is anticipated that agreement will be reached with Christie’s in the near future concerning the

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partnership working and profit share. Depending on the nature of this agreement, the new facility will not only improve the patient experience, but also make a positive contribution to the Trust EBITDA. This contribution cannot be quantified until this agreement is reached. Given that the anticipated activity increase will be 5%, the growth will be as follows:

2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20105% Base 5% Growth 5% Growth 5% Growth 5% Growth 5% Growth 5% Growth

Chemo Procurement 2,672 2,806 2,946 3,093 3,248 3,410 3,581 Chemo Delivery 3,589 3,768 3,957 4,155 4,362 4,581 4,810 Daycases 2,884 3,028 3,180 3,339 3,506 3,681 3,865 OP FIRST 638 670 703 739 775 814 855 OP FOL 2,658 2,791 2,930 3,077 3,231 3,392 3,562

Anticipated Growth numbers

Chemo Procurement 78 140 147 155 162 171 Chemo Delivery 105 188 198 208 218 229 Daycases 84 151 159 167 175 184 OP FIRST 19 33 35 37 39 41 OP FOL 78 140 147 154 162 170 Total 363 653 686 720 756 794

£000 £000 £000 £000 £000 £000Anticpated Income Growth 291£ 306£ 321£ 337£ 354£ 371£

Anticpated activity growth - 2.5% 181 327 343 360 378 397 Anticpated income growth - 2.5% 146£ 153£ 160£ 168£ 177£ 186£

Anticpated activity growth - 7.5% 544 980 1,029 1,080 1,134 1,191 Anticpated income growth - 7.5% 437£ 458£ 481£ 505£ 531£ 557£

Cancer Service Growth Estimate

6 Quality

Pathology ESL The purposed designed environment will provide: A modern laboratory to accommodate the new equipment expected as part of the

renegotiation of the Managed Equipment Contract for PAWS. This will enable PAWS to take advantage of the technological advances that will drive greater efficiency and improved performance.

Assures compliance with CPA, MHRA, HTA and clinical governance requirements. Standardisation of equipment across PAWS will facilitate the co-location of a broader

volume of staff that will help to assure future resilience and quality of service delivery. Cancer Care Centre The purposed designed environment will improve the patient experience and streamline their pathway by co-location of outpatient and chemotherapy delivery services. In addition the unit will offer dedicated complimentary therapy facilities for patients receiving chemotherapy to provide a fully holistic patient experience. The establishment of the Macmillan Information and Support Service will directly benefit patients and the public by providing on-site support and information. As part of the Trust’s strategic priority to improve partnership working the Trust are currently in discussion with The Christie to bring chemotherapy treatment currently undertaken at their main site to be delivered at WWL. The Cancer Care Centre acts as an enabler to this by

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ensuring WWL have a suitable environment for treating the more complex cancer patients that at present are not able to access chemotherapy closer to home. The new Oncology building will bring out trust mission, vision and strategy to the forefront for cancer patients in the Wigan Locality. The new build will facilitate the provision of quality healthcare which is safe, effective, patient-centred, timely, efficient and equal by the following means

Improved environment- current environment is outdated and not inviting for patients and relatives.

New build provides ground floor accommodation thus providing easier access for patients for those who are unable to use stairs. Additionally the position provides easier access in emergency i.e. acutely unwell patients.

Improved capacity to treat patients locally. Currently lift frequently breaks down resulting in a risk to patients not receiving treatment or inability to manage emergency situation appropriately.

Facility of having outpatient clinics on site. Thu enabling treating consultants to clinically review patients in an area adjacent to the treatment area. Currently Consultant clinic is in TLC which has logistical issues

Dedicated Complementary therapies room. This will provide separate area for Complementary therapies therefore ensures more privacy and dignity to the patients whilst receiving their complementary procedure. At present the facility is not available.

7 Impact on activity Cancer Care Centre The current activity for chemotherapy within WWL is expected to grow at rate of 5% per annum. This activity will increase once the first phase of the Christie partnership working is implemented and further activity is currently being identified by Christie that would benefit from the new facility. Pathology ESL Will facilitate the on-going provision of laboratory support and protect those acute services for WWL. It will support the broader efficiency gains and cost savings model associated with PAWS. 8 Impact on other divisions Cancer Care Centre

Medical Division – The Division hosts the clinical haematology service and development of the new cancer care centre will improve their patient’s experience and provide opportunity for partnership working with Oncology on service development at the RAEI site. The Clinical teams will also benefit from on site access to Oncology support for patients with complications of their cancer or treatment who are admitted via A&E as part of the Acute Oncology Service.

Specialist Services – The Cancer Care Centre will impact on radiology and pathology services through the natural growth in the service, for the activity that will return from Christie the Radiology department should not see significant impact as the majority of the scans are already undertaken locally.

Surgical Division – The new cancer care centre has created some displacement of an area for the Urology team to undertake treatments for bladder cancer, however, this was identified as a risk and the service will re-locate to Hanover development with the Urology service.

Estates & Facilities – The Cancer Care Centre will support E&F in the delivery of the wider Trust site & service strategy by releasing space in the old Victorian stock as a

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precursor to it’s demolition. Once the additional activity begins to move from Christie there will be an increased requirement for cleaning and waste management services, however, this will be managed on an SLA basis with recharge to Christie. Where transfer is possible e.g. domestics, the E&F savings are incorporated into this case. However, as stated in section 4, further savings will be determined as part of the business case for demolitions.

Pathology ESL The ESL will operate 24/7 providing an essential pathology service for all urgent and acute admissions, ITU, theatres and obstetrics, etc.

In year Part Year Full Year 10 YearSUMMARY 2013/14 2014/15 2015/16 Total

£000's £000's £000's £000's

Captial Expenditure (0) (5,060) 0 (5,060)0 0 0 0

Net Income 0 0 0 0Specialist Services 0 221 394 3,870Surgery 0 0 0 0Medicine 0 0 0 0Estates & Facilities 0 0 0 0Other 0 0 0 0

Total 0 221 394 3,870

Net ExpenditureSpecialist Services 0 (135) (239) (2,313)Surgery 0 0 0 0Medicine 0 (1) (1) (14)Estates & Facilities 0 0 0 0Other 0 (33) (27) (113)

Total 0 (169) (268) (2,441)

Contribution (before overheads) 0 52 126 1,429Contribution Margin % N/A 23.6% 31.9% 36.9%

Overheads 0 (92) (157) (1,350)

EBITDA £ 0 (40) (32) 80EBITDA Margin % N/A -17.9% -8.0% 2.1%

Capital Charges (0) (2,960) (275) (4,979)

Surplus / (Deficit) (0) (3,000) (307) (4,900)

ESL and Cancer suite Business Case (Cancer includes the Christie agreement at Christie Prices)

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9 Risk Cancer Care Centre The main risks in failing to move this service would be the inability to improve the patient experience, being unable to meet anticipated growth and the repatriation of Wigan patients currently travelling to the Christie for treatment. The following should be used to calculate the scores: Consequence Likelihood

Insignificant

Minor Moderate

Major

Catastrophic

Likelihood

Score

Rare 1 2 3 4 5 Rare 1 Unlikely 2 4 6 8 10 Unlikely 2 Possible 3 6 9 12 15 Possible 3 Likely 4 8 12 16 20 Likely 4 Almost certain

5 10 15 20 25 Almost certain 5

In terms of status, the risks should be shown in a table as follows with the appropriate RAG scores (Red, Amber, Green) details of which are contained below:

Risk Likelihood Impact Score RAG Status

Mitigation

If the service were decommissioned and/or transferred, the Trust/Provider would be tied into accommodation that is not utilised

2 5 10 Clear communication and contractual arrangements to be in place

Changes in activity or service delivery which reduce or increase clinical space requirements may result in inefficient space utilisation

3 3 9 Need to design accommodation to ensure it can be used flexibly to meet the future needs of the service

Activity may not be deliverable and thus financial performance may not reach anticipated levels

3 3 9 Clear and concise monitoring of activity levels and corrective action such as marketing if levels look like underachieving.

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Insufficient car parking available on RAEI site

3 3 9 Need to review car parking at RAEI with potential for dedicated parking for the unit

The Commissioners may not agree to fund the Macmillan nurses and these will need to be funded by WWL

3 3 9 The commissioners have been asked to put the additional funding into the contract.

No deal is agreed with Christies and as such they attempt to take our existing market share

3 3 9 The on going negotiations have been going well and there appears to be a consensus that the partnership working is the best for all parties.

The final profit share agreement with Christies may not be as beneficial as anticipated

3 3 9 Negotiations with Christies are ongoing with the intention that WWL will protect its existing profit levels.

Recommendation for Cancer Care Service The division recommend that the Trust approve this business case to enable the development of the new cancer care centre and re-location of the current chemotherapy service. Pathology ESL

Risk Likelihood

Impact

Score RAG Status

Mitigation

Current pathology accommodation on RAEI site is outdated and in very poor condition, is likely to impact on WWL ability to retain its CPA accreditation in the future. CPA is essential requirement for pathology service supporting Emergency and Acute services for WWL.

4 4 16 New ESL Acute demand cannot be diverted to SRFT as the facility cannot guarantee a TAT for urgent samples.

Recruitment and retention of staff given existing fabric of the building. There is already a retention issue

3 4 12 New ESL

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within those PAWS staff who predominantly work on the RAEI site. Ability to meet efficiency gains within the current accommodation may compromise PAWS ability to meet 20% cost savings across the whole pathology service.

4 4 16 Requires the relocation of any new equipment into modern environment, procured as part of the PAWS MES tender, to again the maximum benefit, if current GP work is to be retained.

Recommendation for Pathology ESL The Division recommend that the Trust approve the provision and build an ESL on the RAEI site. 10 Benefits Realisation –This section should be used to fully describe the benefits expected from the business case Pathology / ESL Benefits Realisation The benefits of the ESL clearly rest within: ESL capacity to up-grade a tired and out-dated WWL facility within RAEI site, and

mitigate the compromise that current provision may represent in the future in terms of its CPA accreditation.

Support the on-going local (WWL) requirements for pathology for acute and urgent evaluation of samples.

Provides a modern facility that will help to address the retention of staff. Provide the means to gain the most from the due replacement of equipment within a

purpose built environment that will ensure the most effective and efficient process, that will support the previously approved PAWS business case, which incorporated a 20% reduction in price to commissioners and improve quality of service delivery.

Cancer Care Benefits to Cancer Care Service detailed in the table below: Benefit April 2014 April 2015 April 2016 April 2019

Quality Decrease in number of negative comments regarding the environment

Baseline Assessment

10% reduction from baseline

25% reduction from baseline

75% reduction from baseline

Reduction in waiting time for treatment caused by logistical issues

Baseline Assessment

10% reduction from baseline

25% reduction from baseline

75% reduction from baseline

Improvement in 10% 25% 50%

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WWL FT Business Case Template Version April 13 Page 21 of 21

12/07/2013

results from National Chemotherapy Survey

Baseline Results

Improvement on identified areas

Improvement on identified areas

Improvement on identified areas

11 Recommendation It is recommended that the Trust Board approve the construction of a new build on the RAEI site to accommodate the Cancer Care and Pathology ESL services. This development forms part of the Trust Service and Site investment programme and provides benefits to both service delivery and efficiency and primarily patient care and experience. Appendix 1 – Estates Revenue Consequences

Appendix 1.xlsx

Appendix 2 – Additional Financial Information

Business Case - App 2 V18 Final.docx

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Trust Board Agenda Item 12. Date: 31.07.13

Title of Report Monitor Quarter 1 Governance Return

Purpose of the report and the key issues for consideration/decision

The paper sets out the details of the Q1 governance exception report to be submitted to Monitor.

Prepared by: Name & Title

Helen Hand Trust Board Secretary

Presented by: Andrew Foster, CEO

Action Required (please X)

Approve x Adopt Receive for information

Strategic/Corporate Objective(s) supported by this paper

Performance: Score 0 points on the MCF each month Performance: Achieve quarterly and full year financial risk rating of 3

Is this on the Trust’s risk register?

No

Yes

x If Yes, Score

20/20

Which Standards apply to this report?

CQC Governance C7a/c NHSLA Governance BAF Objectives 13/14 Performance WWL wheel Performance

Have all implications related to this report been considered?

Finance Revenue & Capital x Equality & Diversity National Policy/Legislation Patient Experience x NHS Contract x Governance & Risk

Management x

Human Resources Terms of Authorisation x Consultation/Communication Human Rights Other: Carbon Reduction

Previous Meetings Please insert the date the paper was presented next to the relevant group

Meeting Point

Audit Committee

Quality & Safety

Committee

Finance & Investment Committee

HR Committee

IM&T Strategy

Committee

Management Board

NED Other

N/A N/A N/A N/A N/A N/A N/A N/A N/A

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Monitor Q1 Governance Declaration

Exception Report 2013/14 Performance The Monitor Compliance Framework was rated amber/red for Q4. At Q1 performance has been achieved across all of the access indicators. The Trust continues to achieve all of the 18 weeks indicators, at an aggregate level, each month, and has continued to do so since May 2012. The Trust has achieved a performance of 95.28% against the A&E indicator. At April 2013 the Trust had achieved an HSMR of 81.5 as reported in the latest data available from Dr Foster and a full financial year for 1.4.12 to 31.3.13 of 96.9. The Trust has reported 14 Clostridium Difficile Toxin (CDT) cases, against a cumulative monitoring threshold of 6. The Trust has therefore breached the Monitor de minimus of 12 cases in quarter one.

CQC An engagement meeting was held with the CQC on the 15th May 2013. A Medications improvement plan following the April CQC inspection was presented and was accepted. Concerns were raised by the CQC regarding a number of incidents relating to anticoagulation prescribing for patients discharged to nursing homes. Anticoagulation has now been added to the Medicines Improvement Plan with specific actions, responsibilities and timescales. Significant third party investigations Nothing to report. Trust Board Changes There have been no changes in Quarter 1. Recruitment for an additional Non Executive Director will be completed by the end of September 2013. Council of Governor Changes Mrs Anne Heaton, public governor for Wigan resigned in June 2013 due to other personal commitments. Her vacant seat is currently included in the 2013 elections due to conclude in September 2013. Serious Untoward Incidents The following serious untoward incidents have occurred in Q1:

StEIS Ref &

Date

Incident Detail StEIS SUI Criterion Incident Description

StEIS Log Number 2013/10835

Patient Death

Patient undergoing unplanned complex vascular surgery. Operating table changed position itself and would not

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11/04/13

revert back using the electronic controls. Staff managed to transfer patient safely to another operating table and surgery continued. Superficial laceration of spleen occurred during continued surgery (known risk) and although sealed at time bleeding later continued and patient passed away. Post mortem has not been able to conclusively exclude the table malfunction as contributing/causing the splenic laceration. HSE, Police and MHRA all advised of incident.

2013/12583

Incident Date: 21/04/2013

StEIS Log Date: 26/04/2013 following Exec

review and decision 25/04/2013

Drug incident (General)

Trust contacted by Nursing Home regarding change in patient's medication. Patient discharged home on 21/04/13 with the wrong take home drugs. Patient had been taking the drugs for 4 days before the Trust was contacted. Patient brought back to A&E on advice of Trust. Patient admitted for observation, medical review and medication review. No harm to patient and patient discharged. Relatives spoken to by senior manager on call and advised full investigation to be undertaken. Escalated to Executive on call and full RCA investigation immediately commenced. Referred for review at planned weekly Executive Scrutiny meeting on Thursday 25 April 2013 at which it was requested incident be submitted to StEIS.

StEIS Log: 2013/17116

Incident Date:

(identified 3 May 2013)

StEIS Log Date: 11/06/2013

Screening Issue

Following SUI recommendations of 2008 a new software system, Digital Healthcare (Optomize) was purchased. As part of the import process all data was cleansed by ALW DES and LASCA in 2009. Following some initial teething problems, this has been the referral source for all newly diagnosed diabetics since 2010. This interface does not appear to have been audited since January 2011. There had been concerns in regard to the pathway from the GP to the Diamond register and from the Diamond register to Optimize Patients known to Diamond database but not imported to Optimize had triggered the business intelligence team (WWL Trust) to undertake an interrogation of the Diamond system which found 51 patients not imported to Optimize during the period covering 1st Jan 2011 – 3rd May 2013. Review extended back to May 2010. All patients identified and screened. Joint Action Plan agreed and implemented to rectify data transfer issues. It has now been agreed following joint Public Health, WB CCG, ALWPCT and WWLFT meeting to review all facts

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and action plan, that the Diabetic Screening reported incident is a SUI and as such reportable to STEIS. Although the incident primarily sits with public health, WWLFT as providers of the service were to submit to StEIS.

StEIS Log: 2013/17963

Incident Date:

(Identified 18 June 2013)

StEIS Log Date: 19 June 2013

Medication

Patient admitted from Nursing Home (history of advanced carcinoma).Patient’s wife resident at same Nursing Home. On 16 June 2013 medication was required for the patient and the MAR (medication administration record), forwarded by the Nursing Home was used by pharmacy to check the accuracy of the prescription. A clinical check, on the accuracy of the chart, was completed but it failed to notice that the Christian name on the MAR chart as that of the patent’s wife. Patient subsequently received the wrong medications until error identified on 18 June 2013. Patient appeared dry biochemically and clinically. Medicines stopped except for correct essential therapy and dehydration treated and following this, the patient appears better biochemically and clinically. Immediately discussed with family present at time and followed up with conversations with medical staff. Relatives attended PDR today and stated that they will be submitting a formal complaint to the trust and are planning to report the Nursing Home to the CQC.

