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TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017
Agenda Item6b
TitleChief Executive’s Report
Sponsoring Executive DirectorKaren James
Author (s)Tom Neve
PurposeTo discuss and note the various items covered bythis report.
Previously considered bySome items previously considered by the ExecutiveManagement Team
Executive Summary:
Government to extend protections for NHS Whistle-blowers – Consultation
Plans have been published that will prohibit discrimination against whistle-blowers when they
apply for jobs with NHS employers.
Sir Bruce Keogh to step down from NHS England role
Professor Sir Bruce Keogh has announced he will stand down as NHS England medical
director at the end of the year, after 10 years in the role.
NHS England national director to step down next month
New care models director Samantha Jones is to step down next month to spend more time
with her children.
Related Trust Objectives This report relates to all of the trust’scorporate objectives
Risk Assurance – risk impacted uponRelates to all aspects of Board AssuranceFramework and Significant Risk Report.
Legal implications/Regulatoryrequirements
This report impacts on the regulatoryrequirements from NHSI and the CQC
Financial ImplicationsMay have some financial implications
Has a quality impact assessment beenundertaken?
N/A
How does this report affectSustainability?
Some items in the report have a directimpact on the organisation’s sustainability
Action required by the Board
To note and discuss the items contained within the report
Chief Executive’s Report
Government to extend protections for NHS Whistle-blowers – Consultation
Plans have been published that will prohibit discrimination against whistle-blowers
when they apply for jobs with NHS employers.
These changes were a recommendation from Sir Robert Francis’ Freedom to Speak
Up review which found a number of people struggled to find employment in the NHS
after making protracted disclosures about patient safety.
The consultation, Protecting whistle-blowers seeking jobs in the NHS seeks views on
the draft regulations that aim to:
Give the applicant a right to an employment tribunal if they have been
discriminated against because it appears they have previously blown the
whistle
Set out a timeframe in which a complaint to the tribunal must be lodged
Set out the remedies that the tribunal may or must award if a complaint is
upheld
Make a provision as to the amount of compensation that can be awarded
Give the applicant a right to bring a claim in the county court or the High Court
for breach of statutory duty in order to, among other things, restrain or prevent
discriminatory conduct
Treat discrimination of an applicant by a worker or agent of the prospective
employed (NHS body) as if it were discrimination by the NHS body itself.
The consultation on the Department of Health website closes on 12 May 2017.
Sir Bruce Keogh to step down from NHS England role
Professor Sir Bruce Keogh has announced he will stand down as NHS England
medical director at the end of the year, after 10 years in the role.
He will then take up a new role as chair of Birmingham Women’s and Children’s
NHS Foundation Trust.
NHS England national director to step down next month
New care models director Samantha Jones is to step down next month to spend
more time with her children.
Ms Jones was appointed by NHS England in January 2015 to lead the vanguard
programme to set up and test five new models of care outlined in the Five Year
Forward View.
The vanguard programme is in its final year. In 2017-18 the vanguards and national
new care models team will increasingly focus on supporting the rest of the country to
implement new care models.
Louise Watson, currently deputy director for new care models, will take over as
director.
IR35 regulations
The IR35 regulations, which took effect at the beginning of April 2017, force “off-payroll” workers to pay the same level of tax as substantive employees, by makingemployers responsible for paying their tax and national insurance.
This has resulted in locum doctors and other contractors at some trusts demandingsignificant uplifts in their pay, or threats not to come to work.
In relation to this trust, it has resulted in some difficulties in covering the emergencydepartment.
TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017Agenda Item 7a
Title Integrated Performance Report : March 2017
Sponsoring ExecutiveDirectors
Trish Cavanagh, Director of OperationsBrendan Ryan, Medical DirectorAmanda Bromley, Director of HRClaire Yarwood, Director of FinanceTracey McErlain-Burns, Chief Nurse
Author (s) Peter Nuttall, Director of Performance & Informatics
Purpose To note/receive
Previously considered by This report has not been considered by any othermeeting
Executive SummaryThis Board Report includes an appendix showing the metrics and triggers included in theSOF. Not all metrics are currently measured, but work is being undertaken to ensure that: a.performance data is generated; and b. this report is developed to reflect the new Framework.The Trust reported failure of one of the performance metrics included in the SOF: the four-hour- wait target.
Related Trust Objectives Objective 1 - All patients receive harm-freecare through the delivery of the Trust’sPatient Safety Programme.Objective 2 - To improve the quality ofpatient care through the implementation ofthe Trust’s agreed Quality Strategy.Objective 3 - To improve the patientexperience through a personalised,responsive, compassionate and caringapproach to the delivery of patient care.Objective 7 - To deliver against the requiredlocal and national frameworks in order tomeet all the requirements of the Trust’soperating licence and the commissioners’requirements.
Risk Assurance – risk impacted upon Relates to all aspects of Board AssuranceFramework and Significant Risk Report.
Legal implications/Regulatoryrequirements
This report indirectly impacts on CQCfundamental Standards of Care and licencerequirements.
Financial Implications Tameside and Glossop CCG may applyfinancial penalties for failing to achievespecific performance targets as detailed inthe Contract.
Has a quality impact assessment beenundertaken?
This is the Medical Director and Chief Nurseview on the impact of any service change
How does this report affectSustainability?
Reflects current risks to the Trust’s businessand strategic objectives
Action required by the Board The Board is asked to review the quality and performancestandards noted in the Integrated Performance Report.
Page 2
INTEGRATED PERFORMANCE REPORT: April 2017 Board (March 2017 performance)
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Page 3INTEGRATED PERFORMANCE REPORT: April 2017 Board (March 2017 performance)
Board of Director’s Meeting 27th April 2017
Integrated Performance Report 2016/17
Contents
Introduction 4
List of Acronyms 5
Dashboard March 2016/17 6
Exception Reports
Medical Director/ Director of Operations
Cancer 62-day target 7
Director of Operations
Four-hour wait/ ambulance handover 8
Inpatient discharge summaries) 9
Director of Human Resources
Staff attendance 10
Mandatory Training 11
Thresholds for 2016-17 12
Single Oversight Framework (SOF) metrics and triggers (draft) 13
Page 4INTEGRATED PERFORMANCE REPORT: April 2017 Board (March 2017 performance)
Integrated Performance Report – March 2017 Performance
IntroductionThis report provides the Trust Board with: an overview of the Trust’s performance across a range of qualityand operational indicators for the month of March 2017; and year-to-date performance, along with a RAGrating, to support the Board in evaluating performance against each indicator.
Exception ReportsAlongside the Quality and Performance Dashboard, the report includes exception reports, which respond tothe performance data and allow the Executive Team and Trust Board to be assured of, and contribute to,plans to rectify performance and quality issues. All serious incidents are reported to Trust Board in Part 2 ofthe meeting for patient confidentiality reasons; therefore, no exception report is provided for this indicator.
March PerformanceThe Trust reported failure of one performance target included in the Single Oversight Framework (SOF):the four-hour- wait standard. This report includes exception reports for the following metrics: four-hour waitand ambulance handovers; Emergency Department and inpatient discharge summaries; staff attendancerate and mandatory training.
Mortality
In the latest Summary Hospital-level Mortality Indicator (SHMI) publication, THFT has a value of 111 for theperiod October 2015 - September 2016. This value means that the SHMI is ‘as expected’. The hospital’sStandardised Mortality Ratio (SMR) for the latest available twelve months (January 16 - December 16) is93.05, which is ‘better than expected’ but not statistically significantly so.
Mixed-Sex Accommodation Breach
The Trust reported its first mixed-sex accommodation breach of 2016-17 in March. The affected patientwas delayed on ICU, over the weekend of the 18th/ 19th March, as a result of the unavailability of suitablecapacity on the medical wards. An assessment of the current escalation process and its application,particularly at weekends, is being undertaken.
Referral-to-Treatment
In March, the Trust met the national Referral-to-Treatment standard (incomplete pathways) withperformance of 92.45% against the threshold of 92%. The Trust reported that no patients had a waiting timeof more than 52 weeks at the end of March.
Outpatient DNA Rate
The outpatient DNA rate for March was 7.94%, which is significantly better than the 9.5% target.
Stroke TargetsThe Trust Board is asked to note the Trust’s banding of ‘b’ for the SSNAP (Sentinel Stroke National AuditProgramme) national stroke audit for the period August- November 2016, where the poorest performingtrusts are classified as ‘e’ and the best as ‘a’. The SSNAP audit includes 44 measures in 10 domains. TheTrust’s banding for the previous period was ‘c’.
Emergency Readmissions within 30 daysThe 30-day readmission rate remains above the local target level of 10%, at 12.3% (year-to-date),although the rate has reduced steadily from around 14% in 2014.
Appraisal
It was not expected that the appraisal rate would reach the 90% target at the end of March, because theAppraisal Window opens on the 1st April and managers were asked to wait until April and use the updatedpaperwork. Monitoring will recommence on the 1st April.
Page 5INTEGRATED PERFORMANCE REPORT: April 2017 Board (March 2017 performance)
List of Acronyms
ADT Admission, Discharge, TransferC DIFF Clostridium difficileCIP Cost Improvement PlanCQC Care Quality CommissionCT Computerised TomographyCWT Cancer Waiting TimesDNA Did-not-AttendDPH Director of Public HealthDToC Delayed Transfers of CareED Emergency DepartmentENP Emergency Nurse PractitionerESDT Early Supported Discharge TeamETD Education, Training and Development teamFFT Friends & Family TestGM Greater ManchesterGMCCN Greater Manchester & Cheshire Cancer NetworkHSMR Hospital Standardised Mortality RatioHAS Hospital Arrival ScreenIAU Integrated Assessment UnitIR35 Tax legislation relating to workers supplying services to clients via an intermediaryICO Integrated Care OrganisationMRSA Methicillin-resistant staphylococcus aureusMSA Mixed-sex AccommodationNWAS North West Ambulance ServicePTL Patient Tracking ListRAID Rapid Assessment Interface and Discharge (psychiatry liaison service)RCA Root Cause AnalysisREACT Rapid Assessment Emergency Care TeamRIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences RegulationsROSIER Rule Out Stroke In the Emergency RoomRTT Referral-to-TreatmentSAFER Patient Flow Bundle (Senior review; All patients with expected discharge date; Flow of
patients at earliest time; Early discharge; Review of patients with extended lengths-of-stay)SALT Speech and Language TherapySHMI Summary Hospital-level Mortality IndicatorSOP Standard Operating ProcedureSSNAP Sentinel Stroke National Audit ProgrammeSTAR Staff Accident Rate
StEIS Strategic Executive Information SystemTIA Transient Ischaemic AttackTNA Training Needs AnalysisVTE Venous ThromboembolismWTE Whole Time EquivalentYTD Year-to-Date
Page 6
* Governance indicators, which appear in Monitor's Risk Assessment Framework
Target Actual 4-mth Actual Current 1-mth Staff Health & Safety Target Actual 4-mth Actual Current 1-mth Target Actual 4-mth Actual Current 1-mth16/17 16/17 Trend Month Period F'cast 16/17 16/17 Trend Month Period F'cast 16/17 16/17 Trend Month Period F'cast
Mortality 0 12 1 Waiting times
≤100 93.05 NA NA 155 0 NA NA ≥92% 92.81% 92.45%
SHMI (rolling 12 months- to Sep 16) ≤100 111 NA RTT waits- incompletes (>52 weeks) 0 0 0
Infection Prevention & Control Staff accident rate A&E
0 6 0 (STAR) ≥95% 85.68% 88.24%
C-difficile - actual cases YTD* N/A 63 6 N/A N/A Trolley waits in A&E (>12 hrs) 0 0 0
97 19 0Target Actual 4-mth Actual Current 1-mth
HAS compliance ≥95% 95.41% 96.43%
NHS Safety Thermometer 16/17 16/17 Trend Month period F'cast Notify to Handover (30-60mins) 0 645 73
NA 91.6% 92.2% NA NA Q4: ≥96% 94.71% 94.9% Notify to Handover (>60mins) 0 248 16
≥98.5% 98.4% 97.9% 90% 71.60% 71.6% Cancer
Patient Safety FFT- Staff Survey (quarterly)
≥96% 96.83% 94.38% Recommend Treatment (Jul-Sep 16) ≥80% NA 79%
Recommend Work (Jul-Sep 16) ≥74% NA 74%
Mandatory Training Target Actual 4-mth Actual Current 1-mth
≥90% 96.5% 100% E-learming Info Gov ≥95% NA 73.3% 16/17 16/17 Trend Month Period F'cast
E-learming SG Children ≥95% NA 75.9% ≥90% 87.42% 89.13%
E-learming Infection Control ≥95% NA 85.0% ≤9.5% 9.31% 7.94%
0 0 0 E-learming E-MH ≥95% NA 92.0% ≥90% 87.46% 86.94%
0 54 7 E-learming E &D ≥95% NA 93.1% ≤0.8% 1.20% 0.59%
0 0 0 E-learming SG Adults≥95%
NA 88.6% 0 0 0
0 0 0 E-learming H&S ≥95% NA 88.2% Discharge Summaries
0 2 0 Manual Handling ≥95% NA 86.9% A&E (within 48 hours) ≥95% 84.7% 89.8%
Stroke Resus ≥95% NA 64.9% Inpatients (within 48 hours) ≥95% 80.8% 79.2%
SSNAP DSC Stroke Indicators Fire Safety ≥95% NA 83.6% Outpatients (within 5 days) ≥95% 82.0% 92.6%
Number achieved out of 9 (Aug-Nov 16) ≥95% NA 81.2% Discharge Summary Quality Audit 100% NA 96.0%
SSNAP Grading (Aug-Nov 16) B NA B Delayed Transfers of Care- Days (Feb-17) NA 11,899 717 NA NA
Safer Staffing Target Actual 4-mth Actual Current 1-mth
TBC 93.4% 93.3% NA NA 16/17 16/17 Trend Month Period F'cast Actual 4-mth Actual Current Yr-end
TBC 105.7% 104.4% NA NA 1 3 - NA 3 - 16/17 Trend Month Period F'cast
- - Cum. Net surplus (£'m) -14489 348 14489
Target Actual 4-mth Actual Current 1-mth Cum. CIP (% of plan) 98.8% 72% 99%
16/17 16/17 Trend Month Period F'cast Cum. Capital (£k) 2937 840 - 2937
FFT positive responses (all) NA 89.7% 90.6% NA NA Cum. CQUIN (% of plan) 97% 97% 97%
FFT response rate (A&E/ Inpatients) 20% NA 21.38% strong improvement
Complaints received NA 446 40 NA NA improvement
Complaints responded to within no change
agreed timescale deterioration
Ombudsman cases upheld 0 3 0 strong deterioration
Patient Access
SMR (rolling 12 months- to Dec-16)
MRSA - actual cases YTD*
Actual is upto March unless stated otherwise.
Overall Clinical Quality
<10 0.214-hour wait*
18-week incomplete*Calendar days lost
RIDDOR incidents reported
0.00
Nutrition risk assessment
Harm-free care (new harms)
due to staff accidents
C-difficile - avoidable cases YTD* (Feb-
17)
Harm-free care (all harms)
83.13%on admission (Feb-17)
VTE risk assessments (provisional)
Medicines reconciled ≥95% 85.00%
Staff Attendance
Appraisals - rolling 12 mths
12.28%Outpatient DNA rate
Serious Incidents reported (StEIS)
30 days (Feb 17)13.02%
Failure of safer-surgery process
Emergency re-admissions within
93.57%
RN/RM hrs on shift (% of planned)
Outpatient slot utilisation
Urgent operations cancelled for a second time
HCA hrs on shift (% of planned)
'Duty of Candour' breaches
Regulation 28 reports (inquests)
Never Events reported (StEIS)
Theatre utilisation (capped)
NA NA 7
Cancelled operations- last-minute (provisional)
Q4: ≤ 11%
≥90%
Patient Experience
Single Oversight Framework (Jan-Mar 17)
Good ≤-£17500
The one-month forecast is an informed prediction of the next
month's performance, which may be based on part-month data,
operational intelligence and historical trends.
≥100% of plan
≥70% of plan1-month forecast 4-month trend
CQC Rating* (Jan-Mar 17)
16/17
92%
Cancer- Composite Indicator
Number achieved out of 8 (Feb-17)
Target
Operational Efficiency
Finance
78 NA
People
Regulatory
Mandatory training (Overall)NA NA
QUALITY ACCOUNT: April 2017 Board (March 2017 performance)
THFT QUALITY ACCOUNT 2016/17
Quality DashboardMarch 2017
Page 7
QUALITY ACCOUNT EXCEPTION REPORTS: Medical Director/ Director of Operations (1/1)
Cancer Services Target CurrentPerformance
4 MonthTrend
PreviousPerformance
Forecast
62-day GP Referral to Treatment-Overall (reporting Period: February 2017) 85% 92.7%
Acute trusts are required to support the NHS England/ Trust DevelopmentAuthority/ Monitor commitment to ‘Improving and Sustaining CancerPerformance’. One action required of trusts is that they report tumour- site-specific performance against the 62-day cancer target to their Board, irrespectiveof performance against the aggregate target.
This report highlights the Trust’s overall and tumour- site- specific performanceagainst the 85% threshold. The period that it relates to is February 2017 and theposition stated has been fully validated, in line with the Greater Manchester- wideReallocation Policy. For the month of February 2017, the aggregate 62-dayposition was 92.7%, which means that the Trust met the national standard for themonth. The reasons for the 4 breaches in February were as follows:
2 x complex / multi- tumour sites / patient comorbidities; 2 x internal diagnostic delays.
‘Near Misses’Acute trusts are also required to include, in the reports provided to their Board,data relating to patients treated within 48 hours of their breach date. Fourpatients were classified as ‘near misses’ in the month of February. The ‘nearmisses’ were the result of:
1 patient fitness review prior to surgery; 1 patient holiday; 2 external treatments (patients referred on/before day 42).
‘Treated after day 104’A full breach analysis, and clinical assessment, must be conducted on patientswith a total wait greater than 104 days. If harm has been caused by the treatmentdelay, a full ‘Serious Incident’ investigation must be undertaken by the treatingTrust. In February two of the Trust’s patients were treated, post day- 104, attertiary hospitals. These delays were the result of: an internal diagnostic delay;and delay at the tertiary provider. Both patients were referred to the tertiaryprovider on/ before day 42 of the pathway.Expected date to meet target NA Signed off by Janet Smart
Signed off by Trish Cavanagh/ Brendan Ryan
Page 8
QUALITY ACCOUNT EXCEPTION REPORTS: Director of Operations (1/2)
Patient Access-A&E
Target CurrentPerformance
4 MonthTrend
PreviousPerformance
Forecast
4-hour wait (Reporting period: March 2017)
Notify to Handover: 30-60 mins (Reporting period: March 2017)
Notify to Handover: 60+ mins (Reporting period: March 2017)
95%
0
0
88.24%
73
16
ISSUEThe Trust did not meet the four-hour emergency care standard in March:
Bed capacity across the organisation was problematic, causing delayedfirst assessments due to a lack of capacity in the Department;
IAU remained escalated as a bedded area rather than functioning asoriginally planned;
Reduced ambulatory-care service because of staffing shortages; National and local shortages of medical and nursing cover exacerbated
by difficulties with IR35 regulation; Medical bed-pool occupancy was routinely at >96%; Delayed-transfers-of-care occupied 5.7% of the ‘General and Acute’ bed
pool, a reduction from 10% in January; Increased acuity, as measured using the Charlson Comorbidity Index
(43% of patients with a Charlson comorbidity; 34% in 2009-10).ACTIONS
NHSI’s Head of Service Improvement ‘significantly assured’ about theTrust’s response to the challenges relating to emergency flow;
Silver Command, including the deployment of Ward Liaison Officers, inplace during February;
Additional medical staffing resources deployed, especially on days ofexpected increased activity (Monday/Tuesday).
PROPOSED ACTIONS NHSI to offer focused support concerning ED streaming; Pilot streaming for one month (Monday, Tuesday and Friday for four
weeks) commencing 6th March; Visit to Derby Hospital to assess streaming model.
Notify To Handover Time
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17 YTD
30-60mins
47 59 44 42 109 98 49 73 645
60+Mins
2 28 15 9 56 53 23 16 248
Expected date to meet target Quarter 42017-18
Signed off by DebbieDavies
Signed off by Trish Cavanagh
Page 9
QUALITY ACCOUNT EXCEPTION REPORTS: Director of Operations (2/2)
Operational Efficiency Target CurrentPerformance
4 MonthTrend
PreviousPerformance
Forecast
Discharge Summaries- A&E: (Reporting period: March 2017)
Discharge Summaries- Inpatients: (Reporting period: March 2017)
95%
95%
89.8%
79.2%
ISSUEPerformance was below target for Emergency Department and inpatientdischarge summaries. Performance against the outpatient- clinic letter standardimproved again during February to 93% so that an exception report is notrequired.
80.5% of inpatient discharge summaries were completed within 48 hours inMarch, which is consistent with reporting from the most recent months. 89.8% ofEmergency Department summaries were completed within 48 hours against the95% standard. This performance represents a marginal deterioration from theperformance in February but is a significant improvement upon performance inthe months prior to that, as can be seen in the chart opposite.
ACTIONSReview at the Patient Safety Board and feedback with proposed actions. Meetingwith Director of Performance, Medical Director, Director of Quality andGovernance and CCIO regarding strategy for discharge summaries. Significantimprovements in performance may require increased digitisation: such optionsare being explored by the Health Records Group.
PROPOSED ACTIONS Start development of eCAS card, which will guarantee delivery of a
summary within target; Develop reporting mechanism to directly target missing/ late summaries; Target areas of underperformance, such as General Medicine,
Cardiology, General Surgery, Paediatrics and Trauma and Orthopaedics.ASSESSING IMPROVEMENTUsing the bespoke performance reports.Expected date to meet target Quarter 2-2017/18 Signed off by Geoff
Lavelle
Signed off by Trish Cavanagh
Page 10
QUALITY ACCOUNT EXCEPTION REPORTS: Director of Human Resources (1/3)
People Target CurrentPerformance
4 MonthTrend
PreviousPerformance
Forecast
Staff Attendance: (Reporting period: March 2017) 96% 94.86%
ISSUEThe staff attendance rate was below the target for March, although there was areduction in sickness (from 5.3% to 5.1%).
PROPOSED ACTIONSThe HR Business Partners are working closely with ‘hotspot areas’ with highlevels of absence and associated costs. Progress is being monitored via themonthly HR Divisional Management Team Meeting. Actions include:
A review of all sickness cases, ensuring management plans are in place. Delivering 1:1, and small- group, training sessions to raise the profile of
return- to- work interviews. A focus will be put on return- to- workcompliance this month, given the recent increase in short- term sickness.
Attendance Management Masterclass sessions were launched inFebruary. The next session is scheduled for June and 22 managers arebooked to attend.
Discussions are underway with Staff Side with regards to theamendments to the Attendance Management Policy. The main change tothe policy is the reduction of the Trust trigger levels.
A full management ‘toolkit’ will be released with the new policy.
ASSESSING IMPROVEMENTExpect to see improved KPI performance, including an improvement inattendance and a decrease in costs associated with sickness absence includingNHSP/Agency/Bank expenditure. Return-to-work interview compliance is also tobe closely monitored.
Expected date to meet target Quarter 1 2017-18 Signed off by NicolaWilkinson
Signed off by Amanda Bromley
Page 11
QUALITY ACCOUNT EXCEPTION REPORTS: Director of Human Resources (2/2)
QUALITY ACCOUNT EXCEPTION REPORTS: Director of Human Resources (2/2)People Target Current
Performance4 MonthTrend
PreviousPerformance
Forecast
Mandatory Training: (Reporting period: March 2017) 95% 83.3%
ISSUEMandatory Training performance did not meet the target of 95%:
The Porters/ Domestics staff group was largely non-complaint forMandatory Training upon transfer to the Trust (performance is 52.9%, upfrom 22%); this had a significant effect on the organisation’s overall %performance.
Community staff compliance (currently 77.6%, up from 67.8%) alsoreduced overall compliance upon transfer.
Trust compliance, excluding these groups of staff, is 83.3% (see chartopposite).
ACTIONS Close monitoring of, and the development of action plans for, individual
subjects has had a positive impact on mandatory training elements. Thisincludes reviewing what training should be provided on a face- to- facebasis and which can be delivered via e-learning.
Managers in areas with low compliance have been requested to provideaction plans and trajectories for improvement.
The gap analysis, relating to training in the Community services and forPorters and Domestics, continues
Consideration is being given as to what sanctions can be applied to staffwho are not compliant with mandatory training, and a review ofapproaches, taken by other trusts to this issue, is being undertaken.
