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Trust Public Board Agenda 29.07.15

Trust Public Board Meeting

TO BE HELD ON WEDNESDAY 29 July 2015

IN THE BOARDROOM, LEVEL 5, WHISTON HOSPITAL

A G E N D A Paper Presenter

9:30 1. Employee of the Month

Richard Fraser

9:35 2. Patient Story Sue Redfern

10:00 3. Public Health Annual Report – Knowsley CCG Presentation Sarah McNulty

10:25 4. Apologies for Absence Richard Fraser

5. Declaration of Interests

Richard Fraser

6. Minutes of the previous Meeting held on 24th June 2015 Attached

6.1 Correct record & Matters Arising

6.2 Action list Attached

10:35 7. Committee Report Executive Team NHST(15)

058 Ann Marr

10:45 8. Committee Report Finance & Performance

NHST(15) 059

Denis Mahony

10:50 8.1 Integrated Performance Report NHST(15)

060 Damien Finn

11:00 BREAK

Trust Public Board Agenda 29.07.15

11:10 9. Committee Report – Quality NHST(15)

061 Sue Redfern

11:15 9.1 HR Indicators NHST(15)

062 Anne-Marie

Stretch

11:25 9.2 Infection Control Report NHST(15)

063 Sue Redfern

11:35 9.3 Safer Staffing Report NHST(15)

064

11:45 10 FT progress report including TDA Self-Certification

NHST915) 065

Damien Finn

11:50 11. Board Assurance Framework NHST(15)

066 Sue Redfern

11:55 11.1 Risk Register Report NHST(15)

067

12:00 12. Medical Revalidation Report NHST(15)

068 Anne-Marie

Stretch

12:10 13. Effectiveness of meeting

Richard Fraser 12:15 14. Any other business

15. Date of next Public Board meeting – Wednesday 30th September 2015

General population – facts and figures • Life expectancy continues to rise for both

males and females, but remains lower than North West and national levels.

• Smoking prevalence (17.9%) in 2014 was highest across Merseyside.

• Alcohol related hospital admissions are higher than the whole of England and North West region.

• 1 in 4 adults reported having low levels of wellbeing.

Main causes of death in Knowsley

in 2013

• Asthma in children and young people

• Childhood obesity • Risk taking behaviour • Educational attainment,

aspirations and preparing for adulthood

• Engagement and involvement

Report overview • Emotional and mental

wellbeing • Children at risk and in

need • Protecting children from

risk • Children with complex

needs • Accident prevention • Vaccination and

immunisation

If Knowsley were 100 people

Emotional and mental wellbeing

• 1 in 10 children and young people aged 5 to 16 suffer from a diagnosable mental health disorder.

• Prevention and early intervention is key.

• Risk factors - poverty, chaotic home environments and disabilities.

• Poor emotional wellbeing in childhood is a key determinant of mental health outcomes and life chances in adulthood.

• Emotional resilience built in childhood leads to lifelong benefits.

Knowsley Headstart Programme • Big Lottery funded programme to improve

resilience in children and young people aged 10 to 14 years. Programme is piloting new ways of providing early

support in four domains of a child/young person’s life: • Time and experiences at school • Experiences outside of school • Home life • Interaction with digital media

Evaluation of the programme will be used to develop and implement a preventative and resilience promoting support system for children and young people.

Emotional and mental wellbeing • Services and resources boroughwide: Child and Adolescent Mental Health Services –

emotional, behavioural or mental health difficulties. Butterflies Programme – loss and bereavement.

Kooth – online and face to face counselling. Ariel Trust – “Cyber Sense” online educational

resource to promote awareness around cyber-bullying and staying safe on-line.

Children at risk and in need

• Children are at risk and in need if they experience one or more of the following:

Live in poverty and/or chaotic home environments Experience or witness issues such as physical, emotional

and sexual abuse Live with a parent who has a mental health problem

and/or long term illness or disability Live with parents who have substance misuse issues or

have sibling with behavioural issues.

• These experiences increase the risk of health harming behaviours in adulthood.

Children at risk and in need

• Work with City Region and local partners to reduce child and family poverty.

• Ensure young carers are supported.

• Knowsley Integrated Recovery Service – supports service users and their families to address substance misuse issues.

Protecting children from risk – domestic abuse

• Not just physical violence - can be emotional too such as threats and controlling behaviour.

• 1 in 4 young people aged 10 to 24 have experienced domestic abuse during their childhood.

• 1 in 3 women and 1 in 6 men have experienced domestic abuse since aged 16.

• Programmes and interventions in place for both victim/survivors and their families.

• Be a Lover Not a Fighter Campaign.

• Operation Encompass.

Protecting children from risk – child sexual exploitation

Chelsea’s Choice • Part of co-ordinated

campaign to raise awareness of child sexual exploitation.

• Drama production watched by over 4,000 young people, plus 1,000 front line staff.

Children with complex needs • Children with disabilities have poorer health, wellbeing and

social outcomes.

• Suffer from inequalities in health, employment, education and the wider society.

• Estimated between 1,100 and 2,700 under 18s living with a disability. 470 with severe disability.

• Numbers likely to be higher as not all are known to services.

• Specialist School Nursing Service delivered by 5 Boroughs Partnership NHS Trust.

Accident prevention • Leading cause of preventable deaths, injuries and hospital

admissions.

• Knowsley has higher levels of accident related hospital admissions than the North West and England.

• 2013/14 - average 30 admissions to hospital due to falls in ages 5 to 17 years.

• Most accidents can be prevented as they often happen as a result of non-deliberate actions or lack of prevention.

• Knowsley Accident Prevention Task Group has been established.

Vaccination and immunisation • MMR uptake rate is good.

• In at risk groups, current uptake of flu vaccination

46.4% falls below target of 75%.

• HPV uptake of 94% exceeds national target of 90%.

• Campaign encouraged university students to have MenC vaccination.

Asthma in children and young people

• Asthma commonly starts in childhood. • At least 3,200 children under age 18 have

asthma. • Being exposed to tobacco smoke, particularly

during pregnancy increases the likelihood. • Exposure to air pollution, mould or damp can

make asthma worse. • Introduction of Smokefree Legislation has had

positive impact. • Education, support and self-management can

help control asthma.

Childhood obesity • Impact on child’s self-esteem, anxiety,

depression and educational attainment.

• 1 in 4 Reception year children are overweight or obese.

• 1 in 3 Year 6 children are overweight or obese.

• 4 out of 5 children who are overweight/obese in their early teens are more likely to be obese in adulthood.

Childhood obesity • Obesity Plan for Knowsley 2014-2017

aims to reduce obesity rates overall. • Promoting physical activity in

teenage girls. • Improving access to green spaces. • Knowsley’s Green Gyms. • Services/programmes available to

address the barriers to achieving a healthy weight.

Risk taking behaviour

• Unhealthy risk taking behaviour includes having unprotected sex, drinking alcohol, smoking tobacco or cannabis, gambling or having an eating disorder.

• Teenage Health in Knowsley Campaign (THinK) aims to address these behaviours.

• Services for young people around: – Stopping smoking – Drug and alcohol misuse – Sexual health.

Engagement and involvement

• Services/programmes which are developed in consultation with young people is important.

• KYM works with young people to ensure services meet the needs of children and young people.

Recommendations 1. Ensure the learning from the Headstart programme for 2015/16

contributes to the re-design of future mental health and wellbeing provision for children and young people, including the review of Tier 2 Young Person’s Mental Health Services.

2. Support the implementation of the relevant elements of Priorities 2 and 4 of the Knowsley Child and Family Poverty Plan.

3. To continue during 2015 with the promotion of the “Be a Lover Not a Fighter” campaign to end domestic abuse.

4. To develop and implement a week of action in relation to Child Sexual Exploitation during Autumn 2015.

5. To agree the local accident prevention action plan and start implementation through 2015/16.

Recommendations continued 6. To implement a series of engineering measures during 2015, with

the aim of reducing traffic collisions around Knowsley schools. 7. To develop and implement a campaign aimed at increasing

participation in physical activity in teenage girls and women during 2015.

8. Monitor and evaluate late 2015 the healthy schools pilot implemented in participating Knowsley South Schools.

9. To continue to work with Knowsley Youth Mutual to develop and implement the risk taking behaviour campaign during 2015/16 into a holistic Teenage Health Campaign under the THinK banner.

10. To continue to deliver brief intervention 2 Minute Messages training (children and young people) to frontline staff during 2015/16.

Further information

Further copies of the report are available from:

Emma Thomas 0151 443 4987

[email protected]

An electronic version and the accompanying statistical

compendium are available at www.knowsley.gov.uk/publichealth

mailto:[email protected]

http://www.knowsley.gov.uk/publichealth

Public Board Updated Following 24th June 2015 Meeting Page 1

TRUST PUBLIC BOARD ACTION LOG – 24th JUNE 2015

No Minute Action Lead Date Due

1 27.05.15

(7.4) CIP Plan and Programme Management Office. Bill Hobden and Anne-Marie Stretch to discuss specific objectives and recruiting people with the right skills mix. This action is now closed.

BH/ AMS

24 Jun 15

2 27.05.15

(18.3) Board requests for clinical audits to be carried out: Board members will vote at the next meeting. ALL Ongoing

3 24.06.15 (6.4) Review of charitable donation funds and their restrictions by the Charitable Funds Committee DF TBA

4 24.06.15 (6.4) Specification for fundraising service to be developed by the Charitable Funds Committee DF TBA

5 24.06.15

(6.6) Richard Fraser will look at fundraiser secondment opportunities for the Trust. RF 29 Jul 15

6 24.06.15

(7.4) Reason for increase in births and reduction in income to be explored DF 29 Jul 15

7 24.06.15 (9.13.7)

Denis Mahony asked if the nurse staffing escalation plan could be sent to all Non-Executive Directors. SRe 29 Jul 15

8 24.06.15

(12.4) Kevin Hardy to liaise Ann Marr regarding the establishment of a group to review information on deaths and the role of the Clinical Outcomes Group. KH 30 Sep 15

Trust Board (29-07-15) – Executive Committee Assurance Report Page 1

TRUST BOARD PAPER

Paper No: NHST(15)058

Title of paper: Executive Committee Assurance Report.

Purpose: To feedback to members key issues arising from the Executive Committee meetings.

Summary: 1. Between the 11th June 2015 and 16th July 2015, four meetings of the Executive

Committee have been held (the meeting on 25th June being the Clinical Senate). The attached paper summarises the issues discussed at the meetings.

2. The time-slot for the 2nd July meeting was used to undertake a multi-agency Major Incident desktop exercise.

3. Decisions taken by the Committee included changes to the corporate risk register and approval of the revised ward dashboard.

4. Assurances regarding NICE guidance, eRostering, Trust Policies, and progress with pursuing CIPs, were obtained.

5. There are no specific items requiring escalation to the Board.

Corporate objective met or risk addressed: Contributes to the Trust’s Governance arrangements, and its short and longer-term plans.

Financial implications: None directly from this report.

Stakeholders: The Trust, its staff and all stakeholders.

Recommendation(s): The Board are asked to note the contents of the report.

Presenting officer: Ann Marr, Chief Executive.

Date of meeting: 29th July 2015.


EXECUTIVE COMMITTEE REPORT (11th June to 16th July) The following report highlights the key issues considered by the Executive Committee. 18th June 1. Overseas recruitment of junior doctors

1.1. With the planned reduction in junior doctors allocated to the Trust, a proposal to link-up with the medical school in Prague for recruitment is ongoing.

1.2. The Committee agreed that the target number of doctors for initial recruitment should be twelve.

2. NICE guidance 2.1. Kevin Hardy detailed the processes in place to review NICE guidance received

by the Trust culminating in sign-off by the Clinical Effectiveness Council. 2.2. Assurance was provided of the robust scrutiny undertaken prior to any decision

within the Trust not to fully implement any guidance issued. It was agreed that a regular update to the Committee would be provided.

3. CIP 3.1. Damien Finn provided an update on progress against CIP targets. The structure

in place, which has been modified by John Hampton, is showing benefits but improved engagement with clinicians is still required.