Information Governance Breaches There have been no Information Governance Serious Untoward Incidences in Q1. Serious Complaints There was one serious complaint during the quarter that was a StEIS reportable SUI. Performance Penalties to Commissioners For 2013/14 Q1 the Trust has provided in the main for penalties relating to CDiff, 18 weeks in Trauma and Orthopedics and Surgery and readmissions. These are broadly in line with the budget provided for. CQUIN performance is achieving 89.4% of the target at Q1. Billinge Land Sale Whilst not due to complete until Q2, due to planning delays within Q1 there has been an in year timing setback in relation to the sale of land at the former Billinge hospital site. The implications of this and mitigations are described in the separate finance report. .Enforcement Notices Health & Safety Executive/Fire Authority Nothing to report.

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Awards The Trust’s multi-award winning Catering Team were Highly Commended in the “Team of the Year” category at the Hospital Caterers National Conference 2013. The following Trust staff also had success in the Greater Manchester Clinical Research Awards 2013: Valerie Parkinson, Clinical Research Nurse won the Newcomer of the Year category Joanne Farnworth, Clinical Trials Coordinator was runner-up in the Research

Administrator of the Year category Both Diane Lee (Lead Nurse for Quality Improvements) and Dr Martin Farrier (Consultant Paediatrician) were shortlisted in the national Patient Safety Awards. The Trust’s Finance Department were shortlisted in HSJ Efficiency Awards in the Efficiency in Financial Services category and the Training & Development Department were also shortlisted in the Efficiency in Training and Development category. Good Health, Good Work Charter – Achievement Standard

The Good Work: Good Health Charter is the Workplace Wellbeing Charter for Greater Manchester. It is a toolkit and guide to help businesses on the issue of health, work and wellbeing. It promotes working together to ensure that work doesn’t impact on health, and that health doesn’t impact on work. The Trust reached the achievement standard in April 2013 and is the first Trust to commit to strive for excellence. To date WWL is not only the first Trust to sign up for this but is leading the way as other Trusts are yet to follow our lead.

ILM Lifetime Accreditation – Achieved in June 2013. Hanover Block The construction work on the Hanover block reconversion were successfully concluded at the end of quarter one, this development has seen the existing Hanover Block being reconverted and modernised, based within the block will be a new Womens Health Unit, a new Urology Unit and facilities for the on-site decontamination of endoscopes. The development has seen extensive clinical service redesign work take place to improve clinical pathways for patients and the introduction of one stop services. MRI Scanner The second MRI scanner for the Royal Albert Edward Infirmary Site in Wigan was delivered and installed during quarter one, this has increased the available diagnostic capacity available on site. Recommendation: The Trust Board is asked to agree that the following statements are signed for submission to Monitor for the Q1 return. The board are required to respond "Confirmed" or "Not confirmed" to the following statements:

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For finance, that:

The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months. Confirmed

For governance, that:

The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix B of the Compliance Framework; and a commitment to comply with all known targets going forwards. Not Confirmed As the Trust has reported 14 Clostridium Difficile Toxin (CDT) cases, against a cumulative monitoring threshold of 6, the Trust has therefore breached the Monitor de minimus of 12 cases in quarter one. The Board has agreed significant investment into a range of initiatives to address infection and an action plan is in place to reduce, as much as possible, the risk of further CDT cases. This is monitored regularly by the Executive Meeting Point, Quality and Safety Committee and via the performance report to the Board. At the time of writing (24 July) there have been no cases of hospital acquired C Diff since 27 June 2013.

Otherwise:

The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per Compliance Framework page 17 Diagram 8 and page 63) which have not already been reported. Confirmed

A Foster Chief Executive

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Chairpersons Report

Chairpersons Name Robert Armstrong Committee Name Finance & Investment Committee Date of Meeting 19th June 2013 Name of Receiving Committee Trust Board Date of Receiving Committee meeting

July 2013

Refer to Trust Board Chair: N/A

Key success or achievement discussed at the meeting 1. Good CIP performance to date 2. Achievement of a reduction in cancelled ops 3. Delivery of theatres 9 and 10 on schedule

Details of the top three risks identified during the course of the meeting

and initials of primary member of staff actioning 1. Specialist Services financial position 2. MRSA and C Diff 3. Capital run rate 4. Deferment of the NHSLA assessment

Attendance at the meeting (please highlight):

Excellent (well

attended) X

Acceptable (some

apologies)

Unacceptable (quorate)

Unacceptable(not

quorate)

Was the agenda fit for purpose and reflective of the committee’s terms of reference?

Yes

Narrative report of the key issues of the meeting

The committee spent considerable time on the robustness of the Specialist Services Division plans. It was noted that SS has considerable work to do to pull their plan back on trajectory – this will be closely monitored by F&I. Significant concern raised over the performance in respect of Monitor compliance ( C Diff and A&E ) . Whilst it was noted that both C Diff and A&E performance were related the issues could not be seen in isolation The committee will keep governance issues around performance under review. NHSLA provided the committee with sufficient information to provide an informed recommendation to the Trust Board. Financial performance in month 2 is challenging and will continue to be monitored and auctioned, in particular all Medical Divisions will be presenting their plans and actions to remain within their Quality and Financial budgets. Shared Service – Sterile Services are to re submit their CIP paper to appraise the committee of the requirement and challenges and what they are wanting the committee to look at. Overall a very challenging meeting with respect to time, and topic, good Committee papers helped the decision making process and scrutiny aspects of the committee

Agreed actions from the meeting Name of primary lead for the actions

F Noden to look at the disparity in cancelled ops data in the performance report

F Noden

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A CQUIN report will be brought to the August Committee meeting

F Noden

A safeguarding update will be taken to the Q&S Committee

P Jones / P Law

S Dobson to attend the next meeting to present on the IM&T CIP gap

H Hand

A further paper on the shared services CIP position to come to the next Committee meeting

J Carter

S Nicholls to bring a report on site rationalisation to the next meeting for consideration

S Nicholls

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PRIVATE & CONFIDENTIAL Minutes of a meeting of the Finance and Investment Committee held at 10 am

on 19th June 2013 in the Boardroom, Trust HQ

1. Apologies for absence

As noted in the table above.

2. Committee Chairs opening remarks R Armstrong welcomed all to the meeting and noted that there would be some re-scheduling of the agenda as Tom Fothergill from NHSLA was only due to arrive at 11am.

3. Declaration of interests None were declared.

4. Matters arising a. Action log from 22.05.13

All actions were noted as completed or on the agenda.

b. Work plan 2013/14 This was received and noted by the Committee.

5. Minutes of the meeting on 22.05.13 These were agreed as accurate.

PRESENT

17 04

22 05

19 06

Mr R Armstrong, NED (Chair) Ms L Barnes, SID A Mr G Bean, NED A Mr R Collinson, NED Mr R Forster, DOF Mr A Foster, CEO A A Mr L Higgins, Chairman A A Mr D Hughes, Assoc. DOF Mr J Lenney, ED HR Mr S Nicholls, ED Strategy & Planning Dr U Prabhu, MD A Mr Neil Turner, NED A Mrs Christine Parker Stubbs, NED - - - Mrs Pauline Jones, Director of Nursing A A A Ms Fiona Noden, Director of Performance A IN ATTENDANCE Mr D Evans, Assoc. Director E&F Mrs H Hand, TB Sec Mrs L Hancock, Corporate Services Administrator

A

Ms M Fleming, DDoP Surgery - - Mr S Aspinall, DDoP Medicine - - - Mrs A Cushion, Acting Deputy Director of HR - - - Mrs P Law, Acting Deputy Director of Nursing - Mr T Clayson, DMD Specialist Services A Mr I Bett, DDOP Specialist Services A A

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6. Presentation – Specialist Services Performance Update

Modular theatres I Bett advised that the modular theatres would be going live in 12 days time. He noted the tremendous effort that had gone into making this possible and thanked the E&F team for their support. The recruitment plan connected to this has gone well although there are risks around the recruitment of theatre nurses. P Law explained that this is a national issue at the moment and the Trust were looking to solve this short term by use of a recruitment agency and in the long term by looking to perhaps train existing nursing staff into the roles. It was noted that vacancies in Anaesthetics have now been recruited to although there is some delay to start dates due to the recruitment process. 5 new MSK Consultants have been appointed with 3 of them starting with the Trust in June. All MSK job plans have been re-shaped and will take effect from the 1st August. All necessary equipment has been ordered and will be in place in good time. Finance The Division were proud to have achieved an EBITDA of 9% and a contribution to the Trust of 3m in profit last year. However, the current financial position is not as strong with the Division recording a significant deficit in M2 but action plans are in place to counter this. T Clayson believed that the deficit was in part due to the down turn in pelvic and private patient activity. Areas of overspend, such as theatres, will be looked at and processes changed where necessary to bring costs down. I Bett assured the Committee that individual budget holders are regularly challenged on any overspend on their budgets. It is anticipated that the Division will be back on plan by the end of June although the deficit will not be recovered at this point. CIP plans are slightly behind plan but this was explained as being due to phasing and the Division were confident that these would ultimately deliver. 18 weeks / Outpatient follow up backlogs I Bett advised that these areas remained a significant challenge to the Division though it was anticipated that the opening of the modular theatres would start to reduce the 18 weeks backlog. An action plan has been put in place to look at the outpatient follow up backlog and timescales will be added to this. The action plan will also look at Rheumatology. I Bett noted the need to engage with the CCG on this issue although T Clayson advised that this has been difficult. U Prabhu will take this forward with T Dalton and ensure that a meeting is arranged with the CCG to discuss. I Bett and T Clayson remain confident that the plan for T&O can be delivered but highlighted key risks to the plan as the reduction in pelvic and private work. R Armstrong thanked I Bett and T Clayson for their presentation and the honest responses to the debate that followed.

7. Risk escalations from REMC The Committee received and discussed the risk escalations from REMC around income and surplus and land sale. Income and surplus Resolved: The Income and Surplus risk will be returned to REMC for monitoring The Committee agreed that these issues were already discussed and scrutinised on a monthly basis by the Committee. The information currently received to support this monthly discussion was agreed to provide sufficient assurance and opportunity to identify

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risks early. Areas which could be improved were identified as being around the evaluation of business cases and transformational change to identify if outlined benefits have been achieved. It was agreed that this risk would be deferred back to REMC for monitoring. L Barnes noted that the Specialist Service presentation focused very much on the MSK side of business and asked that future presentations looked specifically at the other areas of Specialist Services such as radiology, healthcare ops etc. Land sale Resolved: The land sale risk will be returned to REMC for monitoring D Evans reported that the process continues in terms of the sale of the Billinge site. He noted that although there was some risk that this was controlled and there was no cause for concern in terms of the process at this stage. It was agreed that this would be deferred back to REMC for monitoring.

8. Performance report M2 P Law advised that C Diff remained an ongoing challenge with 11 cases year to date against a trajectory of 25. There had also been an incidence of MRSA against a trajectory of 0 although this had been found to be due to a contaminated sample. F Noden reported that the figure for cancelled ops in May was the best ever achieved by the Trust. The Friends and Family target is not being achieved, particularly in A&E. This will be looked at. A Foster reported that, in March, the Trust had experienced the worst HSMR figures for 5 years. Reasons behind this have been explored but nothing has been identified and it is thought that this could be due to a statistical variation. Concern was expressed at the disparity between the cancelled ops data reported in the document. F Noden will look at this. Increases in harmful falls are being scrutinised by the Falls Scrutiny Committee. P Law felt that the increased number of falls was due to better reporting. L Barnes raised some concerns with regard to CQUINs, in particular for dementia. F Noden additionally noted the breastfeeding CQUIN as being a concern but advised that all of the CQUINs will be discussed in a report due to come to the August F&I Committee. R Armstrong thanked all concerned for the report and noted that the start to the year had been relatively good. ACTION: FN to look at disparity in cancelled ops data CQUIN report to come to the August meeting Safeguarding update to go to the Q&S meeting

9. Finance report M2 R Forster advised that M2 performance had not been as good as the same time last year. The Trust recorded a deficit in month due to a shortfall in income and over spend in expenditure. CIP is making good progress and is a stronger position than the same time last year. Cash balance continues to be good although capital expenditure has increased. The Trust achieved an FRR 2 in M2 and it was agreed that this needed to return to FRR 3 quickly. The decision to remove the Nurse Director CIP to enable strengthening of the Governance structure was discussed as well as the additional resource requirements for pharmacy staffing and the collaborative working projects with Bolton. R Forster advised that, even with these additional pressures, the Trust was still forecasting a £4m surplus at the end of the year. He had no real concerns at this stage but noted that constant vigilance was needed.

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10. Presentation from NHSLA – Tom Fothergill R Armstrong welcomed Tom Fothergill to the meeting and thanked him for agreeing to attend. He noted that the presentation had been deferred on a number of occasions. T Fothergill began by noting that the NHSLA had seen an increase in the number of claims due to the rise in no win no fee litigation. He noted that this was having a huge impact on the NHS. Obs and Gynae was identified as the area of most spend in terms of claims, in particular compensation awarded for harm to babies. NHSLA have become under increasing pressure to re-look at their premiums and assessment arrangements. This is due to a number of Trusts with much lower claim histories being left feeling that they are over-contributing whilst other Trusts aren’t contributing as much but claiming more. There is a real threat that ‘good risk’ Trusts will opt to leave NHSLA which would not be good for the remaining Trusts left in the pool. He advised that NHSLA had reviewed the Trusts claim history and concluded that the monthly contribution needed to be increased. This was due to a couple of high value claims that had occurred a few years ago. He emphasised that NHSLA want to work with the Trust to enable quality changes to be made in order to bring this contribution back down again over time. He reassured that Committee that the NHSLA were not under the impression that the Trust provided poor quality care and are aware that the opposite is true, but that past claims had to be considered. He advised that the NHSLA were keen to work with the Trust to ensure that the contribution increases were as manageable as possible. The Committee thanked T Fothergill for his presentation and noted the offer of early assistance in terms of inquests that the Trust feel will lead to a claim and that in the future it will be possible for WWL to benchmark itself with other organisations via NHSLA information.

11. NHSLA Level 3 option appraisal Resolved: It was agreed that the Trust would not undertake NHSLA Level 3 assessment but the level 3 work streams would continue An amended version of the paper was circulated to the Committee. In light of the earlier presentation from NHSLA and the confirmation that the assessment arrangements will be changing, the Committee agreed not to proceed with assessment at this time. However, it was agreed that there would be benefit to continuing with the NHSLA level 3 work stream with focus on particular areas of concern such as Obs and Gynae, Surgery, A&E and data quality.

12. CIP / Service Transformation S Nicholls reported that M2 had been a good month in terms of CIP but cautioned that there was still a long way to go. He highlighted a couple of key areas of concern to the Committee:

Shared Services – how realistic is CIP delivery? Bed reconfiguration – further reconfiguration is planned but requires more

analysis following the recent bed pressures Nurse Director CIP – the decision to remove the Nurse Director CIP to enable

investment into the governance arrangements means that the CIP must be picked up elsewhere

IM&T – a significant gap that needs to be closed

He advised that the PMO were looking at other schemes such as cost avoidance, VAT and reduction of run rates in temp spend although it was noted that the effect of these was limited. He felt that it would be important to look at site rationalisation as a means of

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releasing significant savings. The Committee noted these concerns and it was agreed that S Dobson would be invited to the next meeting to present on the IM&T CIP gap. ACTION: S Dobson to attend the next meeting to present on the IM&T CIP gap

a. Shared Services CIP position The Committee received and noted the paper that had been submitted however agreed that it was not clear from the paper what was required of the Committee. It was agreed that a revised paper would be submitted to the next Committee which would include:

The likely position going forward A realistic understanding of the gap What can be achieved in year and recurrently The contribution from Salford

ACTION: A further paper on the Shared Services CIP position to come to the next Committee meeting

13. Capital programme delivery Resolved: The Committee agreed to both proposals put forward in the capital programme paper S Nicholls noted that overall this was making good progress. The Committee were asked if it would support the delay of the final business case by 1 month to January 2014. This was to ensure the best price possible could be agreed with IHP. He also asked for the Committees support in identifying development zones on RAEI and Leigh. The zones would be cleared in preparation for future works. The Committee agreed to both of these proposals. S Nicholls noted that need to accelerate site rationalisation to release savings and advised that he would bring a paper around this to the next Committee meeting. ACTION: S Nicholls to bring a report on site rationalisation to the next meeting for consideration

14. BAF objectives Zero points on MCF : the Committee resolved to score this at 20 The Committee agreed to score this at 20 due to the continued challenges around C Diff and A&E targets. Quarterly and full year FRR of 3: the Committee resolved to score this at 20 Following discussion the Committee agreed to retain the score at 20. 300k investment with 2:1 payback: the Committee resolved to score this at 9 R Forster advised that the ‘dragons den’ process was being set up. Maintain a financially balanced 10 year plan and meet milestones for 13/14: the Committee resolved to score this at 12 Following discussion the Committee agreed to score this at 12 as the plans were on track. Achieve Service Transformation (CIP) targets: the Committee resolved to score this at 20 Following earlier discussion on the CIP challenge the Committee agreed to score this at 20.