ASSESSING IMPROVEMENTData is produced and assessed monthly, and sent to senior managers as soonas the data is produced.Expected date to meet target Quarter 1 2017-18 Signed off by L Harmer
Signed off by Amanda Bromley
Page 12
Indicator Quarter 1 Quarter 2 Quarter 3 Quarter 4
HSMR (amber if not statistically significant) ≤100 ≤100 ≤100 ≤100
SHMI (amber if not statistically significant) ≤100 ≤100 ≤100 ≤100
MRSA - actual cases 0 0 0 0
C. difficile - actual cases 12 24 34 46
Harm-free care (new harms) 98.5% 99% 99% 99%
VTE risk assessments 96% 96% 96% 96%
Medicines reconciled 95% 95% 95% 95%
Nutrition risk assessment 90% 90% 90% 90%
Re-admissions within 30 days 11.0% 11.0% 11.0% 11.0%
Failure of the safer-surgery process 0 0 0 0
Serious Incidents reported 0 0 0 0
Duty of Candour breaches 0 0 0 0
Never Events reported 0 0 0 0
Regulation 28 reports 0 0 0 0
Complaints response time 90% 90% 90% 90%
Ombudsman cases upheld 0 0 0 0
SSNAP Grading B B B B
RIDDOR accidents reported 0 0 0 0
Staff accident rate <10 <10 <10 <10
Staff attendance 95.0% 95.3% 95.7% 96.0%
Appraisals 85% 90% 90% 90%
Mandatory Training 95% 95% 95% 95%
FFT Staff Survey- Recommend Treatment 80% 80% 80% 80%
FFT Staff Survey- Recommned Working 74% 74% 74% 74%
E-Learning Information Governance 95% 95% 95% 95%
E-Learning Safe Guarding Children 95% 95% 95% 95%
E-Learning Infection Control 95% 95% 95% 95%
E-Learning E-MH 95% 95% 95% 95%
E-Learning Equality and Diversity 95% 95% 95% 95%
E-Learning Safe Guarding Adults 95% 95% 95% 95%
E-Learning Health and Safety 95% 95% 95% 95%
Manual Handling 95% 95% 95% 95%
Resus 95% 95% 95% 95%
Fire Safety 95% 95% 95% 95%
18-week incompleted 92% 92% 92% 92%
RTT waits over 52 weeks (incompletes) 0 0 0 0
4-hour wait 95% 95% 95% 95%
Trolley waits in A&E 0 0 0 0
HAS compliance 95% 95% 95% 95%
Notify to Handover -30-60mins 0 0 0 0
Notify to Handover ->60mins 0 0 0 0
Outpatient Slot Utilisation 95% 95% 95% 95%
Outpatient DNA rate 9.5% 9.5% 9.5% 9.5%
Theatre utilisation (capped) 90% 90% 90% 90%
Cancelled Operations (last minute) 0.8% 0.8% 0.8% 0.8%
Urgent ops cancelled for 2nd time 0 0 0 0
Discharge Summaries- A&E 95% 95% 95% 95%
Discharge Summaries- Inpatients 95% 95% 95% 95%
Clinical Letters- Outpatients 95% 95% 95% 95%
Page 13
1
TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017
Agenda Item 7b
Title Safe Staffing Report
Sponsoring Executive Director Tracey McErlain-Burns, Interim Chief Nurse
Author (s) Tracey McErlain-Burns, Interim Chief Nurse
Purpose To note/receive
Previously considered by n/a
Executive SummaryIn-line with the ‘Hard Truths Commitments regarding the publishing of Staffing Data’, the TrustBoard are required to review staffing data on a monthly basis. This report has evolved over thepast three months and this month it includes the results of the January 2017 Safer Nursing CareTool analysis considered alongside professional judgement and NICE guidance on safe staffinglevels for adult in-patients. The Board should note that some of the medical wards are under-established and as such an urgent review of the models of care needs to be carried out. Thisreview will be reported to the Board in June 2017.Finally in terms of summary the Board should note that the CQC requirement for having anAdvanced Paediatric Life Support (APLS) trained nurse on each shift on the children’s ward cannow be achieved following completion of band 6 training.
Related Trust Objectives
1. All patients receive harm free care through the Trust’sPatient Safety Programme.
2. To improve the quality of patient care through theimplementation of the Trust’s agreed Quality Strategy.
3. To improve the patient experience through apersonalised, responsive, compassionate and caringapproach to the delivery of patient care.
Risk Assurance – riskimpacted upon
CR734: Nurse vacancies, leadership and nurse staffing/recruitment across medicine and the ability to provide safecare.AF3480: Failure to meet CQC registration requirementsrelating to staffing.AF3482: Failure to ensure adequate staffing levels to ensurepatient safety and quality of services
Legal implications/Regulatoryrequirements
NHS England monthly requirement to publish and reportStaffing DataThe CQC report published 7th February 2017 states that theTrust must ensure that there are appropriate numbers ofnursing staff deployed to meet the needs of patients (medicalservices).The report also states that the Trust must ensure anadvanced paediatric life support trained nurse is on each shiftin Children’s Services.
Financial ImplicationsThere are no new immediate financial implications albeit thefinancial implications of international recruitment are beingconsidered by the executive team.
Has a quality impactassessment been undertaken?
Yes – where applicable in plans
2
How does this report affectSustainability?
The Trust is required to ensure staffing levels are adequate tomeet patient safety and quality requirements.
Action required by the BoardThe Trust Board is requested to receive this update and note the actions described and theassertive monitoring and management in place.
3
Background
This is a monthly report to the Trust Board following National Quality Board (NQB) guidance issued in
November 2013 to optimise nursing, midwifery and care staffing capacity and capability: “How to
ensure the right people, with the right skills, are in the right place at the right time: A guide to nursing,
midwifery and care staffing capacity and capability”.
The guidance clearly sets out the expectations and requirements of the Trust to meet the ‘HardTruth’s commitments’ (following the Mid Staffordshire report).
In July 2016, the NQB published an updated set of expectations for nursing and midwifery staffing toassist NHS Provider Boards to take local decisions which will deliver high quality care for patientswithin the available staffing resource (Supporting NHS providers to deliver the right staff, with theright skills, in the right place, at the right time – Safe sustainable and Productive Staffing, NQB, July016). This updated guidance incorporates Lord Carter report findings, in setting out the key principlesand tools that provider boards should use to measure and improve their use of staffing resources toensure safe, sustainable and productive services.
As advised in recent months the content of this report is evolving to ensure that the Board has acomplete picture of matters relating to safe nurse staffing. Specifically this report includes a review ofthe Safer Nursing Care Tool data.
Safe Staffing Update – March 2017 Data
Each month the data collection compares the number of nurse staff hours ‘Planned’ against thenumber of nurse staff hours used ‘Actual’. This is collected by ward, by shift, and is reported bycalendar month as a % fill rate by day and by night. Please refer to the Heat map (Appendix 1).
This staffing information is published via NHS Choices. This data is currently available via our publicwebsite in a specific designated section ‘Safe Staffing’: (www.tamesidehospital.nhs.uk/nurse-staffing.htm)
Overall, Registered Nurse (RN) fill-rates remain constant (with minimal change) month on month, butunregistered (Healthcare Support Worker) fill rates fluctuate due to levels of enhanced care required(1:1’s) and additional support for RN shortfalls.
The following graph highlights to the Board that unregistered fill rates for day and night shifts usuallymeet or exceed 100%1 and registered fill rates for night shifts have recently improved to between 97-100%. Senior Nurse leaders review nurse staffing levels (actual against planned) several times a dayand a conscious decision has been taken to increase the levels of fundamental care support byunregistered staff when registered nurses are not available to fill shifts.
The registered nurse fill rate for day shifts is currently running at 89.9% which is marginally reducedin comparison to the rate of 91.1% for the month of February and the details in this report describesome of the actions being taken to address the shortfall. The reasons for the marginal reduction arefirstly the inclusion of the 7 additional beds in the ward 31 establishment for a full month and increasein demand which was associated with the scheduling of annual leave. The latter is an issue that theAssistant Chief Nurses will address through tightened controls over roster sign off.
1Fill rates dipped to 99% in the month of March due to annual leave.
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Exception Report – March 2017
There were 5 inpatient areas with registered nurse/midwife fill rates <80% in March 2017 (Appendix 1heatmap). Those areas were:
• Ward 40• Ward 42• Ward 44• Ward 45• Ward 46
As reported to the Board last month ward 40 is trialling the inclusion of two registered charteredphysiotherapists in the nursing establishment 6 days a week. Excluding those hours of registeredpractitioner input to care on the ward the fill rate is 79.9%. Inclusive of those hours the fill rate was102%. The Board was advised last month that the Interim Chief Nurse was liaising with NHSEngland to seek clarity on whether the physiotherapy hours should be included in the unify return ornot; making the case that they should because of the model being trialled. A response has nowbeing received from NHS England and the advice is that these hours should not be included in theunify return however, NHS England noted the development of new models of care and will considerthe inclusion again in the future when unify returns are reviewed.
Wards 44, 45 and 46 have featured in this section of the Board report for several months due to fillrates being less than 80%. All three wards have 24 beds and their establishments are set atregistered nurse to patient ratios of 1:8 during the daytime and 1:12 at night. A recent review of theSafer Nursing Care Tool data (expanded in a later section of this report) indicates that theestablishment for wards 44 and 45 matches patient dependencies whereas on ward 46 the ward isunder established to meet patient dependencies and as such new models of care will be explored.
There are currently 4.89 whole time equivalent (wte) Registered Nurse vacancies on ward 44; 3.9wtevacancies on ward 45 and 5.29wte vacancies on ward 46. As such recruitment campaigns are beingdevised for these three areas.
Ward 42 has not featured in the list of wards with less than 80% fill rate in recent months. Theestablished RN to patient ratio is 1:8 on days and 1:10 on nights. There are currently vacancies onthe ward and this ward has a considerable number of new members in the team (new recruits).Ahead of the Board meeting the Interim Chief Nurse and Assistant Chief Nurse will be meeting withthe Ward Sisters of the medical wards to discuss models of care, retention, recruitment, capacity anddemand. A verbal update will be provided at the Board meeting.
85
90
95
100
105
110
115
120
125
%Fi
llR
ate
Average Fill Rates
Registered FillDAY
Registered FillNIGHT
Unregistered FillDAY
Unregistered FillNIGHT
5
Since February 2017 this report has included details of the number and impact of escalation beds. Inthe month of March there was an average of 5 additional beds opened across ambulatory care, theday care unit, surgical unit and the heart care unit2 which required 845 hours of nurse staffing (acombination of registered and unregistered) of which 411 hours were filled via NHS Professionalsand the remaining hours were redeployed from other areas within the Trust.
RequestedHours
Filled /Worked Unfilled
%Filled
Ward 30 H C U 545 288 257 53%
Ambulatory Integrated Assessment Unit 136 61 76 45%
Day Surgery Unit 126 61 65 49%
Surgical Unit 38 34 4 89%
Total 845 411 434 48%
Care Hours per Patient per Day (CHPPD)
In recent months the heatmap attached at appendix 1 has included actual CHPPD; a measure usedby NHS Improvement. This provides a consistent way of measuring the deployment of nurses andhealthcare support workers and it needs to be used alongside acuity and skill mix.
Planned CHPPD by ward and Trust has been added to the heatmap from February 2017 to show thehours required (based on nurse staffing establishments) versus that available. This draws attention tofive wards with actual hours less than planned, which includes ward 41 which was not in the previouslist of wards because it exceeded the 80% fill rate. It also draws attention to areas such as thesurgical unit, critical care, the neonatal unit, children’s unit, Stamford Unit and Shire Hill all of whichexceeded their planned RN hours. This was largely due to reduced occupancy in those areas attimes during the month of March, for example occupancy in the neonatal unit was 52%.
The graph below shows the trend in actual CHPPD, as a total of days and nights, registered andunregistered, since the methodology was introduced. Benchmarking data is not yet available but it isanticipated that this may be available via NHS Improvement imminently.
2A reduction of 7 compared with the month of February 2017
7.5
7.0
7.27.1
7.0 7.0
7.7
7.3
7.5
7.2
7.5
6.76.6
6
6.2
6.4
6.6
6.8
7
7.2
7.4
7.6
7.8CHPPD Trust Total
CHPPD Total Planned
6
Safer Nursing care Tool (SNCT)
In accordance with the NQB / Hard Truths guidance the Trust undertakes a review of nurse staffingestablishments, using appropriate tools at least twice per annum. The latest Safer Nursing Care Tool(adult in-patient) review was conducted throughout January 2017 and the results were presented to agroup of professionals comprising corporate nursing, divisional nursing, HR and finance colleagueson 28 March 2017. Each Ward Sister / Matron participated in the review of the staffingestablishments in their own area.
In summary a small number of areas would appear (based on the use of the SNCT) to be over-established and some appear to be under-established. In a number of areas such as the heart careunit and acute care unit, together comprising the cardiology unit the SNCT does not adequatelycapture acuity and dependency and as such professional judgement is essential. Potentiallyefficiencies within the establishment could be achieved if the HCU and ACU were co-located.
The planned orthopaedic unit and the emergency orthopaedic unit are both over established onSNCT analysis. The Board should note that the results of the January 2017 deployment have notbeen considered in isolation; averages over three deployments of SNCT in January 2016, June 2016and January 2017 have been considered.
The orthopaedic unit is part of the modern facilities and has a high percentage of single roomscubicles which do demand higher staffing numbers for the purposes of observation made easier inmore open wards. It is recommended that benchmarking information would be available from otherTrusts and as such this will be requested by the Assistant Chief Nurse for the Surgical Division aheadof the next SNCT deployment. In the interim the Matron and Ward Sisters have been charged withhaving zero tolerance on the use of bank and agency staff based on establishment.
The Surgical Unit would also appear to be over-established however it is noted that consultation isimminent with the Women’s Health Unit part of which may be co-located with the surgical unit andtherefore the outputs from the SNCT will be considered when finalising the establishment at the endof consultation.
In relation to the medical wards and especially wards 40, 41, and 42 these are not established tomeet a 1:8 ratio on days and some, together with wards 44 and 45 only achieve a 1:12 ratio onnights. Options for these wards need to be explored informed by the pilot on ward 40 and the factthat they are co-located. The simple solution of recommending an increase in RN establishment isnot an adequate proposal given the level of vacancies and the temporary staffing fill rates. Solutionsneed to be identified and shared with the Board no later than June 2017.
Finally in relation to the SNCT the review on 28 March identified that there has never been anyvalidation built into the data collection and therefore this will be developed before the nextdeployment in June 2017. Validation would usually involve someone external to the ward reviewingthe assessed dependencies of groups of patients. Going forward the Trust may chose to deployother Health-roster modules including Safecare which would involve data collection every shift, everyday benefiting not only twice per annum staffing establishment reviews but more importantly shiftdeployment and understanding of acuity and dependency.
Safe Midwifery Staffing
A detailed update on the midwifery staffing establishment was presented to Board in March 2017along with a description of the framework being proposed as a replacement for the statutorysupervision of midwives.
On 07 April 2017 guidance of the A-EQUIP model of clinical midwifery supervision was published andthis is now available of the NHS England website. The guidance describes transition from thestatutory model of midwifery supervision to an employer led model of supervision. Until such time as
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the Professional Midwifery Advocates (PMA) are prepared through a programme of education, theTrust as a provider of maternity services is required to deliver the non-statutory elements of thesupervisor of midwives role through effective management and governance arrangements. Thosearrangements are being led by the Head of Midwifery working with 11 of the previous (12)supervisors of midwives.
Unlike statutory supervision which required providers to meet a 1:15 ratio of supervisors to midwivesthe PMA model can be flexible based on tasks, standards and the responsibilities of the PMA inorganisations. The published guidance includes the competencies of the PMA and some roledescriptors / profiles. Unlike the previous arrangements, the Head of Midwifery is now responsiblefor the selection of the PMAs.
Now that the guidance has been published the Head of Midwifery, Deputy Chief Nurse, DivisionalDirector for Surgery and Women’s Health, the Clinical Director for Women’s Health and the InterimChief Nurse will meet to recommend a model of clinical midwifery supervision with a view to thatbeing presented to the Board by the Head of Midwifery in June 2017.
Finally for this section of the report the Board is advised that following the dissolution of the LocalSupervising Authority (LSA) NHS England has now appointed a new maternity leadership team.That team will be led by Mr Neil Tomlin and the Trust is in contact to arrange to meet him and histeam.
Community Nursing
The Board has previously been advised of the concerns of the community nursing team regardingcaseloads both in terms of the number of patients on caseloads and the complexity of thosecaseloads.
Regular meetings with the community nursing team leaders are taking place and a communitynursing (adults) action plan is now in place. An important component of that action plan is the caseload review which has commenced together with a specialist review of the community nursing needsof all patients with a diagnosis of diabetes.
Furthermore all patients requiring a continence assessment are now being assessed by thecontinence team rather than the community nursing team and the post of District Nurse Liaison isbeing appointed to.
In March 2017 NHS Improvement released draft guidance on safe staffing management incommunity nursing settings. The guidance includes a literature review of the evidence to inform thesetting of safe community nursing caseloads. Given the complexity and multifaceted nature ofcommunity nursing the literature review concludes that the notion of understanding safety incommunity nursing caseloads is still far from reach. As such a number of operational and strategicprinciples are proposed including the standardisation of data collection, avoidance of duplication,enriching learning and development environments, developing patient reported out-come measuresand using ‘canary markers’ to provide an early warning system, such as missed breaks.
The guidance advocates the use of professional judgement in setting community nursing staffinglevels. Currently all posts within the community nursing establishment are filled albeit there arestaffing gaps due to sickness and other forms of absence. In recent weeks a small internal staffingbank has been established and it is planned for this to grow in the coming months.
The new Assistant Chief Nurse – Medicine has a community nursing background and thereforetogether with the Community Nursing Clinical Pathway Lead the current action plan will be reviewedto timetable a review of the staffing establishment informed by the published guidance. Updates willbe included in future Board reports.
Children and Young People
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A ‘must do’ action in the Care Quality Commission (CQC) report is to “ensure that there is one nurseon duty on the children’s ward trained and up to date in Advanced Paediatric Life Support (APLS) oneach shift”.
Training of band 6 nurses was completed on 12 April enabling this action to be met. Having devisedmechanisms to capture this on e-roster the Assistant Chief Nurse for Surgery and Women’s andChildren’s Services will be accountable for ensuring that the requirement is met when signing off therosters.
Red Flags
There were a total of 69 incidents with 163 Red Flags recorded via the incident reporting system withregards to Nurse Staffing for March 2017 – this is due to the fact that multiple red flags can bereported on one incident3. The number of red flags recorded can be broken down as follows:-
DepartmentMissedbreaks
A shortfall of morethan 8 hours or25% of RegisteredNurse timeavailablecompared with theactual requirementfor the shift
Intentionalrounding
Delay of 30minutes inprovidingpain relief
Patientvital signsnotassessedorrecordedas outlinedin the careplan
Unplannedomissioninprovidingmedication
Less than2registerednursespresenton a wardduringany shift Total
Ward 31 14 9 8 10 5 2 48
Ward 42 5 6 2 5 4 1 23
IAU 5 3 2 4 2 1 17
DepartmentMissedbreaks
A shortfall of morethan 8 hours or
Intentionalrounding
Delay of 30minutes in
Patientvital signs
Unplannedomission
Less than2 Total
3A three fold increase on February 2017, as predicted.
9
25% of RegisteredNurse timeavailablecompared with theactual requirementfor the shift
providingpain relief
notassessedorrecordedas outlinedin the careplan
inprovidingmedication
registerednursespresenton a wardduringany shift
A&E -Childrens
1 1
ACU 4 3 2 9
DewsnapLane Clinic
1 1 2
Hyde Clinic 1 1 2
MossleyClinic
7 7 1 15
Surgical Unit 1 1 2
Ward 41 16 12 11 2 41
Ward 44 1 1
Total 55 45 25 21 11 6 0 163
The Board should note that there were no shifts with less than two registered nurses on duty duringany shift. This is because the Interim Chief Nurse and the senior nursing team consider any suchevent to be an ‘internal never event’ and as such must be prevented. There were a small number ofoccasions when the potential for only having one registered nurse on duty existed and in order toprevent this redeployment was managed.
Strategies to Address Shortfalls in Nurse & Midwifery Staffing Levels
The Trust has a range of strategies which include recruitment, workforce redesign through thecreation of new roles, retention and flexible staffing solutions. This section of the report provides anupdate on some of those strategies.
Recruitment & Retention
During the month of March 6 Registered Nurses left the organisation; a total of 5.42 wte, and 11Registered Nurses (10.29 wte) commenced employment with the Trust. However at any one timethe Trust continues to experience a minimum of 100 RN vacancies.
At the beginning of April the Executive Management Team (EMT) considered the proposal to investin international recruitment and this has now progressed to the next stage of consideration.
Meetings between colleagues in HR, Communications and the Interim Chief Nurse have taken placeto look at redesigning our advertising and reach campaigns and the next recruitment open day willtake place on a Saturday in June.
Temporary Staffing
The Trust works with NHS Professionals to provide a temporary staffing solution. In March 2017 theoverall temporary staffing fill rate was 78.7%, up slightly on the fill rate in February 2017 and onregional comparative fill rates despite an 11.5% increase in demand. The top booking reasonsremain vacancy, sickness, escalation and 1-1 specialling.
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Of note whilst the new HMRC rules (IR35) have temporarily impacted on the shift uptake of someprofessional groups the Trust’s Advanced Nurse Practitioners, Advanced Paediatric NursePractitioners and Emergency Nurse Practitioners have stepped up to strengthen rotas.
Trainee Nurse Associates
The Trust is part of the Nurse Associate pilot and had 20 Trainee Nurse Associates in post. The pilotis receiving very positive feedback to date however the number of trainees has now decreased to 18due to the personal circumstances of 2 of the candidates. This will create a deficit in funds receivedfrom Health Education North West impacting on the financing of the Clinical Educator role. Non-recurrently that will be avoided in year from underspends in the corporate nursing budget due tonatural time-lags in recruitment of new personnel. In year a solution to the £1750 cost pressure for2018/19 will be identified.
Preceptorship
The Trust continues to place importance of the preceptorship period of newly registeredprofessionals. Twenty one preceptees joined the Trust on 03 April, 15 of whom are adult nurses.
In March several members of the team led by the Preceptorship Lead attended the Ashton SixthForm College to raise the profile of the Trust as an employer and to discuss career options.Discussions between the corporate nursing team and HR colleagues are taking place to understandif there are opportunities to work with other education establishments more frequently and what thereturn on that resource (time) investment might be.
Summary
Ensuring the correct numbers of suitably skilled Nurses, Midwives and Healthcare Support Workersare in post is essential for the delivery of safe and effective patient centred care.
As described in this report there are a number of daily challenges not least due to vacancies andtemporary staffing fill rates affecting the ability to have adequate numbers of suitably skilled nurses,midwives and HCSW on duty each day.
The Safer Nursing Care data indicates that there are a number of wards under-established and someover-established and this data has been reviewed, for the first time jointly with nursing, HR andfinance. It is clear that alternative models of safe staffing need to be quickly reviewed, informed by
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the pilot on ward 40 for both the short and longer-term at the same time as exploring internationalrecruitment to RN vacancies.
Recommendations
The Trust Board is asked to note the details of this report and the actions being taken.
12
Inpatient Ward Compliments Complaints
Moderate
Harm +
Incidents
Falls
with
Harm
MRSA C.Diff
PU
(+G2
only)
FFT
Positive
(%)
Registered
Staff
Fill Rate -
Days
% of
Temp
Staff
Used
Registered
Staff
Fill Rate -
Nights
% of
Temp
Staff
Used
Unregistered
Staff
Fill Rate -
Days
% of
Temp
Staff
Used
Unregistered
Staff
Fill Rate -
Nights
% of
Temp
Staff
Used
Planned
Registered
CHPPD
Actual
Registered
CHPPD
Planned
Unregistered
CHPPD
Actual
Unregistered
CHPPD
Actual
CHPPD
TOTAL
Planned Orthopaedic Unit 32 2 0 0 0 0 0 100.0% 95.4% 1.35% 98.6% 21.55% 106.1% 22.99% 154.6% 61.83% 3.45 4.2 2.93 4.3 8.5
Surgical Unit 85 0 1 0 0 1 0 96.5% 94.3% 19.13% 99.2% 25.07% 89.3% 26.33% 109.0% 46.79% 3.12 4.40 2.92 4.30 8.70
Emergency Orthopaedic Unit 18 1 2 0 0 0 4 98.0% 92.3% 3.50% 97.8% 40.75% 116.0% 20.68% 143.1% 37.41% 3.31 3.50 3.00 3.70 7.10
Critical Care 0 1 0 0 0 0 1 100.0% 99.3% 11.28% 90.8% 34.41% 103.2% 13.15% N/A N/A 25.0 33.70 1.33 2.00 35.6
AMU 0 5 0 0 0 0 1 94.4% 100.8% 16.40% 98.0% 44.81% 94.9% 14.11% 97.6% 22.83% 3.85 4.30 4.27 4.60 9.00
Acute Cardiology Unit 15 0 0 0 0 0 1 96.2%
Heart Care Unit 18 1 2 2 0 0 0 100.0%
Ward 31 0 0 3 2 0 1 0 100.0% 84.3% 35.72% 90.7% 76.43% 101.1% 57.86% 100.1% 59.98% 2.40 2.40 3.60 3.60 6.10
Ward 40 40 1 1 0 0 0 0 95.8% 79.9% 6.07% 99.6% 52.07% 81.3% 23.45% 118.5% 34.74% 2.40 2.40 2.79 2.90 5.30
Ward 41 32 0 1 0 0 1 1 0.0% 84.4% 13.81% 97.8% 74.84% 98.4% 12.11% 100.6% 18.31% 2.47 2.40 3.00 3.00 5.40
Ward 42 11 1 2 0 0 1 0 82.4% 72.8% 0.00% 99.3% 45.57% 110.0% 11.33% 114.8% 34.27% 2.80 2.60 3.14 3.20 5.80
Ward 44 7 0 0 0 0 0 2 91.7% 73.7% 25.50% 100.0% 45.21% 146.1% 20.72% 132.2% 48.45% 2.59 2.30 3.31 4.60 6.90
Ward 45 6 1 1 0 0 0 1 100.0% 76.7% 26.29% 98.3% 44.43% 103.1% 22.36% 100.8% 17.70% 2.50 2.40 4.25 4.40 6.80
Ward 46 32 0 0 0 0 0 0 100.0% 73.4% 20.92% 82.4% 38.84% 109.5% 16.93% 182.4% 31.06% 2.81 2.40 2.50 3.50 5.90
Ward 27 (Maternity) 20 1 0 0 0 0 0 91.8% 84.2% 25.41% 91.3% 7.17% 84.8% 9.94% 112.9% 11.79% 2.57 3.60 1.65 2.00 5.60
NICU 52 0 0 0 0 0 0 100.0% 95.6% 12.38% 99.2% 14.87% 100.0% N/A N/A N/A 7.38 14.60 0.66 1.20 15.80
Children's Unit 40 1 0 0 0 0 0 99.0% 95.0% 17.67% 95.7% 12.29% 69.8% 25.41% N/A 11.11% 3.93 8.10 0.99 2.10 10.20
Stamford Unit 1 9 0 1 0 0 0 2 95.4% 10.94% 99.9% 63.28% 91.3% 21.54% 102.3% 62.18% 1.50 2.20 3.75 4.90 7.20
Stamford Unit 2 7 1 2 0 0 0 2 100.6% 5.42% 103.3% 45.22% 94.7% 30.24% 103.9% 40.84% 1.50 2.30 3.75 5.00 7.30
Shire Hill 0 1 0 0 0 0 0 90.0% 100.2% 27.06% 99.7% 22.35% 90.5% 20.25% 91.8% 51.94% 2.33 2.90 3.33 3.50 6.30
Inpatient Totals/Averages 424 17 16 4 0 4 15 98.2% 89.9% N/A 97.7% N/A 99.0% N/A 112.7% N/A 3.5 3.8 3.01 3.7 7.5
100.0%
Heat map - Inpatient Ward Areas - March 2017
84.7% 25.16% 110.5% 46.28% 121.8% 25.78% 102.4% 51.07% 4.65 4.20 2.91 3.10 7.30
KEY
Complaints Moderate Harm + Falls with Harm MRSA CDIFF PU(+G2) Staffing Fill Rates0 - Green 0 - Green 0 - Green 0 - Green 0 - Green 0 - Green > 90% - Green
>1- Amber >1 - Amber >1 - Amber >1 - Red >1- Amber >1 - Amber 80 - 90% - Amber>2 - Red >2 - Red > 2 - Red >2 - Red >2 - Red < 80% - Red
NB: Please note that Inpt FFT Total shown does not include Community areas.