3.2. The issue of fines to be imposed on the Trust by CCGs as a result of targets not being fully met was discussed. It was agreed that early discussions are required to ensure that any money obtained from applying fines is used to the benefit of the health economy and not as a CCG CIP opportunity.

4. CQUIN plan divisional requests 4.1. Paul Williams presented a proposal for the additional resources required by

Care Groups to ensure that new national and local CQUIN targets can be met. - Following discussion it was agreed that the Information Department would

streamline the data collection requirements; the clinical resources required to meet Sepsis and Dementia CQUIN targets would be provided; and that further discussion is required regarding the clinical resources for COPD.

5. Risk Management Policy EC15-73 5.1. Peter Williams presented a paper recommending slight modifications to the Risk

Management Policy approved in January 2015. The key change was with regards to escalation of risks scoring 15 and above (included on the Corporate Risk Register), and that these should automatically be transferred under an appropriate Director lead. This was approved.

5.2. The report also captured the views of the Institute of Risk Management that in general the Policy is of a good quality and fit for purpose.

6. Theatre IT system 6.1. Neil Darvill reported that he has agreed with representatives of the equipment

supplier to reassess the shortcomings to the Trust requirements and to provide a plan for recovery. A further meeting is scheduled for 28 July.

7. Attendance at courses and conferences 7.1. Anne-Marie Stretch reported on expenditure against the budget and of the

revised system for approval going forward.


8. Multifunction Printers 8.1. A positional update was provided by Tom Fitzpatrick. Whilst the cost

effectiveness of strategically placed multifunction printers is acknowledged, and proposals were approved in principle by the Finance and Performance Committee, further details including any dis-benefits, in relation to staff time were required.

8.2. The plan for 120 devices across the Trust was discussed and approved. It was noted that good communication will be essential to successful implementation.

9. Update on Fundamental Standards 9.1. The proposed Strategy Board presentation was reviewed.

10. CQC update 10.1. An update on preparation for the planned visit was provided by Nicola Bunce

and Anne Rosbotham-Williams. The challenge of gathering all the required documentation was noted and a commitment was provided by Directors to lead in obtaining outstanding data/ paperwork.

25th June 11. CQUIN update

11.1. Sue Redfern provided an update on the current performance against CQUIN targets and the potential financial risk.

12. Surgical Assessment Unit (SAU) 12.1. Phil Nee attended to report on the impact from the 2013 service reconfiguration.

Whilst the redesign had enabled recommendations from the Royal College of Surgeons, NCEPOD and ECIST to be met, there were unintended consequences on activity indicators such as LoS, RTT, HSMR and readmissions, as well as income.

12.2. Lessons have been learned so that future business cases capture all potential consequences from service changes.

13. EDMS print permission 13.1. Francis Andrews reported on the scale of printing of medical records which still

occurs despite the Trust moving to the EDMS system which allows instant access to records via computer.

13.2. This practice presents an Information Governance risk and the Committee agreed with the proposal for greater controls on the ability to print.

14. Clinical Quality and Performance Group (CQPG) 14.1. Sue Redfern provided feedback from the meeting of 19th May. Key issues

discussed included cancer referral breaches and 2015/16 clinical audit plans. 9th July 15. eRostering

15.1. Malise Szpakowska and Lizzie Duffy attended the meeting to give a status update and demonstration on eRostering.

15.2. It was noted that KPIs are being set and a benefits realisation exercise is planned.


16. Corporate Risk Register and Risk Management Council report 16.1. The CRR was reviewed. It was agreed that further work is required to clearly

describe the risk, in completing the mitigation and also reviewing risks. Mitigation plans were reviewed and where appropriate scores modified.

16.2. The Chair’s Assurance report from Risk Management Council was noted. 17. Board Assurance Framework (BAF)

17.1. The BAF was reviewed and Directors requested to check the risks for which they are the designated lead.

18. CQC update 18.1. An update on preparation for the planned visit was provided. It was noted that

comments on the briefing pack issued by the CQC are required on 21st July. 19. Policies update

19.1. Anne Rosbotham-Williams briefed members on the current status with policies. 20. FT update

20.1. Peter Williams provided a briefing that covered: - The Strategic Delivery Governance Council meeting of 14th July. - The Integrated Delivery Meeting with the TDA. Key issues included the letter

expected on 24th July regarding the Trust’s financial YE forecast, and the requirement for an action plan regarding A&E 4-hour performance.

- The draft monthly self-assessments which were approved for submission to the Board.

- The assessment carried out on 13th July on the Well Led Framework, which was approved for submission to the Board for consideration.

21. Finance: 21.1. Sue Hill attended to provide an update on the financial position. 21.2. John Hampton provided an update on progress against the cost improvement

programme. Whilst the situation is improving, there is still a significant element of unidentified schemes, and schemes RAG rated as red.

21.3. The draft Integrated Performance Report was discussed. It was noted that due to the recent receipt of Dr Foster data the report is being revised for issuing on 20th July. Actions for closing out the information, and providing the appropriate text were agreed.

22. Ward dashboard 22.1. Ian Roberts attended to demonstrate the latest version of the Ward Dashboard.

Following discussion, a number of minor changes were agreed, and the system approved for launching. It was agreed that this would be presented monthly to the Clinical Senate, and quarterly to the Quality Committee.

23. Workforce Plan 23.1. The data and wording for inclusion in the plan were agreed.

ENDS

Trust Board (29-07-15) – Finance & Performance Committee Report Page 1

TRUST BOARD PAPER


Title of paper: Finance and Performance Committee Assurance Report.

Purpose: To report to the Trust Board on the activities of the Finance and Performance Committee held in July 2015.

Summary: 1. Agenda Items

1.1. Maternity Income analysis 13/14 – 14/15 1.2. Ambulance activity / A&E attendances 1.3. CIP Governance review: scheme 175 1.4. Medical SLR – Q4 2014/15 1.5. Capital Programme 15/16 1.6. Bank and Agency update 1.7. Committee Briefing Papers from CIP, Procurement, and Management

Information and Technology Councils 1.8. IPR Report Month 3 1.9. Finance report Month 3

2. Assurance Received 2.1. A comparison of Income and Activity for Maternity over the last two years was

discussed. 2.2. Medical Care Group presented on Quarter 4 SLR performance, identifying

loss-making services and actions needed to improve performance and CIP progress.

2.3. A&E and Ambulance attendances across Cheshire And Merseyside were reviewed in light of our own performance and activity.

2.4. The process for prioritising and agreeing the detailed capital plan for 2015/16 was presented and approved by the Committee.

2.5. Expenditure on Bank and Agency Staffing was discussed and the specific action plan by Care Group was presented to the Committee.

2.6. Progress on the CIP Programme was presented, including potential risks to delivery.

2.7. The Trust’s operational performance was reviewed and attendances at the Trust continue to rise.

2.8. The finance performance as at Month 3 was marginally better than plan and the forecast outturn is unchanged at £9.8m deficit.

Trust Board (29-07-15) – Finance & Performance Committee Report Page 2

3. Actions Agreed 3.1. Benchmark Maternity services with Liverpool Women’s Hospital 3.2. Review NWAS bespoke contract and escalate if necessary 3.3. Review allocation of beds between Medicine and Surgery in relation to

demand, bed capacity and activity projections 3.4. Analyse bank and Agency spend by reason and value 3.5. Present analysis of Surgery theatre start times and improvement opportunity 3.6. Review outpatient clinic start times and analyse improvement opportunity 3.7. Neil Darvill to attend in September to review IT plans / strategy with Christine

Walters 3.8. Kevin Hardy to present Trust wide mortality performance 3.9. Finance target for 15/16 to be circulated to Board when issued by TDA.

Corporate objectives met or risks addressed: Financial and Performance duties.


Stakeholders: The Trust, its staff, patients and commissioners.

Recommendation(s): It is recommended that the Board note this report and support the actions proposed.

Presenting officer: Damien Finn, Director of Finance and Information.

Date of meeting: 29th July 2015

INTEGRATED PERFORMANCE REPORT

Paper No: NHST(15)060Subject: Integrated Performance Report Purpose: To summarise the Trusts performance against corporate objectives and key national & local priorities.

Executive Summary

St Helens and Knowsley Hospitals Teaching Hospitals (“The Trust”) has in place effective arrangements for the purpose of maintaining and continually improving the quality of healthcare provided to its patients.

The Trust has an unconditional CQC registration which means that overall its services are considered of a good standard and that its position against national targets and standards is relatively strong.

The Trust has in place a financial plan that will enable the key fundamentals of clinical quality, good patient experience and the delivery of national and local standards and targets to be achieved. The Trust continues to work with its main commissioners to ensure there is a robust whole systems winter plan and continued delivery of national and local performance standards whilst ensuring affordability across the whole health economy. Patient Safety, Patient Experience and Clinical Effectiveness

The CQC found the Trust compliant with all the essential standards of quality and safety assessed following their unannounced routine inspections of the Trust in September 2013 and February 2014. The CQC undertook a desk top review of the complaints process in March 2014 for which the Trust were deemed as compliant. The Trust is expecting a new style CQC inspection in Quarter 2 2015-16. Overall the Trust has achieved level 2 CNST certification from the NHS Litigation Authority. Following an inspection in March 2014 the Trusts Maternity services were awarded CNST level 3 (the best score available). There have been no cases of MRSA bacteraemia during 2015-16. The Trust has a zero tolerance of MRSA. The tolerance for C.Difficile in 2015-16 is 41 cases. There have been 3 confirmed C.Difficile cases in June. In total there have been 10 confirmed cases YTD against a YTD trajectory of 17. In addition to the confirmed cases the Trust is also appealing against 3 cases YTD. RCAs are currently being undertaken on these cases. There were no hospital acquired grade 3 / 4 pressure ulcers in June. An action plan is in place and is being monitored by the Patient Safety Council. The latest CQC Intelligent Monitoring Report (May 2015) has shown an improved priority banding to Band 5 (where Band 1 represents highest risk and Band 6 represents lowest risk ). There have been no “never events” since May 2013. The last official full year HSMR (2013-14) was 98.8

Corporate Objectives: Achievement of organisational objectives. Stakeholders: Trust Board, Finance Committee , Commissioners, CQC, TDA, patients. Recommendation: To note performance Review Date: July 2015 Presenting Director: D Finn Board Date: 29th July 2015

1

Patient Safety, Patient Experience and Clinical Effectiveness (continued) The trust eDischarge performance remains strong compared with peers, with recent CCG-led audits showing 100% transmission of electronic discharge summaries (c.f. paper). Paper discharges are now switched off for all but those practices unable to receive electronic discharges. Actions have been put in place to improve VTE performance which has resulted in over 95% of patients receiving assessment in May 2015. Further work will continue to sustain the target pending implementation of updated eVTE system. Operational Performance Positive and sustained performance in elective waiting times, stroke access and cancer treatment standards continued, despite the continued significant volumes of non-elective admissions. A focussed, clinically led group is working through how discharges can be brought forward earlier in the day, which will both provide improved patient experience together with enhanced 4 hour performance. Due to the sustained increases in both acuity and admissions, the Trust need to develop alternative pathways for medically optimised patients. Work has commenced on the 'discharge to assess' model with Knowsley CCG which will allow the assessments required to safely discharge patients with complex needs to be undertaken outside of the hospital. This is a positive development which we are also encouraging St Helens to adopt. Financial Performance The Trust is reporting a Month 3 deficit of £5.5m which is slightly better than the agreed plan. The Trust has submitted a plan to deliver a £9.8m deficit for the full year. To date the Trust has delivered £2.1m of CIPs which is £0.4m better than plan. The Trust is forecasting to deliver its full CIP target of £12.7m and the Turnaround Director is expecting to have plans for the full CIP target of £12.7m by the end of July. Human Resources Staff Friends and Family Test Q1 survey was completed on 30th June. Results still awaited from Quality Health who administer the test on our behalf. The Trust has maintained the positive position on attendance at mandatory training and completion of appraisals . Performance at Mandatory training has remained stable at 87.9% and Appraisals at 89.7% continuing to exceed the compliance targets for both of 85%. Year to Date all staff sickness is 4.5%. Early indictors show that June is 4.35%, which will give the Trust a total of 4.4% against a Trust Q1 target of 4.25%. This is an improvement on the 4.65% sickness rate for the same period last year.