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15. Minutes received for information The Committee received and noted the following minutes:

SSI Committee

16. Any other business No further items for discussion.

17. Key successes / key risks Key successes were agreed to be:

Good CIP performance to date Achievement of a reduction in cancelled ops Delivery of theatres 9 and 10 on schedule

Key risks were agreed to be:

Specialist Services financial position MRSA and C Diff Capital run rate Deferment of the NHSLA assessment

18. Date and time of the next meeting 24th July 2013, 9.40am, THQ Boardroom

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Chairpersons Report Chairpersons Name Geoff Bean Committee Name Audit Committee Date of Meeting 22.05.2013 Name of Receiving Committee Trust Board Date of Receiving Committee meeting August 2013 Strategic Items for referral to Trust Board No Items for escalation? None

Please detail up to 3 key successes or achievements discussed at the meeting 1. Not discussed this meeting 2. 3.

Details of the top three risks identified during the course of the meeting and initials of primary member of staff actioning 1. Not discussed this meeting 2. 3. 4. 5. Attendance at the meeting (please highlight):

Excellent (well attended)

x

Acceptable (some apologies)

Unacceptable (quorate)

Unacceptable (not quorate)

Was the agenda fit for purpose and reflective of the Committees terms of reference?

Yes

Narrative report of the key issues of the meeting

Agreed actions from the meeting Name of primary lead for the actions

HH to circulate the Charitable Account power point presentation after the meeting

Helen Hand

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MINUTES OF A MEETING OF THE AUDIT COMMITTEE

HELD ON WEDNESDAY, 22 MAY 2013 AT 9.00AM IN THE THQ BOARDROOM

1. COMMITTEE CHAIRS OPENING COMMENTS

G Bean welcomed all present to the meeting and noted the challenges of today’s agenda.

2. DECLARATION OF INTERESTS None declared.

3. APPROVAL OF MINUTES OF MEETING HELD ON 01.05.13 These were agreed as accurate.

4. MATTERS ARISING a. ACTION SHEET FROM 01.05.13

This was received and noted as all actions were confirmed as completed.

b. WORK PLAN 13/14 The work plan was received and noted.

PRESENT 2013/14

0105

22 05

Mr G Bean, (Chair) Non Executive Director Mr R Armstrong, NED Mr R Collinson NED Mr N Turner NED A A IN ATTENDANCE Mr S Baldwin, Financial Controller Mr R Forster, Director of Finance & Informatics Mrs Pauline Law, DD Nursing Mrs H Hand, Trust Board Secretary Mrs F Noden, Director of Performance Mrs P Jones, Director of Nursing A Mr J Lenney, Director of HR & OD A A Ms F Middleton, Deloitte Mr David Rogers, Head of Internal Audit A Mrs C Ryan, Counter Fraud A Mr P Thomson, Deloitte A Ms L Warner, Internal Audit Manager Mrs A Highton, Head of Governance and Assurance - Ms Mary Fleming, DDOP Surgery – 1 item only - - Mrs Lynda Hancock, Corporate Services Administrator

A

Ms Alison Whitehead, Head of Resilience - - Mrs Audrey Cushion, ADDHR Mr P Burke, Deputy Financial Controller -

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5. CORPORATE GOVERNANCE

a. REVIEW OF DRAFT CHARITABLE FUND ANNUAL REPORT AND ACCOUNTS Resolved: To receive and approve the draft CT annual report and accounts. P Burke presented the draft charitable fund annual report and accounts. It was noted that the 5 year plans had been set up and the investment policy reviewed in year. The investment issues had had been resolved without loss to the Charity. The CSS fund has been incorporated in to the Nurse Director fund following the service transformation. It was expected to consolidate the CT accounts with the WWL Trust accounts from 13/14. It was noted that the membership of the Board had been altered and would include 2 Governors and 1 lay member to increase independence on the Board. RF advised that the audit was due to start. It was also noted that protected time had been agreed within the audit committee to consider CTF audit matters. It was further noted that the in house fund manager post had been delayed on legal advice while the investment claim was still being progressed. Action: HH to circulate the power point presentation after the meeting.

b. ANNUAL ACCOUNTS AND FINANCIAL STATEMENTS 12/13 and ANNUAL REPORT AND QUALITY REPORT/ACCOUNT 12/13 Resolved: To approve the annual accounts and financial statements for submission to Trust Board. To receive and note the draft ISA260 report. To approve the annual report and quality report/account for submission to Trust Board

To receive and note the draft report of findings and recommendations from the external assurance review of the quality report

G Bean noted the report on minimal changes to the accounts which did not represent any significant change in performance since previously reported. SB detailed the changes. It was confirmed that the changes did not affect the external audit opinion on the account represented within the ISA260 report. The EA draft ISA260 report was presented. The annual accounts and financial statements were received and approved. In presenting the EA opinion F Middleton advised it was expected that a clean opinion will be issued. PT noted the good position of the Trust showing the Trust to have robust systems in place. PT confirmed he was confident of meeting the deadlines for the Trust Board meeting. The tight timescales were discussed and ongoing lobbying of Monitor on this issue was taking place. PT advised that an important issue next year as a result of changes to the risk rating arrangements would be the need to ensure that capital expenditure does not move away from plan and it was noted that changes to tariff could also present a future risk. PT presented the draft external assurance review of the quality report confirming that the quality account had been reviewed to ensure that all the information required by Monitor had been included and was consistent with patient and staff survey and CQC reports. Overall PT confirmed this was a good report and there were no issues. The

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recommendations for improvement had been received and accepted by the Trust. The report was received and approved. GB gave thanks to all involved in producing the annual report, annual quality report and accounts.

c. SCHEDULE OF MATTERS H Hand advised that the Schedule of matters will be updated following sign off of the SFIs by the F&I committee.

6. ANTI FRAUD a. REVIEW STATUS OF ANTI-FRAUD INVESTIGATIONS

There were no issues to report.

7. INTERNAL AUDIT

a. INTERNAL AUDIT PROGRESS REPORT L Warner presented the report. There had been a limited assurance report relating to care and welfare of service users. This was related to a lack of evidence to demonstrate that timely information is provided to Trust Board on service provision outside core hours. It was noted that actions had been agreed by management including the drafting of a formal policy on senior review, regular senior review audits to be presented to the Quality Executive and support for FY1 doctors was being discussed with DMDs. RA asked about issues raised within the Board reporting audit report that had referred to a lack of evidence of NED challenge within the F&I minutes, RA welcomed an opportunity to discuss this outside of the meeting as he was not in full agreement with this observation. GB agreed with RA and suggested that this report reference was more a comment about the content of the Board Meeting minutes rather than the level, content and robustness of NED challenge. All present noted that DR was shortly due to retire and thanks of the committee were extended to him for his work with the Trust.

b. HEAD OF INTERNAL AUDIT OPINON Resolved: To receive and note the HOIA opinion as” significant assurance” GB advised that the number of IA limited assurance reports had changed and this had been reflected in the annual report and AGS. The report on medicine management had not been completed but would act as a useful tool in support of taking forward actions from the CQC findings. L Warner presented the final HOIA opinion confirming this included a summary of work undertaken and whilst during the year some limited opinion had been given this was not sufficient that a final overall significant assurance opinion could not be given.

8. RISK MANAGEMENT

a. CONSIDER ADEQUACY OF ALL POLICIES None received this meeting.

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b. RISK ESCALATIONS None received this meeting.

9. MINUTES OF OTHER SUB COMMITTEES

The Committee received and no minutes at this meeting.

10. SINGLE TENDER WAIVER REQUESTS The Committee received no report at this meeting.

11. DATE AND TIME OF NEXT MEETING Wednesday 7 August 2013, at 10.00am, THQ Boardroom.

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Chairman: Les Higgins Chief Executive: Andrew Foster CBE Template Version 2 – reviewed June 2011, next review June 2012

your hospitals, your health, our priority

1

Chairpersons Report Chairpersons Name Louise Barnes Committee Name Quality & Safety Committee Date of Meeting 12.06.13 Name of Receiving Committee Trust Board Date of Receiving Committee meeting July 2013

Please detail a key success or achievement of the committee discussed at the meeting 1. The response to the CQC / Medicines Management issues 2. Results of the strategic benchmarking for Healthier Together 3. Escalation helpline 4. 5.

Details of the top three risks identified during the course of the meeting and initials of primary member of staff actioning 1. The internal inspections 2. Senior review 3. Medicines Management 4. 5. Attendance at the meeting (please highlight):

Excellent (well attended)

Acceptable (some apologies)

X

Unacceptable (quorate)

Unacceptable(not quorate)

Was the agenda fit for purpose and reflective of the Committees terms of reference?

Yes

Narrative report of the key issues of the meeting

The 7 themes in response to FrancisII were noted, along with identified Exec sponsors The Committee had an open and transparent debate about the issues around the Medicines Management improvement notice from the CQC, the issues highlighted and organisational responses. Greater Pharmacy presence on the wards, increased Pharmacy staffing, training for junior doctors, double checking on medicine rounds, and unannounced internal audits are among actions that gave the Committee assurance. Further work is being undertaken on strengthening anti-coagulation medication in a forward-looking exercise. It was noted that internal inspections to evidence data in the Performance Accelerator had not been undertaken for some time. These are now being picked up, and will form part of a wider compliance agenda. The only BAF rating changed was Healthy Nutrition which was raised to 12 An evidence-based report on Senior Review was requested for next meeting A report on WWL outcomes benchmarking against Healthier Together challenged some assumptions, showing better outcomes than HT would forecast. Some issues surfaced within Surgery which are being managed internally or via joint working with Bolton

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Chairman: Les Higgins Chief Executive: Andrew Foster CBE Template Version 2 – reviewed June 2011, next review June 2012

your hospitals, your health, our priority

2

Key actions Name of primary lead for the actions The Committee are to receive a further update on Francis in July which will include information on which subcommittee will be monitoring each of the key themes

P Jones / S Nicholls

IV fluids / nutrition to be included in the Medicines Management policy

L Wyre / A Edis

Discussion to take place about resource required to train staff appropriately on the use of the upgraded Datix system. To be reported back to a future Q&S Committee

L Wyre / A Edis

An update on the internal inspections and progress on anti-coagulation to come to the July Committee

L Wyre / A Edis

Anti-coagulation and senior review to be included on the new quality dashboard being developed

L Wyre / A Edis

H Hand to review the work plan to ensure it is rag rated appropriated

H Hand

J Lenney to provide an update to the July Committee on how the Trust can access trainee feedback

J Lenney

A Edis / L Wyre to amend the escalation process to enable REMC to refer risks directly to the appropriate subcommittee

L Wyre / A Edis

The agreed amendments to be made to the risk management strategy 13/14 for final sign off at Trust Board

L Wyre / A Edis

A further, more evidence based, report on senior review to come to the next Committee meeting

U Prabhu

The Quality Executive to look at possible driving Senior Review forward via the Quality Champions

A Foster / L Smyth

F Noden to look at monitoring performance out of hours and at weekends

F Noden

Infection Control Committee minutes to be submitted to Q&S Committee for information going forward

P Jones / H Hand

Healthier Together impact on quality issues to remain a standing item on the agenda for report by exception

H Hand

S Nicholls to provide a similar report on paediatrics for the next meeting

S Nicholls

F Noden to look to see if there is any link between ambulance waiting times and increased HSMR

F Noden

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MINUTES OF A MEETING OF THE QUALITY AND SAFETY COMMITTEE HELD ON WEDNESDAY 12th JUNE 2013 AT 10AM AT TRUST HEADQUARTERS

PRESENT

2012 2013 11 04

09 05

06 06

11 07

12 09

10 10

14 11

09 01

13 02

13 03

10 04

07 05

12 06

Mrs L Barnes, (Chair) Non Executive Director A Mr L Higgins, Chairman Mr R Collinson, NED A A A Mr A Foster, Chief Executive A A A Mrs P Jones, Director of Nursing - - A A A Mr J Lenney, Director of HR & OD A A A A A A Dr U Prabhu, Medical Director A A A A A Mrs C Parker Stubbs, NED Mr Silas Nicholls, Deputy CEO / Director of Strategy and Planning

- A A A A A

Ms F Noden, Director of Performance & Operations - - A A A Mr Geoff Bean, NED - - - - - - - IN ATTENDANCE Ms G Edwards, Associate Director of Finance A - - Mrs H Hand, Trust Board Secretary A A A A Mrs L Hancock, Acting Corporate Services Administrator Mrs A Highton, Head of Governance and Assurance - Ann Heaton, Governor A A A A - - - David Evans, Associate Director of E&F - A A Pauline Law, Deputy Director of Nursing - - - A Martin Farrier, Consultant Paediatrician - - - - - - - - - Bob Horrocks, Governor - - Diane Swindlehurst, Head of Midwifery - - - - - - Audrey Cushion, Acting Deputy Director of HR A - - - - Jean Prescott, Head of Nursing Surgery - - - - A Sanjay Arya, DMD Medicine - - - - - - - Lynne Wyre, HoN Service Transformation Stephen Dobson, Head of IM&T Tracy Joynson, Governance lead for Surgery Gill Smith, Governance lead for SS A A Lesley Boyd, Governance lead for Medicine A

1. APOLOGIES FOR ABSENCE As noted above.

2. COMMITTEE CHAIRS OPENING REMARKS L Barnes welcomed all to the meeting, particularly the Divisional Governance Leads that were in attendance and would now be attending each meeting. She observed that the format of the agenda for this meeting was different to usual in that papers had been circulated for the main agenda item, CQC / Medicines Management, rather than a presentation being delivered on the day. She hoped that this would enable better opportunity for debate. The CQC letter regarding Medicines Management had been tabled at the meeting for the Committee to note, L Barnes felt that this would add an element of reality to the discussions. At this meeting, the Committee would also be looking to debate and agree whether or not the forms / quality of assurance received around key issues were adequate or needed to be improved.

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3. FRANCIS RESPONSE This item was taken first for discussion. A significant amount of work has been undertaken around the Francis report over the past few months and P Jones updated the Committee with regard to this before noting that the Executive team had agreed to focus on 7 key themes with an identified Exec sponsor. The Committee will receive a further update in July which will identify which sub Committees will be responsible for monitoring which themes. The discussion then turned to the item on CQC / Medicines Management. ACTION: The Committee to receive a further update on Francis in July which will include information on which sub-committee will be monitoring each of the key themes (P Jones / S Nicholls) 4. CQC / MEDICINE MANAGEMENT A number of clear and comprehensive actions have been undertaken in response to the CQC report and warning which include the recruitment of additional pharmacy staff to enable dedicated time given to each ward for a portion of each day. It was reported that the CQC had been pleased with the speed of progress that had been made and were understanding that some of the actions were more long term and likely to be ongoing over a period of time. From a clinical perspective, A Wardman advised that he was pulling together a competency framework with Pharmacy for junior doctors as well as putting training sessions in place as this group of staff are responsible for the majority of prescribing. To support this, U Prabhu has sent out a number of communications to medical staff advising them of the importance of tightening up practices and the possible consequences of not doing so. However, A Wardman noted the importance of making change happen in a positive way. From a nursing perspective, P Jones advised that the number of staff present on drug rounds has been increased, although the second checker does not need to be a registered nurse. This is working well despite some teething problems and has been well implemented by staff. It was noted that one member of the nursing staff had been dismissed due to repeated drug errors and P Jones felt that all nursing staff were fully aware of how seriously medication management was being taken by the Trust. From a Pharmacy perspective, F Noden reported that the team had been shocked at the issues highlighted by the CQC and are enthusiastic and committed to bringing about change. An external review of Pharmacy will be taking place to identify further improvements that need to be made. It was queried whether IV fluids / nutrition and blood transfusions had been considered as part of the Medicines Management Policy. P Jones advised that blood transfusions were separate and already had robust systems and procedures in place. However, she acknowledged that IV fluids / nutrition should be included in the policy. L Wyre advised that a task and finish group had been pulled together to review and tighten up the Medicines Management Policy. In order to ensure that the Trust have early awareness of any issues, a schedule of internal CQC type audits will be put in place. These will be unannounced and will focus on a number of things, not just Medicines Management. It is anticipated that these will begin to take place shortly with some initial internal assurance being available by the end of July. Additionally, the corporate nursing team go out to the wards once a month

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unannounced. Discussion also took place around the Datix system upgrade which is scheduled for September which will enable instant flagging of any drug omissions etc. Further discussion around staff training resource for Datix will be discussed outside of the meeting. With regard to anti-coagulation issues that had been highlighted by the CQC, it was noted that a task and finish group had been put in place and gap analysis was being undertaken. A Wardman noted that this was a high risk area as administration was undertaken by all medical teams and therefore was difficult to control. However, Hitesh Patel has put a more robust system in place which should help. It was agreed that an update around the internal inspections and anti-coagulation progress will come to the July meeting. Anti-coagulation will also be added to the medicines safety dashboard. P Law advised that an escalation helpline was due to launch from mid-July. This will be a dedicated line for the use of patients and relatives to escalate any concerns they have which they feel are not being dealt with appropriately. The line will be covered by the on call matron and any concerns that the matron is not able to deal with will be escalated to the most senior clinician / nurse available for response within 30 minutes. The news of this helpline was welcomed by the Committee. L Barnes thanked all present for the excellent discussion that had taken place. She noted that the Committee could feel assured that the appropriate action was being taken in a timely manner. The Committee also welcomed the message that was being delivered to staff in terms of responsibilities and accountability and noted the work being undertaken to introduce a new governance compliance unit with internal inspections linked to the PCAs to support internal assurance. ACTIONS: IV fluids / nutrition to be included in the Medicines Management Policy (L Wyre / A Edis) Discussion to take place about resource required to train staff appropriately on the use of the upgraded Datix system. To be reported back to a future Q&S Committee (L Wyre / A Edis) An update on the internal inspections and progress on anti- coagulation to come to the July Committee (A Edis / L Wyre) Anticoagulation and senior review to be included on the new quality dashboard being developed 5. MINUTES OF THE Q&S COMMITTEE HELD ON 07.05.13 These were agreed as accurate. 6. MATTERS ARISING a. ACTION LOG FROM MEETING HELD ON 07.05.13 L Barnes advised that she had been unable to meet with C P Stubbs and S Dobson as yet. This meeting would take place immediately following this meeting and reported back at the next Committee. All other actions were noted as completed or on the agenda.