Appendix 1
TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017Agenda Item 7c
Title Director of Finance Report - Month 12, March 2017)
Sponsoring Executive Director Claire Yarwood, Director of Finance
Author (s) Finance Team
Purpose Discussion and Endorsement
Previously considered by This paper has been reviewed by the Finance andPerformance Committee
Executive Summary:The financial position for the full year as at March 2017 is a £14.5m deficit which is £2.8mbetter than plan. Cash balances are slightly above plan.
Related Trust Objectives6 – To deliver against the required local and nationalregulatory frameworks as part of the GreaterManchester Health and Social Care Devolution,securing the best economy efficiency andeffectiveness in use of resources the Trust spends todeliver services both directly and through partnerorganisations.
Risk Assurance – risk impactedupon
723 – Failure to meet, deliver the Trust’s financialplan
Legal implications/Regulatoryrequirements
In breach of licence
Financial ImplicationsNone
Has a quality impact assessmentbeen undertaken?
None
How does this report affectSustainability?
Sustainability is subject to the outcome of the systemwide review by the CPT
Action required by the Board
The Board are asked to discuss the contents of the report, recognise the risk and endorsethe actions required.
Executive Summary
1
Summary of Performance• For the financial period to the 31st March 2017, the Trust is reporting a normalised deficit of £13.3m which is £3.98m better than plan. The position is driven by
the Trust receiving additional Sustainability and Transformation Funding from NHSI, and strong financial control measures implemented throughout the year.• For the full year, the Trust has spent £12.7m on agency staffing, broadly in line with the NHS Improvement ceiling of £12.5m. The Trust has been reliant on
agency usage to support winter pressures, and to cover medical vacancies in several areas where recruitment has been challenging.
Key Risks for 2017/18:• The Trust has still not agreed as control total with NHSI. Failure to do so could
result in additional financial implications not yet included in the 2017/18financial plan.
• As the Trust is planning for a deficit, there is a requirement for a DH loan tofund it. The Trust will be subject to a higher interest rate for borrowing if acontrol total is not agreed.
• At the end of 2016/17, the Trust has loan liability of £54.8m. It is anticipatedthat this will increase to £78.1m in 2017/18. The Trust could be required torepay part of this liability in 2018.
Key I&E issues:• Agency expenditure for the year end forecast is £12.7m so is broadly in
line with the NHSI ceiling of £12.5m. A lot of hard work has beenundertaken to strengthen control of agency usage within the Trust.
• The Trust Efficiency Savings target has been exceeded by £610k. This isan excellent achievement, although continued work is required in2017/18 to increase the value of recurrent savings.
Key Balance Sheet issues:• Cash is c.£1.9m greater than planned. This is due to NHSI releasing STF
earlier than planned.• Better Payment Practice Code is currently below the target of 95%
across all metrics, because the DH will only lend the Trust funding tomeet the deficit plan, not improve the Trust creditor position.
• The annual capital plan of £3m has been delivered in full.
Plan
(£'000)
Actual
(£'000)
Variance
(£'000)
Plan
(£'000)
Actual
(£'000)
Variance
(£'000)
Plan
(£'000)
EBITDA (273) 2,107 2,384 (7,912) (4,811) 3,101 (7,922)
Normalised Surplus/(Deficit) (1,056) 1,364 2,420 (17,300) (13,320) 3,980 (17,300)
Net Deficit after Exceptional Costs (1,056) 844 1,900 (17,300) (13,993) 3,307 (17,300)
Trust Efficiency Savings 764 721 (43) 7,832 8,442 610 7,808
Use of Resources Metric 3 3 3 3 3
Financial Overview - Dashboard
2
Plan
(£'000)
Actual
(£'000)
Variance
(£'000)
Plan
(£'000)
Actual
(£'000)
Variance
(£'000)
Income 17,227 22,384 5,157 202,453 212,355 9,902
Expenditure - Pay 12,277 12,212 65 147,603 148,501 (898)
Expenditure- Non Pay 5,223 8,065 (2,841) 62,762 68,665 (5,903)
EBITDA (273) 2,107 2,380 (7,912) (4,811) 3,101
Financing 782 743 40 9,388 8,509 879
Normalised Surplus/(Deficit) (1,056) 1,364 2,420 (17,300) (13,320) 3,980
Exceptional Costs 0 520 (520) 0 673 (673)
Net Surplus/(Deficit) (1,056) 844 1,900 (17,300) (13,993) 3,307
Deficit (% of Turnover) -6.1% 3.8% -8.5% -6.6%
Trust Efficiency Savings 764 721 (43) 7,832 8,442 610
Capital Expenditure 165 815 650 3,016 2,937 (79)
Cash and Equivalents 1,000 2,945 1,945
Use of Resources Metric 3 3 3 3
Analysis of Income
Elective 2,352 1,914 (438) 24,636 23,398 (1,238)
Non Elective 4,207 4,797 591 51,037 52,816 1,779
Outpatients 2,447 2,310 (137) 27,788 27,398 (390)
Other Clinical Income 7,273 10,465 3,192 87,525 91,369 3,844
Total Clinical Income 16,279 19,486 3,208 190,985 194,981 3,995
Non Clinical Income 948 2,897 1,949 11,467 17,374 5,907
Total Income 17,226 22,384 5,157 202,452 212,355 9,902
Month 12 Full Year
Breakdown of Deficit Improvement
3
£m Notes
Planned 2016/17 Deficit (17.3)
Balance Review (1) Sept 2016 0.4Once indications suggested the Trust would not deliver
the Q3 and Q4 A&E trajectory, mitigations were sought.
Matched STF for Balance Sheet Review (1) 0.4 NHSI 'incentive' for improving the financial position.
Balance Sheet Review (2) January 2017 0.5
Matched STF for Balance Sheet Review (2) 0.5 NHSI 'incentive' for improving the financial position.
GM H&SC Partnership Transformation IM&T Review 0.5 Funding to offset previously incurred expenditure
Matched STF for Transformation Funding 0.5 NHSI 'incentive' for improving the financial position.
Bonus STF 1.0NHSI additional payment for delivering a financial
position better than planned.
Revised Year End Deficit (13.4)
‘Valuing Care’ – Productivity and Efficiency Programme
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
£
Year to Date Performance
Plan
Actual
Recurrent
Key Messages
The 2017/18 savings target has been exceeded by £653k. Thisattributable to the hard work from the operational and financeteams in identifying and delivering savings.• Surgery and W&C: The division broadly delivered the target
for the year.• Corporate: The division overachieved the annual target due
to non recurrent benefits. The division is working towardsidentifying recurrent savings for 2017/18.
• Medicine and CSS; The division exceeded the annual target by£188k. However, the majority of savings are non recurrent,and so work is ongoing to identify recurrent savings.
• Community Services: The savings target for 2016/17 has beenachieved non recurrently.
• Invest to Save – £70k was invested in a creating a new postfor a medical staffing specialist within HR. This post hasachieved the following;
Supported an increase in Direct Engagement from 70%to over 90% resulting in a saving of over £150k.
Supported the procurement of Brookson – predictedannual saving of £200k although this could be offsetby increased costs relating the implications of IR35
Is an integral part of the 2017/18 Medical Staffing TEPand is the lead for the majority of schemes.
Actions for 2017/18:• Development and implementation of 2017/18 schemes.• Working with the local health economy to develop system
wide efficiency schemes.
4
Annual
Plan
(£'000)
Plan
(£'000)
Actual
(£'000)
Variance
(£'000)
Plan
(£'000)
Actual
(£'000)
Variance
(£'000)
Surgery and W&C 2,266 244 268 23 2,266 2,265 (1)
Corporate 2,114 180 198 18 2,114 2,580 465
Medicine and CSS 2,928 299 255 (44) 2,951 3,096 145
Community Services 500 42 0 (41) 500 501 1
Grand Total 7,808 764 721 (43) 7,832 8,442 610
Month 12 Year to Date
Financial Performance to Month Twelve (March 2017)
Pay: is slightly worse than plan for the full year (£898k, 0.6%). Underspends in the Community , Corporate and Surgery and Women and Children’s divisions relating tovacancies are offset by overspends in Medicine and CSS staffing for escalation beds and the premium cost of temporary staff to cover vacancies. In addition,expenditure category changes in reserves are offset by corresponding underspends in non pay.
Drugs: expenditure is overspent by £154k for the full year. Benefits relating to unrequired prior year anticipated expenditure is offset by activity related overspendsacross several areas. £347k of this is offset by income for PbR excluded drugs.
Clinical Supplies: are overspent by £4.7m cumulatively to year end. This predominantly relates to expenditure plan category movements in reserves, which are offsetby underspends on other types of expenditure, and overspends on medical and clinical equipment across all operational divisions.
General Supplies: are overspent by £1.1m for the year to date. Expenditure plan category movements in reserves are offsetting overspends in the commercial sector(156 T&O cases, 30 General Surgery cases and 24 ENT cases- totalling £785k) and radiology private sector expenditure.
Clinical Income: is cumulatively above plan by £3.9m, this includes an additional £2.4m of Sustainability and Transformation funding.
Other Income: is better than plan by £6m, relating to recharges for staff and equipment funded by other organisations. This is predominantly offset by expenditure.
5
-30,000
-25,000
-20,000
-15,000
-10,000
-5,000
0
£'0
00
Cumulative Financial Position
Cumulative Plan
Cumulative Actual
Pay Analysis – Bank and Agency
Key MessagesSpend on bank and agency staff for the year to March 2017 is £19.5m which is c.£3.7m higher than in 2015/16. The Trust is now commissioned toprovide Community Services for Tameside and Glossop, so bank and agency expenditure associated with this service in included in the 2016/17figure.• Bank usage has increased in comparison to the trend at the beginning of the year– this is to support winter pressures. However, agency
expenditure has been steadily decreasing since September 2016.
6
0
200
400
600
800
1,000
1,200
1,400
£'0
00
Tameside Rolling 12 Months Bank and AgencyExpenditure
Agency
Bank
Agency w/o credit
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb
2014-2015 2015-16 2016-17
Exp
en
dit
ure
£
Trust Agency Usage April 2014 to March 2017
Medical
Nursing
Other
Trust Total Agency Spend• The Trust has been assigned a year end ceiling of £12.5m total agency spend for 2016/17. Planned agency expenditure has been profiled based on
the average of monthly expenditure over the last two years.• The Trust spent £12.7m on agency for the full year, which is broadly on line with the NHSI ceiling.• Overall, the pay budget is slightly above plan, however some of the overspend is offset by income to fund various staff posts. The Trust is also
paying significantly for premium staffing costs due to the difficulties in recruiting certain staff groups.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total
Plan (£'000) 994 908 1,043 1,065 1,106 1,033 1,038 1,123 983 1,053 1,054 1,102 12,499
Medical Actual (£'000) 699 584 509 236 584 753 726 667 472 556 408 514 6,708
Nursing Actual (£'000) 238 229 271 284 364 300 218 223 287 250 259 347 3,268
Other Actual (£'000) 178 259 211 339 201 253 261 185 237 162 182 248 2,716
Total Actual (£'000) 1,115 1,073 991 859 1,148 1,306 1,205 1,075 995 968 848 1,109 12,692
Variance (£'000) (121) (165) 52 206 (43) (273) (167) 48 (12) 85 205 (7) (192)
NHS Improvement Agency Cap
Key Messages
• On the 1st April 2016, the NHS Improvement capped rates were reduced.• The Trust has to report to NHSI on a weekly basis how many agency shifts are being used which exceed the capped rates.• The latest return is shown below;
7
Actions
• A&E and General Medicine middle grade rotas have been redesigned to reduce the reliance on agency staffing. Substantive recruitmentis now in progress, and some posts have been filled.
• Information by specific staff breaching the cap rate is being shared with the Executive Management Team on a weekly basis.• A summary report is presented at the monthly Finance and Performance Committee for review.• A review of medical staff recruitment and the impact on service delivery is ongoing.
Staff Group
Number of Shifts Exceeding the
Price Cap Week Ending 26/03/17
Nursing, Midwifery & Health Visitors 76
Scientific, Therapeutic and Technical 40.1
Medical & Dental 181
Administrative & Estates 0
Total 297
Clinical Income - Contract Analysis
Key Messages:
• Overall, clinical income is above plan by £3.9m. The Trust has a sophisticated block contract with Tameside and Glossop CCG has agreed ayear end settlement.
• The value of over-performance blocked back to contract plan for Tameside and Glossop CCG year to date is £324k. Areas of over-performance in ambulatory care, non elective discharges and excess beddays are offset by underperformances in A&E, electivedischarges and outpatients.
• Tameside MBC has provided funding to support costs incurred relating to delayed transfers of care. This funding offsets expenditureoccurred by the use of spot beds.
• ‘All Other Commissioners’ includes the Sustainability and Transformation funding (STF), of which the Trust is receiving £9.4m.
8
Commissioner Plan (£m) Actual (£m) Variance (£m)
Annual Plan
(£m)
15/16 Outturn
(£m)
Tameside and Glossop CCG 154.7 154.3 (0.3) 154.7 128.4
Oldham CCG 6.3 6.4 0.0 6.3 7.1
Manchester CCG's (All) 6.0 5.9 (0.1) 6.0 5.7
Stockport CCG 1.3 1.2 (0.0) 1.3 1.2
NHS England Specialised Services 5.6 6.3 0.7 5.6 5.1
Secondary Dental - NHS Area Team 1.7 1.6 (0.1) 1.7 1.6
Tameside MBC 5.7 7.2 1.5 5.7 0.0
All Other Commissioners 9.8 12.1 2.3 9.8 2.1
Grand Total 191.0 195.0 4.00 191.0 151.1
Year to Date
Income and Activity - Year to Date
Key Messages:
• Critical Care is under plan by £1m. Adult critical care is worse than plan by(£613k, 321 bed days) and neonatal critical care is worse than plan by(£396k, 639 bed days).
• Elective income is worse than plan by £841k, (494 procedures below plan).Under performances in Cardiology (£176k), General Surgery (£164k),Orthopaedics (£197k) and Gynaecology (£100k) are offset by small overperformances in Breast Surgery, ENT and Paediatrics.
• Day-Case income is worse than plan by £397k (25 procedures below plan).Over performance in General Surgery (£204k, 602 procedures above plan) isoffset by underperformances in Colorectal Surgery (£133k), GeneralMedicine (£166k), Pain Management (£114k) and Plastic Surgery (£90k).
• Non-Elective income is better than plan by £1.7m. Over performance inObstetrics (£334k), Paediatrics (£377k) and Medicine (£654k) is offset byunder performance in General Surgery (£396k) and Trauma andOrthopaedics (£61k). Excess bed-days are above plan by £882k.
• Outpatient income is under performing by £389k, equating to 6,000attendances. Over performances within Cardiology, Dermatology andGynaecology are offset with underperformances in Anti Coagulant, PainManagement, Orthopaedics and Urology.
• Drugs and device income is cumulatively above plan by £347k. This is offsetby corresponding overspends in expenditure.
• Other income additional STF funding of £9.3m and £1.5m additional fundingfrom commissioners in relation to A&E and RTT pressures.
9
-2,000
-1,000
0
1,000
2,000
3,000
4,000
5,000
6,000
£'0
00
Clinical Income Variance by Point ofDelivery
-7,000
-6,000
-5,000
-4,000
-3,000
-2,000
-1,000
0
1,000
2,000
3,000
A&E Critical Care Elective Daycase Non Elective Out-Patients
Act
ivit
y
Activity Variance by Point of Delivery
Pay Analysis
Key Messages:
• Pay expenditure is £898k worse than plan for the year todate. This is largely driven by expenditure categorychanges in reserves. *
• Community Services pay expenditure is underspent by£175k. This underspend has slowed down since thebeginning of the year as teams have worked hard torecruit into vacancies.
• Corporate is underspent by £1.5m relating to vacanciesacross all Directorates The Corporate team have reviewedall budgets to ensure they accurately reflect serviceprovision, and this will be reflected in the 2017/18budgets.
• Surgery and W&C is underspent by £566k. This is due tovacancies relating to several specialties.
• Medicine and CSS is overspent by £914k. This largelyrelates to premium cost temporary staff to cover medicalvacancies, as well as expenditure to staff unfundedescalation beds and additional staffing to support the CQCinspection.
10
-1,000
0
1,000
2,000
3,000
4,000
5,000
6,000
Surgery andW&C
Corporate Medicineand CSS
CommunityServices
£'0
00
In Month Divisional Pay Analysis
Bank
Agency
Payroll
Budget
4,000
9,000
14,000
£'0
00
Tameside Rolling 12 Months Pay Expenditure
Budget
Bank
Agency
Payroll
* As per NHSI, once a budget is set by expenditure type for thefinancial plan, it cannot be changed. For example, whenbusiness cases are finalised in year it may be decided that abudget set for the commercial sector (non pay expenditure) atthe beginning of the year would now be required for payexpenditure to perform the work in house. This category changewould be transacted through reserves so the division has theappropriate budget in the correct expenditure category.
Divisional Performance (EBITDA) – Month Twelve (March 2017)
Key Messages• Surgery and W&C: Contribution is £351k worse than plan for the full year. This is driven by underperformance in clinical income, unfunded
expenditure within the independent sector due to a shortfall in internal capacity and overspends on clinical prosthesis.• Corporate: Full year contribution is £735k better than plan. This is largely driven by under-spends on pay expenditure relating to vacancies is offset
by over-spends on non pay relating to efficiency savings targets.• Medicine and CSS: Contribution is £1m worse than the full year. Minor over-performance on income is offset by overspends on pay relating to the
premium costs covering vacancies, and activity related overspends on non pay.• Community Services: Contribution is £76k better than plan for the full year which is due vacancies throughout the division. A significant number of
these have no been recruited to, so the underspend has reduced in year. This is partially offset with the costs associated with running the StamfordUnit, an element of which are unfunded.
• EBITDA movement to Normalised Deficit position: The total Trust position is supported by a number of underperforming non operatingexpenditure budgets with an annual budget of £9.4m, which are not counted within the EBITDA. This is predominantly PDC payments (£581k betterthan plan), depreciation (£203k better than plan), exceptional costs (£561k worse than plan) and interest payable (£131k worse than plan).
11
Division
Plan
(£'000)
Actual
(£'000)
Variance
(£'000)
Plan
(£'000)
Actual
(£'000)
Variance
(£'000)
Surgery and W&C 1,529 1,569 40 15,588 15,236 (351)
Corporate (3,083) (2,993) 90 (36,811) (36,076) 735
Medicine and CSS 874 (298) (1,172) 8,053 7,047 (1,006)
Community Services (277) (360) (83) (1,767) (1,691) 76
Reserves 683 4,245 3,561 7,024 10,728 3,704
Trust EBITDA (274) 2,163 2,436 (7,913) (4,753) 3,154
Month 12 Year to Date
Cash Flow, Capital Expenditure and Debtor and Creditor Analysis
Key Messages:Cash: The March month end cash balance was £2.9m, above the £1m plan. This is due to the Trustreceiving STF earlier than indicated by NHSI. The overall level of cash is forecast to remain at circa£1m across the next 13 weeks. Peaks in cash balances during this period reflect cash timing ofreceipt of monthly contract payments from NHS commissioners and payment to suppliers.Capital: Cumulatively, £2.9m of capital expenditure has been incurred as planned. Investments in2016/17 included development of the Antenatal Clinic , upgrade of Critical Care and ITdevelopments.Debtors: The majority of the debt relates to NHS debt. This has been reduced significantly in March.Loans: The cash support to the Trust is funded from an Interim Revenue Support Loan (IRSL) of£13.2m. For the remainder of the loan required to fund the deficit, the Trust agreed anuncommitted revenue support loan with DH, up to the value of £6.6m. The uncommitted loan canbe withdrawn and full repayment requested at any time. The total distressed loan liability the Trusthas at year end is £54.8m.Creditors: The creditor balances are predominantly current balances which will be settled in linewith the Trust’s payment terms. This is currently at 60 days due to the low levels of cash theorganisation can maintain whilst operating in a deficit.Public Sector Payment Compliance (Target 95%):
0
100
200
300
400
500
600
700
800
900
Apr
-15
May
-15
Jun-
15
Jul-1
5
Aug
-15
Sep-
15
Oct
-15
Nov
-15
Dec
-15
Jan-
16
Feb-
16
Mar
-16
£'00
0
Capex Expenditure
Capex Budget
Capex Actual
0
5,000
10,000
15,000
20,000
25,000
£'00
013 Week Cash Flow from 13th March 2017
Forecast (£'000)
Target Minimum CashReserve
Category
Balance
(£'000)
0-30 Days
(£'000)
31-90 Days
(£'000)
Over 90 Days
(£'000)
Total Sales Ledger Debtors 5,900 4,187 885 828
Total Aged Creditors 5,510 3,984 422 1,104
Top Five Debtors £m
Tameside MBC Other 1,563 1,493 32 38
NHS Tameside and Glossop CCG NHS 957 828 129 0
NHS England North West (Manchester) NHS 638 501 0 137
NHS England North West (Commissioning Hub) NHS 561 95 466 0
Pennine Care NHS Foundation Trust NHS 297 296 0 1
Top Five Creditors £m
NHS Professionals LTD Other 994 977 17 0
Central Manchester University Hospitals NHS Foundation TrustNHS 869 523 0 346
NHS Tameside and Glossop CCG NHS 404 404 0 0
Tameside MBC Other 350 350 0 0
University Hospital of South Manchester NHS Fooundation TrustNHS 253 127 20 106
12
Total
NHS Value (£'000) 47,402 40,510 85.5% 6,892 14.5%
NHS Number 2,186 572 26.2% 1,614 73.8%
Non NHS Value (£'000) 116,632 77,797 66.7% 34,693 29.7%
Non NHS Number 41,282 18,384 44.5% 22,898 55.5%
30 Days Greater 30 Days
Statement of Financial Position (formerly Balance Sheet)as at 31st March 2017
13
31 Dec 2016
Actual £'000
31 Jan 2017
Actual £'000
28 Feb 2017
Actual £'000
31 Mar 2017
Actual £'000
Feb - Mar
Movement
£'000
Total Non Current Assets 118,234 118,201 118,388 125,415 7,027
Current Assets
Inventories - Stock - Finished Goods 1,619 1,426 1,743 1,430 (313)
Trade & Other Receivables:-
> NHS Trade Receivables 1,952 1,995 1,201 3,665 2,464
> Non NHS Trade Receivables 956 876 746 2,235 1,489
Provision for doubtful debt (559) (559) (545) (594) (49)
> PDC Dividend Receivable
> Other Receivables 871 1,133 685 317 (368)
> Accrued Income 4,348 4,128 5,573 5,844 271
> Prepayments - Non PFI Related 2,926 3,259 1,647 1,287 (360)
Cash 1,247 1,028 1,235 2,945 1,710
Investments
Total Current Assets 13,360 13,286 12,285 17,129 4,844
Current Liabilities
Trade & Other Payables:-
> NHS Trade Creditors (1,459) (1,599) (828) (1,899) (1,071)
> Non NHS Trade Creditors (2,932) (2,836) (2,229) (3,612) (1,382)
> Other Creditors (7,062) (7,199) (6,852) (6,992) (141)
> Capital Creditors (61) (210) (123) (704) (581)
Other Liabilities:-
> Accruals (14,462) (13,157) (12,060) (10,862) 1,198
> Deferred Income (2,619) (3,874) (3,323) (2,342) 981
>PFI Leases (1,282) (1,282) (1,282) (1,336) (54)
>PDC Dividend Creditor
Provisions (179) (174) (337) (149) 188
Total Current Liabilities (30,057) (30,332) (27,035) (27,897) (862)
Net Current Assets/Liabilities (16,697) (17,046) (14,750) (10,768) 3,983
Non Current Liabilities
Other Financial Liabilities:-
> Deferred Income 0
> PFI Leases (53,964) (53,855) (53,757) (53,594) 163
> Interim Revenue Support Loan - DOH (47,175) (48,150) (51,525) (54,801) (3,276)
Provisions (767) (766) (681) (694) (13)
Total Non Current Liabilities (101,906) (102,772) (105,963) (109,089) (3,126)
TOTAL ASSETS EMPLOYED (369) (1,617) (2,325) 5,559 7,884
Financed By Taxpayers Equity
PDC 53,285 53,285 53,285 53,285 0
Revaluation Reserve 29,298 29,298 29,298 35,287 5,989
I&E Reserve (33,588) (33,588) (33,588) (32,538) 1,050
I&E reserve 2014/15 (15,703) (15,703) (15,703) (15,703) 0
I&E reserve 2015/16 (20,779) (20,779) (20,779) (20,779) 0
TOTAL TAXPAYERS EQUITY (368) (1,616) (2,324) 5,559 7,883
Page 1 of 29
TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017
Agenda Item 7d
Title Significant Risk Report
Sponsoring Executive Director Karen James Chief Executive
Author (s) John Fletcher, Acting Director of Quality andGovernance
PurposeFor discussion and agreement of futureactionsFor approvalTo note/receive
Previously considered by Risk Management Group, Service Quality andOperational Governance Group
Executive SummaryThe Significant Risk Report provides details on all identified significant risk exposurethrough the Risk Register and Board Assurance Framework across servicesprovided by the Trust.