2

The following key applies to all sections of the Integrated Performance Report:

= 2015-16 Contract Indicator£ = 2015-16 Contract Indicator with financial penalty = 2015-16 CQUIN Indicator

3

Jun-15 28 19 4 23

CORPORATE OBJECTIVES & OPERATIONAL STANDARDS - EXECUTIVE DASHBOARD

Committee Latest Month

Latest month

2015-16YTD

2015-16Target

2014-15 Trend Issue/Comment Risk Management ActionExecLead

CLINICAL EFFECTIVENESS

Mortality: Non Elective Crude Mortality Rate

Q Jun-15 2.1% 2.5% 2.6%

Mortality: SHMI (Information Centre) Q Sep-14 1.03 1.00

Mortality: HSMR (Dr Foster) Q Mar-15 96.6 100.0 102.9

Mortality: HSMR Weekend Admissions (emergency)(Dr Foster)

Q Mar-15 117.4 100.0 109.9

Readmissions: 28 day Relative Risk Score (Dr Foster)

Q Dec-14 105.2 100.0 106.0

Length of stay: Non Elective - Relative Risk Score (Dr Foster)

F&P Mar-15 85.5 100.0 87.5

Length of stay: Elective - Relative Risk Score (Dr Foster)

F&P Mar-15 96.3 100.0 100.7

% Medical Outliers F&P Jun-15 2.2% 2.0% 1.0% 1.8% Patients not in right speciality inpatient area to receive timely, high quality care

Increase in LoS, patient experience and impact on elective programme

A continuation of increased medical NEL admissions has had a significant impact upon overall Trust capacity utilisation. 3 work streams identified to improve LoS and work has commenced on those in MCG.

PJW

Percentage Discharged from ICU within 4 hours

F&P Jun-15 61.7% 54.5% 67.7% 54.1% Failure to step down patients within 4 hours who no longer require ITU level care.

Quality and patient experience

Small improvement in June despite the NEL pressures. To achieve the enhanced KPI throughout the year will require sustained step change improvement in LOS. This is underway within both surgical and medical specialities.

PJW

E-Discharge: % of E-discharge summaries sent within 24 hours (Inpatients)

Q May-15 82.4% 82.8% 85.0% 80.9%

E-Discharge: % of E-attendance letters sent within 14 days (Outpatients)

Q May-15 91.3% 88.6% 85.0% 84.3%

E-Discharge: % of A&E E-attendance summaries sent within 24 hours (A&E )

Q May-15 98.9% 98.9% 95.0% 89.5%

Paper discharges are now switched off for all but those practices unable to receive electronic discharges.

KH

The trust eDischarge performance remains strong compared with peers, with recent CCG-led audits showing 100% transmission of electronic discharge summaries (c.f. paper).

Changes to admission unit recording still impacting on reported SHMI value.

Palliative care input will improve with appointment of replacement consultant.

Crude mortality is consistently below English & NW average & SHMI consistently below NW average.

HSMR is now reported re-based.

Patient Safety and Clinical Effectiveness

Advertise & appoint palliative care consultant and continue to work with commissioners and hospice to deliver integrated service. Drive to reduce use of R codes in ED/EAU/AMU which negatively impact SHMI & HSMR.

KH

This is a key efficiency, productivity and patient experience measure

Patient experience and operational effectiveness

To ensure consistent ward practices in the management of patients. Consistent reductions in NEL LOS are assurance that medical redesign practices continues to successfully embed. The elective improvement is welcomed with focus now on maintaining this.

PJW

KHReadmissions consistently higher than desired, mostly related to EAU usage.

Patient experience, operational effectiveness and financial penalty for deterioration in performance

Audit of readmissions in collaboration with CCG to better understand issues is underway.

4

Jun-15 28 19 4 23



Latest month

2015-16YTD

2015-16Target


CLINICAL EFFECTIVENESS (continued)

Stroke: % of patients that have spent 90% or more of their stay in hospital on a stroke unit

QF&P

Jun-15 86.9% 88.8% 83.0% 84.4% Target is being achievedPatient Safety, Quality, Patient Experience and Clinical Effectiveness

Performance will be sustained through current actions PJW

PATIENT SAFETY

Number of never events Q £ Jun-15 0 0 0 0 There have been no never events since May 2013

Quality and patient safety

New Never Event Guidance published In April 2015 has been implemented within the organisation

SR

% New Harm Free Care (National Safety Thermometer)

Q Jun-15 98.3% 98.5% 98.6% 98.6% Figures quoted relate to all harms excluding those documented on admission


The organisational ambition to reduce episodes of avoidable harm is supported by the Trusts sign up to safety campaign.

SR

Prescribing errors causing serious harm Q Jun-15 0 0 0 0 The trust continues to have no prescribing errors which cause serious harm


Intensive work ongoing to reduce medication errors and maintain no serious harm. Trust approved national insulin training programme to try to prevent insulin errors.

KH

Number of hospital acquired MRSAQ

F&P£ Jun-15 0 0 0 2

Number of confirmed hospital acquired C Diff

QF&P

£ Jun-15 3 10 41 33

Number of avoidable hospital acquired pressure ulcers (Grade 3 and 4)

Q Jun-15 0 1 2 no grade 3 or 4 pressure ulcers in JuneQuality and patient safety

Revised Policy presented at PSC 15/07/2015 which includes enhanced assessment tools for paeds/maternity and neonatal care.

SR

Number of falls resulting in severe harm or death

Q May-15 1 4 19 1 severe harm fall in May resulting in a # neck of femur injury


All falls resulting in severe harm or death are reported as a serious incident and have a Level 2 RCA. Actions learned are cascaded Trust wide.

SR

VTE: % of adult patients admitted in the month assessed for risk of VTE on admission

Q £ May-15 95.24% 95.15% 95.0% 92.54%

Hospital acquired VTE events rate (National Safety Thermometer)

QF&P

Jun-15 0.47% 0.25% 0.45% 0.45%

To achieve and maintain CQC registration Q Jun-15 Achieved Achieved Achieved Achieved This Trust continues to maintain CQC registration


Through the Quality Committee and governance councils the Trust ensures it meets CQC standards. CQC inspection predicted for Q2, project team in place to collect and collate required evidence.

SR

Safe Staffing: Registered Nurse/Midwife Overall (combined day and night) Fill Rate

Q Jun-15 97.8% 97.7% 98.6%

Safe Staffing: Number of wards with <80% Registered Nurse/Midwife (combined day and night) Fill Rate

Q Jun-15 0 0 0

Intelligent Monitoring Risk Banding Q May-15 5 6 4

The Trust has improved priority banding to band 5 (Band 1 = highest risk and Band 6 = lowest risk ).


Actions plans in place for areas identified as requiring improvement.

SR

SR

There have been 10 confirmed Cdiff cases YTD. The trust are appealing a further 3 cases from those RCAs completed.

15-16 tolerance = 41 casesYTD tolerance = 17 cases


The Infection Control Team continue to support staff to maintain high standards and practices, Trust Board monitor infection rates. Monitor and undertake RCA for any hospital acquired BSI and CDT. CDT and Antibiotic wards rounds continue to be undertaken on appropriate wards.

SR

KH

62 patient audit undertaken on two medical wards demonstrated: 94% completion of risk assessment, 90% completion of appropriate prescribing following risk assessment, but only a 50% compliance with administering the prescribed dose of thromoboprohylaxis. Audit presented at grandround 30th June.


VTE screening is now on target. New E-VTE system anticipated to be rolled out Q2.

Overall the Nurse/Midwife fill rate remains consistent


Daily staffing huddles supported by escalation flow chart. Six monthly nurse staffing and acuity report was presented to Trust Board in June 2015. Plans to do the Contact Time on the Intermediate Care wards and the Shelford Assessment Unit tools for the Assessment Units.

5

Jun-15 28 19 4 23



Latest month

2015-16YTD

2015-16Target


PATIENT EXPERIENCE

Cancer: 2 week wait from referral to date first seen - all urgent cancer referrals (cancer suspected)

F&P £ May-15 94.2% 94.4% 93.0% 94.0%

Cancer: 31 day wait for diagnosis to first treatment - all cancers

F&P £ May-15 98.1% 97.2% 96.0% 98.8%

Cancer: 62 day wait for first treatment from urgent GP referral to treatment

F&P £ May-15 86.3% 86.5% 85.0% 89.9%

18 weeks: % of Admitted patients who waited 18 weeks or less (adjusted for clock pauses)

F&P £ Jun-15 96.1% 96.3% 90.0% 95.9%

18 weeks: % of Non Admitted patients who waited 18 weeks or less

F&P £ Jun-15 98.5% 98.6% 95.0% 98.5%

18 weeks: % incomplete pathways waiting < 18 weeks at the end of the period

F&P £ Jun-15 97.7% 97.7% 92.0% 98.1%

18 weeks: % of Diagnostic Waits who waited <6 weeks

F&P £ Jun-15 100.0% 100.0% 99.0% 100.0%

18 weeks: Number of RTT waits over 52 weeks (incomplete pathways)

F&P £ Jun-15 0 0 0 0

Cancelled operations: % of patients whose operation was cancelled

F&P Jun-15 0.7% 0.6% 0.6% 0.7%

Cancelled operations: % of patients treated within 28 days after cancellation

F&P £ May-15 100.0% 100.0% 100.0% 100.0%

Cancelled operations: number of urgent operations cancelled for a second time

F&P £ Jun-15 0 0 0 0

A&E: Total time in A&E: % < 4 hours (Whiston: Type 1)

F&P £ Jun-15 91.8% 91.9% 95.0% 92.8%

A&E: Total time in A&E: % < 4 hours (All Types)

F&P £ Jun-15 93.9% 94.0% 95.0% 94.2%

A&E: 12 hour trolley waits F&P Jun-15 0 0 0 1

Failure to ensure patients are managed within 4 hours in the Emergency DepartmentAll Type activity includes the Trusts contribution to the Widnes WIC

Patient experience, quality and patient safety

Clinically led process improvement teams continue to focus on shifting the discharge profile to earlier in the morning, ensuring that ED processes are optimal throughout each 24 hour period and discharging patients earlier than present (e.g. through discharge to assess). All are making good progress. Breaches due to lack of an available bed has reduced by 20% since the last report. A pattern of breaches occurring after 18:00 and before 08:00 is now more visible. Mitigations include extending the role of the night throughput coordinator to cover seven days/week and the role re designation of an existing band 4 nurse as 'progress chaser'/support to the night coordinators. Additional medical grade staff now appear to have only minimal impact.

PJW

Patient choice to delay their appointment or procedure remains a major reason for failing to achieve the access standard in a small number of cases.

Quality and patient experience

The Trust is monitoring referrals to ensure it can accommodate the increasing trend in 2 week referrals. Ongoing achievement of this target will require on going management and clinical review of clinical pathways and process.

PJW

The trust is continuing to achieve 18 weeks but this remains by a very small margin in certain specialties, particularly Orthopaedics.

There is a risk due to the current surgical bed pressures that the elective programme will be compromised

18 weeks performance continues to be monitored daily and reported through the weekly PTL process.

PJW

Although June saw a slight increase, the Trust continues to have one of the best rates for this metric within England. Performance has been directly impacted by increased orthopaedic trauma and medical admissions.

Patient experience and operational effectivenessPoor patient experience

This metric is directly impacted by the significant increase in NEL admissions. A discussion regarding alternatives to acute care will be held at the health economy System Resilience Group.

PJW

6

Jun-15 28 19 4 23



Latest month

2015-16YTD

2015-16Target


PATIENT EXPERIENCE (continued)

MSA: Number of unjustified breaches F&P £ Jun-15 0 0 0 7Increased demand for IP capacity has a direct bearing on the ability to maintain this quality indicator.