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b. WORK PLAN 13/14 This was received and noted by the Committee. B Horrocks noted that there were a number of reds / ambers on the work plan and queried how these were monitored to ensure nothing was missed. H Hand advised that most of these items had been dealt with and the work plan will be reviewed and amended accordingly. ACTION: H Hand to review the work plan to ensure it is rag rated appropriately c. QEC REPORT – A FOSTER The last meeting had followed the usual format with a main presentation from IHI attendees followed by updates from 3 of the Quality Champions. The Committee had also received a very positive presentation from Dr Sundar on Pneumonia. Good progress is being made with the Quality Champion work. d. REMC REPORT – P JONES Positive discussions had taken place around the robust escalation process to Q&S Committee, staff training and the arrest of a thief that had stolen a doctor’s bag from a ward. Risks identified during discussion included: local induction of NHSP staff, SSDU and Medicines Management. 7. OVERALL ASSURANCE TO THE Q&S COMMITTEE KPIS L Barnes advised that she was concerned that a couple of key items had kept returning to Q&S, despite assurance being given that issues were being dealt with. This had prompted her to query whether the level / type of assurance that the Committee received was appropriate. She opened this up to the Committee for debate. S Nicholls felt that it was impossible to achieve 100% assurance on everything but believed that if the Committee could tighten up on deadlines for actions and gain access to feedback directly from on the ground staff / trainees, and that this would help provide better assurance. P Jones agreed and noted that the internal inspections would also provide a greater level of assurance. J Lenney observed that Rob Cragg (new Deputy Director of OD) was undertaking a piece of work to access the views of trainee nurses and doctors. It was agreed that J Lenney would provide an update on this for the next meeting. ACTION: J Lenney to provide an update to the July Committee on how the Trust can access trainee feedback 8. BOARD ASSURANCE FRAMEWORK a. CQC Registration Compliance Resolved: The Committee agreed to score this at 15 (3x5) It was noted that although the concerns in relation to medicines were significant, they were not felt to be a threat to registration. b. Achieve HSMR max 90 and stretch 83 Resolved: The Committee agreed to score this at 20(5x4) The Committee noted the dip in March for HSMR and the challenge of the stretch target. It was agreed to keep the score at 20 at this time. c. Staff introductions to patients Resolved: The Committee agreed to score this at 12 (4x3)

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This had achieved green last month but it was agreed to retain at 12 as there was no definite trend as yet. d. Healthy nutrition Resolved: The Committee agreed increase this score to 12 (4x3) This was rag rated as red last month, therefore the Committee agreed to increase the score to 12. The Committee were advised that scores around worries and fears and pain control had dipped recently. Action was being taken to increase these again by adding emphasis to them on intentional rounding. e. Real time patient survey assurance report In response to queries raised at the last Committee, H Hand advised that the real time patient survey was simply a snapshot of patients on one given day. The process was not repeated to capture patients not able to respond at the original time of survey and patients are not awoken to undertake the survey. All steps are taken to capture as much information as possible. f. Friends and Family update H Hand reported that progress was steady in terms of the Friends and Family test but the necessary return was not being achieved. All avenues to increase the return were being explored including the redesign of the card, an LiA event, use of volunteers in A&E and the possibility of using text messaging. 9. RISK ESCALATION MONITORING REPORT The Committee received and reviewed the risk escalation monitoring report. a. New risk escalations from REMC Income and Surplus – it was agreed that it would be more appropriate to discuss these via F&I Committee Sale of Land – it was agreed that it would be more appropriate to discuss these via F&I Committee Moving and handling – the Committee discussed and agreed that it was appropriate to refer this back to REMC for monitoring The Committee felt that the risk escalation had not worked on this occasion with regard to income and surplus and sale of land. It was agreed that it would have been more appropriate to send these directly to F&I Committee. Therefore, the escalation process will be amended to allow REMC to escalate risks to the relevant subcommittee where appropriate. ACTION: A Edis / L Wyre to amend the escalation process to enable REMC to refer risks directly to the appropriate sub committee b. Risk Management Strategy 2013/14 Resolved: The Committee approved the Risk Management Strategy 13/14 subject to agreed amendments A Edis advised that this strategy had been reviewed and amended in line with identified gaps. The Committee received and approved the strategy subject to the following amendments being made:

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• Lead EDs to be updated on Page 10 • The reference to Meeting Point conducting a monthly deep dive of a BAF objective to be removed

The strategy will now go to Trust Board for final approval. ACTION: The agreed amendments to be made to the risk management strategy 13/14 for final sign off at Trust Board (A Edis / L Wyre) 10. StEIS REPORTS SUBMITTED The Committee received and reviewed this report for information. 11. SENIOR REVIEW UPDATE L Barnes noted that a further update had been requested due to some concern expressed at the last Committee that actions on this were not moving quickly enough. In the absence of U Prabhu, A Wardman reported that there were still issues with senior review out of hours and at weekends due to lack of resource. However, he noted that senior review was carried out on the patients that were poorly or due to be discharged. A Wardman reported that his concerns were more around handovers which he felt were not effective enough. It was agreed that there wasn’t enough evidence demonstrated within the action plans i.e. evidence taken from patient notes, rotas etc. Therefore a further update which was more evidence based was requested for the July Committee. It was further agreed that the Quality Executive look to drive this if possible by perhaps identifying quality champions to take this forward. F Noden will also look at monitoring performance out of hours and at weekend for feedback at the next meeting. S Nicholls suggested exploring the possibility of junior doctors supporting the senior review audit as part of their management module. ACTION: A further, more evidence based, report on senior review to come to the next Committee meeting (U Prabhu) The Quality Executive to look at possibly driving this forward via the Quality Champions (A Foster / L Smyth) F Noden to look at monitoring performance out of hours and at weekends 12. ITEMS RECEIVED BY THE COMMITTEE FOR INFORMATION a. DIPC Report P Jones advised that the report was based on infection control performance last year. She highlighted the challenges around C Diff and MRSA and noted that she had personally flagged up with Divisions the importance of ensuring adequate representation at the Infection Control Committee meetings. L Barnes asked that Infection Control Committee minutes were submitted to the Q&S Committee going forward. This report will now be taken to Trust Board for final sign off. ACTION: Infection Control Committee minutes to be submitted to Q&S Committee for information going forward (P Jones / H Hand)

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b. Healthier Together impact on quality issues S Nicholls reported that the document circulated showed high level outcome measures for WWL compared against other GM Trusts. He explained that a number of the assumptions made by Healthier Together were not supported by the data. Also included within the report was a self assessment undertaken by surgery which highlighted some areas of non-compliance and partial compliance. These areas will be addressed internally if possible or by collaborative working with Bolton. This information will be used to inform discussion with both Healthier Together and Bolton. S Nicholls felt that the Q&S Committee would not be required to do anything further with the information at this time but that the Committee would have a role to play in reviewing the proposed clinical model when established. S Nicholls advised that a study similar to this could be carried out for paediatrics and this would be available for the next Committee. It was agreed that this item would remain a standing item for report by exception (for information only). ACTION: This item to remain a standing item on the agenda for report by exception (H Hand) S Nicholls to provide a similar report for Paediatrics for the next Committee meeting c. Winter planning report The report circulated to the Committee was an update to the report taken to the meeting in January. The pressures on the system due to an extended Winter period were noted by the Committee. It was also noted that A&E performance was now on track once again. Discussion took place on the long waits experienced by the ambulance service in terms of being able to offload patients. It was queried whether these longer than usual waits could have had an impact on the HSMR. F Noden agreed to look at this. ACTION: F Noden to look to see if there is any link between longer ambulance waiting times and increased HSMR d. DQEC minutes Divisional Quality Executive Committee minutes for Medicine and Surgery were received and noted by the Committee. C P Stubbs noted some concern at the mention of 2 SUI’s within the Surgery minutes but was reassured that these were incidents rather than SUI’s and were being investigated thoroughly within the Division. e. QEC minutes Quality Executive Committee minutes were received and noted by the Committee. f. Safeguarding Committee minutes Safeguarding Committee minutes were received and noted by the Committee. g. REMC minutes REMC minutes were received and noted by the Committee. 13. STRATEGIC ISSUES FOR REPORT No issues to escalate this meeting. 14. KEY SUCCESSES / TOP 3 RISKS Key successes were agreed as:

• The response to the CQC / Medicines Management issues • Results of the strategic benchmarking for Healthier Together

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• Escalation helpline

Key risks were agreed as: • The internal inspections • Senior review • Medicines Management

15. DATE, TIME AND LOCATION OF NEXT MEETING The next meeting will be taking place on Wednesday 10th July from 10am in the THQ Boardroom.

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Chairman: Les Higgins Chief Executive: Andrew Foster CBE Template Version 2 – reviewed June 2011, next review June 2012

your hospitals, your health, our priority

1

Chairpersons Report Chairpersons Name Christine Parker Stubbs Committee Name IM&T Strategy Committee Date of Meeting 20.05.13 Name of Receiving Committee Trust Board Date of Receiving Committee meeting July 2013

Please detail a key success or achievement discussed at the meeting 1. PAS update 2. HIS tender responses received 3.

Details of the top three risks identified during the course of the meeting and initials of primary member of staff actioning 1. Communication of black spot in Bleep system 2. Information Asset Owners still to be identified 3. Potential for lack of transparency at tender selection process 4. 5. Attendance at the meeting (please highlight):

Excellent (well attended)

Acceptable (some apologies)

Unacceptable (quorate)

Unacceptable(not quorate)

Was the agenda fit for purpose and reflective of the Committees terms of reference?

Yes

Narrative report of the key issues of the meeting

Key focus of the meeting was the HIS project update. The project is on track, 2 tender responses have been received and supplier scoring is underway. It was agreed that it is essential that we assess the suitability of Lorenzo as a solution in parallel with scoring the 2 tenders, given the huge financial incentives involved in implementing Lorenzo. If we choose not to proceed with Lorenzo then we must be clear on the reasons for that decision given the financial incentives involved. It is equally important that we don’t unnecessarily divert resources from the project should we establish that Lorenzo is unsuitable. Useful discussions regarding improving the engagement of the IM&T department and committee with the clinicians. Actions agreed to monitor engagement and to produce a more useful service dashboard.

Agreed actions from the meeting Name of primary lead for the actions SD to bring an IAA/IAO update to the next meeting.

S Dobson

SD to provide update on the bleep system review and the operational plan. SD to ensure black hole areas are fully

S Dobson S Dobson

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Chairman: Les Higgins Chief Executive: Andrew Foster CBE Template Version 2 – reviewed June 2011, next review June 2012

your hospitals, your health, our priority

2

communicated to all staff likely to be affected C Hudsmith to bring an update on paper light project to the September meeting.

C Hudsmith

Lorenzo recommendation to come to the July meeting unless an ad hoc meeting is required before this date

G Hodgson/R Forster

Pulse check exercise to be conducted with all CDs on engagement with IT projects.

S Dobson

SD/CPS to discuss other ideas for the IT service dashboard report outside the meeting SD to include requested information in future IT dashboard reports

S Dobson/CP Stubbs S Dobson

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MINUTES OF A MEETING OF THE IM&T STRATEGY COMMITTEE HELD ON MONDAY 20 MAY 2013 AT 2PM IN THE THQ BOARDROOM

PRESENT

2013 20 05

Robert Armstrong, Non Executive Director Robert Forster, Director of Finance and Informatics Andrew Foster, Chief Executive A Christine Parker Stubbs, Non Executive Director Umesh Prabhu, Medical Director A Neil Turner, Non Executive Director A Fiona Noden, Director of Performance A Pauline Jones, Acting Director of Nursing A Stephen Dobson, Head of IM&T Les Higgins, Chairman A Karen Foster, Head of Business Intelligence A Pam Green, Head of Clinical Coding and Data Quality Paul Hampson, Head of IM&T Business Analysis A Lynda Hancock, Acting Corporate Services Administrator A Helen Hand, Trust Board Secretary Garry Harris, Head of IT Services Steve Izzat, Clinical Director for IM&T Pauline Law, Deputy Director of Nursing Tony Clayson, Interim DMD for Specialist Services Martyn Smith, Head of Production and Modernisation A Steve Aspinall, DDOP Medicine Andrew Budory, Head of Commercial Planning and Investment

-

1. APOLOGIES FOR ABSENCE As noted in the table above. 2. COMMITTEE CHAIRS OPENING REMARKS CP Stubbs welcomed all to the meeting. 3. MINUTES a. MINUTES OF THE IM&T STRATEGY COMMITTEE 20.5.13 These were agreed as accurate.

4. MATTERS ARISING a. ACTION LOG FROM THE MEETING HELD ON 20.05.13 All actions were noted as complete with the exception of item 7 which would be carried forward to the next meeting.

b. WORK PLAN 13/14 The Committee received and noted the work plan. 5. BAF SCORING a. COMPLETE THE PROCUREMENT OF A NEW HIS AND COMMENCE

IMPLEMENTATION (CURRENT SCORE OF 10) Resolved: The Committee agreed to reduce the BAF score to 2x4=8

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The committee noted that the procurement was on track and the only outstanding risk was one of affordability. It was agreed that a score of 5 for consequence was set too high at 5 and that this should be reduced to 4 whilst retaining the likelihood score at 2, giving a new BAF score of 8.

6. ESCALATIONS FROM REMC None received this meeting. 7. RISK REPORT IAO/IAA rollout timetable and milestones The IAO/IAA rollout has commenced. The IG toolkit received the highest score ever achieved by the Trust but this remained unsatisfactory due to non-achievement of the mandatory training 95% target. Some IAO areas were still to be confirmed and SD was meeting with the DMDs to go through the detail of their responsibilities.

ACTION: SD to bring an update to the next meeting SD gave an overview of the risks. Data quality Progress had been achieved with data quality and Divisions were working on the problem areas. The risk had been agreed at 16. Clinical system failure out of hours Progress had been made and further work as being aligned to the 7 day working project. The score had been assessed at 15. Loss of PAS As a result of the success of the move to new servers on 6.4.13, this risk had been closed down. Bleep System New aerials had been installed and testing completed. A small number of black spots remain one being in radiology. The score was assessed at 15. Clinical case notes This risk had been removed from the register. RF advised that the remaining black hole in radiology needed to be fully communicated to staff working in this area. S Aspinall joined the meeting at this point. SD confirmed that a complete review of the full report was being undertaken and upgrade of the entire system was also being progressed. ACTION: SD to provide update on the review and the operational plan SD to ensure black hole areas are fully communicated to all staff likely to be affected 8. PAPER LIGHT

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C Hudsmith gave an update on the paper light vision, which would require a change in culture across the organisation. The timelines of the project were noted starting with Out Patients in 13/14 leading to a paperless system by 2017/18. It was noted that F Noden as the ED sponsor for the project. In response to N Turner, C Hudsmith confirmed that the project was looking at a health economy approach. RF reported that a joint paper was being worked on with the CCT to apply for funding for the HIS. RA commented that the Board needed to have a role in supporting the development of IT systems across the health economy as a key enabler for VI. It was agreed that a future B2B with the CCG should discuss this. ACTION: C Hudsmith to bring an update to the September meeting 9. HIS PROGRESS UPDATE G Hodgson gave an overview of the progress achieved. It was noted that responses to the tender had been received from TPP and Allscript and these were now undergoing detailed analysis. Funding streams via Healthier Together could also be applied for. The evaluation will take place throughout May. The Lorenzo funding arrangements had changed and £14m was now available. An evaluation plan had been established to dovetail with the TPP and Allscript process. A project board had been established and the first meeting would be held 7.6.13. Minutes from the project board would be submitted to the committee and the final business case would require full Trust Board approval. RF stressed that clinical engagement was essential to the project to ensure that the correct product was procured. RF noted that as Lorenzo had not replied to the tender and this could be a subject of challenge. It was agreed that an ad hoc meeting of the committee could be called should an urgent meeting be required on Lorenzo. ACTION: Lorenzo recommendation to come to the July meeting unless an ad hoc meeting is required before this date 10. STRATEGY AND ENGAGEMENT SD presented the strategy and engagement plan which was broken down into 5 key objectives covering 12 projects relating to integrated clinical systems. Information on all projects was available via sharepoint. RF reported that better use of management board to provide information on progress of IM&T projects would be taken forward. RF suggested that an LiA pulse check of CDs could be undertaken within the next few weeks and then reviewed in six months time to test if engagement had improved. ACTION: Pulse check exercise to be conducted with all CDs on engagement with IT projects 11. PROJECT AND PRIORITIES UPDATE The update was received and noted. 12. IT SERVICES DASHBOARD The dashboard was received and noted. The following information was requested to be included in future reports:

type of incidents key trends number of calls not answered timescale taken to resolve problems

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ACTION: SD/CPS to discuss other ideas for the report outside the meeting SD to include requested information in future reports 13. ITEMS RECEIVED BY THE COMMITTEE FOR INFORMATION The Committee received and noted the following items for information:

Data Quality Committee minutes Information Security Committee minutes

14. ANY OTHER BUSINESS No items raised for discussion. 15. TOP 3 SUCCESSES / TOP 3 RISKS Key successes were identified as:

PAS upgrade Receipt of tender responses from allscripts and TPP

Key risks were identified as:

Communication of black spot bleep areas Information Asset Owners still to be fully identified Risk of not having transparent selection process for HIS tenders

16. DATE / TIME AND LOCATION OF NEXT MEETING 22 July 2013, 2pm, THQ Boardroom

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Trust Board

Agenda Item 20. Date: 31 July 2013

Title of Report NHS Constitution Compliance Q1 Report 2013/14

Purpose of the report and the key issues for consideration/decision

To update the Trust Board on the Trust’s position in relation to compliance with the patient and public and staff rights and pledges at Quarter 1. The Trust is legally required to take account of the NHS Constitution in performing its NHS functions. There are seven key areas of the NHS Constitution relating to patients and the public. The elements of the NHS Constitution that refer to NHS Staff covers four key areas The attached report provides a position statement in respect of the Trust’s compliance with the NHS Constitution.