Related Trust Objectives Impacts on all Trust Objectives
Risk Assurance – risk impacted upon Impacts on all BAF and Risk Registers
Legal implications/Regulatoryrequirements
Referred to if necessary in the paper
Financial ImplicationsReferred to if necessary in the paper
Has a quality impact assessment beenundertaken? Referred to if necessary in the paper
How does this report affectSustainability? Reflects current risks to the Trust’s
business and strategic objectives
Action required by the GroupMembers are asked to discuss and consider the current position in relation tosignificant risks and the proposed changes to reporting and Trust Risk Strategy
Page 2 of 29
April 2017 – Significant Risk and BAF Report
1.0 Summary Narrative of April Significant Risk and BAF Paper
This paper provides members with a report on the significant risk exposure through
the Risk Register and Board Assurance Framework across services provided by the
Trust. The recently revised format places more emphasis on the target risk score
and timescales for achieving the target score and focusses attention on the gap
between the current and target risk scores. A review of target risk scores is
progressing to ensure achievement of the target is realistic and possible.
Alongside the changes there will be focussed organisational development sessions
to support the review of the risks in the context of the changes and the revision of the
Risk Management Strategy Policy and Guidance.
The risks included in this report have been subject to review by the Quality and
Governance Unit following discussion with responsible Directors. The risks have
been consistently and systematically reviewed in light of the regulatory requirements
and mapped against the Trust’s Strategic plans and responses to regulatory
oversight which contain specific actions against identified risks. The Treatment Plans
for these risks have been reviewed by responsible Directors and leads to ensure
reflection of the assertive improvement work and current mitigations. Horizon
scanning for future risks to ensure foresight and insight is continually taking place
with systematic examination of information to identify potential threats, and
vulnerabilities, and detect opportunities and options to reduce existing risks. Where
applicable, necessary third party assurances are referred to.
1.1The Trust has identified a range of significant risks to its strategic objectives, which
are currently being mitigated, the impact of which could have a direct bearing on
compliance with NHS Improvement Provider Licence, CQC registration or the
achievement of corporate objectives, should the mitigation plans be ineffective.
Currently, the significant risks relate to the following areas:
Discharge processes and the management of the Urgent CarePathway across the whole health economy
Health economy capacity to manage patient flow and Urgent Careimpacting on Emergency Department pressures
Finance (Cost control, TEP delivery and liquidity) Information technology Medicines management Recruitment and Staffing Third party decisions /Transition to Integration Environmental monitoring Results Governance
Page 3 of 29
The main controls and action plans for each significant risk have been reviewed and
collated in the Trust’s Risk Register. Our Risk management programme has
incorporated the Corporate Risks (CR) and aligned them to the Board Assurance
Framework (BAF). Updates against the BAF and Risk register significant risks are
summarised in the analysis table in Appendix 1 and detailed risk information
provided in Appendix 2.
1.2Detailed updates against the BAF significant risks are included in this report. The
Board have informed the principal risks described.
The report reflects the revision of the BAF to include consideration of the potential
impact of Greater Manchester Health and Social Care Devolution and external
reconfiguration and the iterative development of Models of Care between acute,
community, primary and social care providers. We continue to keep a line of sight on
these and emergent risks through the Care Together Programme.
The risks associated with Healthier Together implementation, Greater Manchester
Health and Social Care Partnerships and the Care Together programmes are
aligned through the Board as they emerge and are identified.
The Director of Operations is currently overseeing the development of the risk
assessments related to the five Neighbourhoods for inclusion in the risk register from
April 2017.
The BAF is being aligned to the 2017/18 Corporate Objectives and updated through
a schedule of reviews by the Executive Directors, prior to next Trust Board.
1.3 New Significant Risks
The following risks have been included within the report since the previous Trust
Board meeting
CR4302 Introduction of IR35 tax regulations on the 6th April 2017 may increase
existing issues relating to medical and nursing staff. The risk has emerged
following assessment of the impact of HMRC enforcement of Tax Law IR35 which
relates to medical and nursing staff who are employed via an agency and being paid
by a limited company which are now subject to normal PAYE and National
Insurance. This has impacted specifically on medical staffing rotas and the ability to
maintain medical staffing levels. The impact has the potential to impact on the
consistency of supervision to trainee doctors. This is currently scoring 16 with a
target score of 8.
CR 4212 Delay/inability to obtain microbiology results
This risk is concerned with the risk of inappropriately treating a significant infection
due to delay/inability to obtain microbiology results. The risk has arisen out of delays
in samples being transported to the Laboratories at Manchester, and delays in these
being processed for cultures/microscopy. These are contributing to delays in results
Page 4 of 29
being received from the Manchester Laboratory. The risk has been presented at Risk
Management Group and is currently scoring 16 with a target score of 4 and a gap
score of 12. Mitigations are in place to reduce the clinical risk, but there is impact on
clinical time.
1.4 Reduction in Risk ScoresNone to report
1.5 Increased Risk ScoresNone to report
1.6 Other Notable Changes / Update
Following the last Risk Management Group meeting divisions are focussing on
revisiting the risk target scores and ensuring target scores are realistic and gap
scores are aligned with the organisations risk appetite. Divisions will be supported by
the Quality and Governance Unit in the new format and requirements.
There will be a schedule of reviews by the Executive Directors supported by the
Quality and Governance Unit to review the BAF in the context of the new corporate
objectives for 2017/18. There will also be emphasis on reviewing the target score,
gap score and risk appetite.
2.0 Recommendations
Members are requested to note current significant risks, current controls and
mitigations within the report.
Page 5 of 29
Appendix 1 Summary of risks and analysis
Sub-Committee Key:
AC: Audit Committee SQOGG: Service Quality & Operational Governance GroupCoG: Council of Governors IPCG: Infection Prevention & Control GroupQGC: Quality & Governance Committee ISB: Internal Safeguarding Board
FPC: Finance & Performance Committee IMTG: IM&T GroupEMT: Executive Management Team IG: Information Governance Group
Risk Lead Key: BS: Board Secretary
CEO: Chief Executive DoHR: Director of Human Resources
MD: Medical Director DoE: Director of Estates
CN: Chief Nurse DoP: Director of Performance & Informatics
DoO: Director of Operations DoSP: Director of Strategy & Partnership
DoF: Director of Finance DoQG: Director of Quality & Governance
Risk MatrixConsequence
Likelihood Insignificant Minor Moderate Major Catastrophic
Rare 1 2 3 4 5
Low/Unlikely 2 4 6 8 10
Possible 3 6 9 12 15
High/Likely 4 8 12 16 20
Almost ccertain 5 10 15 20 25
Gap Score Matrix (Difference between Target Score andCurrent score)
Gap score ≤0 Risk target achieved
Gap score 1 - 5 Tolerable
Gap score 6 - 9 Close monitoring
Gap score 10 Concern
Gap score > 10 Serious
Direction of travel - Change since previous review
Escalated
De escalated
Unchanged
Target achieved
Page 6 of 29
BAF Ref/ RiskRef
Description Analysis of RiskSubCommittee
ExecutiveLead
CurrentRiskScore
RiskTarget
RiskTargetGap
RiskAppetiteGuide
Risk AF
1.24
(3483)
If demands increase beyond predicted
levels and outside current capacity, and
the management of the urgent care
pathway across the Health Economy is
not undertaken in a cohesive and
standardised way, this could result in
delay, increased clinical risk and a
reduced positive patient experience.
The risk score remains in excess of the target score and
continues to be closely monitored, The achievement of
the target score is dependent on the transformation of
services and pathways across the Health Economy. The
Trust continues to engage with other service providers
and to progress models of care to improve capacity and
patient flow.
QGC DoO
DoSP
20 10 10 Moderate
AF 1.23
(3482)
Medical Staffing - The ability to recruit
to Consultant and Middle Grade posts
due to national shortages in certain
specialties i.e. Radiology, Medicine and
A&E. This may impact on patient
experience and the ability to provide
safe care
This risk remains at 20 and continues to be challenging.
The risk is influenced by the national picture and
availability of workforce. There still remains a significant
operational risk profile against the BAF risk as the
organisation continues to meet challenges in relation to
medical staffing particularly speciality medical staff.
International recruitment and alternative staffing models
are being reviewed in difficult to recruit specialities.
SQOGG DoHR
MD
20 10 10 Moderate
AF 1.23
(734)
Nursing Staff The ability to
consistently sustain and maintain safe
nurse staffing levels is compromised as
a result of operational demand, use of
escalation and additional capacity beds
third party decisions and actions and
continuous readmission challenges
This risk remains at 20 and continues to be challenging.
The risk is influenced by the national picture and
availability of workforce. The Trust has been actively
addressing staffing and has been utilizing a number of
strategies to maintain consistent staffing levels, which
include recruitment fast track events, skilling up of staff,
and the recognition and certification of Health Care
Workers. There still remains a significant operational
risk profile against this BAF risk as the organisation
continues to meet challenges around staffing
particularly for registered nurses.
International recruitment and alternative staffing models
are being reviewed in difficult to recruit specialities.
SQOGG DoHR
CN
20 10 10 Moderate
AF2.2
(3485)
Failure to deliver financial plans in line
with National guidance from NHS
Improvement
This risk has remained static and links with other
financial risks within the BAF. There are a number of
monitoring processes in place and regular reporting to
Trust Board.
FPC DoF
20 10 10 Moderate
CR3618
linkedIf demands on the service outstrip
capacity this may result in inability to
Related closely to AF1.24 this risk score remains in
excess of the target score and continues to be closely
OG DoO 20 5 15 Moderate
Page 7 of 29
BAF Ref/ RiskRef
Description Analysis of RiskSubCommittee
ExecutiveLead
CurrentRiskScore
RiskTarget
RiskTargetGap
RiskAppetiteGuide
with
AF3489
deliver the 4 hour Emergency Access
Standard.monitored, The achievement of the target score is
dependent on the transformation of services across the
health economy. The Trust continues to engage with
other service providers and to progress models of care
DoSP
AF2.8
(3526)
Failure to achieve VFM services andfinancial sustainability.
This risk score has remained at 20 throughout the
financial year and was reviewed at Audit Committee in
February 2017. The risk continues to be closely
monitored and assurance of the position provided
through performance and financial reporting
AC DoP
20 10 10 Low
AF2.9
(3527)
Cash Management and Capital
Investment
Failure to achieve :
a) cash/ liquidity targets,
b) Capital Investment within planned
resources
c) Capital Absorption rate targets
This risk was recently updated to reflect current
terminology. The risk score reduced in Q1 2016/17 from
25 to 20 and has remained stable at 20 since this time.
This BAF risk links closely with AF2.8 and AF2.9. There
are a number of controls and assurance processes in
place in relation to this risk which include internal audit.
AC DoF
20 10 10 Low
AF5.1
(4059)
Failure to deliver Trust efficiency
programme
This risk emerged following the decision to separate a
previous risk made following discussion at the Finance
and Performance Committee in Q2 2016/17 the risk
score remains at 20
FPCDoF
20 10 10 Low
CR4201 Healthier Together
Risk that the Trust will be in breach of
its financial control limit due to the
significant stranded costs caused by
the reconfiguration of emergency and
elective (cancer) general surgery as
part of the Healthier Together
Programme across Greater
Manchester.
This risk was identified in Quarter 3 2016/17 and is
being monitored closely. The risk score will be adjusted
accordingly as mitigations and controls take effect. The
Trust is continuing to engage with the Healthier
Together clinical Advisory Group and the Trust
Executives are being informed of any significant
financial and/or clinical implications
SQOGG
DoO
20 10 10 Low
CR4183 There is a risk of delayed patient
diagnosis and/or treatment as a result
of lack of availability of
radiologists/radiology staff in the
service.
This risk emerged in Quarter 4 2016/17 and is being
monitored closely. The risk score will be adjusted
accordingly as mitigations and controls take effect.
SQOGG
DoO 20 12 8 Low
Page 8 of 29
BAF Ref/ RiskRef
Description Analysis of RiskSubCommittee
ExecutiveLead
CurrentRiskScore
RiskTarget
RiskTargetGap
RiskAppetiteGuide
CR4012 Banking Trojans now using Locky
ransomware resulting in potential data
loss due to encryption
This risk score saw an increase following the realisation
of a ransomware occurrence. The risk is expected to be
decreased following implementation of anti-ransomware
software being procured
IM&T Group DoP&I
20 10 10 Moderate
CR4147 Ability to consistently sustain and
maintain a workforce with capability andcapacity to deliver community nursing
services
This risk was identified following the transfer of the
Community Services. The Division is reviewing options
for alternative service delivery and staff skill
requirements to further mitigate the risk. This risk was
reviewed and reworded in March 2017 by the DoO and
controls updated.
OG DoO
16 12 4 Moderate
CR3472 The ability to consistently apply, sustain
and maintain processes relating to themanagement of medicines
This risk score has remained the same in Q1 and Q2 of
2016/17. Assertive work is being undertaken to
understand and address the risks. Assurances are
being scrutinised and challenged through the
governance processes. This risk is currently being
reworded and refocussed to more accurately reflect the
specific areas of risk
QGC, OG MD
16 12 4 Moderate
CR4219 Radiology requests on Lorenzo for in
patients and out patients are being
recorded as cancelled by the Radiology
department without reference to the
requesting clinician.
This risk emerged in March 2017 and is undergoing
further validation of information and evidence to support
the score.
SQOGG DoO
16 4 12 Moderate
CR4302 Introduction of IR35 Tax Regulations
on the 6th April 2017 may increase
existing issues relating to medical and
nursing staff.
This is a new risk and ongoing rota monitoring is in
place to ensure mitigations are in place and to minimise
the clinical risk. The risk is a National risk arising from a
change in UK Tax Law this is impacting on the
availability of Locum doctors. This also have a potential
to impact on the nursing service and the supervision of
doctors in training.
RMG MD/DoO
16 8 8 Moderate
Page 9 of 29
BAF Ref/ RiskRef
Description Analysis of RiskSubCommittee
ExecutiveLead
CurrentRiskScore
RiskTarget
RiskTargetGap
RiskAppetiteGuide
CR4212Delay / inability to obtainmicrobiology results
Risk of missing a significant infection
due to delay/ antibiotics which may
result in morbidity or inability to obtain
microbiology results and therefore risk
of mis-treating a patient with an
inappropriate death.
This is a new risk arising in Quarter 1 2017/18 from the
Division of Surgery Women and Children which has a
specific area of focus within the Paediatric speciality.
Mitigations are in place which is expected to reduce the
risk these include active follow up of results.
SQOGG MD
16 4 12 High
AF4.2
(3488)
Failure to ensure on-going compliancewith terms of NHS Improvement
Provider Licence requirements
This risk reduced from 25 to 15 in Quarter 4 2016/17 as
a result of positive assurances. There are no gaps in
controls or assurances identified at this time.
AC DoF15 10 5 Low
AF4.8
(3491)
Failure to have in place an IM&T
infrastructure and service supporting
the organisational objectives
This risk score remains at 15 and has been static at 15
throughout this financial year to date. Although the risk
score remains that same further assurances are being
sought in relation to the integration of Community
Services
IMTG DoP
15 10 5 Moderate
CR3997 Inconsistent room temperatures in
NICUThis risk has remained static and following discussions
at Risk Management Group in April 2017 assertive
action has been requested by the Risk Management
Group to resolve this issue via the Estates Department.
SQOGG DoO
15 3 12 Moderate
CR4158 Transfer of microbiology laboratory to
Manchester Royal Infirmary andrelates to IT issues with Telepath and
ICNet connectivity.
This risk emerged with the transfer of microbiology
services, manual systems for ensuring effective
communication have been implemented to mitigate the
risk and the risk is being closely monitored on an
ongoing basis.
SQOGG CN
15 9 6 Moderate
Direction of travel - Change since previous review
Escalated Residual Risk Score (Current Risk)
De escalated (Target Risk / Risk Appetite Threshold)
Unchanged * New Risk Score
Target achieved
Page 10 of 29
Appendix 2 Detailed Risk Tables
Strategic Priority (Objective)
Corporate Objective 1, Corporate Objective 3, Corporate Objective 4, Corporate Objective 5, Corporate
Objective 6,
BAF Ref:
AF1.24
Risk ID number:
AF 3483
Risk Description: If demands increase beyond predicted levels and outside current capacity, and the
management of the urgent care pathway across the Health Economy is not undertaken in a cohesive and
standardised way, this could result in delay, increased clinical risk and a reduced positive patient experience.
Potentially this could lead to;
Delays in treating 95% of patients within the 4 hour standard
Increased levels of cancellations for elective surgery
Increased financial cost of escalation areas
Longer length of stay and associated complications.
Executive Director Lead
Director of Operations
Assurance Committee
Quality & Governance Committee
Current Risk Score (L x C)
4 x 5 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
10 Concern
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
The Trust is not willing to risk the
ability of the organisation to
delivery safe effective care or
compliance with regulatory
requirements
Date When Target Risk score expected to be achieved
Unable to quantify currently. Multiagency and Multi-organisational Agenda and transformation programme
Rational for Risk appetite
Current Reported performance information and impact on patient flow
Controls:
Working in partnership with external agencies to improve discharge process
Care Together models of Care Work
Patient flow list reviewed twice weekly to determine actions required for each patient
A&E Delivery Group monitoring of recovery plan established across the health economy and monitored
through the Finance and Performance, Operational Board and Executive Management Team meetings
Internal escalation plans in place to maintain safe and effective care during periods of increased pressure
Partnership working with other providers to ensure a long term strategy is in place regarding
sustainability and service provision
Community Care Model being extended to support existing structures
Assurance: (how do we know if the things we are doing are having an impact)
Daily monitoring of bed capacity and ED Waiting times
Waiting List Steering Group
Activity Planning
Monthly contract performance reporting to Executive Management Team & Board
Monthly finance and activity reporting to Board
MIAA audits
Monthly submission of DTOC data
Trust/Social Services Director level interface meetings
A&E Delivery Group
Mitigating actions: (what more should we do?)
Development of integration strategy and further models with key partners
Implementation of Recovery Plan by all partners
Gaps in assurance and actions not being actioned
Third party action by other parties and stakeholders has impact upon organisation. Delays in
delivery due to funding
Risk source
Third party review and internal monitoring, incidents, complaints and claims and Operational performance
Anticipated effect of controls
(Expected /risk score reduced) Reported at Board meeting aligned to performance trajectory and
performance report
0
5
10
15
20
25
Target score
Risk score
Page 11 of 29
Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 3, BAF Ref:
AF1.23
Risk ID number:
AF 3482 linked to CR1549
Risk Description: Medical Staffing - The ability to recruit to Consultant and Middle Grade posts due to national
shortages in certain specialties i.e. Radiology, Medicine and A&E. This may impact on patient experience and
the ability to provide safe care.
Executive Director Lead
Director of Human Resources
Medical Director
Assurance Committee
Quality & Governance Committee
Current Risk Score (L x C)
4 x 5 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
10 Concern
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
There is a national shortage of
Consultant and Middle Grade
doctors in some specialties
therefore there is additional
reliance on Locum and Agency
staffing to provide full staff
compliment
Date When Target Risk score expected to be achieved
Unable to quantify currently despite mitigations. Local and National agendas and changes influence the
Trust’s ability to achieve this target
Rational for Risk appetite
The Trust is not willing to risk the ability of the organisation to delivery safe effective care or
compliance with regulatory requirements
Controls:
Workforce strategy
Sickness Policy and monitoring
Use of Agency and Locum staff to bridge the gap
Temporary staff management monitoring
Senior Managers receive daily staffing report summaries
Capacity & Demand being reviewed through job planning process
Robust job planning process
Staffing monitoring via Quality Account dashboard and HR metrics.
International recruitment
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc.?):
Improvement Plan
HENW Review Action Plan monitored by Educational Governance and SQOGG
Reports to
Medical Staffing Group
HR & OD Workforce Group
Medical Staffing Expenditure Review Group (MSERG)
Mitigating actions: (what more should we do?)
Reports to Board and Executive Team
Continuous recruitment in to the vacant posts is underway and to continue under monitoring
Weekly monitoring of KPI’s
Stronger links to the annual Trust planning process
Lack of workforce availability at an operational level leading to difficulty in recruitment
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
No gaps in assurance identified however implementation of real time operational management
requires consistent application of agreed systems and processes by all staff at all levels across all
divisions
Risk source
Operational performance
Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score reduced)
Reported at Board meeting aligned to performance trajectory/ performance report
05
10152025
Target score
Risk score
Page 12 of 29
Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 2, Corporate Objective 3, BAF Ref: AF1.23 Risk ID number: CR734 Linked to
CR 3909 and AF1.23 (3482)
Risk Description : Nurse Staffing -The ability to consistently sustain and maintain safe nurse staffing levels is
compromised as a result of operational demand, use of escalation and additional capacity beds, third party
decisions and actions are continuous as admissions challenges
Executive Director Lead
Chief Nurse
Assurance Committee
Quality & Governance Committee
Current Risk Score (L x C)
4 x 5 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
10 Concern
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current operational processes
and daily staffing reviews
Date When Target Risk score expected to be achieved
Unable to quantify as local and National agendas and changes influence the Trust’s ability to achieve this.
Rational for Risk appetite; The Trust is not willing to risk the ability of the organisation to
delivery safe effective care or compliance with regulatory requirements
Controls:
Workforce Strategy
Recruitment open days
Monitor safer staffing analysis/submission and oversight with Acuity and dependence reviews
Nurse staffing are informed by National Guidance
Continuous monitoring at each operational bed meeting.
Monitoring of KPI’s Ward level dashboards.
Roster approval signed off by Ward Manager and Matron through e-rostering standards. Processes for
authorisation to backfill in place
Incident reporting systems analysis of variance
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?):
NHSP monthly contract monitoring meetings
E Rostering
Reports to:
Executive Management Team
Quality & Governance Committee
Mitigating actions: (what more should we do?)
Continuous recruitment in to the vacant posts is undertaken and continually monitored.
Monitoring of KPIs.
Utilisation of a partnership model and secondment opportunities from other trusts.
Recruitment from abroad
Return to Nursing and Pre nursing care Support Worker programme
Weekly recruitment tracker to EMT
Monthly Staffing Board Report to Trust Board informs this risk score.
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
Decision of other parties
Ability and availability of temporary staffing to meet demands
Use of escalation areas and operational demand drawing from wider compliment of
Trust resources.
Risk source
Operational performance, incidents and complaints
Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score reduced)
Reported at Board meeting aligned to performance trajectory and performance
0
5
10
15
20
25
Target score
Risk score
Page 13 of 29
Strategic Priority (Objective) Corporate Objective 6 BAF Ref: AF2.2 Risk ID number:AF3485
Risk Description : Failure to deliver financial plans in line with FT (Provider Licence) compliance framework Executive Director Lead
Director of Finance
Assurance Committee
Finance & Performance Committee
Current Risk Score (L x C)
4 x 5 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
10 Concern
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current financial performance.
Service model for financial
sustainability being implemented
Date When Target Risk score expected to be achieved
The delivery of the financial plan for 2017/18 should be achieved by April 2018 however this should be
assessed in the context of the longer term financial plan
Rational for Risk appetite
The Trust not willing to risk the ability of the organisation to achieve NHS Improvement
requirements and financial sustainability
Controls:
Continued use of appropriate NHS Reference Costs information led by the Finance Department to
ensure control and rigor of TEP delivery
Finance Team work with budget holders to drive down costs and increase income and contribution
margin and, with clinical teams, to exploit opportunities and repatriate activity and develop new
markets
Established Governance structure
Ensure Divisional teams work with finance to review income, expenditure and TEP variances and to
identify root cause analysis and where appropriate update systems and controls.