Patient Experience Maintained focus and awareness of this issue across 24/7. PJW

Complaints: Number of New (Stage 1) complaints received

Q Jun-15 24 86 281

Complaints: Number of New (Stage1) complaints received in 2015-16 and resolved in 2015-16

Q Jun-15 30

Complaints: Number of New (Stage1) complaints received in 2015-16 and resolved in 2015-16 within agreed timescales

Q Jun-15 60.0%

Complaints: Number of New (Stage1) complaints received in 2014-15 and resolved in 2015-16

Q Jun-15 79

Complaints: Number of New (Stage1) complaints received in 2014-15 and resolved in 2015-16 within agreed timescales

Q Jun-15 5.1%

Friends and Family Test: % recommended - A&E

Q Jun-15 92.9% 93.5% 95.0% 94.8%

Friends and Family Test: % recommended - Acute Inpatients

Q Jun-15 98.2% 97.3% 95.0% 97.2%

Friends and Family Test: % recommended - Maternity (Antenatal)

Q Jun-15 98.6% 97.8% 97.3% 97.3%

Friends and Family Test: % recommended - Maternity (Birth)

Q Jun-15 98.9% 96.9% 98.7% 98.7%

Friends and Family Test: % recommended - Maternity (Postnatal Ward)

Q Jun-15 93.0% 91.8% 96.6% 96.6%

Friends and Family Test: % recommended - Maternity (Postnatal Community)

Q Jun-15 98.6% 99.0% 99.4% 99.4%

Friends and Family Test: % recommended - Outpatients

Q Jun-15 97.7% 97.1% >14/15 out turn

SR

The past 4 months has seen a sustained increase in the number of complaints resolved. Due to the backlog, performance remains below desired levels for complaints received in 2014-15, however performance is much improved for complaints received this financial year.

Patient experienceThe Trust is currently undertaking a review of complaints and has employed temporary additional staff to assist with addressing the backlog.

The Trust continues to achieve high recommended %'s for A&E, Maternity and Inpatients, which indicates positive experience of care.

A&E: YTD response rate is 33.9%.

Inpatients: YTD response rate is 31.3%

Maternity: YTD response rate is 23.8% (Question 2 - Birth)

Patient experience & reputation Scores fed back to ED and Maternity departments. Presently

undertaking review and costing to roll out to additional areas.

SR

7

Jun-15 28 19 4 23



Latest month

2015-16YTD

2015-16Target


WORKFORCE

Sickness: All Staff Sickness RateQ

F&P May-15 4.2% 4.5%

Q1 - 4.25%Q2 - 4.35%Q3 - 4.72%Q4 - 4.68%

4.8%

Sickness: All Nursing and Midwifery (Qualified and HCAs) Sickness Ward Areas

QF&P

May-15 5.2% 5.0% 5.3% 5.8%

Staffing: % Staff received appraisalsQ

F&PJun-15 89.7% 89.7% 85.0% 89.6%

Staffing: % Staff received mandatory training

QF&P

Jun-15 87.9% 87.9% 85.0% 88.3%

Staff Friends & Family: % recommended Care

Q Q4 82.5% >14/15 out turn

Staff Friends & Family: % recommended Work

Q Q4 72.1% >14/15 out turn

Staffing: Turnover rateQ

F&PJun-15 0.7% 8.3% AMS

FINANCE & EFFICIENCY

CoSRR - Overall Rating F&P Jun-15 1.0 1.0 1.0 1.0

Progress on delivery of CIP savings (000's) F&P Jun-15 2,117 2,117 12,700 15,000

Reported surplus/(deficit) to plan (000's) F&P Jun-15 (5,494) (5,494) (9,790) (2,551)

Cash balances - Number of days to cover operating expenses

F&P Jun-15 11 11 >10 10

Capital spend £ YTD (000's) F&P Jun-15 298 298 4,923 4,906

Financial forecast outturn & performance against plan

F&P Jun-15 (9,790) (9,790) (9,790) (2,551)

Better payment compliance non NHS YTD % (invoice numbers)

F&P Jun-15 95.0% 95.0% 95.0% 94.8%

The HR Advisory Team have drafted an action plan for Attendance Management that looks at ST/LT plans in addressing absence across all Care Groups and also an Improvement Trajectory. Localised improvement plans will be initiated, regular (weekly) and granular level management of sickness absence. This is in addition to the initiatives implemented recently by HWWB & HR i.e. Self Care at Work.

AMS

AMS

AMS

The Trust is currently in line with submitted plans

Financial

Adherence against the submitted plan and delivery of CIP. Future positive Cash flow will depend upon the Trust maintaining control on Trust expenditure and agreeing with Commissioners and NHSE a more advantageous profile for receipt of planned income.

DF

Effort by L&D and LMS team continues to maintain target compliance for both Mandatory Training and Appraisals.

Quality and patient experience, Operational efficiency, Staff morale and engagement.

The Learning & Development team continue to support with the inputting of appraisal data. Capacity of training sessions for mandatory training will continue to be monitored to ensure ongoing compliance throughout the year.

Absence rate for May is 4.2%, a 0.6% improvement on last month (4.8%). The Trust is 0.25% behind Q1 target in May. The HCA absence rate of 6.3% is at its lowest rate since November 2013.

Quality and Patient experience due to reduced levels staff, with impact on cost improvement programme.

8

Trust Board (29-07-15) Quality Committee Assurance Report Page 1

TRUST BOARD PAPER


Title of paper: Quality Committee Assurance Report.

Purpose: The purpose of this paper is to summarise the Quality Committee meeting held on 21st July 2015 and escalate issues of concern.

Summary: 1. Complaints: The handling of complaints has been an important issue over recent

months. Additional resource and a great deal of effort have developed the system and addressed the problem. The matter remains under close review.

2. Safer Staffing: While overall Trust compliance is 98.6% there are 5 wards with 90% or below fill rates. A number of initiatives have been set in place to address the problem.

3. NICE guidance governance, processes and future plans was escalated to the Quality Committee from Clinical Effectiveness Committee.

4. Advancing Quality performance was also escalated; a paper will be presented at the Executive Team meeting in the near future.

Corporate objectives met or risks addressed: Five star patient care and operational performance.


Stakeholders: Patients, the public, staff and commissioners.

Recommendation(s): It is recommended that the Board note this report.

Presenting officer: David Graham, Non-Executive Director



QUALITY COMMITTEE ASSURANCE REPORT Summary of the discussions and outcomes from the Quality Committee meeting held on 21st July 2015. Action Log 1. All actions on the log were reviewed, those which remain open related to:

1.1. No Smoking Policy – SR gave further assurance that work is being done with Ward teams, especially COPD and AQ nurses regarding brief intervention (referral to smoking cessation services for patients). There is a system in place to support the policy.

1.2. AMS reported that all actions on the Francis action plan had been completed. AMS will report back to the committee in November to present a formal update.

Complaints, Claims & Incidents Report 2. S Redfern reported:

2.1. In the period April to June 2015, the Trust received 84 stage 1 complaints compared to 72 complaints in the same period in 2014.

2.2. The intervention and improvements to the complaints process has resulted in a reduction in the number of outstanding complaints.

2.3. Active complaints as of 30th June 2015 was 43 complaints (at the latest weekly update of 10th July 2015.

2.4. Weekly reports will continue to be provided to the Director of Nursing and performance will be reported to the Board and Quality Committee.

CQC Operational Planning Group 3. S Redfern reported:

3.1. The data was submitted on 23rd June 2015 and the data packs have been received; these are being checked for factual accuracy. The project plan is up to date and the briefing pack will be ready for distribution on Monday, 27th July. Posters and comment cards will be ready by 4th August and Ann Marr will give a presentation to the CQC on 18th August.

3.2. The CQC have arranged two listening events/focus groups; one at the Old School House in Huyton and one at St Helens Town Hall.

Safer Staffing Report 4. S Redfern reported:

4.1. Overall Trust compliance was 98.6% 4.2. There were five ward areas with 90% or below fill rate:

4.2.1. Ward 2B 4.2.2. Ward 2C 4.2.3. Ward 3E 4.2.4. Ward 5A 4.2.5. Ward 5D

4.3. The situation remains under close and active review.


4.4. The 6 monthly nurse staffing establishment review was presented to Board in June.

Kirkup Maternity Report Update 5. R Douglas reported:

5.1. Following the Kirkup report on Morecambe Bay Hospital, the Trust Maternity Service has produced three papers. The paper presented to the committee was the Trust Maternity Service Gap review paper.

5.2. The service had considered each recommendation in the report. There were five key issues reported by Kirkup:

5.2.1. Clinical competence of a proportion of the staff. 5.2.2. Working relationships 5.2.3. Dominant midwives 5.2.4. Failure to undertake appropriate risk assessments/incident reviews. 5.2.5. Response to serious incidents.

5.3. The Trust Maternity Service review paper identifies gaps, provides assurance and details an action plan against any gaps.

Infection Control Update 6. S Redfern reported:

6.1. There have been no cases of MRSA bacteraemia. 6.2. There has been 1 case of MSSA bacteraemia. A lot of work has been carried

out regarding cannula sites – all cannula sites will now be checked for 48 hours after a cannula has been removed.

6.3. There have been two cases of C.Diff on Ward 5A and the RCA has found that specimens are not being taken in a timely fashion, but the ward has been deep cleaned and hand hygiene posters are on display.

6.4. The Trust received positive feedback from the TDA peer review, however some challenges remain, including the bare below the elbow policy, the sink in A&E, leaflets on the wall and the use of stool charts.

Consent Action Plan 7. M Manning reported:

7.1. This paper highlights the actions required to ensure that the main requirements of the new consent policy are understood and followed by clinical staff.

7.2. Problem areas include: 7.2.1. Delegated consent training 7.2.2. Consent training for junior medical staff new to the Trust 7.2.3. Patient information sheets.

IPR 8. Quality Indicators were discussed by the Committee

9.


Dementia Strategy 10. S Redfern reported:

10.1. The strategy outlines the aims and objectives for the next three years.

10.2. The strategy will assist with benchmarking and performance monitoring of dementia care received within the Trust.

10.3. Our vision is that we will become a centre of excellence for the care of people living with dementia who access our services.

Feedback from Patient Safety Council 11. N Jones reported:

11.1. There are changes to the process for information external to the Trust regarding the Serious Incident Framework produced by NHS England. There will no longer be a set list of reportable events/incidents.

11.2. Due to collaborative working, falls have reduced by 50%.

11.3. Following the request from Healthwatch to report of community acquired pressure ulcers, we are negotiating with the CCG to fund this activity as it will take a day and a half of admin time.

11.4. NJ updated the committee on the blood sampling errors. An action plan is in

place and the “no sticker, no sample” campaign should roll out in August.

Feedback from Patient Experience Council 12. S Duce reported:

12.1. Healthwatch have requested assurances that the complaints backlog is

improving.

12.2. The Dementia strategy, mortuary vehicle manual and friends and family test were all discussed.

12.3. There were no issues to be escalated to Quality Committee.

Feedback from Clinical Effectiveness Council 13. S Duce reported:

13.1. KPI’s, Dr Foster were discussed. Regarding “never events” all action are now

closed apart from RCA training which is ongoing.

13.2. Issues brought to the attention of the Quality Committee are NICE guidance and AQ performance.

Feedback from CQPG

14. K Hardy reported: 14.1. Key issues discussed at CQPG were:


14.1.1. Ambulance Handovers. 14.1.2. Nurse safer staffing 14.1.3. Infection Control 14.1.4. 62 day cancer breaches 14.1.5. CQC Inspection

Feedback from Workforce Council 15. A M Stretch reported:

15.1. Key issues discussed were:

15.1.1. Recruitment 15.1.2. Ward Manager Development Programme 15.1.3. Equality & Diversity Scheme

15.2. AMS will report back on the Francis Action plan formally in November.

Feedback from Executive Committee 16. P Williams reported:

16.1. The BAF and Corporate Risk Register were discussed at the Executive Team

Meeting.

16.2. There has been a change of the Risk Management Policy; it was approved in January but changes have been made to reflect that any risk scored 15 and above will now automatically transfer to an Executive Director, who will manage it.