Prepared by: Name & Title

Helen Hand, TB Secretary Audrey Cushion, Acting Deputy Director of HR

Presented by: Jon Lenney, Director of HR Helen Hand, Trust Board Secretary

Action Required (please X)

Approve Adopt Receive for information

x

Strategic/Corporate Objective(s) supported by this paper

Compliance with terms of authorisation

Is this on the Trust’s risk register?

No

x

Yes

If Yes, Score

Which Standards apply to this report?

CQC N/A NHSLA N/A BAF Objectives N/A

Have all implications related to this report been considered?

Finance Revenue & Capital x Equality & Diversity x National Policy/Legislation x Patient Experience x NHS Contract x Governance & Risk

Management x

Human Resources x Terms of Authorisation x Consultation/Communication x Human Rights x Other: Carbon Reduction

Previous Meetings

Please insert the date the paper was presented next to the relevant group

Meeting Point

Audit Committee

Quality & Safety

Committee

Finance & Investment Committee

IM&T Strategy

Committee

HR Committee

NED Other

N/A N/A N/A N/A N/A N/A N/A N/A

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NHS Constitution Patient & Public Quarter 1 report 2013/14

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Executive Summary One of the primary aims of the Constitution is to set out clearly what patients, the public and staff can expect from the NHS and what the NHS expects from them in return. All NHS organisations are legally required to take account of the NHS Constitution in performing their NHS functions. The constitution was revised 26 March 2013 including changes to the first, fourth, fifth and sixth of the seven guiding principles which are underpinned by the six NHS values of:

Working together for patients Respect and dignity Commitment to quality of care Compassion Improving lives Everyone counts

Compliance with the revised patient and public pledges (changes noted in red) of the NHS Constitution has been assessed for the Q1 period and evidence provided at Appendix 1, is attached to this report. Recommendation The Trust Board is asked to note the content of this report to receive assurance that the Trust was fully compliant with the legal requirement to take account of the NHS Constitution in provision of its NHS services for April to June 2013.

Helen Hand

Board Secretary

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Appendix 1 NHS CONSTITUTION PATIENTS AND PUBLIC

1. Access to Health Services

Pledges: • to provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution; • to make decisions in a clear and transparent way, so that patients and the public can understand how services are planned and delivered • to make the transition as smooth as possible when you are referred between services, and to include you in relevant discussions. Rights Update RAG Compliant/Non

Compliant You have the right to receive NHS services free of charge, apart from certain limited exceptions sanctioned by Parliament.

PCT commissioned services are provided free at the point of delivery by WWL with the exception of those sanctioned by Parliament. In addition some services now require prior approval via Commissioners.

Compliant

You have the right to access NHS services. You will not be refused access on unreasonable grounds.

Access to services is available using a range of options including Choose & Book, Direct Access Clinics, A&E, WIC

Compliant

You have the right to expect your NHS to assess the health requirements of your community and to commission and put in place the services to meet those needs as considered necessary and in the case of public health services commissioned by local authorities, to take steps to improve the health of the local community

Commissioning plans in place to commission services from WWL

QIPP Board established to forward plan future of locally provided services

18 weeks performance reported to Trust Board

Council of Governors engaged in service planning

Monitor 3 year plan publically available

Healthy Hospital Strategy approved by Trust Board

Engagement of membership and Governors in service redesign including service and site investment and QIPP LTC.

Ongoing EBD surveys

Compliant

You have the right, in certain circumstances, to go to other European Economic Area countries or Switzerland for treatment which would be available to you through your NHS commissioner.

Commi ssioner responsibility N/A N/A

You have the right not to be unlawfully discriminated against in the provision of NHS services including on grounds of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status.

WWLFT Single Equality Scheme in place.

Equality & Diversity Steering Group in place to monitor Trust’s performance

Equality & Diversity procurement plans

Equality impact assessment on policies/plans ongoing

E&D Plan in place Equality Objectives agreed March

2012

Compliant

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2. Quality of Care and Environment Pledges:

to ensure that services are provided in a clean and safe environment that is fit for purpose, based on national best practice (pledge);

to identify and share best practice in quality of care and treatments that if you are admitted to hospital, you will not have to share sleeping accommodation with patients

of the opposite sex, except where appropriate, in line with details set out in the Handbook to the NHS Constitution

Rights Update RAG Compliant/Non Compliant You have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality

CQC registration maintained without conditions

NHSLA standard level 2 achieved Monitor quarterly reporting in

accordance with terms of authorisation

SBAR and NPSA alerts regarding patient safety issues.

Adherence to NICE guidance AQUA programme E4E programme AQ Programme Quality Strategy Monitoring by Quality Executive

Compliant

You have the right to expect NHS organisations to monitor and make efforts to improve continuously, the quality of healthcare they commission or

Staff IMPACT training Divisional Quality Accounts Internal clinical and non clinical

audits are undertaken against standards

PLACE audits demonstrate clean and safe environments.

Real Time Patient Experience

Compliant

1. Access to Health Services continued

Pledges: • to provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution; • to make decisions in a clear and transparent way, so that patients and the public can understand how services are planned and delivered • to make the transition as smooth as possible when you are referred between services, and to put you, your family and carers at the centre of decisions that affect you or them.Rights Update RAG Compliant/Non

Compliant Right to access services within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of alternative providers if this is not possible.

Monitoring of all access/waiting targets as outlined in the NHS Operating Framework reported in the monthly performance report.

Whilst the MCF target was achieved overall for the quarter, MSK did not achieve in month.

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provide. This includes improvements to the safety, effectiveness and experience of services.

Survey, Exit Survey Ward to board reports National Survey Programme Time to Care Project Rapid Spread initiative Quality Executive Quality Champions Quality Faculty E4E Harm Free Wards initiative 5 C’s nursing strategy

3. Nationally approved treatments, drugs and programmes

Pledges: The NHS commits to provide screening programmes as recommended by the UK National

Screening Committee

Rights Update RAG Compliant/NonCompliant You have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you.

Medicines Management Policy NICE guidance adherence Antibiotic prescribing policy Medicines Safety Committee Medicine Safety Annual

Report and monitoring by exception at Q&S committee

Medicine management action plan

Anticoagulation policy and action plan

Compliant

You have the right to expect local decisions on funding of other drugs and treatments to be made rationally following a proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you and your doctor feel would be right for you, they will explain that decision to you.

Medicines Management Policy NICE guidance adherence Antibiotic prescribing policy Medicines Safety Committee

Compliant

You have the right to receive the vaccinations that the Joint Committee on Vaccination and Immunisation recommends that you

N/A National Programme N/A N/A

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should receive under an NHS-provided national immunisation programme

4. Respect, Consent and Confidentiality

Pledges:

To ensure those involved in your care and treatment have access to your health information so they can care for you safely and effectively

To anonymise the information collected during the course of your treatment and use it to support research and improve care for others

Where identifiable information has to be used, to give you the chance to object wherever possible To inform you of research studies in which you may be eligible to participate To share with you any correspondence sent between clinicians about your care

Rights Update RAG Compliant/NonCompliant You have the right to be treated with dignity and respect, in accordance with your human rights.

Code of Confidentiality, Dignity and Respect Policies in place and adhered to.

Clinical care policies, procedures and guidance are in place. These are subject to impact assessments.

Compliance with mixed sex accommodation.

Mix sex accommodation audits undertaken

Mixed Sex Occurrence Policy Chaperone Policy .

Compliant

You have the right to accept or refuse treatment that is offered to you, and not to be given any physical examination or treatment unless you have given valid consent. If you do not have the capacity to do so, consent must be obtained from a person legally able to act on your behalf, or the treatment must be in your best interests.

A range of clinical care policies, procedures and guidance are in place. These are subject to impact assessments.

Compliant with mixed sex accommodation.

Chaperone Policy adhered to. Treatments will be explained to

patients as far as possible and repeated if necessary.

Consent audits undertaken Learning from complaints

monitoring Vulnerable

child/adults/safeguarding policies in place

LD Hospital visit programme

Compliant

You have the right to be given Information about the test and treatment options available to

Information Leaflets NHSLA compliant

Pre Op assessment Speciali st Nurse support Learning from complaints

Complaint

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you, what they involve and their risks and benefits.

monitoring NHSLA Level 2 achieved Working towards NHSLA Level 3 CNST Level 2

You have the right to privacy and confidentiality and to expect the NHS to keep your confidential information safe and secure.

Protecting your data information Information Governance Toolkit

monitoring via Audit Committee SIRO position held on Trust Board Caldicott Guardian on Trust Board Information Governance

Committee monitoring role Working towards achievement of

all Information Governance Level 2 standards

Compliant

You have the right to be informed about how your information is used.

Information Governance Toolkit monitoring via Audit Committee

SIRO position held on Trust Board Caldicott Guardian on Trust Board Information Governance

Committee monitoring role Working towards achievement of

all Information Governance Level 2 standards

Compliant

You have the right to request that your confidential information is not used beyond your own care and treatment and to have your objections considered and where your wishes cannot be followed, to be told the reasons including the legal basis. .

Access to Health Records information

Patient Relations support PALS service Patient Choice website feedback Copying Letters to patients Policy Interpreter service available. Patients can apply under the data

protection to access their health records.

Information Governance Toolkit – compliance monitored via Audit Committee

Code of Conduct in place

Compliant

5. Informed Choice

Pledges: To inform you of healthcare services available to you, locally and nationally

To offer you easily accessible, reliable and relevant information in a form that you can understand,

and support to use it. This will enable you to participate fully in your own healthcare decisions and to support you in making choices. This will include information on the quality of clinical services where there is robust and accurate information available

Rights Update RAG Compliant/NonCompliant You have the right to choose your GP practice, and

N/A Primary Care n/a N/a

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to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons You have the right to express a preference for using a particular doctor within your GP practice and for the practice to try to comply.

N/A Primary Care n/a N/a

You have the right to make choices about the services commissioned by NHS bodies and to information to support these choices. The options available to you will develop over time and depend on your individual needs. Details are set out in the Handbook to the NHS Constitution

Patient Information Leaflets NHSLA Level 2 compliance

achieved Leaflets are also available in

alternative formats such as large print Braille alternative languages and audio.

Leaflets are available for download on the internet/intranet

Information on National ratings Choices Website

CQ C ratings Monitor Compliance Framework Consultant Profiles on WWL

internet Patient Opinion Project Dr Foster Publications PROMS & PREMS information Friends and Family test

information

Compliant

6. Involvement in your healthcare and in the NHS

Pledges: to provide you with the information you need to influence and scrutinise the planning and delivery of

NHS services to work in partnership with you, your family, carers and representatives . to involve you in discussions about planning your care and to offer you a written record of what is

agreed if you want one to encourage and welcome feedback on your health and care experiences and use this to improve

services

Rights Update RAG Compliant/NonCompliant You have the right to be involved in discussions and decisions about your

Decisions in clinical care monitored by national survey programme

Involvement in decision

Compliant

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health and care, including your end of life care and to be given information to enable you to do this. Where appropriate this right includes your family and carers.

monitored in RTPE survey Information on how to become

involved in the design and delivery of services is distributed via the Membership and Engagement Department.

Membership panels used to comment on patient information

Membership panels used to comment on Trust plans and performance

Monitoring through national and internal surveys

Focus Groups Workshops using EBD LTC QIPP engagement Intentional Rounding Friends and family test Bereavem ent Service Speciali st Nursing services

You have the right to be involved, directly or through representatives, in the planning of healthcare services commissioned by NHS bodies, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services

Membership events in the Community.

Membe rship Engagement Strategy

COG involvement in service planning

Membership panels used to provide service planning feedback

Trust consultations on significant changes will be undertaken in full compliance of Section 242 of The 2006 Act and 2012 Act

Close liaison with OSC in service change

Engagement with Healthwatch in service change

Engage ment with GP Commissioners in service change

Governor and patient involved in Service redesign teams

Compliant

7. Complaint and redress

Pledges: To ensure you are treated with courtesy and you receive appropriate support throughout the

handling of a complaint; and the fact that you have complained will not adversely affect your future treatment

when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things

right quickly and effectively

to ensure that the organisation learns lessons from complaints and claims and uses these to improve NHS services

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Rights Update RAG Compliant/NonCompliant You have the right to have any complaint you make about NHS services acknowledged within three working days and to have it properly investigated

Patient Relations Team support complaints

Complaints monitoring reported at Trust Board

Complaints reported within the Annual Report

Internal target for response to complaints set

Complaints policy revised to embed system at Divisional level

Medical Director sees all complaints

Compl aints response devolved to Divisions

Patient opinion launched

Compliant

You have the right to be kept informed of progress and to know the outcome of any investigation into your complaint,

Complaints letter signed off by the CEO

Meetings facilitated by Patient Relations Team to discuss individual complaints

Complaints reviewed by Medical Director

Red RAG rated complaints and SUI monitoring meeting established

Survey of complainant satisfaction

Compliant

You have the right to take your complaint to the independent Parliamentary and Health Service Ombudsman or Local Government Ombudsman, if you are not satisfied with the way your complaint has been dealt with by the NHS.

Complaints policy in place in accordance with legislation requirements

Compliant

You have the right to make a claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body or local authority

Complaints policy in place in accordance with legislation requirements

Complaint

You have the right to compensation where you have been harmed by negligent treatment.

Legal Services Department in place for compensation claims

Legal Services annual report received by Trust Board

Compliant

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your hospitals, your health, our priority

Audrey Cushion Acting Deputy HR Director

NHS Constitution – Staff

June 2013

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your hospitals, your health, our priority

NHS Constitution – Update on Staff Rights

Have a good working environment with flexible working opportunities, consistent with the needs of patients and with the way that people live their lives. Rights Update RAG Compliant / Non Compliant To fair treatment regarding leave, rights and flexible working and other statutory leave requests relating to wo rk and family, including caring for adults that you live with.

A range of policies are in place to support this right: Flexible working policy & toolkit Special Purposes Leave Policy Job Share Policy Equality, Diversity & inclusiveness in Employment Policy.

Compliant

To request other ‘re asonable’ time off fo r emergencies (paid and unpaid) and other statutory leave subject to exceptions).

A range of policies are in place to support this right: Flexible working policy & toolkit Special Purposes Leave Policy

Compliant

To expect reasonable steps are t aken by the employer t o ensure protection from less favourable treatment by fello w emplo yees, patients a nd others (e.g. b ullying an d harassment)

A range of policies are in place to support this right: Dignity at Work Policy Equality, Diversity & inclusiveness in Employment Policy Open Door Policy for Handling Staff Complaints Divisional Equality Champions and quarterly E&D Steering Group Development and publication of of Equality Objectives Dignity at Wok promoted within SID Walkabouts 2012. Listening into Action Events.

Compliant

Have a fair pay and contract framework Rights Update RAG Compliant / Non Compliant To pay; co nsistent wit h the national Minimu m Wage or alternative contractual agreement. To fair treatment regarding pay.

The Trust a dheres to National Policy on minimum wage a nd other national fra meworks such as Ag enda for Change, Consultant Contract etc.

Compliant

Be involved and represented in the workplace Rights Update RAG Compliant / Non Compliant To be acco mpanied by either a T rade Union official or a work colleagues at disciplinary or grievance hearings in line with legislation, your employer’s policies or your contractual rights.

A range of policies are in place to support this right: Partnership Working Policy updated in February 2010 to include

reference to the NHS Constitution and staff pledges. Grievance and Disciplinary Policies

Compliant

To consult ation and represent ation eithe r through th e Trade Union or other st aff representatives (for exa mple where there is n o

A range of policies are in place to support this right: Partnership Working Policy updated in February 2010 to include

Compliant

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trade union in place) in line with leg islation and any collective agreements that may be in force.

reference to the NHS Constitution and staff pledges. Job Security and Change Policy

Have healthy and safe working conditions and an environment free from harassment, bullying or violence. Rights Update RAG Compliant / Non Compliant To work within a health and safe workplace an d an environment in which the employer has taken all practical steps to ensure the workplace is free from verbal or physical violence from patients, the public or staff, t o work your contractua l hours, take annual leave and to t ake regular breaks fro m work. An updated values and behaviours leaflet is to be distribute d to staff at the end of April 2013.

A range of policies are in place to support this right: Annual Leave Policy Behaviour and Attitudes at Work Leaflet (updated for April 2013) Dignity At Work Policy Code of Conduct Policy Flexible Working Policy & Toolkit Time Owing Policy Open Door Policy for Handling Staff Concerns In addition the Trust provides training to underpin these rights: Conflict resolution eCompulosry Conflict resolution training – high risk areas IMPACT Training ILM Leadership and Management Programmes Specific Training to Security Staff Incident Reporting Training (Datix)

Compliant

Be treated fairly, equally and free from discrimination Rights Update RAG Compliant / Non Compliant To a working environment (including practices on recruit ment and promotion) free from unlawful discrimination on the ba sis of ra ce, gender, se xual orientation, di sability, age o r religion or belief.