Improvements to clinical coding team
Standing Financial instructions
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence
Weekly EMT
Performance and financial reports to Board
Review of assurance and management structure/ meetings for TEP delivery
Ensure PIDs and QIA are completed for each scheme
Establish a recovery plan for all schemes not achieving targets
Ensure Divisional infrastructure regularly review TEP Schemes, complete recovery plan
and identify new schemes either in mitigation or for next financial year
TEP programme alongside Improvement Plan to ensure they complement each other
2017/18 programme outline developed.
Contractor meetings with the single Commissioner
MIAA Audit
Mitigating actions: (what more should we do?)
Revised programme of financial management
Certify that all material non-recurrent TEP's have also been subject to a rigorous QIA
Fully develop schemes to deliver the TEP target on a recurrent basis.
Develop and submit to regulators milestones and financial modelling
Review of clinical coding and impact on income.
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
Level of recording of non-recurrent TEP versus recurrent TEP.
Timely planning of TEP programme to ensure future delivery
Risk source Strategic Insight and Foresight Anticipated effect of controls Reported at Board meeting aligned to performance trajectory and
performance report
05
10152025
Target score
Risk score
Page 14 of 29
Strategic Priority (Objective)
Corporate Objective 2 Corporate Objective 6
BAF Ref:
AF 1.1, 1.24
Risk ID number:
CR3618 linked with AF3489
Risk Description : If demands on the service outstrip capacity this may result in inability to deliver the 4 hour
Emergency Access Standard
Executive Director Lead
Director of Operations
Assurance Committee
Operational Group
Current Risk Score (L x C)
4 x 5 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
1 x 5 = 5
Target Gap Score
15 Serious
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current Reported performance
information and impact on
patient flow
Date When Target Risk score expected to be achieved
Reduction of risk score is dependent on sustained proven performance and ability to influence external
partners
Rational for Risk appetite
The Trust is not willing to risk the ability of the organisation to delivery safe effective care
Controls:
Additional ED Management Support and Infrastructure.
Extended out of hours management presence.
Bed meetings.
Additional staffing (all services)
Breach analysis and system resilience work.
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?):
Emergency Department daily performance report
Bed meeting reports
Executive Team reports
Board reports
Divisional action plans and analysis of information
Improvement Board Actions
Detailed Improvement Plan and system resilience work.
Mitigating actions: (what more should we do?)
Daily management oversight on a patient by patient basis.
On site management support overnight.
In-reach from medical consultants to ED
Trust wide focussed work regarding patient flow
System resilience work
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
Impact of Third party action and third party decision – e.g. impact of Primary care and
Local Authority
Risk source
Strategic Insight and Foresight
Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score reduced)
Reported at Board meeting aligned to performance trajectory and performance report
05
10152025
Target score
Risk score
Page 15 of 29
Strategic Priority (Objective)
Corporate Objective 6,
BAF Ref:
AF2.8
Risk ID number:
AF3526
Risk Description : Failure to achieve Value For Money (VFM) services and financial sustainability Executive Director Lead
Director of Finance
Executive Team
Assurance Committee
Finance & Performance
Committee
Current Risk Score (L x C)
4 x 5 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
10 Concern
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
The Trust is currently working to
a deficit plan, therefore is not
currently financially sustainable
Date When Target Risk score expected to be achieved
Unable to quantify currently. The achievement of this for all services will only be realised with the
achievement of a fully Integrated Care System
Rational for Risk appetite
The Trust is not willing to risk the ability of the organisation to achieve NHS Improvement
requirements and financial sustainability
Controls:
Standing Financial Instructions (SFI’s) in place
Routine monthly service and financial meetings
Regular monthly reporting to Executive Team and Board
Monthly TEP reporting to Executive Team /Board
Contract performance meetings
Planned process
Scheme of Delegation. Budgetary Systems and Procedures
Appropriate insurance protection established
Activity Planning income and activity
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?):
Strategic plan in place to work with other organisations to ensure sustainability going
forward
Audit Committee
Finance and Performance Committee
Trust Board Report.
Internal and External Audit Reports to Audit Committee
Annual (External) Audit. Annual Report to Trust Board on Financial Plans and Budgets
for the new year
Mitigating actions: (what more should we do?)
Divisional action plans and recovery plans where required
Implementation of CPT plan and formation of an integrated Care organisation
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
No gaps in assurance identified
Risk source
Strategic Insight and Foresight
Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score reduced)
Reported at Board meeting aligned to performance trajectory and performance report
05
10152025
Target score
Risk score
Page 16 of 29
Strategic Priority (Objective) Corporate Objective 6 BAF Ref: AF2.9 Risk ID number: AF3527
Risk Description : Failure to achieve:
a) Cash/ liquidity targets,
b) Capital Investment within planned resources
c) Capital Absorption rate targets
Executive Director Lead
Director of Finance
Assurance Committee
Finance & Performance
Committee
Current Risk Score (L x C)
4 x 5 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
10 Concern
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
The Trust requires financial
support to achieve liquidity
targets and deliver the Trusts
Efficiency Programme
Date When Target Risk score expected to be achieved
The delivery of the financial plan for 2016/17 should be achieved by April 2017 however this should be
assessed in the context of the longer term financial plan
Rational for Risk appetite
The Trust is not willing to risk the ability of the organisation to achieve NHS Improvement
requirements and financial sustainability
Controls:
SFIs and Scheme of Delegation. Budgetary Systems and Procedures
Capital Budget Monitoring. Cash Flow monitoring and forecast against monthly profile over a two
year forward look
Treasury Management Policy
Business case development controls.
Monthly Board reports
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?):
Monthly finance reports to Finance and Performance Committee and Board
Audit Committee reports (shadow investment committee)
External Audit opinion on Accounts
MIAA Audit
Mitigating actions: (what more should we do?)
Divisional action plans and recovery plans where required
Implementation of CPT plan and formation of an Integrated Care Organisation
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
No gaps in assurance identified
Risk source
Strategic Insight and Foresight
Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score reduced)
Reported at Board meeting aligned to performance trajectory and performance report
05
10152025
Target score
Risk score
Page 17 of 29
Strategic Priority (Objective)
Corporate Objective 6,
BAF Ref:
AF5.1
Risk ID number:
AF4059
Risk Description : Failure to deliver Trust Efficiency Programme Executive Director Lead
Director of Finance
Assurance Committee
Finance & Performance
Committee
Current Risk Score (L x C)
4 x 5 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
10 Concern
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
To be confirmed following Board
development session
Date When Target Risk score expected to be achieved
Currently being reviewed to be reported at the next Board meeting aligned to performance trajectory
Rational for Risk appetite
To be confirmed following Board development session
Controls:
Benchmarking with other organisations to ensure challenge and appropriateness of TEP
Review of Lord Carter Report to ensure TEP reflects outputs of reports
Ensuring valuing care efficiency programme is communicated effectively across the organisation
Divisional structures performance manage delivery of TEP
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?):
TEP Assurance Meeting
Operations Board
Finance and Performance Committee
Trust Board
Divisional Performance Groups
Internal Audit VFM work covers arrangements in place to deliver TEP
Mitigating actions: (what more should we do?)
Revised programme of financial management
Certify that all material non-recurrent TEP's have also been subject to a rigorous QIA
Fully develop schemes to deliver the TEP target on a recurrent basis.
Develop and submit to regulators milestones and financial modelling
Review of clinical coding and impact on income.
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
Level of recording of non-recurrent TEP versus recurrent TEP.
Timely planning of TEP programme to ensure future delivery.
Risk source
Strategic Insight and Foresight
Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score reduced)
Reported at Board meeting aligned to performance trajectory and performance report
0
5
10
15
20
25
Target score
Risk score
Page 18 of 29
Strategic Priority (Objective)
Corporate Objective 1, Corporate Objective 4, Corporate Objective 5, Corporate Objective 6.
BAF Ref:
AF2.6, AF2.8
Risk ID number:
CR 4201
Risk Description : Healthier Together
Risk that the Trust will be in breach of its financial control limit due to the significant stranded costs caused by
the reconfiguration of emergency and elective (cancer) general surgery as part of the Healthier Together
Programme across Greater Manchester.
Unless recurrent transformational funding is agreed the loss of income to the Trust would be far greater than
the levels of costs which could be safely extracted.
Currently GM is proposing to fund 2 years non recurrent stranded costs which would leave the organisation in
serous financial deficit
Executive Director Lead
Director of Operations
Assurance Committee
SQOGG
Current Risk Score (L x C)
4 x 5 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
10 Concern
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Reconfiguration across Greater
Manchester effecting services
and financial income
Date When Target Risk score expected to be achieved
Unable to assess at this time
Rational for Risk appetite
The Trust is not willing to accept risk with the preference being for maintaining financial stability
Controls: (what are we currently doing about the risk?)
Continue to engage with the Healthier Together Clinical Advisory Group and inform the Trust Executives
of any significant financial and/or clinical implications.
Ensure identified actions are worked through and completed
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?):
Monitoring of data and financial position.
Executive Management Team Board Reports
Mitigating actions: (what more should we do?)
Continue to attend HT clinical advisory group
Input into key work streams, finance, human resources, cancer MDT.
Contribute to and complete the outline business case and identification of stranded costs vs costs
which can be influenced
Completion of detailed bottom up analysis of stranded costs vs costs to be extracted.
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
Ultimately the controls are third party reliant.
Risk source
Operational performance and finance
Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score
reduced)
Continued transformation and financial awareness.
05
10152025
Target score
Risk score
Page 19 of 29
Strategic Priority (Objective)
Corporate Objective 1, Corporate Objective 3
BAF Ref: AF1.23 & CR3482 Risk ID number:
CR 4183
Risk Description
There is a risk of delayed patient diagnosis and/or treatment as a result of lack of availability of
radiologists/radiology staff in the service. This is related to risk CR770, reduced sustainability of Radiology
Services.
This risk is multifaceted and impacts on activity and the ability of the department to undertake investigations
within timescales, particularly to support the cancer pathways
• report investigations within timescales
• quality of service provided
• delivery of key objectives
• budgetary control
• reduction of backlogs (see risk no. 1880)
• Workload pressures - stress on the current workforce due to long working hours/complexity of work
Executive Director Lead
Director of Operations
Assurance Committee
SQOGG
Current Risk Score (L x C)
5 x 4 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
3 x 4 = 12
Target Gap Score
8 Close monitoring
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current reported performance
information
Date When Target Risk score expected to be achieved
July 2017
Rational for Risk appetite The Trust is not willing to accept risk with the preference being for
maintaining service stability
Controls: (what are we currently doing about the risk?)
use of locum and agency radiologist reporting and direct clinical sessions EG ultrasound scanning and
Breast interventions
Radiographer reporting
advanced practice
Consultant Radiographer in post
planned development of additional radiographer advanced practice
outsourcing of CT and MR scanning and reporting
use of WLI and ECP’s
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?):
Reports to
Divisional Governance meeting
SQOGG
Mitigating actions: (what more should we do?)
submission of Radiology staffing paper to Executive Team in early 2017
Scoping exercise to identify possibility of support from local organisations across GM.
Review of options to widen scope of practice/skill set of radiographer staff in the mid to longer term
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
Locum cover not sustainable in the long term due to high cost implication
locum availability
heavy reliance on very small substantive Consultant Team
Risk source Risk register, and Operational performance Anticipated effect of controls To be monitored closely to ensure impact is minimised
05
10152025
Target score
Risk score
Page 20 of 29
Strategic Priority (Objective) Corporate Objective 4, Corporate Objective 6 BAF Ref: AF4.8 Risk ID number: CR 4012
Risk Description : Banking Trojans now using Locky Ransomware and potential for data to be unavailable due
to encryption of files
Executive Director Lead
Director of Performance & Informatics
Assurance Committee
IM&T
Current Risk Score (L x C)
4 x 5 = 20
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
10 Concern
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current IM&T infrastructure and
local intelligence
Date When Target Risk score expected to be achieved
Currently being reviewed to be reported at the next Board meeting aligned to performance trajectory
Rational for Risk appetite
The Trust is not willing to accept risk with the preference being for maintaining delivery systems
Controls: (what are we currently doing about the risk?)
ITIL (Information Technology Infrastructure Library) change Control process in place.
IM&T Group structure.
Risk Assessment in place with plans to mitigate.
Strengthened structure to support service flow and ownership within IT.
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?):
Monitoring of data/incidents.
Executive Management Team Board Reports
Exception Reports
Audit – Internal & External
Mitigating actions: (what more should we do?)
All user communication
Propose to block macro’s at point of entry into the Trust for all email communications
Review options to enforce disablement of Macros within Office or quarantine emails with macros
from none trusted sites
User Training – Information Security as part of mandatory training
Review options to block the downloading of documents with macros enabled – This would require
significant investigation due to risk of impact.
Purchase of software to reduce the risk further
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
Ultimately the solution is operator reliant.
Knowledge and Skills Gaps
Risk source
Operational performance
Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score
reduced)
Continued stability and prevention of incidents.
Embedding of best practice re user responsibility.
Improved understanding, communication and visibility
05
10152025
Target score
Risk score
Page 21 of 29
Strategic Priority (Objective)
Corporate Objective 1, Corporate Objective 2, Corporate Objective 3
BAF Ref:
AF1.23 AF1.24 & AF4.6
Risk ID number:
CR 4147
Risk Description : Ability to consistently sustain and maintain a workforce with capability and capacity to
deliver community nursing services
Executive Director Lead
Divisional Directors and Head of Adult Services / Head of
Children, Young People & their Families Services
Assurance Committee
Operational Group
Current Risk Score (L x C)
4 x 4 = 16
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
3 x 4 = 12
Target Gap Score
4 Tolerable
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current IM&T infrastructure and
local intelligence
Date When Target Risk score expected to be achieved
Unable to quantify at this time
Rational for Risk appetite
The Trust does not have any risk appetite for tolerating risk to quality of service
Controls: (what are we currently doing about the risk?)
Continue to encourage self-management at all visits, particularly for administration of injections
Review of existing workforce provision and exploration of options for transformation of services.
Daily scoping of work across the whole service to try to minimise the mismatch between demand
and capacity
Assurance: (how do we know if the things we are doing are having an impact and can we validate
or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?):
CRIG
Service Quality and Operational Governance group and sub groups reporting to Quality
and Governance Committee
Regulatory compliance monitoring
Mitigating actions: (what more should we do?)
Engagement from finance and HR to support timely recruitment to current vacancies
Review of resources and services to obtain a robust baseline and align existing skills and
competencies with service requirements.
Leadership model review
Assess the need for further workforce development ensuring services are sufficiently resourced to
meet service requirements
Identify DN representation for each of the neighbourhoods and links with all GP practices. Continue
to engage in and influence the development of integrated neighbourhoods and identify
opportunities for new care models that transformation will enable
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
No gaps identified
Risk source
Incidents, Complaints and Operational performance
Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score
reduced)
Unable to quantify at the current time.
05
10152025
Target score
Risk score
Page 22 of 29
Strategic Priority (Objective)
Corporate Objective 1,
BAF Ref:
AF1.12
Risk ID number:
CR3472 linked with Risk CR656
Risk Description : The ability to consistently apply, sustain and maintain processes relating to the
management of medicines is compromised due to inappropriate prescribing of drugs/ineffective medicines
management and/or theft/ loss of drugs
Executive Director Lead
Medical Director, Director of Operations
Assurance Committee
Quality and governance
Committee, Operational Group
Current Risk Score (L x C)
4 x 4 = 16
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
3 x 4 = 12
Target Gap Score
4 Tolerable
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current IM&T infrastructure and
local intelligence
Date When Target Risk score expected to be achieved
It is expected that this risk score will reduce by Quarter 4 following assertive focus on medicines safety
Rational for Risk appetite
The Trust does not have any risk appetite for tolerating medicines regulatory risks
Controls: (what are we currently doing about the risk?)
Medicines Management Committee
Compliance with CAS Alerts for medicines
Drugs and Therapeutic Group and Medicines Safety Work Stream
Joint working arrangements with CCG re antibiotic prescribing
Antimicrobial management Team
Pharmacy stock control systems and procedures.
Ward stock control systems and procedures.
Review of Trust Medicines Policy
Assurance:
Drug and Therapeutic Committee
Service Quality and Operational Governance Group and sub groups reporting to Quality
and Governance Committee which has the Chief Pharmacist as a member
Safety Walk rounds
Periodic progress reports to Safety Programme Board
Audit Committee and Clinical Audit reports
Internal Audit reviews regularly undertaken
Pharmacy Dept. undertakes quarterly audits of compliance against Medicines Policy
and Safety Thermometer monitoring against metrics.
Regulatory compliance monitoring
Mitigating actions: (what more should we do?)
Medicines management Patient Safety Work Stream and programme
CQC assurance plan and agreed action
Recommendations and actions following the MIAA Audit Report and the Review of Service to be
completed.
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
No gaps identified
Risk source
Incidents, Complaints and Operational performance
Anticipated effect of controls Recommendations and actions following the MIAA Audit Report
and the Review of Service will reduce the risk
0
5
10
15
20
25
Target score
Risk score
Page 23 of 29
Strategic Priority (Objective)
Corporate Objective 1,
BAF Ref: AF1.12 Risk ID number: CR4219
Risk Description : Radiology requests on Lorenzo for in patients and out patients are being cancelled by the
Radiology department without reference to the requesting clinician
Executive Director Lead
Medical Director, Director of Operations,
Assurance Committee
Service Quality and Operational
Governance Group
Current Risk Score (L x C)
4 x 4 = 16
Risk Direction
Date of last review:
April 2017
Target Risk Rating
1 x 4 = 4
Target Gap Score
12 Serious
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current incident information and
local intelligence
Date When Target Risk score expected to be achieved Rational for Risk appetite
The Trust does not have any risk appetite for tolerating clinical risks of this nature
Controls: (what are we currently doing about the risk?)
Medicines Management Committee
Patients that are cancelled are re-booked and letter sent to the Radiology department.
Assurance:
Service Quality and Operational Governance Group and sub groups reporting to Quality
and Governance Committee
Periodic progress reports to local Quality and Safety Board
Mitigating actions: (what more should we do?)
Speak with and write to the management team in Radiology requesting immediate action.
Radiology department are looking to invest in a system to solve the stated issue
All Trust consultants to be emailed informing them of the risk and potential compromise this may
have to their practice
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
Radiology department are aware of the issue. Radiology state that they have a system
in place to notify the relevant clinician. Clinicians are not aware of this system and have
not received emails.
Risk source
Incidents, and Operational performance
Anticipated effect of controls Recommendations and actions following and the review of system
will reduce the risk
05
10152025
Target score
Risk score
Page 24 of 29
Strategic Priority (Objective)
Corporate Objective 1, Corporate Objective 3
BAF Ref: AF1.12 Risk ID number: CR4302
Risk Description: Introduction of IR35 tax regulations on the 6th April 2017 may increase existing issues
relating to medical and nursing staff.
Executive Director Lead
Medical Director, Director of Operations,
Assurance Committee
Service Quality and Operational
Governance Group
Current Risk Score (L x C)
4 x 4 = 16
Risk Direction
NEW*
Date of last review:
April 2017
Target Risk Rating
2 x 4 = 8
Target Gap Score
8 Close monitoring
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current staffing information and
local intelligence
Date When Target Risk score expected to be achieved
This risk is still under assessment in relation to achievement of the target risk score
Rational for Risk appetite
The Trust does not have any risk appetite for tolerating clinical risks of this nature
Controls: (what are we currently doing about the risk?)
Daily discussions with medical staffing team to optimise rotas.
Substantive recruitment continues, including international recruitment
Internal bank rates increased to try and mitigate financial impact on clinicians and encourage rota
fill.
Communication with clinicians to try and understand and mitigate their concerns/issues.
Assurance:
Service Quality and Operational Governance Group and sub groups reporting to Quality
and Governance Committee and Trust Board
Mitigating actions: (what more should we do?)
Ongoing monitoring and oversight by Senior Managers and Clinicians
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
None identified
Risk source
Operational performance
Anticipated effect of controls Reduction in clinical risk and impact on services
05
10152025
Target score
Risk score
Page 25 of 29
Strategic Priority (Objective)Corporate Objective 1, Corporate Objective 6
BAF Ref: Risk ID number: 4212
Risk Description : Delays/inability to obtain microbiology results
Risk of missing a significant infection due to delay/inability to obtain microbiology results andtherefore risk of mis-treating a patient with an inappropriate antibiotics which may result inmorbidity or death.
Doctors time taken to chase results is a risk of less clinical time (more so at weekends/nights) toprovide clinical care. Risk of delay in clinical decisions and prolonged hospital stay due tomicrobiology samples being delayed in being transported to Manchester, delay in being put forcultures and direct microscopy and delay in results being received from the Manchester Laboratory.
Executive / Divisional LeadMedical Director Divisional Director
Assurance CommitteeDivisional Governance Meeting
Current Risk Score (L x C)4 x 4 = 16
Risk DirectionNEW*
Date of last review:April 2017
Target Risk Rating1 x 4 = 4
Target Gap Score12 Serious
Date of next review:May 2017
Graph of Risk over time Risk AppetiteNonelow
ModerateHigh
Significant
Rationale for current score:Incidents
Date When Target Risk score expected to be achieved Rationale for Risk appetiteInappropriate prescribing of Anti-biotics.
Controls: (what are we currently doing about the risk?)
Active chasing up of results.
Emails to laboratory regarding risks of delay in samples being sent and viewed.
Assurance: (how do we know if the things we are doing are having an impact)
SQOGG
Divisional Safety & Quality Group
Mitigating actions: (what more should we do?) Directorate Manager for Diagnostic Services/Associate Divisional Director for Scheduled Care to
liaise with CMFT regarding concerns.
Gaps in assurance and actions not being actioned
Risk sourceClinical Risk
Anticipated effect of controls (when reduction is risk trajectory expected /risk scorereduced)To be agreed in line with Trust approach
0
5
10
15
20
25
Target score
Risk score
Page 26 of 29
Strategic Priority (Objective)
Corporate Objective 5, Corporate Objective 7
BAF Ref:
AF4.2
Risk ID number:
AF3488
Risk Description : Failure to ensure on-going compliance with NHS Improvement Provider Licence requirement Executive Director Lead
Company Secretary with Executive Team
Assurance Committee
Trust Board
Current Risk Score (L x C)
4 x 5 = 15
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
5 Tolerable
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current IM&T infrastructure and
local intelligence
Date When Target Risk score expected to be achieved
To be achieved and sustained on a continual basis
Rational for Risk appetite
The organisation is not prepared to accept risks to the ability of the Trust to maintain compliance
with the Provider licence
Controls: (what are we currently doing about the risk?)
Board reporting in line with FT provider licence requirements
Board Financial reporting procedures fit for purpose
FT metric performance framework
Regular contact with Monitor and Board reporting re actions taken to maintain authorisation
Assurance:
Regular contact with NHS Improvement and Board reporting re actions taken to
maintain authorisation
Trust Board seminars
Board Reports
Financial governance infrastructure
MIAA Audit – review of Annual Report
Mitigating actions: (what more should we do?)
Continuous implementation of required actions by all staff at levels required
Implementation of action plan re TEP identification and implementation of Trust Improvement
Programme and Agreed Monitoring action
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
No gaps in control identified
Risk source
NHS Improvement Provider licence requirements and Regulatory Monitoring
Anticipated effect of controls
It is anticipated that current controls and mitigations will align performance to ensure compliance
05
10152025
Target score
Risk score
Page 27 of 29
Strategic Priority (Objective)
Corporate Objective 4, Corporate Objective 6
BAF Ref: AF4.8 Risk ID number: AF3491 linked to
CR3511 and 3604
Risk Description: Failure to have in place an IM&T infrastructure and Service supporting the organisational
objectives. (Linked to AF 4.8)
Executive Director Lead
Director of Performance & Informatics
Assurance Committee
Quality & Governance Committee
Current Risk Score (L x C)
3 x 5 = 15
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
2 x 5 = 10
Target Gap Score
5 Tolerable
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current IM&T infrastructure and
local intelligence
Date When Target Risk score expected to be achieved
Unable to quantify as assessment is still being undertaken in respect of additional IM&T risks transferred or
arising out of the integration of services
Rational for Risk appetite
The Trust is not prepared to accept risks to the achievement of acceptable outcomes
Controls: (what are we currently doing about the risk?)
Director of Performance and Informatics Leadership.
ITIL (Information Technology Infrastructure Library) change Control process in place.
IM&T Group structure.
Risk Register in place with plans to mitigate.
Strengthened support service flow and ownership within IT
Assurance:
Significant reduction in number of unscheduled outages impacting Trust services.
Executive Management Team Board Reports
Exception Reports
Audit – Internal & External (MIAA)
Third party reviews and feedback
Mitigating actions: (what more should we do?)
Production of a detailed 1-3 year roadmap with 4-5 at a holistic level.
Review of roadmap at key junctions, changes in business strategy or 6-monthly.
Alignment of resource structure to meet the business model.
Identification and mitigation plans reported via the risk board.
IM&T Group in place to support developments across the Trust.
Single points of failure to be identified and mitigated against.
Departmental business plans in place in the event of an IT outage.
Skills gaps to be addressed through training matrix.
Funding for some elements of disaster recovery requirements
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
Lack in business understanding of the infrastructure supporting key services.
Financial constraints.
Technical refresh programme supporting the business strategy.
Business strategy is not in place.
Business leads not engaging with IT through Change Control and Service Desk.
Skills Gaps.
IM&T Group
Risk source
Operational performance
Anticipated effect of controls Continued stability as experienced over the last twelve months.
Embedding of best practice utilising the ITIL model.