Effectiveness of the Meeting 17. P Williams was asked to provide feedback. He reminded the committee of the value

of prompt submission of papers in the agreed corporate style. He felt that the meeting had been constructive, challenging and effective.

AOB None noted.

Trust Board (29-07-15) – HR Indicators Report Page 1

TRUST BOARD PAPER


Title of paper: HR Indicators Report

Purpose: To provide assurance to the Board of the Trust’s achievement of workforce indicators that supports the achievement of the Trust’s Corporate objectives specifically to developing organisation culture and supporting our workforce.

Summary: The Trust is committed to developing the organisational culture and supporting our workforce. This paper summarises achievements/progress to date.

Corporate objective met or risk addressed: Developing organisation culture and supporting our workforce

Financial implications: N/A

Stakeholders: Staff, Managers, Staff Side Colleagues and Patients

Recommendation(s): The Trust Board are requested to accept the report and to note the areas of achievement/progress against corporate objectives.

Presenting officer: Anne-Marie Stretch, Director of Human Resources & Deputy CEO



HR Indicators Report June 2015

1. Developing our Workforce Culture

As part of our continuing development as an organisation, the Trust recognises that our staff are central to the provision of excellent services to our patients, their loved ones, commissioners and our local communities. The Trust HR & Workforce Strategy states that the Trust’s vision is to develop a management culture and style that: Empowers, builds teams and recognises and nurtures talent through learning and

development. Is open and honest with staff, provide support throughout organisational change

and invests in Health and Well Being. Promotes standards of behaviour that encourage a culture of caring, kindness and

mutual respect. 2. Purpose of the Paper This paper is presented to provide assurance to the Board of the workforce indicators that support the achievement of the Trust’s corporate objectives specifically to develop organisation culture and supporting our workforce. 3.1 Appraisals & Personal Development Plans To support our staff in delivering meaningful appraisals, 148 staff with responsibilities for completing appraisals attended training workshops during the period January to June 2015. Against a target of 85% (which is 100% of available staff), at the end of June 2015 the Trust continues to exceed the compliance target for Appraisals in 2015/16 by achieving 89.35% - which means that 89.35% of available staff took part in an appraisal meeting and had a Personal Development Plan (PDP) during May 2014 and June 2015.

3.2 Corporate Induction During Q4, Jan- April 2015 - 232 new starters attended either the clinical or non-clinical Corporate Induction on joining the Trust. Following Corporate Induction, all staff complete a documented local induction in their respective department where they agree any initial training needs with their line managers or clinical leads to support them in performing their roles. 3.3 Mandatory Training During January-June 2015 - 2497 staff attended Mandatory Training, across 93 sessions (both clinical & non-clinical). Against a target of 85% (which is 100% of available staff), the Trust again exceeded the compliance target for Mandatory Training in 2015/16 by achieving 87.99% by 30th June. 3.4 Apprenticeships The Trust is leading the way in the North West in delivery of the Apprenticeship scheme. In 2014/15 - 122 Learners started and are progressing through their Apprenticeship.


During Jan-April 2015:

32 - New Learners inducted onto an apprenticeship

11 - Apprentices completed their qualifications in: Business Administration: 4 Health - Maternity & Paediatric Support: 1 Health - Clinical Healthcare Support: 6

3.5 Customer Service (including conflict resolution)

Customer Service skills are offered to staff to develop the communication skills required to deliver professional and effective customer care; to patients, relatives/visitors and other members of staff. The training incorporates conflict resolution training in order to appreciate barriers to effective communication and to enable staff to manage the more challenging situations they are presented with. The need for conflict resolution is at more of an extreme point on a spectrum of differing communication requirements; also on the spectrum is the need for demonstrating empathy and care through effective communication, as is developing a good rapport and emotional connection with patients and relatives. During Jan-Apr 2015, of the 138 places booked by staff, across 8 workshops, there was a 55% attendance (76 staff). 19 staff did not attend (DNA) and gave no notice; 43 staff withdrew/cancelled (WD) at some point prior to the workshop. This is an on-going trend, with Q3 reporting 44% attendance. A review is required to understand the reasons for high levels of DNAs and cancellations and communications are required to improve attendance. 3.6 Developing Personal Resilience

Leadership & Organisational Development (L&OD) deliver a regular Developing Personal Resilience workshop, for all staff; to equip the workforce at all levels with the capability to have the resilience to cope with the challenges in their life, their jobs, their teams/departmental pressure; as well as those facing the Trust and NHS generally. The workshop is open to all Trust staff but is also signposted via L&OD and HWWB for staff who are experiencing difficult work or personal circumstances that may be impacting on their psychological health. These staff are at high risk for their next potential move to be sickness absence due to stress. This workshop introduces various skills, coping mechanisms and strategies to understand themselves and situations more effectively. It is also signposted for staff who are returning from any long-term absence. During Jan-April 2015 we held 4 workshops, with a total of 39 staff attending. 3.7 Healthwrap – Prevent

The Trust is required to raise the awareness of staff of the potential of terrorist activity in the UK. The Safeguarding and L&OD Departments have been preparing for the new HealthWrap 3 Training Programme and planning our approach as a Trust to ensure we meet our contractual obligations to NHS England and the Home Office. This is that all staff have some basic awareness of the PREVENT agenda (via information leaflet) and approximately 3100 staff must receive the one hour HealthWrap 3 training. During Jan-April 2015, 42 staff attended Healthwrap train the trainer workshops across 5 sessions. There are now a number of nominated facilitators across the Trust who will become accredited and deliver training locally, in order to achieve the required target figures. It is mandatory that the Healthwrap3 training is delivered and the aim is to roll out the programme to achieve full compliance by March 2016.


3.8 Mentorship Programme The Trust offers an internal Mentorship programme aligned to the NHS Leadership Academy with many Trust leaders in reciprocal arrangements supporting leaders from other NHS Trusts across the North West. As of April 2014 (figures provided by the NW Mentoring scheme 7th May):

• Mentors registered: 140 • Mentees registered: 119 • Relationships: 124 (Including both Mentors and Mentees in the Trust)

To support Mentors the L&OD Department provide Continuous Personal Development (CPD). A 12-month CPD timetable has been implemented covering a variety of subjects each 90-120 minutes. Jan-May 2015 the following have been delivered:

Jan 2015: Introduction to Resilience Feb 2015: Confidence & Assertiveness Mar 2015: Reflective Practice May 2015: Confidence & Assertiveness

In addition, Anaesthetics and Pharmacy teams are being supported in order to set up their own local mentor programmes, at their request. 3.9 Enhancing our Leadership & Developing Teams

The Trust provides a range of Organisational Development (OD) interventions to support the effectiveness and performance of teams. Examples of engagement, performance improvement, team facilitation/building and leadership interventions include: Leadership & Well-being Programme: developed in-house by L&OD. Robertson Cooper diagnostic tools are utilised (Asset Well-being Survey and Leadership Impact questionnaire) as the first part of a programme of activity with the aim of improving engagement and performance, developing staff/ teams and driving departmental culture change from within. The KPIs focused on are primarily the reduction of sickness absence. Leadership & OD are still working with Care of the Elderly, Respiratory & ICU wards where leaders have completed the leadership questionnaire and require one-to-one feedback; and staff solutions workshops (focus groups) are to be set up to review staff well-being. From here actions plans will be prepared. The programme is rolling out to Trauma & Orthopaedics wards in autumn 2015 and the communications process with staff has started. The engagement of the management team in T&O is extremely positive.


The Leadership & Well-being Programme Model:

Ward Manager and Matrons Leadership Development Programme: developed in-house by L&OD for Trust Band 7 & 8 nursing leaders; totalling 82 staff across four cohorts. Each cohort attends 8 days, over an 8-9 month period; the first one starting in July 2015. There will be ongoing home-work and a CPD log. Each day of the programme is split to incorporate theory, practical and experiential learning and Action Learning. Each delegate will complete a ward-based project that they will work on throughout the programme. The programme is designed to support staff in their roles as leaders of teams/departments; to reflect and build on their on their strengths, their role and abilities; to learn new skills, more about themselves and how they can pro-actively take this learning back to the work-place. Objectives of the programme are closely aligned to those of the North West Leadership Academy Front-line Programme. Over the course of the programme delegates will:

Build their confidence and capability to have even greater influence on care. Learn to recognise what they do well - and find out what they can do better. Develop new skills and put them into practice immediately back in the work-place Develop enhanced people management skills. Take the opportunity to think about how their behaviour impacts on those around them. Learn skills to drive and sustain change – building a culture of patient-focused care at a

departmental or functional level. Gain greater business acumen.

Whiston Theatres Review: an in-depth evaluation of culture in Theatres undertaken via a number of one-to-ones and team meetings between Dec 2014-Mar 2015. Report submitted March 2015. A work programme is underway with theatres. L&OD OD “commissioning”: typically where a particular department is experiencing challenges due to, for example, team dynamics, sickness, and performance issues – L&OD will be requested to review and introduce suitable interventions. Typically involves some form of engagement related activities, facilitated team meetings/activities to support objectives/expectations, team coaching, individual coaching, supporting action planning with the aim to improve staff morale, leadership and team effectiveness. MBTI (Myers Briggs Type Indicator) & Belbin Team Roles workshops: Support staff in gaining increased self-awareness by understanding their personality type and associated behaviours. Provides a framework for understanding individual differences and strengths; for staff to recognise what they do well, why they behave in a certain way, where they can develop and change. Also how staff can use this self-awareness to better inform their


interactions with others; in turn improving the effectiveness of working relationships, individual and team performance and ultimately, in front-line roles, patient care. Open MBTI workshops are usually held monthly and available to all staff. During March and April 2015, 20 staff from across the Trust attended over two workshops. In addition, MBTI and Belbin are both utilised as team building interventions. Bespoke Team Building workshops: for example, all band 6 and 7 Emergency Department nurses, to support department planning and communication. 3.10 Assessment/Development Centres During Jan-April, Leadership & OD designed and supported seven assessment centres and interviews, working with the appropriate recruiting manager: Cancer Manager, ED Directorate Manager, Deputy Director of Operations Director of Finance and Director of Informatics Each involved the preparation of personality psychometrics for candidates, observed exercises, facilitation on the day, assessing observed exercises and administering psychometrics tests. L&OD provide 121 feedback sessions to candidates following the process to support on-going learning and reflection. 3.11 Supporting Organisational Change/TUPE During the TUPE process the Trust has supported Pathology staff in the transition from Southport & Ormskirk and Therapies staff transferring from 5 Borough Partnerships. L&OD actively supported the re-structure process within Pathology, through provision of assessment centre/ interview preparation support to developing and running assessment centres. Subsequently, all staff who were impacted in the re-structure through bands 7-8d (c. 45 staff) have been offered one-to-one feedback and development support by L&OD. This is to feed into team development (dynamics, objectives), to support the embedding of the new structure. 3.12 Senior Management Development The Trust offered Senior Managers and Directors a comprehensive range of leadership support interventions to ensure the Trust remains a well-led organisation and to support talent management and retention. This comprises leaders taking part in leadership development opportunities provided by the national NHS Leadership Academy and local interventions including development centres and coaching programmes. These include15 managers who have either enrolled or completed one of the following Leadership Academy programmes:

Edward Jenner, May Seacole, Elizabeth Garrett Anderson, Nye Bevan, Aspiring Talent, Frontline Nursing & Midwifery Senior Operational Leaders


3.13 Staff Engagement The Trust carried out the annual NHS staff satisfaction survey during quarter 3 of 2014/15. The feedback results were published in February, and a report presented the March 2015 Trust Board meeting. The Staff Engagement action plan aligned to the recommendations from Keogh and Francis reports was presented to the Workforce Council in March 2015 as part of the assurance process. The following actions have taken place as part of this plan:- Completed a review of the provision of training in Customer Care to ensure it meets

the requirements for de-escalation skills as part of Conflict Resolution Training (CRT). Additional training is being offered to selected high risk areas in the skills of breakaway techniques.