A range of policies are in place to support this right: Behaviour and Attitudes at Work Leaflet Dignity At Work Policy Equality, Diversity & inclusiveness in Employment Policy Recruitment and Selection Policy In addition the trust ha s consulted and ratified the following scheme and training to underpin these rights: Single Equality Scheme Equality Impact Assessment Equality and Diversity Champions

Compliant

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Can raise an internal grievance and if necessary seek redress, where it is felt that a right has not been upheld Rights Update RAG Compliant / Non Compliant To have disciplinary an d grievance procedures conducted appropriately and within internal and legal requirements

A range of policies are in place to support this right: Partnership Working Policy updated in February 2010 to include

reference to the NHS Constitution and staff pledges. Grievance Policy Disciplinary Policy & Procedures

Compliant

To appeal against wrongful dismissal A range of policies are in place to support this right: Grievance Policy Disciplinary Policy & Procedures Both policies have clear appeal processes contained within them

Compliant

If internal pr ocesses fail to overturn a dismissal, you have t he right to pursue a claim in th e employment tribunal, if you meet required criteria

A range of policie s ar e in place to support t his right prior to the employee pursuing a claim via an Employment Tribunal: Grievance Policy Disciplinary Policy & Procedures Both policies have clear appeal processes contained within them

Compliant

To protection from detriment in e mployment and the right n ot to be unfairly dismissed fro m ‘whistleblowing’ or repor ting wrongdoing in the workplace.

A range of policies are in place to support this right: Open Door Policy for Handling Staff Concerns Equality, Diversity & inclusiveness in Employment Policy Code of Conduct Policy Dignity At Work Policy Grievance Policy The Trust works with NWCoun ter Fraud who independently investigate any complaints via this route. The Open Door Policy for Handling Staff Concerns is consistent with the Counter Fraud legal framework.

Compliant

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Have employment protection (NHS employees only) Rights Update RAG Compliant / Non Compliant You have a right to e mployment protection in terms of c ontinuity of service for redundancy purposes if moving between NHS employers.

A range of policie s / co ntractual ob ligations are in place to support this right: Job Security and Change Policy Terms & Conditions of employme nt ( e.g. Ag enda for Ch ange &

Medical Staff T&C’s) In addition t he Trust ha s agreed to work with NHS North West and local Trusts in the area to facilita te redeployment where there is opportunity to do so.

Compliant

Can join the NHS Pension Scheme (NHS Employees and some other groups, e.g. GPs) Rights Update RAG Compliant / Non Compliant You have rights relat ing to the ability to join t he NHS Pension Scheme

The Trust operates an opt out approach as o pposed to an opt in process to joining the NHS Pension Scheme and therefore any new employees are automatically registered with the schem e. Auto-enrolment from April 20 13 will also give the o ption of a non NHS scheme (NEST) for those not eligible to join the NHS scheme. During 2010 and 2011 the Trust took part in the national campaign to promote a mendments to the sch eme among st all employees and specifically target those staff already in the scheme – NHS Pension Choices. The Trust will also comply with any Auto Enrolment Legislation from May 2013 although full implementation of Auto Enrolment will not take place until 2017.

Compliant

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NHS Constitution – Update on Staff Pledges

Pledge One: The NHS commits to provide all staff with clear roles and responsibilities and rewarding jobs for teams and individuals that make a difference to patients, their families and carers and comities. Update RAG Compliant / Non Compliant Role Design and responsibilities to enable high quality care:

Modernisation of Roles in line with Service Requirements – Chaired by Director of Operations Agenda for Change Job matching, Evaluation and Consistency Checking processes in place. Job Security and Change Policy to provide a framework for organisation and service reviews. IMPACT course includes Patient Experience references Ongoing Patient Experience Survey and reporting to Trust Board and cascaded through Team Brief.

Compliant

Contract of Employment for most staff supports this pledge: Agenda for Change Terms & Conditions available for majority of staff Consultant Contract and other nationally agreed Medical staff contracts adhered to by the organisation All staff receive contract of employment & Job Descriptions, supported by KSF light outline. All Consultants undertake annual Job Planning reviews – this process is being further developed and ongoing.

Compliant

Regular Appraisals and Training opportunities: PDR compliance rates by division reported to Trust Board each month PDR System is under r eview and revised documentation to support the pay progression policy will be introduced

in 2013/14 Training opportunities promoted via Trust News, e-mail and Focus on a regular basis Comprehensive eCompulsory Training available to all employees to ensure that they are safe and updated in line

with risk management requirements. E-compulsory has been revised and a new system impl emented in April 2013.

KSF light framework used alongside PDR Appraisal.

Compliant

Pledge Two: The NHS commits to provide all staff with per sonal development, access to ap propriate training for their jobs and line management support to succeed. Update RAG Compliant / Non Compliant Utilisation of the Knowledge and Skills Framework:

The Trust reports over 98% compliance month on month of staff having a KSF PDR compliance rates by division reported to Trust Board each month – hotspots in compliance are Surgery and

Medicine PDR Documentation under review to support values and behaviours. 180 feedback tool to be developed during 2013/14

Compliant

Educational Governance and Investment in Continuous Personal Development (CPD): Compliant

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The Trust has signed the Skill’s Pledge The Trust w as acknowledges to b e the Top 10 of organisa tions in the North West to access Joint Investment

Framework (Invest in Health) monies for Band 1 to 4 staff Protected Time to Study is available for Medical and non medical staff. Allocation of Finance for Time Off and Training Policy available for all non medical staff. All staff are entitled to an additional days study provided they are compliant with mandatory training Investment in personnel to support medical staff revalidation and appraisal process . Series of Leadership Masterclass events for 2013/14

Spotting and Developing confident leaders: Development potential discussed as part PDR process. External accessible Leadership Programmes a vailable for Executives / Senior Managers – e.g. a number o f the

Executive Team are on the NHS Top Leaders development Programme. Leadership Development Programme to be progressed during 2013 ILM Level 4 and NVQ programmes available for supervisory and management grades. ILM Level 5 for emerging leaders

Compliant

Pledge Three: The NHS commits to provide support and opportunities for staff to maintain their health, well-being and safety. Update RAG Compliant / Non Compliant Trusts are r equired to prevent violence against staff when ever possible and to ta ke all appro priate actio n, includ ing prosecutions of offenders, when violence occurs:

The Trust has a lead manager and executive for implementation of guidance and training from the NHS Security Management Services.

The Trust has an eCompulsory Training module – Conflict resolution and bespoke training for high risk areas. Conflict resolution is covered on the Trust Induction Programme

Compliant

Staff, patients and others are protected against the risks of acquiring a healthcare associated infection: The Trust has an eCompulsory Training module for all staff on Infection control HACI are reported to Trust Board monthly and are communicated via Team Brief. Quality and Safe Matrons have been appointed to each division in the Trust.

Compliant

Staff are supported in their health and well being: Occupational Health services available to staff including self referral for counselling services. There is an EAP facility available for staff Stress Committee reports via HR Committee and REMC – with good fe edback on progress being made received

from HSE Inspector and formal sign off from HSE received in May 2011. Health and Wellbeing report presented to Trust Board in March and associated Action Plan. 22 recommendations

endorsed by the Board with con siderable work required to take forwar d the recom mendations within the T rust

Compliant

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over the next 6 months H&WB Group established with departmental champions Achievement Standard of H&WB Charter 2013

Pledge Four: The NHS commits to engage staff in decisions that affect them ad the services th ey provide, individually, through representative organisations and through local partnership working arrangements. All staff will be empowered to put forward ways to deliver better and safer services for patients and their families. Update RAG Compliant / Non Compliant Involvement in Social Partnership Forum:

The Trust has a lead manager and executive for implementation of guidance and training from the NHS Security Management Services.

The Trust has an eCompulsory Training module – Conflict resolution and bespoke training for high risk areas. Conflict resolution is covered on the Trust Induction Programme The Trust works in partnership with staff side, consulting on organisational change The Trust invested in Listening int o Action d uring 2012 a nd further investment in Staff Eng agement during

2013/14 to improve processes and ensure staff engagement The Trust supports SID (Staff Involvement Delivers) to wo rk in partne rship with staff side to facilitate staff

engagement The Trust holds listening events with Executive and Senior Team members.

Compliant

Staff, patients and others are protected against the risks of acquiring a healthcare associated infection: The Trust has an eCompulsory Training module for all staff on Infection control HACI are reported to Trust Board monthly and are communicated via Team Brief. Quality and Safe Matrons have been appointed to each division in the Trust.

Compliant

Staff are supported in their health and well being: Occupational Health services available to staff including self referral for counselling services. The EAP contract line was introduced in 2013 Stress Committee reports via HR Committee and REMC – with good fe edback on progress being made received

from HSE Inspector Health and Wellbeing report presented to trust Board in March and associated Act ion Plan. 22 recommendations

endorsed by the Board with con siderable work required to take forwar d the recom mendations within the T rust over the next 6 months

HWB Group established 2011and divisional champions introduced in 2013. Achieved H&WB Standard at Achievement Level and action plan to aspire to excellence will be developed during

2013.

Compliant

Please note that the Department of Health is currently consulting on whether there should be an additional staff pledge specifically related to Whistle blowing.

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They are seeking views on a number of amendments to the Constitution that will:

insert an expectation that NHS staff will raise concerns about safety, malpractice or wrong doing at work which may affect patients, the public, other staff or the organisation itself as early as possible.

insert a NHS pledge to support all staff in raising concerns about safety, malpractice or wrong doing at work, responding to and where necessary investigating the concerns raised.

highlight in the NHS Constitution the existing staff legal right to raise concerns about safe, malpractice or other wrong doing without suffering any detriment.

Audrey Cushion Acting Deputy HR Director June 2013

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Trust Board Agenda Item 21. Date: 31 July 2013

Title of Report Use of Company Seal Q1 Report

Purpose of the report and the key issues for consideration/decision

To advise the Board of the use of the Company Seal and report building and engineering tenders with a tender price of £100,000.00 or more during the period April to June 2013.

Prepared by: Name & Title

Mrs Helen Hand, Board Secretary Mr Ian Bradley, Head of Capital and Property Services

Presented by: Mrs Helen Hand, Board Secretary

Action Required (please X)

Approve Adopt Receive for information

x

Strategic/Corporate Objective(s) supported by this paper

n.a.

Is this on the Trust’s risk register?

No

x Yes

If Yes, Score

Which Standards apply to this report?

CQC n.a. NHSLA n.a. BAF Objectives 13/14 n.a. WWL Wheel n.a

Have all implications related to this report been considered?

Finance Revenue & Capital x Equality & Diversity National Policy/Legislation x Patient Experience NHS Contract Governance & Risk

Management x

Human Resources Terms of Authorisation x Consultation/Communication Human Rights Other: Carbon Reduction

Previous Meetings

Please insert the date the paper was presented next to the relevant group

Meeting Point

Audit Committee

Q&S Committee

Finance & InvestmentCommittee

Management Board

NED HR committee

IM&T committee

Other

n.a n.a n.a n.a n.a n.a n.a n. a n. a

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WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST

Use of Wrightington Wigan and Leigh NHS Foundation Trust Company Seal For the Period April to June 2013

Date Register No. Documents Sealed 29.5.13. 58 Measured Term Contract 2013 John Turner Construction Group Ltd

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TENDERS IN EXCESS OF £100,000 FOR THE PERIOD APRIL TO JUNE 2013 TENDERS WITH A TENDER PRICE OF £100,000 OR MORE, RECEIVED IN THE SAME PERIOD Scheme Contract Sealed Comments RAEI – New Build Cancer Care Facility & Pathology ESL WLT1606 Thomas Barnes – lowest tenderer. Leigh – New Sandwich Facility (Mod Build) Block 46 WLT1622 MTX Contracts Ltd – lowest tenderer.

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Trust Board

Agenda Item 22. Date: 31 July 2013

Title of Report Safeguarding Children / Vulnerable Adult reports

Purpose of the report and the key issues for consideration/decision

To provide the Trust Board with the annual report for safeguarding of children and vulnerable adults.

Prepared by: Name & Title

Various

Presented by: Pauline Jones, Director of Nursing Umesh Prabhu, Medical Director

Action Required (please X)

Approve Adopt Receive for information

x

Strategic/Corporate Objective(s) supported by this paper

Governance

Is this on the Trust’s risk register?

No

X Yes

If Yes, Score

Which Standards apply to this report?

CQC All NHSLA Governance BAF Objectives 13/14 Governance WWL wheel strategic priority

Performance

Have all implications related to this report been considered?

Finance Revenue & Capital Equality & Diversity National Policy/Legislation x Patient Experience x NHS Contract Governance & Risk

Management x

Human Resources Terms of Authorisation Consultation/Communication Human Rights Other: Carbon Reduction

Previous Meetings

Please insert the date the paper was presented next to the relevant group

Meeting Point

Audit Committee

Quality & Safety

Committee

Finance & Investment Committee

HR Committee

IM&T Strategy

Committee

Management Board

NED Other

Na Na 10.07.13 Na Na Na Na Na Na

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Safeguarding Vulnerable Adults & Children Annual Reports 2012 - 2013

Authors: Margaret Jolley, Head of Adult Safeguarding &

Vulnerable Adults

Dr E Abbas Consultant Community Paediatrician Designated Doctor for Safeguarding Children Debbie Spruce Named Nurse Child Protection Safeguarding Children

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Executive Summary

Safeguarding Vulnerable Adults Annual Report 2012/13

The purpose of this report is to provide assurance to the Board that there are robust arrangements in place to ensure Adult Safeguarding is fully integrated into the Trust’s systems and meets the required regulations and standard. The information contained within this report comprises the period from 1 April 2012 to 31 March 2013 in respect of the following:

Adult Safeguarding concerns raised An analysis of the data during the 2012/2013, using comparative data from previous

years. The key achievements throughout the year and future developments.

The report also provides an update to the Board on the progress and developments made in addressing the needs of Vulnerable Adults within Wrightington Wigan & Leigh NHS Foundation Trust with specific reference to:

Responsibilities Reporting Wigan Adult Safeguarding Board (WASB) Safeguarding Referrals Mental Capacity / Deprivation of Liberty Safeguards (MCA/DOLS) Learning Disabilities Dementia Training

Safeguarding Vulnerable Children/Child Protection Annual Report 2012/13

The purpose of this report is to:

Inform the Trust Board about their responsibilities for safeguarding children and to promote children’s wellbeing to prevent them from suffering harm.

To discuss future plans, strategy and developments in safeguarding children. To report the key achievements over the last 12 months. To share information from the Integrated Health Group, Heath Commissioning

Group Safeguarding Subgroup and Wigan Safeguarding Children’s Board (WSCB).

Provide information on the future needs of the service

Recommendation The Board is asked to receive and approve the attached reports for the period 2012/13.

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SAFEGUARDING VULNERABLE ADULTS ANNUAL REPORT 2012/13

- 2013 Responsibilities Safeguarding Vulnerable Adults is the responsibility of all healthcare staff and the Trust is responsible for ensuring all staff are familiar with the Trust Safeguarding Adults policy and joint local procedures that must be implemented if staff suspect a vulnerable adult is at risk. Safeguarding is wider than ’adult protection’ which predominately focuses on reacting to incidences of harm. WWL’s approach to safeguarding is about addressing inequalities, creating an environment where patients feel safe and where their dignity is respected and whatever their circumstances are free from discrimination. The following Trust wide policies have been developed to support / guide staff working with Vulnerable Adults:

Missing Persons Policy- ratified June 2013 Therapeutic Management of Vulnerable Adults with Challenging Behavior (including

Control & Restraint Management) – ratified June 2013 Mental Capacity (2005) including Deprivation of Liberty Safeguards – awaiting

ratification Reporting The Director of Nursing is the identified Executive lead for Safeguarding Vulnerable Adults and is therefore responsible for reporting to the Trust Board. The Trust Safeguarding Committee addresses both the adult and child/young person’s safeguarding agenda. Bi-monthly Adult Safeguarding reports are presented to the Safeguarding Committee by the Head of Adult Safeguarding. These reports indentify the number and type of adult safeguarding concerns raised by staff across the organisation, highlighting any trends identified. Wigan Adult Safeguarding Board updates are also presented together with updates on training figures and new training initiatives. The Safeguarding Committee chair reports on a bi-monthly basis to the Quality & Safety Committee, which, in turn reports quarterly to the Trust Board. The Head of Adult Safeguarding provides a detailed annual update on Safeguarding & Vulnerable Adults to Trust Board. Wigan Adult Safeguarding Board (WASB) The Director of Nursing, with support from the Head of Adult Safeguarding, represents the Trust on the Wigan Adult Safeguarding Board, reporting back to the Trust Safeguarding Committee. Professor Paul Kingston has been appointed as independent chair of WASB, all organisations within the board welcome this appointment. Professor Kingston’s expertise is in ageing, mental health, safeguarding vulnerable adults and measuring quality of life. This is a positive step within Adult Safeguarding, WWL, together with other agencies within the borough, have contributed from a financial perspective in support of this appointment.

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There have been 3 local case reviews of vulnerable adults who have died, one currently undergoing murder investigation, all cases were community based. WWL Head of Adult Safeguarding attends and contributes to the North West Safeguarding Network, chaired by the Assistant Director of Patient Safety and Clinical Quality. This network provides peer support for the Adult Safeguarding Leads across the North West and ensures the sharing of innovations and good practice across the region. Safeguarding Referrals During 2012/13 there has been a further increase of acute Trust referrals in relation to Adult Safeguarding (Graph 1). 141 potential safeguarding referrals were made from the period April 2012 through to 31 March 2013. In the same period 2011 /12 there were 81 referrals and in 20010/11 57 referrals.