Improved understanding, communication and visibility
05
10152025
Target score
Risk score
Page 28 of 29
Strategic Priority (Objective)
Corporate Objective 1, Corporate Objective 2
BAF Ref: Risk ID number:
CR3997
Risk Description : Inconsistent temperatures in NICU
Clinical risk to babies dropping temperatures and nurses are giving, what could be considered as, conflicting
advice to parents about wrapping babies. This is due to dropping temperatures in breastfeeding room and
room 2 on NICU, due to fluctuating environmental temperature, especially at night and on cold days. This has
the potential to lead to babies needing to be swaddled and/or put back into incubators.
Executive Director Lead
Director of Operations
Assurance Committee
Service Quality and Operational
Governance Group
Current Risk Score (L x C)
5 x 3 = 15
Risk Direction
Date of last review:
April 2017
Target Risk Rating
1 x 3 = 3
Target Gap Score
12 Serious
Date of next review:
May 2017
Graph of Risk over time Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Incident occurrence
Date When Target Risk score expected to be achieved
It is expected that this risk score will reduce by Quarter 4 following assertive focus on medicines safety
Rational for Risk appetite
The Trust does not have risk appetite for tolerating incidents of this nature
Controls: (what are we currently doing about the risk?)
Medicines Management Committee
Breastfeeding room: doors are kept closed. Wall thermometers in situ; temperature monitoring is
ongoing.
Staff are advised to keep the door closed, when this is safe and feasible.
Wall thermometers in situ; temperature monitoring is ongoing.
Estates Manager continues to lead on the management of this risk; plan of action to fully rectify this
issue remains outstanding. New vents installed to regulate temperature.
Assurance:
Service Quality and Operational Governance Group and sub groups reporting to Quality
and Governance Committee
Safety Walk rounds
Periodic progress reports to local Quality and Safety Board
Mitigating actions: (what more should we do?)
Interim Head of Estates will review the building management system for anomalies. Director of
Estates and Facilities has oversight of the NICU risk assessment to ensure awareness and for
reflected risk assessment on estates to ensure cohesive team work to mitigate the risk.
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
No gaps identified
Risk source
Incidents,
Anticipated effect of controls Monitoring is initially demonstrating controls may be stabilising
the issue, it is expected the risk should be reducing once controls are demonstrating consistent
compliance
05
10152025
Target score
Risk score
Page 29 of 29
Strategic Priority (Objective)
Corporate Objective 1, Corporate Objective 6
BAF Ref: Risk ID number:
CR4158
Risk Description: Transfer of the Microbiology laboratory Services to Manchester Royal Infirmary to begin
earlier than anticipated, commencing October 2016, and relates to IT issues with Telepath and ICNet
connectivity (IP Electronic Surveillance System). No ICNet connection for a period of 27 days whilst remedial
works to solve the connectivity Issues takes place
Executive Director Lead
Chief Nurse
Assurance Committee
SQOGG
Current Risk Score (L x C)
3 x 5 = 15
Risk Direction
Unchanged
Date of last review:
April 2017
Target Risk Rating
3 x 3 = 9
Target Gap Score
6 Close monitoring
Date of next review:
May 2017
Graph of Risk over time
Risk Appetite
None
low
Moderate
High
Significant
Rationale for current score:
Current IM&T infrastructure and
local intelligence
Date When Target Risk score expected to be achieved
To be reviewed once the connectivity issues is resolved
Rational for Risk appetite
The Trust is not willing to accept risk of disruption brought about by business contingency and
maintains an overall preference for safe delivery options
Controls: (what are we currently doing about the risk?)
Notification by email (NHS.net accounts) on a daily basis plus additional phone call with urgent
results
Manual opening of cases into ICNet and inputting of results.
Assurance:
Provision of manual systems
Daily monitoring of communication
Mitigating actions: (what more should we do?)
Business continuity plans in place
Gaps in assurance and actions not being actioned (what additional assurances should we seek?)
External pressure and decisions influence the ability of the Trust to limit action
Risk source
Restructuring of service delivery of Microbiology to Manchester Royal Infirmary
Anticipated effect of controls
With proposed actions implemented the Risk will reduce from a Major to a Moderate in Severity
although will remain as a "red" risk
05
10152025
Target score
Risk score
TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27 April 2017
Agenda Item 7e
Title Sealed Documents – Quarter 4 2016/17
Sponsoring Executive Director Tom Neve
Author (s) Tom Neve
Purpose To notify the Board of the documents to which theTrust seal has been applied in Quarter 4
Previously considered by This report has not been considered by any othermeeting
Executive SummaryThe Trust’s Seal has been applied on three occasions during Quarter 4 of the 2016/17financial year
Related Trust Objectives Objective 6To deliver against the required local/nationalregulatory frameworks and standards, inaddition to securing the most effective andefficient use of resources to deliver servicesthat we provide directly or indirectly throughout partner organisations
Risk Assurance – risk impacted uponN/A
Legal implications/Regulatoryrequirements
Complies with the Trust’s Standing Orders
Financial ImplicationsN/A
Has a quality impact assessment beenundertaken?
N/A
How does this report affectSustainability?
N/A
Action required by the BoardTo note that the trust’s seal has been used on three occasions during Q4 of the 2016/17financial year
Sealed Documents – Quarter 4 of 2016/17
The Trust’s Standing Orders require a report to the Trust Board identifying alldocuments to which the Common Seal has been applied during the precedingquarter. These documents were secured and sealed under “Tameside and GlossopIntegrated Care NHS Foundation Trust”.
The Trust’s seal was applied on the following occasions during quarter 4 of the2016/17 financial year:
1. Lease for Stamford Unit from L and M
2. Deed of novation – Consort Healthcare
3. Lease for Stamford Unit (replacement documents)
TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017
Agenda Item 8a
TitleQuality and Governance CommitteeAggregated learning summary report –attached
Sponsoring Non-ExecutiveDirector
Ms T Kalloo
Author (s) John Fletcher, Director of Quality and Governance
Purpose To note/receive
Previously considered by Not applicable
Executive Summary
Summary aggregated learning report
Related Trust Objectives Relates to all Corporate objectives
Risk Assurance – risk impacted upon Relates to all areas of risk
Legal implications/Regulatoryrequirements
None identified
Financial Implications None
Has a quality impact assessment beenundertaken?
Not applicable
How does this report affectSustainability?
Not applicable
Action required by the Board
The Board is asked to receive and note the Summary notes of the walkrounds undertakenand the Summary Aggregated Learning Report.
Page 2 of 7
Quality and Governance Committee
The Quality and Governance meeting took the form of assurance walk rounds. Walkround teamswere convened with Non-executive Directors and Executive Directors supported by Quality andGovernance Unit. The walkround process was unannounced to the areas visited.
Real time assurances were sought and received on the implementation of work previouslyreported through the Governance processes to the Committee and Trust board. Members fedback that the process had provided assurance of implementation of the reported workprogrammes and the progress made to improve and ensure Quality and Safety of serviceprovision. The reports from these walkrounds including any inconsistencies identified will befeedback to the Clinical and service leads to inform further improvement.
The specific areas of focus in the walkrounds were to seek assurance that the actions identifiedfrom the CQC assurance plan had been implemented, to seek assurance on the pilot projectscommenced and production of discharge letters in some medical areas were delivering theanticipated benefits and to speak to Porters and domestic staff following the transfer to an inhouse service.
The areas visited were Maternity Ward 27, Neonatal Intensive Care unit (NICU), Medical Wards31, 40, 41, 42, 46 the Whitehouse and a number of Domestics and Porters who were available.For each area the context of the review was identified and aligned to issues and previousassurance reports to the Committee with potential lines of enquiry being identified in relation toObservation, conversations with patients, relatives and staff as appropriate.
The visit to the Maternity ward and the NICU are both located in the Charlesworth Building, thegeneral fabric of the Charlesworth building was noted as a concern which would require furtherattention and assessment, and be considered in the estates strategy. However the contrast of thispart of estate in the context of the newly upgraded Antenatal suite was noted. Despite this thefeedback received from Patient and family members spoken to in both areas very positive aboutthe care, treatment and services received.
In the maternity ward the visitors were assured that the actions planned following the CQCinspection had been taken relating to replacement of furniture and fridge temperature monitoringappeared to be consistently monitored. The impact of the new ward manager was also noted.However, it was proposed that the ward environment could be further improved and declutteredwith further actions agreed. Consideration was also discussed for what further work on the wardcould take place to upgrade the facilities.
Within the NICU unit it was noted that whilst most CQC actions were completed, some action werestill being progressed, and improved ward communications were being refined and acommunications book to be implemented. The issue of temperature control in one area was still aconcern. Work to monitor this with Estates and Facilities had been progressed and changes made,however the issue had not been resolved, and was currently on the Risk register. It was agreedthat the executives would escalate and review further with the Estates team to understand.
In the medical wards the review team split to cover a greater number of areas. On ward 31 it wasnoted that there was a new ward manager on the ward and band 6 nurse being recruited to furtherstrengthen the ward leadership. It was noted that the area was a specific focus of the Chief Nursewho was overseeing a weekly meeting and improvement work being undertaken which hadcommenced. This included staff recording feedback on what the shift had been like to work on adaily basis on the ward.
Page 3 of 7
The ward felt calm and well organised, the CQC specific action re fridge temperature monitoringwas taking place consistently, and positive feedback was again received from the patients spokento. However, it was noted that recruitment of permanent staff continued to be an issues and theuse of temporary and locum staff a cause for concern which was monitored several times dailyand reported and escalated through the bed meetings to ensure safe staffing levels weremaintained throughout the whole site.
On Ward 40 the Respiratory ward a pilot project using Physiotherapists to support staffingresources appeared to be working very well and had been well received by the team membersspoken to, and was providing addition support and training for ward staff to enhances their skillswith the therapies offered on the ward. Whilst it was acknowledged that further nurse recruitmentwas required and being progressed, it was noted that pilot had developed good team workingacross disciplines. Assurance was noted on the other CQC actions and the feedback from patientwas overwhelmingly positive.
On ward 41 and 46 again the environment was reported to appear calm and well managed calmand well managed, assurance was noted that the CQC actions appeared to be consistentlyimplemented and the new resuscitation trollies were noted to be in place and being monitored,again the patient feedback was positive. On ward 41 the area of the ward assigned to dementiacare included a memories room used which the review team were impressed with.
On Ward 42 Staff interaction with the patients was excellent, and the feedback again was positive,however there were some inconsistencies in the completion of some of the actions required noted,and the ward environment felt less well organised and cluttered. The issues identified werediscussed with the Ward Manager and matron of the ward to identify support needed some delaysin provision of discharge letter production had been identified and is being managed by thedivisional management team.
The improvement work achieved in the Whitehouse over 12 months ag was noted to have beenmaintained, and the staff spoken to were overwhelming ley positive about the continuesachievement of the turnaround times for the discharge letters transcription undertaken. No delayswere identified. It was noted that the Whitehouse building could do with some externalmaintenance which may benefit the internal state of the building. Of particular note was the staffnotice board at the entrance which identified current information and the teams’ position with allmandatory training updates all staff talked positively about being up to date with all mandatorytraining and appraisals.
The engagement with porters and domestics included two Porters who were new and had onlybeen here four months and the other only two weeks. Both were very positive with no negativeword to say. They had undertaken local induction and training. However the four domestics whilsthappy with their working environment and the equipment available provided feedback that nothinghad changed and was a lack of communication of what was taking place in the Trust. Theyidentified that they met their supervisor regularly but had not had regular team meetings, howeverthey had been notified that monthly team meetings were to commence, and hoped that this wouldimprove communications.
The issue was raised around the buffing of floors; Domestics informed the team that they are notallowed to buff as patients with dementia may think the shiny floor is water, however they did notbelieve they could remove all the marks on the floor without the buffers, and they were concernedthat this may reflect on the perceived cleanliness of the Trust. This was agreed to be escalatedwith the management team. It was noted that the Domestic’s and Porters spoken to were a creditto the service they all went and helped the patients, their attitude and demeanour was first class.
Page 4 of 7
The committee noted the feedback and assurance provided. Specific feedback will be provided tothe areas visited and issues identified escalated on the day of the visit or with the managementteams
Trish KallooApril 2017
Page 5 of 7
Summary Aggregated Learning information –
Initial Data for March 2017 **still being validated
Incidents reported March 2017 **
New incidents (reported in month- includes delayed reports) 938
Reported with Moderate harm 20
Reported with Major harm 2
Reported with Catastrophic harm 1
Never Event 0
RIDDOR reported incidents 1
Complaints and PALS issues
New Complaints 40
New MP enquiry 0
New External complaint 0
New Enquiry 2
New PALS issues 154
Total issues received 199
Re opened Complaints 4
Issues /cases responded to 203
Complaints %age closed in agreed timescale 92%
Average time to close issues/cases (working days) 12
Number issues on-going @ time of monthly report 105
Ombudsman Cases upheld 0
Other Indicators
Mortality reviews required 51
Initial Mortality reviews undertaken at time of report within 14 days 51
Inquests with TGH involvement closed /heard 7
Coroner-Prevention of Future Death report (Regulation 28) 0
Potential claims received in month 18
StEIS reports - Internal issue 7
StEIS reports - Never events 0
Safeguarding Adult cases - Allegation on hospital care 14
Safeguarding Adult cases - Allegation on other care 4
DOLS - Cases reported to Supervisory Body 10
PREVENT - Cases reported 0
Compliments 891
Page 6 of 7
Aggregated Dashboard – December 2016 – February 17 dashboard
Incidents reported December 16 January 17 February 174 month
avg trend12 monthavg trend
New incidents (reported in month- includes delayed reports) 940 982 858
Reported with Moderate harm 10 15 19
Reported with Major harm 0 1 0
Reported with Catastrophic harm 1 0 1
Never Event 0 0 0
RIDDOR reported incidents 1 1 1
Complaints and Concerns December 16 January 17 February 174 month
avg trend12 monthavg trend
New Complaints 26 43 38
New MP enquiry 1 0 0
New External complaint 0 0 0
New Enquiry 3 0 0
New Concerns (PALS) issues 115 159 148
Total issues received 150 205 192
Re opened Complaints 7 5 8
Issues /cases responded to 158 176 188
Complaints %age closed in agreed timescale 96% 96% 97%
Average time to close issues/cases (days) 7 6 13
Ombudsman Cases upheld 0 1 0
Complaints & Concerns by Month by Directorate
Top Incident Causes reported withModerate harm and above
February 2017
Slips/Trips/Falls
Pressure Ulcers
Specimen Error
Medication
Failure To Follow Procedures
Staffing Issues
Top issues reported in February 2017 related to
Clinical Treatment
Communications
Prescribing
Admissions & Discharges (Excl Delayed Discharge)
Privacy, Dignity And Wellbeing
Patient Care
Page 7 of 7
Top issues reported in February 2017 related to
Communications
Appointments
Clinical Treatment
Values And Behaviours (Staff)
Other
Admissions & Discharges (Excl Delayed Discharge)
Indicators December 16 January 17 February 174 month
avg trend12 monthavg trend
Mortality reviews required 97 111 77
Mortality initial reviews undertaken (@time of reporting) 97 111 77
Inquests with TGH involvement closed /heard 8 11 8
Coroner-Prevention of Future Death report (Rule 43 ) 1 0 0
Potential claims received in month 14 8 10
Themes reported
Morality – themed feedback to Division for learning from reviews Consistent use of NEWS
Record keeping standards
DNAR
Re-assessment and of patients
Inquest and Coroner n/a
Indicators December 16 January 17 February 174 month avg
trend12 monthavg trend
StEIS reports – Internal issue 4 4 9
StEIS reports – Never events 0 0 0
Safeguarding Adult cases – Allegation on hospital care 14 6 15
Safeguarding Adult cases – Allegation on other care 12 9 10
DOLS - Cases reported to Supervisory Body 11 9 22
PREVENT – Cases reported to Supervisory Body 0 1 0
Compliments 1032 867 877
Themes reported
StEIS Related to Infection control and patients admitted with Pressure ulcers
Care related issues as above
Adult Safeguarding allegations/issues relate to Pressure Ulcers
General Care
Physical Abuse
Self-Neglect
1
TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017
Agenda Item 8b
Title Minutes of the Audit Committee held on 21ST
February 2017
Sponsoring Executive Director Claire Yarwood - Director of Finance
Author (s) Claire Yarwood - Director of Finance
PurposeTo inform the Board of the discussions held by theAudit Committee at its meeting in April
Previously considered by Not previously considered.
Executive Summary :
The attached reflect the minutes of the Audit Committee which met in April
Related Trust ObjectivesTo deliver against the required local andnational frameworks in order to meet all therequirements of the Trust’s operating licenceand the commissioners’ requirements
Risk Assurance – risk impacted upon 723 – Failure to ensure on-going compliancewith the terms of FT Authorisation
Legal implications/Regulatoryrequirements
In breach of Licence
Financial ImplicationsNone
Has a quality impact assessment beenundertaken?
No
How does this report affectSustainability?
Not Applicable
Action required by the Board
The Board is asked to note the minutes from the Audit Committee.
2
AGENDAITEM 3
AUDIT COMMITTEE
Date of Meeting: 21st February 2017 Time: 9.00 am Location: Silver Springs Meeting Room
Present Position InitialMrs A Dray Non-Executive Director (Chairperson) ADMr M Taylor Non-Executive Director MT
In AttendanceMs C Yarwood Director of Finance CYMs L Hulme Assistant Director of Finance, Financial Services LHMr T Neve Trust Board Secretary TNMr J Fletcher Head of Assurance & Governance JFMrs D Chamberlain KPMG DCMr M Holden Partner Governor MHMrs J Bowles Porter Public Governor JBPMr M Husaini Public Governor MHMr N McQueen Mersey Internal Audit Agency Anti-Fraud Manager NMMr Steve Connor Mersey Internal Audit Agency SCMs S Dowbekin Mersey Internal Audit Agency SD
ApologiesMs Karen James Chief Executive KJMr P Connellan Chairman PCMrs T Kalloo Non-Executive Director TKMr P Weller Director Quality and Governance PW
Item NoDescription Action
01/2017 Apologies
As above.
02/2017 Declaration of Interests
None declared
03/2017 Minutes of the meeting held on 8th December 2017
The minutes were approved subject to the following amendments:
57/2016 – the sentence ‘SD confirmed that the following Management requests havebeen finalised; Consultant Job Plans, Medical Locums and Well Led Self-AssessmentWorkshops’ is to be corrected to read ‘SD confirmed that the Management requestre Consultant Job Plans has been finalised. Those for Medical Locums and Well Led
3
Self-Assessment Workshops are outstanding’
04/2017 Action Log
The action log has been updated as per the discussion and is attached.
05/2017 Internal Audit
5.1 - Progress Report
SD provided an update on the latest Internal Audit Progress Report and outlined thefollowing key points.
Work has been completed on follow ups and a management request for medicallocums. As previous discussed at the Committee, management requests will bepresented by management at a later date.
The follow up report has two purposes, one to review the internal processes formanaging internal audit recommendations and also to undertake an independentassessment of the position of the Internal Audit recommendations.
It has been determined that the Trust has a robust process for monitoringrecommendations and the independent assessment reconciles to what the Trust isstating.
There are a number of pieces of work in progress and the overall plan is on schedulefor completion by the end of the financial year.
CY advised the Follow Up report has been presented to the Executive Team meeting.The outstanding items were discussed and it was stressed and acknowledged that anychanges to the recommendations are documented to provide evidence for scrutiny.
5.2 - Audit Committee Update
The report was provided for information. SD highlighted the upcoming events forawareness.
5.3 - Assurance Framework Benchmarking Report
The report was provided for information and consideration. SD highlighted the keypoints for information. The review focussed purely on Assurance Frameworks and nosignificant issues have been identified within the process.
AD enquired if having a high number of risks is positive or negative, SD confirmed thatit is not a negative sign as the risks are organisationally specific and reflects how theBoard Assurance Framework is used. SC explained it is more about what works forthe Trust and the average number is around fifteen and no judgement calls are beingmade in terms of what is right or wrong. CY advised that given where theorganisation has come from in terms of being a Keogh Trust and the previous lack of
4
reporting around risks and issues the report is helpful to the Board around quality andsafety as well as the financial position. JF added the report reflects the progress theorganisation has made and confirmed high numbers are expected due to theintegration and transformation work being undertaken.
MT acknowledged the report endorses the fact that the Trust embraces risk cultureand actions are undertaken to address the issues.
5.4 - External Quality Assessment
SC presented the report and explained there is a mandatory requirement for allInternal Audit Providers to have an independent assessment against the standards.As a result MIAA have been assessed as being fully compliant with the standards, withsome areas for enhancements being identified.
06/2017 Anti-Fraud
6.1 - Progress Report
NM presented the report and outlined the items of interest.
The national fraud initiative has highlighted that the Trust had just under 500duplicate matches in total and work is ongoing to resolve the issues.
The Register of Interest is being reviewed and NM and SD have attended a DivisionalOperational Board to provide information on conflicts of interests, register of interestand general fraud awareness training. NM has attended a Cardiology Business Groupto provide a presentation of fraud awareness which included information on conflictand registers of interest and which interests need to be reported to the Trust.
The local proactive protection exercise into Supplies and Stores is ongoing and theresults are being written up and will be reported to the next meeting.
MT asked if the exercise has highlighted any serious concerns. CY acknowledgedthere are some issues regarding protocols to work on but there are no serious issuesfrom fraud perspective. It has been concluded that this exercise should have beenconducted by Internal Audit rather than the Fraud Investigator.
MT enquired if there is a material issue with regards to finance. CY advised she is notaware of any issues at this stage.
There is one ongoing investigation from 2015/16 which has now been passed to theCPS to consider prosecution.
The second investigation is in the initial enquiry stage.
6.2 - Self Review Toolkit
5
NM presented the draft version and highlighted the changes to the report and askedfor approval to submit to NHS Protect.
AD highlighted the item which states that effectiveness is monitored by the fraudSurvey and enquired whether a high number of responses have been received. NMreplied that the responses have not been high. CY suggested exploring the options tointroduce another method to collect the information.
AD asked if conflict of interest has been rated as Green due the amount of work beingundertaken to ensure the information is presented to groups of staff. NM confirmedhis continued attendance at Divisional meetings (Medicine and Surgery) and advisedthat he is also presenting at meetings with Community staff.
AD enquired how the national framework agreement related to the agency cap. CYadvised that a national review of Agencies has been undertaken and a nationalagreement has been obtained to keep the prices under the cap. This is a way ofnationally controlling the Agency prices. If Agencies meet the nationally setframework they can apply to be added to the Framework. If Agencies not on theFramework are used a report has to be submitted to NHSI.
MT requested information regarding the internal challenge process which informed theoutcome of the self-review. NH stated that NHS Protect challenge the submissionshould an inspection take place. CY acknowledged there are currently no internalforums to investigate issues around fraud and the options on how counter fraud willbe utilised across the Acute and Community services are to be explored. CY outlinedthe benefits of the Anonymous telephone contact number. SC explained an internalQuality Assurance review across a number of clients has been undertaken whichincluded calibration across the piece and advised this would provide some degree ofassurance in terms of how the Trust stands against others and the consistency interms of the way actions are undertaken.
6.3 - Fraud Investigations Benchmarking
Following the benchmarking exercise it has been determined that the Trust’s policiesand procedures provide the necessary information regarding reporting of any potentialfraudulent issues.
NM confirmed the Trust is comparable with other Trusts regarding the types of fraudreported.
07/2017 External Audit
7.1 - Audit Plan and Fees
DC presented the report and outlined the key points.
Materiality levels are £3.25m which has increased from last year and this is torecognise the increase in income following the transfer of the Community services.This means working towards a performance materiality of £2.4m and audit differences
6
over £160k will be reported.
NHS income and NHS receivables is a new significant risk which recognises theuncertainty around Sustainability and Transformation funding and also the incentivesfor Commissioners and Providers to hit the control total and how this may impact onto agree of balance for the process at year end.
Valuation of property plans and equipment was also considered a significant risk lastyear, due to the high value and potential for material misstatement. It has beenrecognised that the Trust has had a valuation in year and a paper is to be presentedto a future meeting and will be reflected appropriately in the Accounts.
Fraud risk from the management over ride controls and fraud risk from revenuerecognition are the significant risks required by the Auditing Standards and all theaudit processes are tailored to ensure they are covered throughout the audit.
The next responsibility is reaching the value for money conclusion which is describedin the report and the arrangements in place to achieve the outcomes are reviewed.
The first initial risk assessment for the BFM value for money risks is the Managementof the Trust’s cash position and the second risk is the delivery of the Trust EfficiencyProgramme which is similar to the previous year and is around achieving the financialposition and ensuring the correct arrangements are in place.
The integration of Community services has been assessed as a risk which recognisesthere has been a significant transaction in-year as a new area of business has beentaken on.
The content of the Quality Account is reviewed to ensure it matches requirements andalso to ensure this aligns to other information available. Two mandated and one localindicator (chosen by the Governors) are also reviewed to check the data quality toensure this is reported appropriately.
AD asked for clarity around the requirements for the Quality Account. JF replied thatthe work required for the Quality Account continues throughout the year, and therequirements for the Quality Account have not changed substantively. Therefore, theinformation received via the Quality and Governance Committee will support the vastmajority of the metrics which are required to be reported through the QualityAccounts. Metrics which are not submitted to the Quality and Governance Committeeare presented to Trust Board or Finance and Performance Committee as theinformation in the Quality Account also includes financial and performanceinformation.
AD enquired if any issues had been identified with outstanding debts with other NHSorganisations. CY confirmed there are currently no issues to report.
7
7.2 - Technical Update
DC highlighted two items for which actions should be considered, Publication of thenational tariff and also the very Senior Manager Guidance.