The Care Certificate has been introduced for all newly appointed HCAs. This Nationally mandated 15 module skills programme was developed to ensure all healthcare support workers meet a minimum competency level at employment to ensure patient safety and experience. All new HCAs are enrolled at the time of appointment and are assessed in the workplace during their first 12 weeks in post.

The Trust continues to work with West Cheshire College to support HCAs and other staff in Bands 1-4 to undertake Apprenticeships in Healthcare as part of the ‘Talent for Care’ initiative

The Trust continues to monitor the effective use of CPD monies for non-medical clinically qualified staff. This ensures that the funding, accessed through HENW, is used to support development directly linked to supporting service provision and patient experience.

Team Talk listening events continue to be hosted and are well received by staff. Suggestions made and actions taken as a result of these events are fed back through a range of means, such as the intranet and News & Views.

The Trust has introduced ‘Little Conversations’ staff engagement & consultation events in order to solicit staff views and suggestions on how to resolve issues that are important to the Trust. To date 2 events have been held which covered the subjects of ‘Speak out Safely’ and the new Trust Values. Further events will be delivered throughout the year.

4.0 Supporting our Workforce The Trust has submitted evidence to Safe, Effective Quality Occupational Health Service (SEQOHS) to enable maintenance of accreditation of the nationally required standard for Health, Work & Well Being Services. The Trust continues to provide HWWB to external organisation’s e.g. local CCGs and as the Lead Employer for c.2000 junior doctors in training on behalf of Health Education North West. 4.1 Health, Work & Well Being HWWB– Key Performance Indicators The Trust’s HWWB services are aligned to needs identified via analysis of the main reasons for absence whilst also offering services to keep staff health and in work.


Physiotherapy support

Physiotherapy referrals (January to June 2015) Physiotherapy Total Total number of referrals to physiotherapy service 108 Of those referred , the number who remained in work 73 Staff absent from work and in receipt is physiotherapy 26 Staff referred but decline support 4 DNA's 15 Unable to contact via telephone 4

Counselling Support (January to June 2015) Staff referred for Counselling (support provided within 2 weeks) - 110 Employee Assistance Programme (EAP) The Trust has procured a 24/7 employee assistance service to ensure that out of hours support is available to staff. Between the period December 2014 – May 2015 22 employees utilised the service Breakdown of Support Provided 7 Ad-hoc Counselling Support from Helpline 6 Telephone Counsellor Referral 3 Email Enquiry (information only) 2 Legal/Financial Advice 2 In-House Services Referral 1 Referral to Sessional Telephone Counselling


1 Support Call Referral Presenting Difficulties 13 employees contacted the service with personal difficulties. 6 employees had work related issues. 2 employees contacted the service to request legal or financial advice. 1 employee contacted the service to request additional information about the

service. January - June 2015 Ill Health Appointments with a Doctor - 463 Ill Health Appointments with the Nurse - 775 Referrals to Occupational Psychologist - 164

Mental Health Nurse telephone contact with staff within 48 hours of reporting absence with a reason of stress/depression or anxiety to offer support January 85 February 74 March 88 April (3 weeks hol) 25 May 70 June 99 Total Contacts 441

4.2 Flu Campaign NHS Employers recently reported the Trust as having achieved the best Acute Trust flu vaccination rates for 2014/15 with 81% of frontline staff having received the flu vaccine. This is an increase of 4.8% since last year and 6% above the national target of 75%.

4.3 HR Support – Attendance Management

• The most recent benchmarking data available covers the period from January 2015 to June 2015 and shows that the Trust sickness absence for this period (4.73%)

Trust Overall Absence Rate 4.73% Trust Overall Absence Rate 5.21% Trust Overall Absence Rate 5.24% Trust Overall Absence Rate 4.44%

Add Prof Scientific and Technical 5.54% Add Prof Scientific and Technical 4.36% Add Prof Scientific and Technical 4.10% Add Prof Scientific and Technical 4.50%

Additional Clinical Services 7.04% Additional Clinical Services 9.13% Additional Clinical Services 8.45% Additional Clinical Services 6.43%

Administrative and Clerical 3.41% Administrative and Clerical 4.55% Administrative and Clerical 4.50% Administrative and Clerical 4.56%

Allied Health Professionals 3.75% Allied Health Professionals 2.79% Allied Health Professionals 2.03% Allied Health Professionals 2.14%

Estates and Ancillary 6.92% Estates and Ancillary 7.66% Estates and Ancillary 7.21% Estates and Ancillary 5.59%

Healthcare Scientists 3.23% Healthcare Scientists 3.07% Healthcare Scientists 4.89% Healthcare Scientists 1.83%

Medical and Dental 1.34% Medical and Dental 1.15% Medical and Dental 2.55% Medical and Dental 1.42%

Nursing and Midwifery Registered 4.94% Nursing and Midwifery Registered 5.78% Nursing and Midwifery Registered 5.54% Nursing and Midwifery Registered 4.45%

Benchmarking of Cumulative Absence January 2015 to June 2015

Warrington & HaltonAlder HeyRoyal LiverpoolSt Helens & Knowsley % ABS% ABS% ABS% ABS


compares favourably to Alder Hey Children’s Hospital (5.54%), Royal Liverpool and Broadgreen (4.78%) but slightly worse than Warrington & Halton NHS at 4.45%

The HR team have focused in particular on healthcare assistant sickness absence and the Trust has seen a month on month reduction in healthcare assistant sickness absence from 8.46% in February 2015 to 6.51% in June 2015. Work is on-going to provide targeted support to healthcare assistants including stress management, carer’s support and provision of external support. The HR Advisory Team continues to work closely with Ward Managers, Matrons and Directorate Managers to address sickness absence, with particular attention being paid to areas with the highest levels of sickness absence. They also continue to work in partnership with the HWWB team to tackle long term sickness absence and support staff back to work. There are currently 36 members of staff who have been absent for 3 months are more. Action plans are in place for all long term sickness absence cases and are updated regularly by ward managers, HR advisory team and HWWB. Across the Trust, there are 322 employees on stages of the attendance management policy and 80 employees on levels of the policy (i.e. with underlying conditions).

The Absence Support Team continue to provide administrative support to line managers in monitoring and managing sickness absence, which includes arranging and producing paperwork for welfare, return to work and stage/level meetings, issuing self-certificates to employees and completing HWWB referrals. In addition, the Absence Support Team provide a call back service to all absent employees (with the exception of stress/anxiety related absence, which are picked up by HWWB team) to ensure the Trust are supporting a swift return to work. The Team also screen Pysio-med referrals to eliminate inappropriate referrals and monitor open absence on a daily basis to all ensure appropriate actions are taken.

2013 2014 20155.33% 5.05% 5.38%4.69% 4.90% 4.91%4.50% 4.75% 4.90%4.31% 4.85% 4.61%4.46% 4.37% 4.24%4.29% 4.77% 4.37%4.44% 4.64%4.28% 4.60%4.18% 4.91%4.81% 4.99%4.93% 5.25%4.72% 5.44%December

JuneJulyAugustSeptemberOctoberNovember

MonthJanuaryFebruaryMarchAprilMay

Stages and levels Medical Care Group

Surgical Care Group

Patient Access

Clinical/Non Clinical Support Medirest Total

Stage 1 89 54 30 44 54 271Stage 2 14 17 2 9 9 51Stage 3 (Dismissal) 0 0 0 1 0 1Stage 4 Appeal 0 0 0 0 0 0Level 1 4 30 8 23 6 71Level 2 0 0 0 1 5 6Level 3 (Dismissal Stage) 1 0 0 2 0 3Level 4 Appeal 0 0 0 0 0 0

Breakdown of Staff on Stages and Levels of The Trust Absence Management policy Period January 2015 to June 2015


In addition to the above, the HR directorate are taking the following actions in order to support a reduction in sickness absence: • Introduction of ‘Improvement Trajectories’ for each ward/department will be used to

monitor progress against required improvement in attendance on a monthly basis by the HR Advisory Team.

• Production of an Attendance Management ‘Quick Guide’ summarising the requirements of the attendance management policy, the triggers and highlighting the appropriate use of other leave (e.g. annual leave, carers leave, bereavement leave).

• 1 hour sessions for line managers on the appropriate management of staff when absent, with a focus on difficult conversations with staff around returning to work, appropriate use of other leave etc. provided by the HR Advisory Team.

• Facilitation of 1 hour, weekly Stress Management sessions by HR & HWWB entitled, ‘You and Your Well-Being’ with a focus on, recognising stress, symptoms/signs, a ‘60 second Tranquiliser’ (a technique staff can apply in real life when they may feel overcome by stress/anxiety etc.) A booklet is to accompany the training and to be readily available for staff and focuses on what stress is? signs/symptoms, causes, coping methods, ‘what can I do to help cope with stress?’, ‘what can the organisation offer me to help me cope with stress?’ A questionnaire will also be piloted at the session to collate and review information regarding stress to ensure the session is fit for purpose and we are providing all opportunities to support staff whilst they are in work

• Exploration of a ‘Book Prescription Service’ in partnership with the Trust library so HWWB can ‘prescribe’ self-help books to individuals when required.

• Citizens Advice Bureau and/or Debt Charities to attend the two hospital sites to hold sessions/stall to provide free, confidential, independent advice to staff regarding financial and legal matters for example. Studies have shown that debt is major contributors to poor mental health which can intern have a detrimental effect on well-being.

• ‘Task & Finish Group’ set up with a multi-disciplinary team i.e. HR, Counselling, HWWB to look at establishing a working group focussing on bereavement leave and the support the Trust can provide including designing staff guidance in relation to bereavement absence that can be provided to staff when attending welfare visits to ensure they are provided with support and advice in response to recent absence cases due to bereavement.

• Explore the current Carer Support Network for staff and establish whether training/awareness sessions are required to ensure the Trust can provide support and guidance to carer’s at all stages i.e. whilst in work, during absence and if required signposting to internal/external agencies in the event that their carer responsibilities conclude.

• Look to utilise technology i.e. ‘App’s’ or staff intranet for easily accessible help and support for staff 24/7 on a range of topics and promotion of Well-Being initiatives.

These are in addition to the staff running and walking groups.


Attendance Management Policy Amendments to the policy approved at the Workforce Council in January 2015 has strengthend the triggers in place for moving staff to stages/levels of the policy as well as ensuring a robust process for managing trends in sickness absence which do not hit a trigger.

5 Enhancing Workforce Systems & Processes 5.1 eRostering Implementation The Trust commenced the roll-out of a new e-Rostering system “Healthroster” in September 2014. Phase 1 is the implementation of an e-rostering solution to all wards and theatres during a 12 month project. Year to date, the Trust has exceeded the project trajectory with c.1200 staff now able to access their rota’s via a mobile device or computer. The systems provide the benefit of a direct interface from managers approving shifts worked for payment to the payroll service and removes the need for inputting onto ESVL, freeing up ward management time for other duties. 5.2 Medical & Dental Workforce e-Job & Jnr Drs eRostering Following the updating of Consultant/Associate Specialist job plans in line with the Trust’s new Job Planning Policy, job plans have been uploaded onto a system aligned to Healthroster, which will also allow for the recording of annual leave, study leave and sickness absence. This will enable Divisional Managers and Clinical Directors to have improved oversight of job plans (previously paper based), so they remain dynamic to service priorities and commissioning intentions. This workstream will follow on from the implementation of the erostering project and is due to commence in September 2015. 5.3 Payroll Services The Trust’s Payroll Department provides a service to c.24,000 NHS staff across Cheshire and Merseyside. A key priority throughout 2014/15 has been supporting Trust and client’s staff to understand the implications of the changes to the NHS Pension arrangements. There are significant changes involving staff making decisions about their future pension benefits (Pensions Choice 2). Some groups of staff (dependent on age, role and service) will have moved into a new pension scheme from April 2015. 6 Workforce Information – Staff in Post

Staff Group FTE Headcount FTE Headcount

January 2015 June 2015 Add Prof Scientific and Technical 130.74 140 135.69 145

Additional Clinical Services 799.42 951 816.9 970 Administrative and Clerical 893.58 1054 903.11 1069 Allied Health Professionals 177.71 200 196.1 218 Estates and Ancillary 310.41 458 299.57 445 Healthcare Scientists 186.42 207 192.41 216 Medical and Dental 370.81 390 380.52 400 Nursing and Midwifery Registered 1,316.99 1478 1,305.78 1468