Graph 1 – Referrals to Adult Safeguarding by Year

The increase in referrals within Wrightington, Wigan and Leigh NHS Foundation Trust continues to be consistent with an increase in safeguarding referrals across all agencies within the Wigan Borough.

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Graph 2- Breakdown of referrals 2012/13

Referrals received in regard of concern for welfare continue to increase, in light of the changes to Welfare reform, this will continue to be monitored and discussed at the WASB and Learning Disability partnership board. Mental Capacity / Deprivation of Liberty Safeguards (MCA/DOLS) The Mental Capacity Act, 2005, provides a statutory framework for acting and making decisions on behalf of people who lack capacity to make those decisions for themselves. The Deprivation of Liberty Safeguards (DOLS) was added to the act by the government in 2008. The safeguards focus on the most vulnerable people in society, who, for their own safety and in their own best interests need to be ‘accommodated’ under care and treatment regimes. These regimes may have the effect of depriving them of their liberty. Within the hospital, application must be made to the supervisory body (Wigan Borough Clinical Commissioning Group), to request authorisation to deprive a patient of their liberty. The Trust has continued to develop in relation to MCA/DOLS and there has been an increase in engagement and requests for authorizations. However, there were no referrals for Independent Mental Capacity Advocate support (IMCA) in the last quarter. The Trust Head of Adult Safeguarding is working with the IMCA service to promote the service and raise awareness across the Trust with particular attention to the Trust Assessment Units and pre – op clinics. Wigan Borough Clinical Commissioning group, since April 2013, have the responsibility in monitoring the Trust implementation of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards.

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Learning Disabilities Winterbourne View Hospital – Panorama (2011) Following the BBC Panorama exposure in 2001 of staff at Winterbourne View hospital staff mistreating and assaulting adults with learning disabilities and autism, a serious case review was commissioned by South Gloucester’s local Adult Safeguarding Board and a report with key findings published in July 2012. Although in the main the recommendations of this enquiry relate to commissioning bodies, there is some learning in relation to whistle blowing process and the need for the Trust to continue to promote the physical and mental health of adult patients who are vulnerable. The Head of Adult Safeguarding, working in collaboration with Partner Organisations to ensure learning actions from Winterbourne view are coordinated and shared. The Trust continues to be work collaboratively with its partner organisations via the following:

Wigan Learning Disability Partnership Board Wigan Borough Clinical Commissioning Group Mental Health Implementation Board 5 BP Mental Health Law Forum

The Trust is committed to integrated working with the hospital liaison team for learning disabilities and together have successfully delivered a 12 month training program to front line staff, in particular reception and outpatient staff across all sites. Tours of A&E and the Surgical Admissions Lounge for individuals with a learning disability continue, with tour dates set for the forthcoming 12 months. The main aim of the tours is to show the individual with a learning disability, what they can expect should they ever have to attend hospital either in an emergency (A&E) or planned surgery (SAU). It is planned that the tours are extended in the coming 12 months to include ooitpatient departments across all three hospital sites. The Head of Adult Safeguarding continues to work in collaboration with catering, I.T. and the Trust nutritional group, in the development of ‘electronic’ pictorial menus. This initiative will not only address the communication difficulties of individuals with a learning disability, but for all vulnerable adult groups with communication difficulties. The Trust will continue, via the Head of Adult Safeguarding, contribute to the Annual Joint Health and Social Care assessment (Learning Disabilities). The utcome/ action plan from this self assessment, when published, will be included in the Trust Safeguarding Committee bi annual report. Dementia The Trust is committed to improve the care and experience of patient’s with Dementia and their family and carers. Dementia continues to be a significant challenge and a key priority for the Trust with an estimated 25% of acute beds occupied by people with dementia. The NHS institute and Dementia Action Alliance launched the ‘Right Care’ creating dementia friendly hospitals in October 2012. The Trust signed up to this call following in November 2012. In signing up to this the Trust agrees to improve the following 5 key areas:

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The environment in which care is given The knowledge skills and attitudes of the workforce The ability to identify and assess cognitive impairment The ability to support people with dementia to be discharged back home The use of a person centred care plan which involves families and carers.

Key achievements to date:

50 Vulnerable Adult/ Dementia Champions across the organisation Successful delivery of the 2nd, 2 day intensive training course on dementia completed

July 2012 for Champions. The Clinical Lead, Senior Nurse and Head of Adult Safeguarding represent the Trust,

and are actively involved in the multi agency Dementia Steering Group led by Wigan Clinical Commissioning Group.

Information and reports from this group are delivered at the Trust Safeguarding Committee.

The Trust Lead Clinician for Dementia provides an integrated elderly cognitive assessment clinic, which is currently being piloted with a senior nurse practitioner from 5 Boroughs Partnership Mental Health Trust. Following evaluation of the pilot, 5 Boroughs Partnership NHS FT have submitted a business case to extend this.

The Trust Lead Clinician for Dementia provides training for junior doctors, feedback from this training is attached with this report. (Appendix 1).

5 Dementia champions attended a 2 day seminar delivered by the Kings fund, ‘Healing the environment’

A WWL ‘dementia friendly group has been established, membership includes Director of nursing and key stakeholders from estates and facilities and the dementia champions. Minutes from this group will be sent to the Trust Safeguarding Committee.

Development of Delirium Pathway (enclosed). Appendix 2. The Trust Lead Clinician has been successful in the following;

- The community collaboration work published .(AQuA) - NT Award for collaborative clinic service with 5BP(attached,) - presented to national BGS meeting, Belfast and well received as best practice- - Produced an action plan following the outcome from the recent National Dementia Audit.

Training Training and awareness raising continues in all vulnerable adult fields, and dates for the coming year have been advertised with requests for nominations to attend. Safeguarding adult’s basic awareness is delivered via a module on the Trust e-compulsory training site, and at the Trust monthly induction sessions. There continues to a month on month slight increase in e-compulsory safeguarding vulnerable adults training, the compliance figure for May 2013 91.4% (75% compliance May 2012) against a Trust target of 95% set by the NHSLA. Divisional Heads of Nursing have produced action plans to ensure this continued improvement of compliance, this is monitored at the Trust Heads of Nursing meetings by the Director of Nursing.

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The continued provision of multi professional training, provided by Wigan Council, is currently under discussion with Wigan Adult Safeguarding Board. The Head of Adult Safeguarding will inform the Trust of the outcome via the Safeguarding Committee. Bespoke training for senior clinicians and practitioners on the Mental Capacity Act / Deprivation of Liberty Safeguards and the Law was carried out in September 2012 and again in February 2013. Key Priorities/ work streams 13/14

Continued development of vulnerable adult senior nursing team.

Vulnerable Adult / Dementia -12 month training plan, training will be delivered in house by the vulnerable adult team for all groups of Trust staff.

Continue in the development of the delivery of specialist service provision for frail elderly patients, including the environment

Engage with the newly formed Wigan Health watch group

Summary

In line with national and local trends, there has been an increase in adult safeguarding referrals.

E–mandatory training compliance, although currently below the Trust target, has increased almost 20% in the last year. Compliance is expected to continue to increase.

There is a robust reporting structure in place to give assurance to the Trust Board

with regards adult safeguarding.

Wigan Borough Clinical Commissioning group, since April 2013, have the responsibility in monitoring the Trust implementation.

The Safeguarding of Vulnerable adults is now a key agenda item on the WWL Quality Safety & Safeguarding Group (CCG).

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Appendix 1

Dementia Training – 15 May 2013 at 13:00 with Arvind Kumar Educational outcomes

Good session on dementia which is such a common problem for us in hospital and common differential increasingly.

You cannot diagnose dementia in an inpatient setting.

Approach to management of dementia patients in hospital

Case presentation on dementia - diagnosis and management

Difference and definition of delirium and dementia

Excellent insight into memory service and its role in treating patient with Dementia. Interesting insight into dementia with lewy bodies and its treatment.

Really good overview of dementia and delirium, the key differences and how to deal with both

Teaching feedback

Great interactive, funny and memorable session. Thank you.

Good sessions, informative.

Very informative session. Useful for updating clinical practice.

Good interactions with crowd, questions were very well answered.

Good session, well presented, relevant topic.

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Appendix 2

The Prevention, Diagnosis and Management of Delirium in Older People Delirium is common in the older medical patients (up to 30%medical and up to 50 % in post op elderly inpatients) and is often unrecognized by medical and allied health professionals. It can result in

Higher mortality and morbidity Increased length of inpatient stay Hospital acquired complications like falls, infection, pressure sores Premature institutionalisation and Three times likelihood of developing dementia.

The main focus of this guideline (adapted from NICE 2010) is to

Identify those at risk of delirium Implement strategies to prevent delirium in those identified to be at risk Diagnose delirium Manage delirium using multicomponent, non-pharmacological interventions as a first

choice to address modifiable clinical factors, and Guide re pharmacological options for delirium

Risks and Prevention Delirium is common, but serious and complex with poor outcomes. Thus every patient should be assessed, on admission, for risk of developing delirium. The main risk factors for developing delirium are Age>65 years (frailty, comorbidities) Dementia or previous delirium (5 times more common in people with dementia) Current hip fracture Severe Illness (surgery, infection, constipation) Those at risk should be assessed for features of delirium, and prevention strategies incorporated into their care plan to prevent delirium. Preventative measures include:

Orientate patient to surroundings and people Ensure call bell in reach, and patient made aware of its use Treat hypoxia if present Maintain hydration and nutrition Ensuring hearing aids and spectacles are available, within reach and in good working

order Minimise pain, constipation Encourage visits by family/friends Avoid moves between and within wards, esp. during nights unless absolutely

necessary Encourage mobilization and ensure walking aids are accessible Review medications- withdrawal/poly-pharmacy, assess for signs of withdrawal and

reduce medications where appropriate. Consider treating electrolyte imbalance if present

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Ensure good sleep pattern (avoid nursing or medical interventions during sleep hours, if possible and reduce noise to a minimum during sleep).

Continue to assess regularly for development of any new symptoms, which could potentially lead to delirium and treat as appropriate. DIAGNOSIS At presentation, as well as regularly throughout their hospital stay, those at risk should be assessed for acute changes or fluctuations in:

Cognition, Perception, Level of activity (hyperactivity or agitation/ hypo activity or lethargy/ mixed), and Behavior (restlessness, agitation).

A careful history from patient, relative or carer about the onset and course of the confusion will help distinguish between delirium and dementia and may help identify the cause of delirium as well. An AMTS should be performed in all the at risk patients. If AMTS shows a score of 7 or less out of 10, or indicators of delirium (as mentioned above) are identified, carry out clinical assessment based on short Confusion Assessment Method (CAM) to diagnose delirium. ABBREVIATED MENTAL TEST SCORE (AMTS) 1 - Age 2 - DOB 3 - Year 4 - Place(Name of hospital) 5 - Name of Monarch 6 - Count backwards from 20 7 - Dates of WW2 8 - Recognition of 2 people 9 - Address to recall (42 West Street) 10 -Time (to the nearest hour). CAM 1-Acute Onset & Fluctuating Course

Is there an evidence of an acute change in mental status from patient’s baseline?

Come and go Fluctuate during the day Increase/ decrease in severity

2-Inattention Does the patient: Have difficulty focusing attention Become easily distracted Have difficulty keeping track of what is said

3-Disorganized Thinking Is the patient’s thinking disorganized or incoherent? E.g. does the patient have

Rumbling/irrelevant conversations? Unpredictable switching of subjects?

4-Altered Level of consciousness

Overall, what is the patient’s level of consciousness? Alert

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Vigilant (hyper alert) Unclear or illogical flow of ideas Lethargic (drowsy but easily roused) Stuporous (difficulty to rouse) Comatose (unrousable)

Formal scoring of CAM requires 1+2+ either 3 or 4 to diagnose delirium. High index of suspicion is suggested to consider delirium if there is a positive response to any of the 4 parts of CAM. In postoperative patients or those on ITU, CAM-ITU should be used. If there is difficulty distinguishing between delirium and delirium with dementia, treat as delirium first and arrange a follow up appointment to review. MANAGEMENT OF DELIRIUM Initial Management a-Find and treat the underlying cause: - There is often more than one cause, commonly, drugs or drug withdrawal, infection, electrolyte disturbances, dehydration, pain or constipation. It is important to take a good history of onset and course of confusion, symptoms suggesting infection, drugs and recent changes, bladder and bowel function, dietary and fluid intake and baseline cognition/ functional status. The clinical assessment should include conscious level, AMTS, CAM, looking for signs of infection, neurological examination, signs of alcohol abuse or withdrawal, ruling out urinary retention or faecal impaction and nutritional status. Routine investigations like CRP, FBC, U&Es, Bone profile, LFTS, glucose, ECG, CXR, urinalysis ( +/- culture) are almost always indicated to help identify the cause. Other investigations like ABG, blood Culture, CT Head, B12, folate, TSH (if pre-existing dementia suspected) and LP should also be considered depending on history and clinical examination findings. b-Non pharmacological strategies

Provide personal and environmental orientation Explain what is being done and why Reduce medications but ensure adequate analgesia

- Ensure hearing and visual aids are available and in working order - Encourage mobility

Maintain good fluid intake Maintain nutrition Avoid constipation Maintain good sleep pattern Familiar objects form home

- Ensure continuity of care Involve relatives and carers and provide with information

- Avoid complications (immobility, malnutrition, pressure sores, over sedation, incontinence and falls)

If wander some behavior exhibited-provide close observation within safe and closed environment, ask relatives to help to provide meaningful distractions. Act in patient’s best interest to keep them safe and use drug treatment only as a final option.

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Do Not Use restraint Catheterize Sedate routinely Argue with the patient Inter ward transfers especially during nighttime c-Pharmacological Management In patients who are distressed or considered a risk to themselves or others, use verbal and non-verbal techniques to de-escalate the situation where possible. Medications should be used as a last resort and may be necessary in the following circumstances.

To carry out essential investigations or treatment To prevent patients endangering themselves or others To relieve distress in a highly agitated or hallucinating patient.

If sedation is to be used

Only one drug (not a cocktail of drugs) should be used, starting with the lowest possible dose taking age, BMI, sex and degree of agitation into consideration.

The dose may be increased in increments if necessary after regular assessments and the effective dose should be maintained for a few days and then tapered off and stopped (ideally within a week’s time) while monitoring for signs of recurrence.

Aim to reduce and stop/taper psychotropic drugs as quickly as possible ~48 hrs. If treatment for symptoms of delirium is required for more than 72 hours, seek PLN review/ specialist advice.

The use and indication for antipsychotics must be reviewed regularly in patients with delirium (2 hourly is recommended and at least every 24 hrs). Antipsychotics have significant adverse effects. They can result in over sedation, increased risk of falls, stroke and extrapyramidal side effects (EPSE). They can be lethal in dementia with lewy bodies (DLB). ECG monitoring is advised due to risk of QTc prolongation and Torsades de pointes. The IV use is associated with higher risk than oral, hence use oral formulation where possible, otherwise IM.

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Drugs options, dose, SE, maximum dose and frequency Drug Oral dose IM (use in

emergency) Side effects

Haloperidol OR

-0.5-1mg bd -Maximum frequency- 2 hourly -Maximum dose -5mg/24 hrs

In emergency, when oral route is not possible- -1-2 mg IM -Max dose in a 24 hrs- 5mg, -maximum frequency-2 hourly

-Avoid in DLB -ECG monitoring recommended -EPSE common & increased if >3mg in 24hours If >2mg in 24 hours required consider referral to PLN

LORAZEPAM -0.5 mg, oral -maximum frequency- 2 hourly, -maximum dose in a 24 hrs- 3 mg

-Use in emergency, when oral route is not possible -0.5-1mg IM -Max dose 3mg in 24 hrs

-Safe in DLB/PD/arrhythmias -May cause respiratory suppression reversible with flumazenil . -Lorazepam tablets can be given sublingually. -Can be given IV in hospital setting in cases of emergency -Due to ongoing supply issues with lorazepam injection (resulting in reduced availability) midazolam may be used as an alternative

Midazolam -1.2-2.5mg IM -max frequency 2hrly -Max dose-7.5 mg in 24 hrs

-May cause respiratory suppression reversible with flumazenil. -Note that flumazenil has a shorter half-life & duration of action than midazolam so patients may become re-sedated.

Those prescribing sedation MUST be familiar with the Mental Capacity Act 2005 and Deprivation of Liberty legislation.