CY provided an update and advised that the new HRG 4 tariff has been implementedand the contract has been adjusted accordingly. As the contract has moved to ablock contract there will be no impact in-year. The Senior Manager guidance hasbeen adhered to in relation to the appointment of an Interim Chief Nurse.
08/2017 Charitable Funds Minutes 15th November
The minutes were noted.
09/2017 Agreement of Final Accounts Timetable 2016/17
LH provided an overview of the timetable and advised the report highlights keysubmission dates for the Committee and includes the Audit Committee dates for Apriland May. A report is to be provided to Finance and Performance Committee prior tosign off and the new Non-Executive Directors are to be invited to attend.
The Committee approved the timetable.
10/2017 Losses and Special Payments Quarter 3
LH advised that the total losses and special payments as at December is at £22k withthirteen new cases being reported.
MT asked if the Pharmacy losses relate to medication which has gone over the expirydate. LH confirmed this is correct and advised that the high number stated forOctober was due to a manual input error which has since been corrected in the report.
11/2017 Update on work plan for Annual Governance Statement
JF advised the work plan has been developed to provide context around how theQuality Governance Framework is routinely monitored and assessed throughout theyear. The framework within the paper articulates the requirements and provides acommentary on how the requirements are being fulfilled. The point of note since theprevious report is the provision of Community Services.
CY reiterated this piece of work is not a requirement but is an example of really goodpractice which provides assurance that the work is being undertaken all year roundand commended JF/PW and the Governance Team for the quality of the workproduced.
AD asked if issues are incremented each time. JF confirmed it is an incrementaldocument and advised a lot of information will be iterative from year to year and thesystems in place will identify assurance in-year that systems have been reproduced orrecycled.
8
AD cited the statement that review work is taking place to support two or three areasand asked if there is an end point of the review to support the final version. JFadvised a comprehensive Community Service review has been undertaken whichinvolved over sixty staff and fifty visits. The review also included an MIAA audit and areport is to be published around the learning disability element and the results willinform the Community Services provision, provide assurance and highlight actionswhich may need to be taken around the requirements for CQC domains.
JF advised no significant concerns were raised. The issues highlighted were aroundstrengthening leadership structures within Community and these are currently beingrealigned within the organisation. It is anticipated that before the end of March areport will be available for distribution to Divisional Teams to provide anunderstanding of what actions are required.
12/2017 Review of the Risk register BAF recommendations
JF highlighted the proposed changes to the Risk Management process and reportingarrangements and advised the proposal has been submitted to Risk ManagementCommittee and is to be presented to Quality and Governance Committee and TrustBoard.
A review of the Risk Management processes and systems has been undertaken andadvised that one of the concerns which has been identified is that focus is given tohow the risks are graded and it is proposed to introduce the concept of a target riskgap score to refocus the organisation’s view on which risks need to take priority.
A change to the way the symbols are used to provide additional clarity has beensuggested and the risk appetite has been rationalised. This will ensure the target riskrating will be vigorously assessed and the target scores set appropriately. This willalso allow the opportunity for the Board and other elements of the organisation toapply a different rigour to the implementation and mitigation actions to achieve realistexpectations of risk reduction. The other element to be included within future reportsis the concept of heat mapping.
The Committee were asked to adopt the revisions and recommendations tosignificantly strengthen the risk assessment process.
AD enquired as to where the initiative came from. JF advised the motivation camefrom the need to reduce the risk exposure and highlight the opportunities for riskreduction. If the target risk is aligned correctly the appetite for managing the riskscan be determined.
DC advised that organisations are starting to look at risk appetite and is recognised asgood practice.
DC suggested a trajectory for the risk over time is included. JF confirmed that theanticipated target achievement date is to be added to the report.
9
MT commended the paper and observed the revisions provide more granularity andstated the gap scoring matrix is a good idea. MT also suggested working out thecosts of managing this type of model. JF replied that if the focus is directed to theright place and people ask the right questions it should cost less overall.
MT commented in relation to Trust Board risk target score metric that he felt it isunusual to see a gap score of 10 being the maximum score as all others have a range.JF explained the logic for the score given the maximum risk score is 25. Howeveragreed that it should probably indicate greater than 10. A gap score of this magnitudescores would indicated that significant mitigation is possible but not yet achieved if thegap score is realistic.
MT stated his approval of the addition of the graph of risk over time within the mainpapers.
MT asked who sets the risk appetite and how is it agreed. JF explained Trust Boardwould set the this for the BAF risks and in terms of reviewing the Board AssuranceFramework on an annual basis is one of the calibrations that if the report is acceptedwould be imposed by adopting the process.
AD enquired how it will be determined that the changes are correct as there will notbe a baseline of the movements of the risks. JF explained that the heat map analysiswill be undertaken quarterly for the Board Assurance Framework risks. JF advised oneof the solutions is to have a pre-mitigation risk and a post mitigation. CY suggestedhaving a post project evaluation.
The final document will be presented to a Trust Board development session fordiscussion and final approval.
JF
13/2017 Outcome of Consultation of Managing Conflicts of Interest in the NHS
TN provided a verbal update and advised NHSE have produced new guidance and thelink will be distributed to all the Non-Executive Directors. The link is also to be addedto the intranet and the policy is to be amended to include the revisions.
Staff awareness sessions are to be arranged, along with including the informationwithin payslips.
TN
14/2017 Governance of the Care Together Programme
AD explained a significant amount of work is being undertaken strategically aroundchanges to the organisation going forward and expressed concerns around theunderstanding of how the Care Together governance arrangements mapped into theTrust’s governance arrangements in order to be sighted on risks, opportunities andcosts etc.
CY highlighted an issue with the timing for approval of the Care Together ProgrammeBoard minutes. A meeting is to be arranged between AD and CY to discuss the issuesin more detail.
AD/CY
10
15/2017 Asset valuation and Impairment
LH stated that the valuation of the assets has been identified as a significant risk andthe paper details the actions undertaken to value land, buildings and equipment.
The District Valuer has been on site and completed the valuation. Within thecalculation a gross internal area has been used to calculate the valuation and this haschanged from previous years and this is due to estates undertaking a more thoroughcalculation on the estates software system. Each change has been reviewed byEstates, finance and the District Valuer.
The element of the building which is through the PFI has not previously been valuedexclusive of VAT and as a result has reduced this element of the building value.
The figures are indicative as they are calculated on the indices and when the valuationwas performed it is showing that the valuation of the land and buildings haveincreased by around £6m.
The valuation of Equipment has to ensure the assets are still in existence and in useand also that there are no indictors that the asset has impaired. A paper has beenpresented to the Executive Team meeting and Operational Board which outlines theresponsibility for staff to manage the assets and communicate to Finance anyindications of any potential impairing event.
A list of the assets has been sent to each responsible Department Manager todetermine whether the equipment is still in existence and in use.
CY reiterated the issues around the gross internal area as this is a material changeand advised that the organisation did not have any mapping software prior to therecent purchase of MICAD. A robust assessment has been undertaken and is nowvalued appropriately.
AD asked how this cross references to the work which External Audit undertakes. DCadvised it is recommended a paper to be brought to Audit Committee to provide theinformation and assurance and explained as part of the work the information will betaken and discussed with the District Valuer to separately gain assurance. The issuearound the VAT on the PFI buildings will also be discussed.
CY advised that Trusts are only required to complete a full valuation every five yearsand desk tops valuations can be undertaken in between.
AD asked what impact will the £6m increase have on the Trust. CY confirmed this willincrease the value on the balance sheet. LH explained it could also increase thedepreciation charge which will have an impact on the I&E account. Once the indiceshave been completed the changes will be reflected within the accounts and the impactwill be forecast.
LH explained that the reduction in the PFI is classified as an impairment and this will
11
technically increase the deficit, but does not affect our control total as we aremonitored against the deficit before technical adjustments.
MT asked if this will create any issues with any of the External bodies. CY confirmedthis is not the case.
MT asked for assurance that the equipment audit has a robust process in place. LHexplained the process and advised responses are being chased weekly and assistancehas been offered to all departments. CY stated that this exercise will highlight anysignificant issues and actions can then be put in place to address these movingforward.
The Committee approved the content of the report.
16/2017 Review of Audit Committee Work plan 2017
The workplan was amended as per discussion.
17/2017 Effectiveness of the Committee
AD and LH to liaise to discuss and agree the process. AD/LH
18/2017 Internal Audit procurement
MIAA representatives left the meeting for this agenda item.
CY advised that the contract with MIAA is due to expire at the end of May andexplained a procurement exercise for the internal audit function would normally beundertaken.
However, on a Greater Manchester basis through the GM Health and Social CarePartnership a number of back office functions are being reviewed to establish if theycan be provided more economically across Greater Manchester. Greater Manchesterhas been awarded Path Finder status which is a DoH and NHSI process which putsscrutiny, review and funding to evaluate whether systems should bring together backoffice functions.
One of the assets in Greater Manchester is perceived to be Mersey Internal AuditAgency who work for a significant number of organisations across the North West.
The proposal is for MIAA to become hosted by Greater Manchester and have anagreed plan over a three year period.
The recommendation from the GMHSCP is for any Trust due to go out to the marketfor Internal Audit services over the next year to put this on hold until the process isput into place.
The paper provided articulates the options available in terms of procurementmethodology and provides a recommendation for option C to be undertaken. Option
12
C is to procure under the framework for one year with the possibility of extending fora further year if necessary.
The paper has been presented to the Executive Team meeting and option C wasrecommended. The Audit Committee were asked to agree the recommendation.
MT agreed to the recommendation in principle and asked if it is considered that MIAAprovide value for money for the service they currently provide to the Trust and askedif they are challenging enough. CY stated in her opinion MIAA do provide value formoney as the added element is the benchmarking across other organisations in theNorth West, development events are also available often at no charge to the Trustwhich also provide a network opportunity.
TN agreed that the Trust gets value for money and added they can be challengingwhen necessary.
DC confirmed that in her experience MIAA are providing good and challenging reports.
The Committee endorsed undertaking Option C.
19/2017 Attendance Matrix
The matrix was noted.
20/2017 Care Together Programme Board Minutes
These were discussed under item 14/2017
21/2017 Any other business
There was no other business.
22/2017 Summary of points to escalate to Board
Annual governance statement Review of the Risk Register and BAF Conflict of interest policy Asset valuation and impairment Internal audit procurement
23/2017 Date of Next Meeting: 25th April 9.00am – Silver Springs Board Room
24/2017 Private Discussions with Internal and External Auditors
1
TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017
Agenda Item 8c
TitleMinutes of the Finance & Performance Committee held on16th February
Sponsoring Executive Director Claire Yarwood - Director of Finance
Author (s) Claire Yarwood - Director of Finance
PurposeTo inform the Board of the discussions held by the Finance& Performance Committee at its meeting in February
Previously considered by Not previously considered
Executive Summary :The attached reflect the minutes of the Finance and Performance Committee which met inFebruary
Related Trust Objectives 5 – Develop a strategic plan to secure clinical andfinancial sustainability for the Trust in conjunctionwith the Trust’s strategic partners and keystakeholders
7 – to deliver against local and national frameworksin order to meet all the requirements of the Trust’soperating licence and the commissioners’requirements.
Risk Assurance – risk impacted upon 723 – Failure to meet, deliver Trust’s financial planLegal implications/Regulatoryrequirements
In breach of Licence
Financial Implications NoneHas a quality impact assessment beenundertaken?
No
How does this report affectSustainability?
Review financial sustainability of organisation
Action required by the BoardThe Board is asked to note the minutes from the Finance & Performance Committee.
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FINANCE AND PERFORMANCE COMMITTEEAgenda item 2
Date of Meeting: 16th February 2017 Time: 2.00 pm Location: Board Room, Silver Springs
Present Position Initial
Mr M Taylor Non-Executive Director (Chair) MTMrs A Dray Non-Executive Director ADMrs A Higgins Non-Executive Director AHMrs C Yarwood Director of Finance CYMrs P Cavanagh Director of Operations TCMr P Nuttall Director of Performance and Informatics PN
In attendance
Mr P Connellan Chairman PCMrs K James Chief Executive KJMs A Bracegirdle Associate Director of Finance ABMs J McShane Divisional Director of Operations (Surgery - W&C) JMMs A Bromley Director of Human Resources (part meeting) ABr
Additional attendees
Ms W Brelsford Public Member – Council of Governors WB
Item No Description Action
15/2017 Apologies
Ms S Derbyshire, Mrs G Parker
16/2017 Minutes of the previous meeting 19th January 2017
Minutes of the meeting were approved as an accurate record.
17/2017 Action log
Action log has been updated as per discussion and is attached.
18/2017 Trust Efficiency Programme
4.1 Month 10 report
AB provided an update and advised £6.4m savings have been identified which is slightlybetter than plan. £1.9m of this are in year recurrent and it is forecast that the £7.8m willbe delivered of which the fill year effect is for £4.3m recurrent savings.All the teams are still being encouraged to identify further recurrent savings and accelerate
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2017/18 saving schemes where possible.
AD asked if there is a formal process to deal with schemes which are not delivering. ABexplained that all schemes are within the tracker and if it is forecast that the scheme willnot deliver the Division will still have the same target to achieve so therefore areplacement scheme will have to be identified. CY advised if an investment had beenagreed this would cease if it was decided the scheme would not deliver the savings.
4.2 2016/17 TEP – Lessons Learned
CY stated that as part of the Audit report on the Efficiency Programme there was arecommendation which suggested a formal lessons learned exercise was undertaken andthe to-date lessons learned has been useful to help shape the programme for 2017/18.
AH asked if the budget holders will use the savings monitoring tool, AB confirmed that it isplanned for this to be available on the Trust intranet.
AB advised there is also a section for the Local Health Economy (LHE) to add the datafrom their savings schemes in order to provide a LHE savings position.
A discussion took place regarding providing the report via the intranet for NEDs to view.PN provided an update on the work being undertaken to enable external access to theintranet from non Trust devices.
PC asked where the 25% of savings (Small change/big difference schemes) which havebeen returned to Departments has been spent on. CY explained a number of departmentshave offered the funds to be used towards their efficiency target.
MT stated that the development of the TEP programme and presentation format has gonewell in 2016/17 and was positive about the enhancements being put in place for next yearand acknowledged that lessons have been learned.
4.3 Improvement in Theatre Utilisation
JM provided an overview of the presentation and advised a target for saving of a full yeareffect of £140k TEP was agreed. A number of service improvements have beenundertaken to improve start times and utilisation.
Ensure all staff are aware of the schedule for the day. Working towards a 50 week elective programme. Early bed meeting arranged – to ensure Theatres start on time. Theatre timetable has been realigned. Pre-op scheme Processes have been put in place for cancellations. Team Leaders have been assigned to each theatre corridor. A review of equipment was undertaken. The ‘Golden Patient’ process was rolled out.
Following a recommendation from an internal audit of theatres, a company called FourEyes to support the improvement journey. A significant amount of work has taken placeand theatre utilisation has increased.
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JM advised that the Theatre Team have been shortlisted for an HSJ award andacknowledged the commitment of the team to continue to improve the service. Four Eyeshave agreed to sponsor the table at the event in order for members of the team to attend.
AD asked whether the early finishes have improved over the past few months. JMconfirmed that there are still issues with cancellations due to bed pressures which have animpact on the early finishes.
4.4 2017/18 Medical Staffing Efficiency
JM provided an update on medical staffing and advised the target of £620k has beenincreased by £60k as the Medical Staffing Business Partner was employed on a ‘spend tosave’ basis.
The forecast of the current schemes has identified a gap of around £400k. Five coreschemes have been identified to deliver the target going forward. A further £328k hasbeen identified for cost avoidance. Overall £1m recurrent savings are anticipated at year-end.
The schemes have been broken down into two categories, avoidance and efficiencies.There are two schemes in avoiding expenditure, increasing direct engagement and reviewand reduce payments above the cap and it is anticipated this will deliver around £328k.
A tender exercise is being undertaken for a employing medical agency staff and thesavings will come from the reduced commission fees. A £200k recurrent cost saving isanticipated.
Discussions are being held with JLNC regarding part of the funding for Clinical ExcellenceAwards being put towards the TEP scheme and a decision as to whether or not to offer theawards is yet to be made.
Job plans and on-call arrangements are being reviewed and £200k has been set as atarget for this scheme. The scheme has been Red risk rated as some of the work isbehind schedule. The challenge is to get the final job plans in place by the end of April atthe latest. A test case has been completed within A&E and a system and process for on-call remuneration has been agreed with the BMA.
CY explained the learning from the previous years’ experience is assisting with this year’sprocess with a realistic and achievable target being agreed. KJ acknowledged that robustsystems are now in place to facilitate the challenge with regards to job plans.
19/2017 Operational Performance
5.1 Performance Report
PN highlighted the key points in the report.
2017/18 Activity Plans
2017/18 activity levels have been agreed at a high level and are now being split byspecialty.
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Outpatients
AD asked if there have been any specific actions undertaken to reduce the DNA rates. TCexplained that this work has been part of one of the service improvement projects andthere has been a number of initiatives around text reminder system, more notice given topatients and moving to agreeing appointments over the telephone. A focused piece ofwork has been undertaken in Paediatrics which has reduced the rate significantly. Followup rates have also been reviewed and telephone assessments have been introduced forsome of the services. An advice and guidance service for patients who do not need aface-to-face appointment is also being introduced.
Single Oversight Framework
The framework is included within the report and around 90% of the metrics are nowincluded. The remaining metrics will be included as soon as the information is available.The format of the report is to be reviewed to ensure the appropriate measures areincluded.
Community Service KPIs
The Information and Governance teams are undertaking a piece of work to agree theCommunity Service KPIs and develop a system in order to measure the KPIs.
AH asked for a breakdown of the process undertaken to set the standards for next year interms of performance targets. PN advised that most of the standards are set nationallyand local target setting come through varies different areas for example the efficiencyprogramme. AH enquired if there are any contractual issues from the Commissionerswhich are driving the standards. PN confirmed the contract KPIs are predominantly thesame as the national standards.
5.2 Financial Performance Month 10 Summary Review
AB provided a summary of the financial performance and advised that the Trust has adeficit of £14.1m at the end of January 2017 which is slightly better than plan. The Trustis now forecasting a year end deficit of £15.5m, which is better than the £17.3m deficitplan.
As it was assumed that the STF funding would not be received due to the Q3 and Q4 A&Etarget not being achieved, mitigation was but in place though a balance sheet reviewwhich identified £400k which could be used to benefit the position. In January it wasannounced by NHSI that if the financial position was improved they would match theimprovement by additional STF funding. As the position was improved by £400k anadditional £400k was allocated. A balance sheet review is undertaken on a regular basisand an additional £500k has been identified which means further matched funding will begiven from NHSI which results in the year-end deficit of £15.5m. In addition, the Trust isappealing the Q3 and Q4 STF funding related to delivery of A&E due to increased numberof patients compared to the plan. Indications have suggested this appeal will besuccessful.
Agency spend is £10.7m and it is forecast that the £12.5m NHSI target will be achieved.
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A £17.3m loan has been agreed for this year due to the timing of the STF funding. TheDH has advised the Trust will require two different types of loan – a revenue support loanfor £13.2m (interest of 1.5%). This is repayable in 2020. The remainder of the £17.3m isan uncommitted loan (value of £4.1m) for which the Trust can be asked to repay in full atany time.
Capital expenditure is at £1.3m below the plan of £2.5m, but the forecast is to spend thefull £3m as planned.
CY advised a letter has been received from NHSI stating that the Trust is below the targetspend and a return has been submitted to provide assurance that the funding will be spentby the end of the year.
MT stated there is a risk around the independent sector expenditure. JM confirmed thatno further expenditure is planned for the remainder of the year.
PC emphasised that as the whole of Tameside and Glossop health economy will meet itstargets for this year is good news in terms of the overall credibility.
5.3 NHS Improvement Agency Cap Report
ABr provided an update and advised there is currently a reduction in agency expenditureabove the capped rates, particularly within medical staffing and there is steady decline innursing agency spend, although there has been a slight increase in early February due tosickness rates in some areas.
There has been a marked reduction in medical agency usage above the capped rate sincethe HR Business Partner for Medical Staffing commenced in post and there is now aproactive stance around recruitment. The first of the three ED consultants havecommenced in post and the other two consultants will be in post by the beginning of April.
Work is continuing with Management Teams to review the vacancy gaps and ensurerecruitment takes place in a timely way.
There are still issues with recruiting to Band 5 nursing staff. A positive interview eventtook place at the end of January and twenty four posts were recruited to. Five of the staffcan start immedicably and the rest will start later in the year.
There has been an increase in short term sickness on some of the ward areas which hashad an impact in early February and alternative options for recruitment are beingconsidered. Discussions regarding international recruitment are taking place.
There are currently seven WTE gaps within Theatres and the options to recruit to theseposts are being explored.
PC enquired if analysis is completed by day of the week and if there are any lessons to belearnt particularly in relation to sickness. ABr explained that there is a tendency forweekend shifts to experience more sickness and explained this is largely due to agencystaff picking up weekend shifts due to the additional enhancement.
AD asked what actions are being undertaken around retention. ABr advised there is aspecific Recruitment and Retention plan which is discussed at the Executive Meeting each
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week and an action plan has been put in place. A member of the HR team is contactingstaff who have handed in their notice to ascertain what actions could have been taken forthem to remain in post and the Exit Strategy is being reviewed to ensure exit interviewsare undertaken effectively.
A pilot is being undertaken to look at self-rostering and amending shift patterns toestablish if this makes recruitment to nursing posts more attractive. A PreceptorshipNurse is o also working with newly qualified staff and the new starters to provide supportand identify any issues.
AH highlighted the high number of applications for the Clinic Fellow and Trust GradeDoctors. ABr confirmed that only the applicants who meet the person specification will beshortlisted. JM advised a rotation has been offered which has resulted in the high levels ofapplications. AB explained that the HR Medical Staffing team have been working with theDivisions and Operational Managers to look at different ways to attract applicants. Ascoping exercise is being undertaken with the Clinical Skills Facilitators to undergo atraining needs analysis to develop a training programme for nursing staff.
AD asked if the cap level is likely to change on the 1st April, AB advised there has been nonotification received that the cap will change, but there will be an impact following thechanges to the IR35 and meetings are being arranged to go through the implications toagency staff and agree actions.
MT cited the section in the report which states it is projected there will be a cost of £13magainst the cap of £12.5m, and in the Finance paper it is stated the target will be met. CYconfirmed this anomaly is due to the timings of the report the agency report contains datawhich is a month behind the finance report.
5.4 Month 10 Contract Performance
CY advised the paper outlines information on the performance against the variouscommissioner contracts.
The Trust has over performed by £275k as at Month 10 which is predominantly from theother Commissioners other than Tameside and Glossop CCG. There is currently a blockcontract with T&G CCG which has been balanced back to zero variance.
Concerns have been raised about the increased income relating to the Acute CardiologyUnit (ACU) as increased significantly from month 8. The coding of the activity on the ACUis being reviewed. MT requested an update report is provided to the next meeting.
A year-end position has been agreed with Tameside and Glossop CCG which assumesthere would not be an over performance on the contract. However, an additional £1.5mof income from Tameside Council in relation to delivery of performance targets has beenagreed.
CY provided an update following the contract meeting and advised the contract will befully signed by the end of March 2017.
JM
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20/2017 Board Assurance Framework Risk Reporting
CY advised the report details risks and the current scores. Each risk was reviewed and thescores amended accordingly. An explanation as to how the score is agreed is to beincluded within future reports.
AF 2.1 = It was agreed to reduce the score to 8
AF 2.2 = It was agreed to reduce the score to 10
AF 2.8 = It was agreed the score remains at 20
AF 2.9 = It was agreed to reduce the score to 15
AF 5.1 = It was agreed to score remains at 12
TC enquired if achieving a deficit which is better than prediction is a risk to the Trustagainst agreeing the financial plan for next year. CY advised this would not be the case asthe improvement is due to one off balance sheet items and funding allocations for the STFfrom NHSI. This issue has been raised with NHSI who have indicated this will not impacton the control total issued for 2017/18.
AB
21/2017 Effectiveness of Finance and Performance Committee Review
AB explained questionnaires are to be distributed for completion before the deadline andthe results will be presented at the next Committee meeting.
22/2017 Transformation Savings Plan
Item deferred to next meeting.
23/2017Capital and Revenue Investment Group Minutes (January 2017)
The minutes have been provided for information.
24/2017 Workplan
The work plan was amended as per discussion.
25/2017 Summary of points to escalate to Board
Agency Cap report TEP Improvement in Theatre Utilisation Medical Staffing Efficiency
26/2017 Any Other Business
There was no other business
27/2017 Date of Next Meeting: 23rd March 2017 at 2pm Silver Springs Board Room
TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017
Agenda Item 9a
Title Corporate Objectives 2017/18
Sponsoring Executive Director Karen James
Author (s) Executive Team
PurposeTo request endorsement of the Corporate Objectivesfor the 2017/18 financial year
Previously considered by Discussed at Executive Management Team
Executive Summary:The attached Corporate Objectives develop the key themes from the previous year whilstincorporating challenging success criteria to allow us to demonstrate the next phase of thetrust’s continuing improvement and integration journey
Related Trust Objectives All
Risk Assurance – risk impacted uponRelates to all aspects of Board AssuranceFramework and Significant Risk Report.
Legal implications/Regulatoryrequirements
The successful achievement of the trust’scorporate objectives will ensure theorganisation complies with the legal andregulatory requirements of all its regulators
Financial ImplicationsThe corporate objectives have a materialimpact on the financial sustainability of thetrust.
Has a quality impact assessment beenundertaken?