Total 4,186.08 4878 4,230.07 4931


Since Jan 2015, the figure for staff in post increased 43.99 wte. There are c. 88 wte staff currently on Maternity Leave, with 41 of staff on internal secondments from their substantive posts, 8 on Career Break and 6 are suspended/action short of suspension. 6.1 Recruitment & Retention – Workforce Information A review of the Trust’s immediate and longer term workforce plans and staffing requirements took place in Quarter 3, 2014. A new Recruitment and Retention Strategy 2015-18 has been approved and implementation of these actions has commenced to address shortage areas. One of the key areas where there is a shortage not only within the Trust but at a National level is Staff Nurses. Recruitment have a planned programme of Staff Nurse Recruitment days which have already taken place in April, July and a further one is scheduled for September. In addition to this HR are also leading on a programme to undertake International Recruitment across India and the Philippines. It is anticipated that we will be able to secure 50 FTE for Quarter 1 and Quarter 2 of 2016. A number of policies were ratified at the Workforce Council in January in relation to Recruitment (Recruitment and Selection, Disclosure and barring Service, Reference and Safer Recruitment and Employment Policies). The key changes to these policies were in the main relating to key changes in legislation (i.e. Right to Work, Fit and Proper Persons Test) and the introduction of the new Recruitment system TRAC. Since the TRAC introduction in October 2014 and as part of the rolling CIP, Recruitment and Finance are in the process of developing an online solution to replace the VAC process which will remove the current paper based system to an automated online system via TRAC. The anticipated benefits of this is that it will speed up the initial Authorisation process and the overall recruitment process. An additional activity that has been undertaken in conjunction with this is mapping the End to End recruitment process in line with the overall CIP. The purpose of this is to identify waste that can be eliminated to provide a more streamlined and effective recruitment process.

Recruitment are also undertaking a Disclosure and Barring Service look back exercise for all employees that were employed with the Trust before April 2002 that do not have a DBS (and require one under new requirements) this will also include a review of all DBS certificates that are over three years old in line with the DBS policy. To ensure that the policies have been implemented and in line with NHS pre-employment checks, a number of Audits have been scheduled to take place in July and October of this year in accordance with the DBS and Safer Recruitment policies. Current Vacancies As at Month 4 (May) there where 68.51 WTE Funded vacancies for Qualified Nurses across the Trust. However recruitment activity to fill these positions is at the following Stages. Trained Staff with Confirmed Start Dates:

July August September October5 WTE 16.15 WTE 9.6 WTE 1 WTE


Results from Recruitment Open Day 11Th July 2015 + Follow up interviews

Summary of Above information is that 59.95 Wte Qualified Nurses have been offered Positions. Proactive recruitment is required to ensure ongoing turnover is accounted for. Staff Turnover Rates Turnover rate is currently 4.83% for the YTD (Jan to June 2015) The Trust benchmarks low against some local Acute Trusts.

The following Age Profile shows that the majority of staff are aged between 41 and 55, with the fewest staff employed being under 20 or over 71 years of age. This is typical of a workforce of this size.

Trained 33 Staff Offered Positions from Open DayUntrained 6 29Total 39Trained 32Untrained 3Total 35

Attended Open day

Interviewed

St Helens & Knowsley Headcount Leavers Headcount

Staff Turnover

%Royal Liverpool Headcount Leavers

Headcount

Staff Turnover

%Alder Hey Headcount Leavers

Headcount

Staff Turnover

%Warrington & Halton Headcount Leavers

Headcount

Staff Turnover

%

Staff Group Staff Group Staff Group Staff GroupAdd Prof and Technical 142.50 13 9.12 Add Prof and Technical 359 19 5.29 Add Prof and Technical 219 5 2.28 Add Prof and Technical 184 11 5.99Additional Clinical Services 960.00 45 4.69 Additional Clinical Services 1640 64 3.90 Additional Clinical Services 406 15 3.70 Additional Clinical Services 734 39 5.32Administrative and Clerical 1,061.50 47 4.43 Administrative and Clerical 1866 75 4.02 Administrative and Clerical 612 34 5.56 Administrative and Clerical 822 45 5.47Allied Health Professionals 208.00 17 8.17 Allied Health Professionals 425 22 5.18 Allied Health Professionals 146 5 3.44 Allied Health Professionals 312 19 6.09Estates and Ancillary 451.50 15 3.32 Estates and Ancillary 135 3 2.22 Estates and Ancillary 192 7 3.65 Estates and Ancillary 403 22 5.46Healthcare Scientists 211.00 12 5.69 Healthcare Scientists 259 12 4.63 Healthcare Scientists 101 6 5.97 Healthcare Scientists 101 8 7.92Medical and Dental 395.00 11 2.78 Medical and Dental 722 81 11.23 Medical and Dental 267 21 7.88 Medical and Dental 304 20 6.59Qualified Nursing Staff 1,473.00 77 5.23 Qualified Nursing Staff 1997 103 5.16 Qualified Nursing Staff 1010 26 2.58 Qualified Nursing Staff 1086 76 7.00

4903 237 4.83% 7402 379 5.12% 2951 119 4.03% 3945 240 6.08%


The above table indicates that in Years 2016 and 2019 there will be a high number of Sister/Charge nurses and staff grade nurses who will be of retirement age. This has been brought to the attention of the HR recruitment team who will factor this in to future recruitment activity. Benchmarking - Band Profiling The Table below illustrates benchmarking data from the Health & Social Care information website on the comparison of Agenda for Change bandings nationally for medium Acute Trusts against StHK. The Trust has significantly more staff on Bands 1 and 2 than both National and Medium Acute Trusts. This is a reflection of robust development of job descriptions and a strict application of the job matching (evaluation) process and the local employment market. With regards to staff employed on middle grades between bands 4 and 5 the Trust falls within an average range, however the Trust has less than the average staff employed above band 5. This data demonstrates that the Trust manages its pay bill on or below national averages. However, work is on-going to ensure banding issues are not contributing to any recruitment or retention issues.

Retirement Profile Next Five Years (Women Aged 60, Men Aged 65)

Staff Group Role 2016 2017 2018 2019 2020 5 yrs SummaryAdd Prof Scientific and Technic Total 3 3 2 8Additional Clinical Services Assistant/Associate Practitioner Nursing 3 4 4 11

Counsellor 1 1 2Health Care Support Worker 1 1 1 3Healthcare Assistant 71 35 39 1 146Healthcare Science Assistant 17 10 1 8 36Helper/Assistant 6 4 7 17Nursery Nurse 1 1Play Specialist 1 1Student Technician 2 2 4Technical Instructor 1 1 2Technician 1 1Trainee Healthcare Science Associate 2 2Trainee Scientist 1 1

Additional Clinical Services Total 103 58 1 63 2 227Administrative and Clerical Total 94 40 1 64 3 202Allied Health Professionals Total 9 6 3 18Estates and Ancillary Total 82 24 4 27 6 143Healthcare Scientists Total 19 7 5 1 32Medical and Dental Total 10 8 5 10 4 37Nursing and Midwifery Registered Enrolled Nurse 2 2

Midwife 9 5 6 20Modern Matron 2 1 3Nurse Manager 1 1 2Sister/Charge Nurse 12 8 1 14 35Specialist Nurse Practitioner 5 6 8 19Staff Nurse 35 14 30 3 82

Nursing and Midwifery Registered Total 66 33 1 60 3 163386 179 12 234 19 830

YearPosition Details

Grand Total

National Position AFC Band 5 and Below AFC Band 6 and AboveSt Helen's & Knowsley 73.98% 26.02%Medium Acute Trusts 68.71% 31.29%Nationally 64.88% 35.12%

Trust AFC Band 5 and Below AFC Band 6 and Above

Wirral University Teach F 74.71% 25.29%Countess Chester F 74.62% 25.38%Aintree Uni F 73.28% 26.72%Mid Cheshire F 73.09% 26.91%Southport & Ormskirk 70.68% 29.32%Warrington & Halton F 69.23% 30.77%Walton Centre F 67.67% 32.33%Liverpool Heart & Chest F 67.67% 32.33%Royal Liverpool & Broad Uni 65.85% 34.15%Alder Hey Childrens F 65.07% 34.93%East Cheshire 61.68% 38.32%Liverpool Women's F 54.98% 45.02%Clatterbridge Cancer F 53.55% 46.45%

Trust AFC Banding Comparison Nationally and Local


7. Governance

The Workforce Council provides assurance to the Quality Committee that policies and procedures are legally compliant and in line with national guidance to comply with. For example, the NHSLA, CQC and the Equality Delivery System (EDS) requirements.

8 Recommendations

The Trust Board are requested to accept the report, noting the areas of achievement/progress against corporate objectives and governance standards.

Trust Board (29-07-15) – Infection Control Report Page 1

TRUST BOARD PAPER


Title of paper: Infection Control Report.

Purpose: The aim of the report is to provide the Trust Board with an overview on the current Trust infection control status against Department of Health Objectives.

Summary: Number of cases for financial year 2015-2016:

• MRSA bacteraemia: 0 cases (target 0)

• CDI: 12 (target 41) Number of cases in May 2015:

• MSSA bacteraemia: 1

• E coli bacteraemia: 5

Corporate objectives met or risks addressed: Contributes towards the achievement of Patient Safety and Workforce planning objectives.



Recommendation(s): It is recommended that the Board note this report and the actions in place to reduce hospital acquired infections.

Presenting officer: Sue Redfern, Director of Nursing, Midwifery and Governance.



INFECTION CONTROL REPORT 1. Methicillin-resistant Staphylococcus Aureus (MRSA) bacteraemia

1.1. All Trusts have been given the target of zero hospital-acquired cases for 2015/16. We have had no cases since the start of the financial year.

2. Methicillin Sensitive Staph Aureus (MSSA) bacteraemia 2.1. The Trust is now required to report all MSSA blood cultures. There is currently

no external target. In May 2015, there was 1 hospital-acquired case. 2.2. Audit of compliance is being conducted by matrons. 2.3. Key message for May and June was “Need to check cannula site post removal

of the cannula for signs of infection”. 3. MRSA hospital acquired colonisation

3.1. There were no cases of hospital-acquired MRSA (not blood cultures) within the Trust during May and 1 case in June.

4. E Coli bacteraemia. 4.1. There is no external target for E Coli Bacteraemia. In May 2015, there were 31

cases of which 5 (16%) were hospital-acquired, the remainder being community-acquired.

4.2. An internal target for 2015-2016 of 55 hospital-acquired cases has been set. 4.3. The hospital-acquired bacteraemia were as follows:

- One patient with biliary sepsis without any previous invasive procedure (unavoidable)

- One patient with urosepsis with no history of urinary catheterisation/invasive intervention in the urinary tract (unavoidable)

- One patient with pneumonia without history of ventilation (unavoidable) - One patient with PICC line infection (potentially avoidable) - One patient with catheter-related urosepsis (potentially avoidable).

5. Vancomycin-resistant Enterococcal (VRE) bacteraemia. 5.1. No cases of VRE bacteraemia so far this financial year.

6. Clostridium Difficile Toxin (CDT) 6.1. The target for 2015-2016 is no more than 41 hospital-acquired cases. 2014/15

was a particular challenge for the Trust; following the HCAI appeal process the Trust had 11 out of 18 cases upheld resulting in 33 cases against a trajectory of 19.

6.2. For 2015/16 to date there has been twelve cases of which the Trust will be appealing 4.

6.3. The revised NHSE Clostridium Difficile infection assessment tool and action plan have now been implemented and saving lives tool kit conducted on each ward with a confirmed case.