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Key stages in assessment and management of Delirium Step 1 Assess all patients on admission for risk factors for delirium and continue to monitor those at risk for changes/fluctuations in behaviour regularly throughout hospital admission. When cognitive impairment is suspected use the AMTS on the first encounter to help assess cognitive function. Step 2 Consider delirium in all patients with cognitive impairment and at high risk (severe illness, dementia or previous delirium, current fractured neck of femur, age >65). Use the CAM screening instrument to diagnose delirium. A history from a relative or carer of the onset and the course of the confusion is essential to distinguish between delirium and dementia.Step 3 Identify the cause of delirium if present from the history obtained from relatives/carers, examination and investigations. Treat underlying cause or causes – commonly drugs or drug withdrawal, infection, electrolyte disturbance, dehydration or constipation. Step 4 In patients with delirium and patients at high risk of delirium: Do: Provide environmental and personal orientation Ensure clear communication Ensure continuity of care Encourage mobility Reduce medication but ensure adequate analgesia Ensure hearing aids and spectacles are available and in good working order Avoid constipation Maintain a good sleep pattern Maintain good fluid intake maintain nutrition Involve relatives and carers Avoid complications (immobility, malnutrition, pressure sores, over-sedation, incontinence and falls) Liaise with old age psychiatry service / refer to “Rapid Assessment Interface Discharge” (RAID Team) where necessary Do NOT: -Use restraint -Catheterize -Sedate routinely -Argue with the patient Step 5 If sedation has to be used, use one drug only starting at the lowest possible dose and increasing in increments if necessary after an interval of two hours. Haloperidol 0.5mg (repeated max every 2 hrs up to a total dose of 5mg in 24hrs in hospital and maximum of 3mg in primary care orally is the recommended drug choice. For patients with Parkinson’s Disease/ Dementia with Lewy Bodies/benzodiazepine withdrawal use lorazepam 0.5mg to 1mg orally which can be given up to 2hourly as required (max 3mg in 24 hrs) Step 6 GP to consider follow-up with Medicine for the Elderly/ collaborative memory clinic or old age psychiatry team (check if already arranged by PLN).

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WWL Annual Safeguarding/Child Protection Report June 2013

Our purpose is to work together to improve life chances

Our Vision is that all children, young people and families are safe, healthy and happy within our Community

We are proud with our safeguarding team achievement in 2012 as we scored

outstandingly in the latest joint care quality commission (CQC) and Ofsted inspection in May 2012.

Introduction:

This report aims to inform the Trust Board about their responsibilities for safeguarding children and to promote children‟s wellbeing to prevent them from suffering harm.

To discuss future plans, strategy and developments in safeguarding children.

To report the key achievements over the last 12 months.

To share information from the Integrated Health Group, Heath Commissioning Group Safeguarding Subgroup and Wigan Safeguarding Children‟s Board (WSCB).

1. Statutory requirements:

The safety and health of a child are mutually dependent aspects of their wellbeing. Many health interventions also equip a child to stay safe.

UN Convention on the Rights of the child, ratified by UK Government 1991 takes into account the European Convention of Human Rights, also it takes account of the requirements of the Children Act 1989, Children Act 2004 and Education Act. It requires that a range of organisations including NHS Trusts make arrangements for ensuring that the functions and services provided on their behalf, are discharged to safeguard and promote the welfare of children.

In March 2012 the Health and Social Care Act was introduced by the Government for Health Reform. The aim of the Act is to devolve power to clinicians through clinical commissioning groups (CCGs) which formed in April 2013. The commissioning of public health services is being devolved to local authorities„ social care. Primary Care Trusts and Strategic Health Authorities have now been abolished. The responsibility of safeguarding children lies now within the CCG.

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All organisations commissioning or providing health care whether in the NHS, independent healthcare sector or social enterprises should ensure there is Board level focus on the needs of children and that safeguarding children is an integral part of their governance systems.

1.1 Responsibility at Trust Board Level

All health services have a duty to protect children, and the Trust is responsible for ensuring that all staff are familiar with the local procedures that they must apply when it is recognised that a child is at risk of harm. All healthcare staff involved in working with children should attend training at an appropriate level in safeguarding and promoting the welfare of children, and have regular updates as part of their continuing professional development. The Medical Director is the Board member responsible for reporting safeguarding matters in children and adults to the Trust Board.

1.2 Named and Designated Professionals

All NHS Trusts must identify Named Professionals (Doctor, Nurse, Midwife) who have a key role in promoting good professional practice within the Trust and who can provide advice and expertise for other staff and assist with the management of child protection cases when the need arises. All staff should also have access to the Designated Professionals (Doctor and Nurse). To fulfil these responsibilities the Trust has a Named Doctor, Named Nurse, Named Midwife and also employs a Designated Doctor. Each professional has their responsibility defined within their job description which should be in line with Guidance “Children and Young People: Rules and Competencies for Health Care Staff 2010”; an intercollegiate document supported by the Royal College of Paediatrics and Department of Health.

Designated Doctor for Safeguarding Children Dr E Abbas

Named Doctor for Safeguarding Children Dr M. Mukherjee (the role will be fulfilled by Dr S Castille from July 2013)

Named Nurse for Safeguarding Children Mrs Debbie Spruce

Named Midwife for Safeguarding Children Caroline Ashton

Lead A&E Consultant for Safeguarding Dr S Khan (Dr Khan will be taking the Designated Doctors responsibility from October 2013)

Lead Nurse for A&E Claire Birchall Strategy for Safeguarding Children

1. The National Service Framework for Children, Young People and Maternity Services 2004 stipulates that all agencies should develop their own strategy to ensure that systems are in place to safeguard children.

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2. WWL‟s Policy for Safeguarding Children was originally produced in 2004. This has been updated twice with the latest one in 2011. The policy is due to be reviewed in August 2013.

3. The Trust‟s Safeguarding Guideline developed in 2004 has been updated three times;

most recently in 2012. There are various policies and procedures available for all the staff via the Child Health/Safeguarding page on the Intranet.

4. The Trust‟s Child Protection, Safeguarding Children and Young People‟s Strategy has

recently been updated in June 2013 and is in line with the Wigan Safeguarding Children‟s Board Plan and Wigan Council Children and Young Peoples Plan.

Referral to the Independent Safeguarding Authority All organisations have a legal duty to inform the Independent Safeguarding Authority (ISA) if they dismiss a member of staff because they have harmed a child or vulnerable adult. The Trust has also a duty to refer such staff to the local authority Designated Officer (LADO). John Lenney, Director of Human Resources for the Trust, is the nominated officer for the Trust to investigate such allegations and work with WSCB. Children’s Safeguarding Virtual Team Development Programme A review of children‟s safeguarding was conducted in 2010 by Organisational Development Services (ODS). ODS consultancy outlined a number of recommendations; one of these was to develop a Virtual Integrated Health Safeguarding Team across the health economy to include the Acute Trust. It was hoped this would reduce duplications and help to develop a seamless system-wide service. The team development programme started in September 2011 and completed in December 2012. A virtual integrated health safeguarding team across the health economy including WWL was formed in January 2013 on the basis of the organisational development service programme (18 month programme). The aim of the team is to work together within the health setting to reduce duplications and develop the seamless system-wide service. The team meets every three months. One of the team‟s achievements is an electronic communication newsletter via WSCB which is distributed to all health as well as WSCB members.

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Training Training is a vital and energising way of improving our skills, professional confidence and strengthening our practice to work collaboratively to protect children and young people. Employers are responsible for ensuring that their staff are competent and confident in carrying out their responsibilities for safeguarding and promoting children‟s and young people‟s welfare. Different levels of training are required in safeguarding according to the staff members‟ exposure to children and families. Level 1 – All clinical staff (fulfilled by completion of mandatory e-training module). Level 2 – Clinical staff who in their work have some contact with children and families. Level 3 – Clinical staff working directly with children and young people and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns. Plan

1. All new staff will have a brief safeguarding awareness training in their induction. 2. All Paediatric staff have an additional safeguarding induction with the Named Nurse for

Child Protection once they have commenced their post on Rainbow ward.

3. A safeguarding e-Learning module was developed for WWLFT and has been in place since 2010. This is considered as mandatory Level 1 training for all clinical staff.

4. From October 2010 the WWL Training strategy has mirrored the Wigan Safeguarding

Children‟s Board training module to ensure all agencies within the Borough can provide a consistent approach to safeguarding children.

5. Level 2/3 in line with other agencies provided within the WSCB training programme.

Level 2 training is an e-learning module hosted by WSCB. Level 3 consists of two parts; part 1 is similar to level 2 e learning module and part 2 is a half day face to face inter agency training. However with the Acute Trust, the Named Doctor, Nurse and Designated doctor have delivered the same package of inter agency level 3 face to face training, organised by the Trust‟s Training Department and facilitated by Mrs Helen Moreton - we delivered 12 to 15 half day sessions achieving the targets for the Trust.

The latest training figures for May 2013 overall safeguarding children training compliance within the Acute Trust is 84%

The total number of non compliant users for May 2013 is 667 Employees

Annual Training - 406

2 yearly Training – 207

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Total No of Users

Compliant Users Non compliant Users

May 2013 April 2013

4165 3498 667 84% 83.5%

No of users for Annual Training 2396

1936 460 80.8%

No of users for 2 yearly Training 1769

1562 207 88.3%

6. The Designated and Named Doctor deliver ½ day training to all new medical staff in A&E, Paediatrics (FY1 and FY2s) and Paediatric middle grades twice per year.

7. The Designated and Named Doctor organised half day awareness sessions regarding

Domestic Violence and Sexual Exploitation from a specialised team in Wigan (28.6.13).

8. Staff working closely with children and families suffering from domestic violence are offered access to multi agency training packages via a WSCB training programme.

9. The Designated Doctor has delivered 1x4 Fabricated and Inducted Illness Training sessions for WWL staff; the most recent one in May 2013, and has also delivered other services for WSCB staff.

10. The Named Doctor and Named Nurse deliver a multi agency one day Training session on physical injuries via the WSCB four times a year.

11. WWL staff also have free access to various courses as part of the interagency training programme via WSCB.

12. The Designated Doctor also contributes to other inter agency training. There is also updated training for Child Heath staff on various topics; the most recent was regarding Abusive Burn Patterns in Children.

Audit

1. The Designated Doctor undertakes an annual child protection audit. An Audit regarding the child protection cases for 2012 is due to be completed in September 2013. This will be the 8th annual audit in the past nine years. The audit is looking at the Trust‟s compliance with the Laming Health recommendations and NICE guidelines for Child Protection. Over these years there has been vast amounts of information gathered by various action plans being implemented to improve our safeguarding system and compliance with the recommendations.

2. Dr Downes (the Named Doctor for Sudden Unexpected Child Death) undertakes an

annual Child Death Audit. Total number of deaths in 2012 was 18 which was higher than the previous year, with 1 suicide (17 years old), 1 fall from cliff top (16 years), 11 deaths were preterm or neonatal death, 1 hypoxic ischaemic encephalopathy (13 years),1 acute obstructive hydrocephalus (6 years), severe intractable epilepsy (3 months), downs

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syndrome (15 years), pontine giloma (7 years). The 2011 audit shows 16 deaths but has not yet been presented.

3. A Bruising in Infants audit was completed in February 2013 under the supervision of the

Designated and Named Doctor. Various recommendations came out of that audit which indicated an improvement in our practice. The audit was also presented by the Designated Doctor to the A&E staff to raise their awareness about the staff compliance needing their support.

4. A safeguarding children internal audit was completed by the Independent North West

Audit Group. The Named Nurse and Designated Doctor contributed various recommendations to the audit which were implemented except the training of locums which is outstanding.

5. The Trust takes part in case file audit as part of WSCB audit three times a year.

6. The Trust contributes to the Section 11 audit as part of an inter agency group on behalf

of WSCB in inline with the Ofsted grading system, to provide assurance to the WSCB that agencies comply with all Section 11 safeguarding standards. The majority of the outcomes were green with a couple which were amber rated.

7. The Designated Doctor is re-auditing the Trust‟s DNA rate looking at the reasons behind the DNA within our paediatric services. This audit is being carried on behalf of the Acute Trust at the request of a Lesson Learned Sub Group of WSCB. This audit will improve our overall health DNA policy.

Work has been undertaken to address the recommendation of the serious case review and local case review action plan recommended by the WSCB. Serious Case Review (SCR), Local Case Review (LCR) and Lesson Learned When a child dies and there may be safeguarding issues it is looked at by the WSCB. If the death is suspicious, a serious case review should be conducted by the Authority. This would be chaired by an independent person. From March 2013 – April 2014 the WSCB is conducting two parallel SCRs regarding Child C and Child D. Both children have attended WWL services and were known to the Acute Trust. We contributed to three multi agency LCRs via the Designated Doctor and Lesson Learned Sub Group under the WSCB. Messages from research (Gateway reference number: 16899) The Safeguarding Children Research Initiative is an important element in the Government‟s response to the inquiry following the death of Victoria Climbie. Its purpose is to provide a stronger evidence base for the development of policy and practice to improve the protection of children in England. Eleven studies were commissioned and this overview focuses on the findings and also refers extensively to a further four important research studies that were also reported at the same time.

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Link: https://www.education.govuk/publications/standard/publicationDetail/Page1/DFE-RB164 Action: NHS and local authority Chief Executives will wish to study this research which provides an overview of the key messages, distilled to meet the need of those professionals who seek to utilise such research findings to shape their day-to-day work. Key achievement 2011 -2012

1. We are proud of our safeguarding team achievement in 2012 as we scored outstandingly in the latest joint care quality commission (CQC) and Ofsted inspection in May 2012.

2. The Trust‟s Safeguarding Committee holds regular joint Children and Adult Safeguarding

meetings to promote the welfare and safety of vulnerable children and adults. The committee is chaired by the Medical Director.

3. Within the Trust we continue to provide a rapid access Child Protection Service. Between

the hours of 9am and 5pm there is a Consultant Paediatrician dedicated to Child Protection with opportunities for training of the middle grade doctors. There is also an Out of Hours On-Call Paediatric Team who provide assessment, support and advice.

4. For 2012 January – December our NAI numbers were 132. We filed 132 cases of Child

Protection medical reports. We discussed over 130 cases at our weekly peer review supervision meeting. There have been more than 300 referrals to our Named Nurse via the Safeguarding proforma completed by staff concerned about a case in their area. The proformas are from the Adult, Paediatric and Accident & Emergency (both Adult and Paediatric) areas.

5. There is a clear line of accountability. The staff are advised to follow an Escalation

Policy to address any conflicting views and opinions.

6. Managing bruises in young babies was one of the messages that came from one of the local case reviews. Since this the Trust has adopted a policy for Bruises in Young Babies, and all babies with injuries will be seen by Paediatric staff in A&E.

7. Maintaining electronic in-house and paper databases of all Safeguarding Proformas

faxed to the Named Nurse Child Protection office. Referrals are made from both Adult and Paediatric areas within the Acute Trust. All of the cases are assessed, and any queries /concerns are followed up prior to the proformas being sent out to Bridgewater Safeguarding Unit. The Named Nurses in Bridgewater disseminate to the relevant health professionals in the community. A report is completed every six weeks and is discussed at our Acute Trust Internal Safeguarding meeting and at the Clinical commissioning safeguarding health group.

8. We are very proud that we achieved implementation of the Flagging System (new policy)

to flag up children at risk who are on a child protection plan. We have a system now where children are flagged on the electronic patient record as well as the child‟s file, and this has been implemented across the child health system and A&E system.

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9. The Trust is also taking part in a national child protection information sharing project. The Trust is part of six authorities being piloted in England, and we will be in the first wave having access to the electronic information held centrally of any children on a child protection plan and known to social services. Our A&E and midwifery system will be taking advantage of the project to start with, and our child health system will follow. This project will be completed by April 2014, and the Designated Doctor has taken the lead in liaising with the Department of Health. IT training of A&E staff has been organised to address this need.

10. All policies and procedures have been updated in 2012 as part of the preparation for the

CQC inspection.

11. We continue to link with Adult Safeguarding Team via the Named Nurse for Safeguarding Adults.

12. A&E has a nominated Lead Consultant Dr S Khan who is available to staff for

supervision and advice. There is a nominated Nurse in A&E who acts as Safeguarding Champion.

13. The Named Nurse has been working closely with the Paediatric Nurses on Rainbow

Ward and has initiated a development post for one day a week under the supervision of the Named Nurse to assist with safeguarding duties, communicating with external agencies and developing their skills in dealing with child protection/safeguarding processes. Two Nurses have successfully completed a six month secondment and a third is due to commence the role. It has been well evaluated by the nursing staff and many of the nurses are keen to undertake the post.

14. Continue to provide weekly peer review safeguarding supervision for child health staff,

chaired by Named Doctor, minuted and monitored

15. Named and designated professional access supervision via Greater Manchester Safeguarding network every three months. The Named Doctor will be supervised by Designated Doctor, and the Named Nurse will be supervised by the Designated Nurse; who will supervise the Named Midwife also.

16. We continue to contribute to Greater Manchester Rapid Response Team to assist with

the investigation of sudden unexpected child deaths. Also, we are contributing to the overarching Child Death Overview Panel (CDOP) via Designated and Named Professionals.

17. We contribute to various WSCB subgroups eg Health Agencies Subgroup, Training,

Lessons Learned, WSCB and Greater Manchester Designated Professionals Group, as well as the CCG clinical commissioning safeguarding health group meetings.

18. Implementations of various recommendations of SCR of Child C and Child D. Further

support from the Executive Team will be required for the Named Professionals as well as the newly appointed Designated Doctor in due course.

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Conclusion WWL has many positive qualities which were reflected in the integral North West audit as well as last year‟s CQC and Ofsted inspections. As there are various reforms within the health system as a result of Health and Social Care Act 2012, various changes may be introduced in the near future regarding roles and responsibilities especially within the Designated and Named Professionals. It is important to ensure that compulsory training targets are achieved, as well as targeted training and staff supervision so that the Trust can be proud of its service for vulnerable children. Future needs include:

Domestic violence training for A&E staff, midwifery and child health staff needs addressing.

Supervision of midwives and nursing staff via named Professionals needs addressing.

Continue to build up and strengthen our communication with other agencies to address child safety and welfare eg flagging of children and young people‟s records where there are social concerns.

Continue to train the front line staff on levels 1-3. Dr E Abbas Consultant Community Paediatrician Designated Doctor for Safeguarding Children Debbie Spruce Named Nurse Child Protection Safeguarding Children

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