N/A
How does this report affectSustainability?
The achievement of the CorporateObjectives directly impacts on the trust’sfuture sustainability
Action required by the BoardTo endorse the 2017/18 Corporate Objectives
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Corporate Objectives 2017/18
Objective Draft 2017/18 Corporate Objectives Success Criteria
1.
To ensure our patients and users receive harm free care byimproving the quality and safety of our services through thedelivery of our Quality and Safety programme.
We will maintain compliance with the CQC FundamentalStandards of Care
We will maintain our overall CQC ratings at good andaspire to gain outstanding ratings in future serviceinspections
We will maintain and or increase our incident reportingrate per 1000 bed days and aim to be in the top 25% ofTrusts
We will minimize levels of severe and catastrophic harmand be below the national average of 1%
We will ensure our patient safety programme workstreams uses metrics for anticipating and predictingpotential future harm in at least five of the work streamsfor 2017/18
We will achieve the identified CQUIN metric related topatient safety
We will maintain or improve the completed eligible VTErisk assessment at an 98% or above
We will continue to seek improvement of the Trust’smortality indices (HSMR and SHMI) and maintain them inthe ‘as expected’ or “better than expected” bandings
We will continue to ensure learning from Deaths is part ofthe organisational learning and reported in line with thenational requirements
We will achieve the Single Oversight Framework metricrelated to emergency re-admissions within 30 days
2.To improve our patient and service user experience through thedelivery of a personalised, responsive, integrated, caring andcompassionate approach to the delivery of care.
We will further reduce the number of KO41 complaintsper 1000 patient contacts to below 1 complaint per 1,000patient contacts
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Objective Draft 2017/18 Corporate Objectives Success Criteria
We seek to increase the number of recorded complimentsand improve the Compliments to KO41 Complaints ratioby a further 20% to 40% from the Q4 2015/16 baseline.
(PROMS) Patient reported outcomes continue to bereported on for a range of conditions. We will improve ourparticipation rates for Hip and Knee procedures forquestionnaires issued by the Trust from the March 2017baseline and aspire to be better than the nationalaverage.
We will improve our organisational PLACE Scoresreported in 2017 to be at or above the 2016 nationalaverage reported scores: Cleanliness 97.57, Food andHydration 88.49, Privacy, Dignity and Wellbeing 86.03,Condition, Appearance and Maintenance 90.11 anddementia 74.51
The 2017/18 annual improvement measures for Patientand Service User Experience described in the Strategyare:
Friends and Family Testo All in-patient areas to achieve a 30% response
rate.o Maternity to achieve a 30% response rate.o ED to sustain the 25% response rate.o Adult community services to achieve a 95%
response rate.o Children’s community services to achieve a
95% response rate.o Out-patients to achieve a 20% response rate.o All areas to achieve 95% positive response
rating.NHS Survey
o Reduction in disturbance from noise in the in-patient environment.
o Improved levels of support at mealtime.
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Objective Draft 2017/18 Corporate Objectives Success Criteriao Improved involvement in decision making
Active Patient Pathwayso A minimum of 70 patients / service users on active
pathways have been spoken to and their feedbackis being presented to the PEG.
3.
To continue to recruit and retain talented individuals.
To develop our staff and future workforce to support theintegration and transformation of our services.
We will achieve the identified CQUIN metrics related tostaff welfare.
We will deliver organisational development sessionsacross the whole system to underpin delivery ofintegration.
We will roll out a Trust wide apprenticeship programmemaximising the benefits of the apprenticeship levy; we willemploy 85 plus apprentices during 2017/18.
We will develop the current workforce within theNeighbourhood teams using the Health EducationEngland (HEE) Workforce Repository and Planning Tool(WRaPT) to review current capacity and roles andconsider alternative roles.
We will work with Neighbourhood teams and Adult SocialCare teams to further transform services within theCommunity and Primary Care.
With the Chief Nurse and Medical Director we will developrecruitment strategies and plans to enable recruitmentand retention of key roles.
We will develop engagement and communicationmechanisms and strategies to communicate with hard toreach groups to further enhance staff engagement withinthese areas
4.
To continue to align and redesign our hospital, community, socialcare, primary care, mental health and voluntary/community sectorservices in order to facilitate our integrated neighbourhoodapproach.
We will establish a senior managers forum across healthand social to understand services and opportunities andco-dependencies
We will establish new structures and governanceframeworks to support the neighbourhoods, with leadsfrom both health and social care.
We will align existing health and social care serviceswhich provide short term interventions to our patient and
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Objective Draft 2017/18 Corporate Objectives Success Criteriaprovide a link between acute care and neighbourhoodservices into an intermediate tier.
Co-locate the intermediate tier into a single location withina community setting to facilitate integrated working.
We will simplify access to our services and ensureeffective use of resources through;
o The introduction of a single point of contact for allintermediate tier services.
o The delivery of the national e-referral programmefor all outpatient appointments.
Introduce GP streaming within our ED department toensure patients requiring access to urgent care aretreated in a timely manner by services most appropriatefor their needs.
Provide a due diligence report to the Trust Board on thetransfer of Social Care services and Commissioner ledservices which facilitates a decision on the potentialtransfer of services from the Local Authority and SingleCommissioner.
5.
To develop and support our five primary care neighbourhood hubsand key partners to enable them to deliver new integrated servicemodels in order to improve user patient outcomes throughsupporting people:
to prevent ill-health and live healthy, independent liveswherever possible;
to manage any ongoing health conditions more effectivelyin their own homes and communities;
to get easy access to joined-up services in the mostappropriate location.
We will introduce and embed person centred careapproaches and support planning and Patient Activationfor people with long term conditions;
We will systems are fully in place to support people toaccess ‘more than medicine’ services through socialprescribing within every neighbourhood.
We will co-locate neighbourhood teams into a singlelocation within each neighbourhood.
We will continue to work with the public sector partnersto develop community hubs which provide easier accessto joined up services within their communities.
We will continue to work with health, mental health andsocial care partners to deliver a core service offer anddevelop new service models to meet the specific needsof the communities they service.
We will ensure that everyone with a long term conditionwho would benefit has a person centred care andsupport plan.
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Objective Draft 2017/18 Corporate Objectives Success Criteria
We will commence the rollout of the Patient ActivationMeasure to 12,500 people with long term conditions.
6.
To deliver against the required local/national regulatoryframeworks and standards, in addition to securing the mosteffective and efficient use of resources to deliver services that weprovide directly or indirectly through out partner organisations.
We will achieve the identified CQUIN metrics We will maintain compliance with the CQC Fundamental
Standards of Care and maintain our overall CQC ratingsat good and aspire to gain outstanding ratings in futureservice inspections
We will continue to ensure learning from Deaths is part ofthe organisational learning and reported in line with thenational requirements.
We will ensure financial and Trust Efficiency saving plansare delivered against agreed improvement trajectories
We will ensure key performance metrics/standards aredelivered in accordance with national requirements
Achieve the Trust financial plan for revenue, capital andcash.
Delivery of audited annual accounts submitted withinrequired timescales.
TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017
Agenda Item9b
TitleNext Steps on the Five Year Forward View
SponsorKaren James
Author (s)Tom Neve
PurposeTo brief board members of the next steps on the NHSFive Year Forward view document (FYFVNS for thepurposes of this briefing)
Previously considered byThe FYFVNS has previously been considered by theExecutive Management Team and delivered to OpenHouse Forum
Executive Summary: The following is a summary of the key points contained within theFYFVNS document which was drafted by both NHS Improvement and NHS England.
Related Trust Objectives This report relates to all of the trust’scorporate objectives
Risk Assurance – risk impacted uponRelates to all aspects of Board AssuranceFramework and Significant Risk Report.
Legal implications/Regulatoryrequirements
This report impacts on the regulatoryrequirements from NHSI and the CQC
Financial ImplicationsThe FYFVNS will have financial implicationsfor the trust.
Has a quality impact assessment beenundertaken?
N/A
How does this report affectSustainability?
Directly impacts upon the organisationssustainability
Action required by the BoardTo note and discuss the summary briefing on the next steps of the five year forward view.
NHS 5 Year Forward View
Next year the NHS turns 70. New treatments for a growing and aging population mean that
pressures on the service are greater than they have ever been. But treatment outcomes are
far better - and public satisfaction higher - than ten or twenty years ago.
NHS England recently published an update on their NHS 5 Year Forward View and the
following summary serves as an update on each of their focus areas.
Urgent and Emergency Care
The key item to note here is the adjustment to the 95% A&E standard which we will be
required to meet. This is in line with what was announced in the Government’s 2017/18
mandate to the NHS.
These changes are:
• before September 2017 over 90% of emergency patients are treated, admitted or
transferred within 4 hours (up from 85% currently being delivered)
• the majority of trusts will have to meet the 95% standard in March 2018
By October 2017:
• Every hospital must have “comprehensive front-door clinical streaming”.
• Every hospital and its local health and social care partners must have “adopted good
practice to enable appropriate patient flow”. This includes better hand-offs between
A&E and acute physicians, ‘discharge to assess’, ‘trusted assessor’ arrangements,
streamlined continuing healthcare processes, and seven day service (7DS)
discharge capabilities.
By March 2018:
• Trusts should work with local councils to ensure that the extra £1 billion provided in
the March 2017 budget for adult social care is used in part to reduce delayed
transfers of care (DTOC), thereby helping to free up 2000-3000 acute hospital beds.
Progress against this figure “will be regularly published” - the document does not say
by whom or how frequently.
• ensure that 85% of all assessments for continuing health care funding take place out
of hospital in the community setting,
• Implement the “High Impact Change Model” for reducing DTOCs.
It also notes a range of actions that the national bodies will undertake:
• Roll-out by spring 2018 of 150 standardised new ‘Urgent Treatment Centres’ which
will open 12 hours a day, seven days a week, integrated with local urgent care
services.
• Implement the recommendations of the Ambulance Response Programme by
October 2017, putting an end to long waits not covered by response targets.
It also notes a range of actions that the national bodies will undertake regarding NHS 111
and primary care:
• Enhance NHS 111 by increasing from the proportion of 111 calls receiving clinical
assessment by March 2018,
• By 2019, NHS 111 will be able to book people into urgent face to face appointments
• Roll out evening and weekend GP appointments, to 50% of the public by March 2018
and 100% by March 2019.
To support these changes, the FVFVNS outlines the following support measures:
£100m in capital funding, as announced in the budget, to support modifications to
A&Es to enable clinical streaming by October 2017.
Referral to Treatment Waiting Times
The document makes reference to the referral to treatment time 18 week 92% target. It says:
“Looking out over the next two years we expect to continue to increase the number of NHS-
funded elective operations. However given multiple calls on the constrained NHS funding
growth over the next couple of years, elective volumes are likely to expand at a slower rate
than implied by a 92% RTT incomplete pathway target. While the median wait for routine
care may move marginally, this still represents strong performance compared both to the
NHS’ history and comparable other countries.”
Integrated Care
The Five Year Forward View (Next Steps) document has a chapter dedicated to integrating
care. This provides two main functions:
1. Outlining key areas of clarification for STPs (now referred to in the document as
Sustainability and Transformation Partnerships), accountable care system and
accountable care organisation integration models
2. Outlining new policy changes associated with these models
Other areas of interest…
1. Free up 2000 to 3000 hospital beds
• Using the extra £1bn awarded to adult social care in the last budget hospital trusts
“must now work with their local authorities, primary and community services to
reduce delayed transfers of care.”
2. Further clamp down on temporary staffing costs and improve productivity
• Trusts are set a target of cutting £150m in medical locum expenditure in 2017/18.
NHSI will require public reporting of any locum costing over £150,000 per annum.
3. Use the NHS’ procurement clout
• All trusts will be required to participate in the Carter Nationally Contracted Products
programme, by submitting and sticking to their required volumes and using the
procurement price comparison tool.
4. Get best value out of medicines and pharmacy
• NHSI support trusts to save £250m from medicines spend in 2017/18 by publishing
the uptake of a list of the top ten medicines savings opportunities, and work with
providers to consolidate pharmacy infrastructure
5. Reduce avoidable demand and meet demand more appropriately
• NHS provider trusts will have to screen, deliver brief advice and refer patients who
smoke and/or have high alcohol consumption in order to qualify for applicable CQUIN
payments in 2017/18 and 2018/19.
6. Reduce unwarranted variation in clinical quality and efficiency
• Trusts to improve theatre productivity in line with Get it right first time (GIRFT)
benchmarks and implement STP proposals to split ‘hot’ emergency and urgent care
from ‘cold’ planned surgery clinical facilities for efficient use of beds.
7. Estates, infrastructure, capital, and clinical support services
• The NHS and Department of Health are aiming to dispose of £2bn of surplus assets
this parliament, following recommendations from the forthcoming Naylor review.
8. Cut the costs of corporate services and administration
• NHSI is targeting savings of over £100m in 2017/18, from trusts consolidating these
services, where appropriate across STP areas. NHSI is also establishing a set of
national benchmarks.
Mental Health
• Expand the mental health workforce – 800 mental health therapists embedded in
primary care by March 2018, rising to over 1500 by March 2019.
• Reform of mental health commissioning so that local mental health providers control
specialist referrals and redirect around £350m of funding.
Clear performance goals for CCGs and mental health providers, matched by unprecedented
transparency using the new mental health dashboard
Cancer
What still needs to be achieved?
• Introduction of a new bowel cancer screening test for over 4m people from April
2018.
• Introduce primary HPV testing for cervical screening from April 2019 to benefit 3m
women per year.
• Expand diagnostic capacity so that England is meeting all 8 of the cancer waiting
standards.
• Performance incentives to trusts for achievement of the cancer 62-day waiting
standard will be applied to extra funding available to our cancer alliances.
• 23 hospitals have received new or upgraded radiotherapy equipment in early 2017,
and over 50 new radiotherapy machines in at least 34 hospitals will be rolled out over
the next 18 months.
Workforce
• A new nurse retention collaborative run by NHSI and NHS Employers will support 30
trusts with the highest turnover.
• A consultation will be launched on creating a Nurse First route to nursing, similar to
the Teach First programme.
• NHSI will publish guidance on effective electronic rostering.
Undergraduate medical school places will grow by 25% adding an extra 1500 places,
starting with 500 extra places in 2018 and a further 1000 from 2019.
Technology
• By summer of 2017 GPs will be able electronically to seek advice and guidance from
a hospital specialist without the patient needing an outpatient appointment.
• In the summer 2017 an updated online patient appointment system will be launched,
providing patients with the ability to book their first outpatient appointment with
access to waiting time information on a smartphone, tablet or computer.
• The NHS e-Referral Service is currently used by patients to arrange just over half of
all referrals into consultant-led first outpatient appointments. By October 2018 all
referrals will be made via this route, improving patients’ experience and offering real
financial and efficiency benefit.
• By December 2018 there will be a clear system in place across all STPs for booking
appointments at particular GP practices and accessing records from NHS 111, A&Es
and UTCs
TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Report to Public Trust Board meeting of the 27th April 2017Agenda Item 9c
Title Care Together Implementation Plan
Sponsoring Executive Director Trish Cavanagh
Author (s) Stephanie Sloan
Purpose To provide the Trust Board with an overview of the CareTogether programme implementation plan
Previously considered by NA
Executive Summary: The paper provides the Trust Board with a high level implementationplan for the next two years for the schemes led by the ICFT within the Tameside andGlossop Care Together transformation programme
Related Trust Objectives This report relates to:Objective 4 –The development of the CommunityIntegration Plans to support the systems integrationstrategy.Objective 5 – to work with our local communities,partners and stakeholders to develop a new modelof integrated care, central to our five yearsustainability and transformation plan.Objective 6 – To deliver against the required localand national frameworks, as part of GreaterManchester Health and Social Care Devolution.
Risk Assurance – risk impacted upon AF3.3(3532)Failure to identify and/or deal with externalopportunities and threats, particularly in the contextof choice and not maintaining and securing place inthe market
Legal implications/Regulatoryrequirements
This report imparts on the Trust complying with theterms of its Provider license
Financial Implications None
Has a quality impact assessment beenundertaken?
NA
How does this report affectSustainability?
NA
Action required by the BoardThe Board is asked to discuss the update on the models of care and progress to date.
Care Together Implementation Plan
1. Introduction
1.1. This paper provides the Trust Board with a high level implementation plan for the projects
included within the Tameside and Glossop transformational programme, Care Together
which the ICFT has responsibility for delivery of.
1.2. The implementation plan is underpinned by a governance and assurance structure including;
Detailed project documentation for each individual project included in the programme,
including project plans, risks, financial modelling, quality impact assessments and key
performance metrics to monitor impact and benefit realisation.
An overarching implementation plan to map interdependencies and critical path.
A programme risk register to monitor the risks of the programme to the Trust.
An oversight group to monitor progress of the schemes within the programme chaired
by the Executive Director of Operations.
1.3. The implementation plan is a live document and will be monitored and updated on a
monthly basis to assure progress against plan.
2. Implementation Plan
2.1. The implementation plan is provided at appendix one.
3. Recommendation
The Trust Board is asked to note and discuss the Care Together implementation Plan
T&G Integrated Care FT - CARE TOGETHER PROGRAMME IMPLEMENTATION PLAN Appendix 1
PROJECT /MILESTONE
2016/17 2017/18 2018/19
Q1APRIL – JUNE 17
Q2JULY – SEPT 17
Q3OCT – DEC 17
Q4JAN – MAR 18
Q1APRIL – JUNE 18
Q2JULY – SEPT 18
Q3OCT – DEC 18
Q4JAN – MAR 19
DIGITAL HEALTH Advanced Nurse Practitionercommenced
Digital Health Pilot launched in 4care homes & Stamford Unit6/3/17
32 contacts in first 4 weeks (12ED attendances & 8 GP call outsavoided)
Digital Health rolled out toCommunity Response Service1/4/17
New Digital Health staffcommence 8/5/17
Digital Health Service hoursextended 8am – 8pm
Roll out of digital health to all T&G care homes BENEFITS DELIVERYReduction in EDattendances from carehomes.
Reduction inemergency admissionsfrom care homes.
Reduction in GP callouts from Care Homes
Develop Digital Health phase twoReview opportunities to link tocommunity Telehealth / serviceexpansion to other economies /infrastructure use for Advice &Guidance
Roll out Digital Health PhaseTwo
HOME FIRST Home First pilot launched July2016 (wards 41 & POU) rolled outto all wards by January 2017
July 16 – Mar 17 423 patientsreferred for Home Firstassessment & 758 bed dayssaved.
BENEFITS DELIVEREDTrust reduced Delayed TransfersOf Care (DTOC) bed days by33,6% between July 2016 and Feb2017
Additional Health and Social carestaff commence in post toincrease Home First Capacity
Embed Home First model across Acute, community and social care services BENEFITS DELIVERY
Reduction in DTOCs from Acute beds for patients awaiting assessment.
Reduction in emergency admissions through step up services and homefirst in-reach to ED
FLEXIBLECOMMUNITY BEDS
1st Floor of Stamford Unitoperational for Winter Capacity.
Notice Served to Grange View forClosure of Intermediate care beds
Grange View Service Closes 30th
June 2017 (40 Beds).
ICFT to provide all flexiblecommunity beds from Shire Hill(36 beds) and Darnton House (64beds).
BENEFITS DELIVERYclosure of 8 communityBeds 1/7/17 fromGrange View.
Embed flexible community bed model in allcommunity beds.
BENEFITS DELIVERY
Reduction in DTOCs from Acute beds for patients awaiting communitybeds.
Step up capacity available in flexible community beds
GP STREAMING INACCIDENT ANDEMERGENCY
Submit Bid for capital funding tosupport estate works toreconfigure space to delivery GPstreaming in A&E
Activity analysis to map demandfor ED streaming
Development of proposal for A&EStreaming.
Draft Proposal for A&E Streamingpresented at A&E Delivery boardand JMT for discussion andapproval (May 17)
Approval of proposal for A&EStreaming (June 17)
Estate & IT works toenable GP streaming atA&E
Communications acrossall Stakeholders
Commencement of GPstreaming in A&E in linewith national timetable(Oct 17)
SOCIAL CARETRANSFER
Development of Strategic Outlinecase for the transfer of Adultsocial care to ICFT
Adult Social Care Transformationgroup established, led by the
Submission of Strategic OutlineCase for transfer of social careservices to Trust Board / NHSI /SCF for approval (May 2017)
Development of social caretransfer implementation plan
Submission of OutlineBusiness Case fortransfer of social careservices to Trust Board /NHSI / SCF for approval(Aug 2017)
Submission of FullBusiness Case fortransfer of social careservices to Trust Board/ NHSI / SCF forapproval (Dec 2017)
Public & Staffengagement
Implementation of theSocial care transferplan.
Transfer of Socialcare services toICFT complete(April 18)
Director of People at TMBC. including staff and publicengagement Due Diligence Due Diligence
Due Diligence
T&G Integrated Care FT - CARE TOGETHER PROGRAMME IMPLEMENTATION PLAN
PROJECT /MILESTONE
2016/17 2017/18 2018/19
Q1APRIL – JUNE 17
Q2JULY – SEPT 17
Q3OCT – DEC 17
Q4JAN – MAR 18
Q1APRIL – JUNE 18
Q2JULY – SEPT 18
Q3OCT – DEC 18
Q4JAN – MAR 19
INTEGRATEDNEIGHBOURHOODSInfrastructure
5 Integrated Neighbourhoodsidentified.
Structures and governanceframework agreed.
Intermediate Tier of servicesbrought together into a singlestructure to supportneighbourhoods
Core offer and Transformationalfunding prioritised for theNeighbourhood programmeagreed.
Co – location of Intermediate tierservices into Cricket’s lane30/6/17
Glossop Neighbourhood teamcollocated in Glossop PrimaryCare Centre (May 17)
East/Stalybridge, Mossley &Dukinfield Neighbourhood team(health and Social care) co-located into Stalybridge Civic Hall(May 17)
North/AshtonNeighbourhood team(Health and Social care)co-located into AshtonPrimary Care Centre
West/ Droylsden,Denton & AudenshawNeighbourhood team(Health & Social Care)co-located into DentonFestival Hall
South / Hyde, Mottram,Hattersley &LongendaleNeighbourhood Team(Health and Social Care)co-located
Development of an Intermediate Tier SinglePoint of Contact (SPOC) including call centretechnology, admin and clinical triage.
Single Point ofContract (SPOC)for intermediatetier servicesoperational(Sept 18)
INTEGRATEDNEIGHBOURHOODSExtensivists
Extensivist service model, criteriaand standard operatingprocedures approved
2 GP Extensivists in post (1 April& 1 May).
Extensivist service cohortidentified and review undertaken.
Extensivist service pilot May –July 17
Extensivist service fullyoperational (30 Sept 17)
BENEFITS DELIVERY
Reduction in ED attendances for Extensivist cohort.
Reduction in emergency admissions for Extensivist cohort
INTEGRATEDNEIGHBOURHOOSCommunity IVTherapy
Recruitment of IV therapy posts.
Agree referral and treatmentpathways and protocols
Primary care and acuteengagement
Commence communityIV therapy 7 day service
BENEFITS DELIVERY
Reduction in admissions to acute beds for patients requiring IV therapy treatment.
Reduction in length of stay for patients requiring IV therapy regime.
INTEGRATEDNEIGHBOURHOODSAdvice & Guidance
Pilot Advice and Guidanceservices in Cardiology &Paediatrics
BENEFITS DELIVEREDReduction in outpatientattendances for patients usingA&G services
Develop service model, pathways and protocols forcommunity based Paediatric MDT Advice and Guidance(A&G) clinics
Roll out community based Paediatric MDT A&Gclinics
Develop A&G phase twoReview opportunities to use Digital Health infrastructure for A&G,opportunities to roll out A&G across other services
INTEGRATEDNEIGHBOURHOODSSelf Care
Patient activation Measures(PAM) pilot launched
Workforce educationalprogramme for self-carelaunched
Glossop ‘More than Medicine’social prescribing servicelaunched (April 17)
Tameside Social prescribingprovider appointed (June 17)
Tameside & Glossop asset basedprovider appointed
Tameside SocialPrescribing serviceoperational
Asset based grantsawarded
Self care Socialmarketing and social
BENEFITS DELIVERY
Reduction in Acute growth
movement strategylaunched
T&G Integrated Care FT - CARE TOGETHER PROGRAMME IMPLEMENTATION PLAN
PROJECT /MILESTONE
2016/17 2017/18 2018/19
Q1APRIL – JUNE 17
Q2JULY – SEPT 17
Q3OCT – DEC 17
Q4JAN – MAR 18
Q1APRIL – JUNE 18
Q2JULY – SEPT 18
Q3OCT – DEC 18
Q4JAN – MAR 19
COMMUNITY ITSYSTEM
Phased Implementation of community EMIS (complete June 17)
WORKFORCE 3 neighbourhood managersrecruited and in post &5Neighbourhood GP leads in placeas part of the ICFT leadershipteam
Developed a senior managersforum across health and socialcare
Established baseline staffing inintermediate tier andneighbourhoods.
Undertake Organisational development programmeincluding;
Whole system scenario workshops supported byRothwell Douglas
Neighbourhood workforce
Undertaken Workforce analysis review including;
data compilation and analysis using the WRaPT tool andanalysing each to determine skills/capacity,
Analysis of activity data in line with initial modellingsuggestions and assessment alignment between activityand WF.
Mapping patient journeys across the current services toidentify areas of duplication and waste
Develop Neighbourhood Workforce Development Planbased on clinical models and WRaPT assessment
Support Neighbourhood teams to review roles, activities, task and competencies to develop the role requirements for theintegrated neighbourhood workforce.