6.4. Actions implemented include : - Bristol Stool chart for all patients - Point prevalence audit 24 June


- Increased education and awareness at ward level - Mattress awareness day - Ward audits after every case of CDI - Review of use of deep clean plus fogging/UV - Rationalisation of environmental cleaning wipes and removal of 70% alcohol

wipes - Improved hand hygiene signage at ward entrances - Antibiotic Policy revised according to updated national guidance. (consultation

completed and Committee approved.) - Key messages posters provided. Hand washing display pull-up provided

outside the ward in the lobby area. 7. Outbreaks

7.1. There were no outbreaks during June 8. Peer review visit

8.1. The TDA and CCG participated in a peer review HCAI visit to the Trust on10 June.

8.2. There were 25 people in the team which included infection control leads and Infection controls nurses.

8.3. The feedback was positive with a few areas for focus which has since been completed.

ENDS

Trust Board (29-07-15) – Safer Staffing Report Page 1

TRUST BOARD PAPER


Title of paper: Safer Staffing Report.

Purpose: The aim of the report is to provide the Trust Board with an overview of nurse and midwifery staffing levels in inpatient areas during the month of June 2015. This will highlight the wards that staffing does not meet the 90% fill and will provide a summary of actions implemented to address any gaps.

Summary: The Trust are required to publish monthly nursing staffing levels by shift and comparing expected versus actual hours worked via the template set up on UNIFY. The month of June data indicates that the overall fill rate was:

• Overall Trust compliance was 98.6% • Registered nurse compliance for days was 98.27% and for nights was 96.8% • HCA compliance for days was 98.96% and for nights was 100.34%

There were 5 ward areas with 90% or below fill rates; these wards were: • Ward 2B - 83.33% RN night shift (106.58% HCA nights ) • Ward 2C - 78.89% RN night shift (108.77% HCA nights) • Delivery suite - 86.1% HCA nights • Ward 3F - 89.3% HCA days • Ward 3E - 88.3% HCA nights.

Corporate objectives met or risks addressed: Contributes towards the achievement of Patient Safety and Workforce planning objectives.



Recommendation(s): It is recommended that the Board note this report and the data to be submitted to Unify.




SAFER NURSE STAFFING Introduction 1. The purpose this paper is to provide assurance on nurse staffing levels and staffing

capacity to provide safe, high quality care across all wards at the Trust. Both the Quality Committee and Trust Board receive monthly reports in relation to Nursing and Midwifery staffing within wards at the Trust.

2. Exception reporting is provided where actual nurse staffing levels are outside the parameters set (90% and 110% of the baseline target). The report also provides a breakdown of the use of bank and agency staff to achieve the establishment levels.

3. The Trust is committed to ensuring that its nursing workforce is sufficiently robust to deliver high quality, safe and effective care in order to meet the acuity and dependency requirements of patients. This report reflects the organisation’s commitment to being open and honest through the publication of data on the Trust’s website and formal data submission via UNIFY which is published on the NHS Choices website ensuring that the Trust is compliant with NHS England guidance.

4. The baseline for the fill rate measure is the ward establishment. The ‘fill rate template’ is included as Appendix 1 to the monthly safer staffing report and is discussed at the senior nurse meeting, Quality Committee and Trust board.

5. The 6 monthly nurse staffing establishment and acuity report was presented to the Board meeting on 24th June and is available on the Trust’s safer staffing website.

6. Further patient dependency audits using the Shelford tool will be undertaken in September and October. The existing NICE guidance on adult acute wards and maternity settings will remain in place.

7. Nurse sickness, absence, vacancies, and leave is monitored by the matrons each day and reported via the central database which highlights the difference between current staff in post and current establishment. Identified gaps are met by bank staff or by existing ward-based staff working additional hours, with agency staff requested when all other avenues have been exhausted.

8. Nurse staffing shortfalls are escalated, discussed and resolved on a day by day basis at the Matron’s Safety Huddle held at 12 noon. Due consideration is given to: 8.1. Any immediate adverse implications from staffing shortfalls. 8.2. The need for additional staff from internal transfers or use of agencies. 8.3. Staffing Solutions provides daily support to address gaps in staffing and

information on bank shifts requested and filled. 8.4. A nurse staffing escalation flowchart is in place to support wards in ensuring

that the appropriate level of staffing is in place across all the ward areas. 8.5. The close observations (1:1 supervision) of patients policy has been revised to

support wards with specific patients who have high nursing dependency needs. 9. It is important to recognise that the ward fill rates include staff who worked additional

shifts on the bank, agency, overtime and pay back from time in lieu. 10. The month of June data indicates that the overall fill rate was:

10.1. Overall Trust compliance – 98.6 % 10.2. Registered Nurse compliance for days was 98.27% and for nights 96.8% 10.3. HCA compliance for days was 98.96% and for nights was 100.34%

https://www.nice.org.uk/guidance/sg1

https://www.nice.org.uk/guidance/sg1

https://www.nice.org.uk/guidance/ng4


10.4. There were 5 ward areas with 90% or below fill rate for registered nurses; these wards were: - Ward 2B - 83.33% RN night shift (106.58% HCA nights ) - Ward 2C - 78.89% RN night shift (108.77% HCA nights) - Delivery suite - 86.1% HCA nights - Ward 3F - 89.3% HCA days - Ward 3E - 88.3% HCA nights.

10.5. Actions implemented were: - Wards 2b and 2c staffing is currently on the risk register with a risk rating of

16, with appropriate mitigation plans to ensure gaps in shifts are covered. - Patients requiring BIPAP are being cared for in HDU. - Block booking for registered nurses from nurse bank and agency. - Shift by shift monitoring of staffing and dependency of patients with escalation

to senior nursing team / Director of Nursing. - Posts recruited to with some delays in start date for newly qualified staff. - Recruitment to nurse bank. - DMOP wards recruitment drive. - Staff focus groups and listening events continue.

10.6. There were 7 wards areas above the 100% fill rate; these wards were: - Ward 2B 106.88% HCA night shift - Ward 2C 108.77% HCA night shift - Ward 2E 106.67% HCA night shift - Ward 3B 102.94.% HCA day shift - Ward 3C 103.47.% HCA day shift - Ward 4B 112.26.% HCA night shift - Ward 4D 103.33% HCA night shift

11. The reliance on temporary staffing solutions to fill vacancies and meet the acuity and dependency requirements of patients within our care is still significant and continues to be an operational challenge. This is managed on a shift by shift basis by Ward Sisters and Charge Nurses in conjunction with Matrons to ensure that their areas are safely and appropriately staffed utilising risk assessment methodologies to mitigate the greatest risks.

12. The Trust was planning an overseas recruitment event for registered nurses from the Philippines. Employers, who wish to recruit from outside the European Economic Area (EEA), require a Tier 2 Certificate of Sponsorship (CoS). The Trust applied for certificates in June but was unsuccessful due to nursing not being considered on the “shortage occupation list”.

13. This is disappointing, however the Trust has continued to hold a number of recruitment days for targeted areas; the last being on 11th July where 34 registered nurses were appointed. A further recruitment day is planned and 74 nurses have been shortlisted.

http://www.nhsemployers.org/your-workforce/recruit/employer-led-recruitment/international-recruitment/immigration-rules-and-the-points-based-system/tier-2


14. During June a total of 29 staffing incidents were reported via the Datix system. This related to 10 areas as indicated in the table below:

Ward Reports Datix details Actions

Ward 2C Respiratory

1 Night shift 1 RN short. Patients needing IVs and CD medication that need counter-signing

Bed manager unable to cover from another ward. RN 1:16 for night

Ward 3B 1 Staff member went home sick during shift

2 RN and 3 HCA remained on ward for 4 hours

Ward 5a 5 RN short x 2 shifts HCA bank request not filled 1 relates to junior doctor cover

RN 1:16 for night shift 2 occasions Cross cover from 5th floor wards

Ward 5B 2 I close observation HCA not available 1 junior doctor cover

Bank unable to cover HCA shift at short notice

Ward 3D 3 3 occasions sickness not covered by bank

Close observation covered by ward staff

Theatre 3 OPD and nurse staffing to return patients to ward

Ward staff to collect patients

Ward 1A Frailty 5 No special for aggressive patient. 2 RN sickness 2 skill mix

Request via bank unable to cover

Ward 1D 4 RN trained nurse reduced on 4 occasions

Due to short term sickness

Ward 4D 1 Special not available Bank unable to cover

Ward 3E Gynae & delivery suite

4 4x Midwife rang in short notice sick reducing staffing levels

2x Covered by community midwife

15. Further analysis and triangulation of the 5 wards that did not achieve the 90% RN staffing threshold demonstrates that Wards 2B, 3F, 3E and Delivery Suite had no infections, no pressure ulcers, and no serious incidents. Ward 2C had no infections, 1x grade 1 pressure ulcer (fully staffed at the time), and no serious incidents.

16. Stabilising the nursing workforce in clinical areas is a priority during 2015.Further work is currently on-going between the senior nursing team, HR and respective divisions in order to validate the nurse staffing vacancies.

17. Analysis of the fill rates demonstrates that the majority of wards fulfil the required standard set. Where it is identified that a clinical area has fallen below the required standard an exception report is generated to ensure that robust plans are in place to militate against further occurrences.

Appendix 1

03 - June 2015 Upload Form.xls

Fill rate indicator returnOrg: RBN St Helens And Knowsley Hospitals NHS Trust Staffing: Nursing, midwifery and care staffPeriod: June_2015-16

(Please can you ensure that the URL you attach to the spreadsheet is correct and links to the correct web page and include 'http://' in your URL)

Comments

0Only complete sites your

organisation is accountable for

Site code *The Site code is

automatically populated when a

Site name is selected

Hospital Site name Specialty 1 Specialty 2Total monthly planned staff hours

Total monthly actual staff hours

Total monthly planned staff

hours

Total monthly actual staff

hours


hours


hours


hours


hours

2 RBN01 WHISTON HOSPITAL - RBN01 1A 430 - GERIATRIC MEDICINE

1734 1659 1935 1972.5 900 860 760 750 95.7% 101.9%

0 RBN01 WHISTON HOSPITAL - RBN01 1B 300 - GENERAL MEDICINE 2689 2689 1128 1098 600 600 600 600 100.0% 97.3%

0 RBN01 WHISTON HOSPITAL - RBN01 1C 300 - GENERAL MEDICINE 2722.5 2677.5 1311 1288.5 1560 1550 600 600 98.3% 98.3%

2 RBN01 WHISTON HOSPITAL - RBN01 1D 320 - CARDIOLOGY 1890 1837.5 1612.5 1650 880 840 600 640 97.2% 102.3%0 RBN01 WHISTON HOSPITAL - RBN01 1E 320 - CARDIOLOGY 2141.5 2141.5 800.5 800.5 1190 1190 140 140 100.0% 100.0%

0 RBN01 WHISTON HOSPITAL - RBN01 2A 303 - CLINICAL HAEMATOLOGY 1405 1405 918.5 918.5 570 570 350 350 100.0% 100.0%

2 RBN01 WHISTON HOSPITAL - RBN01 2B 340 - RESPIRATORY MEDICINE 300 - GENERAL MEDICINE 1807.5 1800 1530 1500 900 750 760 810 99.6% 98.0%

2 RBN01 WHISTON HOSPITAL - RBN01 2C 340 - RESPIRATORY MEDICINE 300 - GENERAL MEDICINE 1876 1861 1524.5 1479 900 710 570 620 99.2% 97.0%

0 RBN01 WHISTON HOSPITAL - RBN01 2D 300 - GENERAL MEDICINE 1425 1425 1011.5 996.5 600 600 600 560 100.0% 98.5%

2 RBN01 WHISTON HOSPITAL - RBN01 2E 501 - OBSTETRICS 2800.5 2617.5 1332 1275 1210 1120 600 640 93.5% 95.7%0 RBN01 WHISTON HOSPITAL - RBN01 3A 160 - PLASTIC SURGERY 1825.5 1806.5 1217.5 1217.5 630 620 570 560 99.0% 100.0%

0 RBN01 WHISTON HOSPITAL - RBN01 3Alpha 110 - TRAUMA & ORTHOPAEDICS 1112.5 1099.5 1532.5 1497 600 600 600 600 98.8% 97.7%

2 RBN01 WHISTON HOSPITAL - RBN01 3B 110 - TRAUMA & ORTHOPAEDICS 1357.5 1305 1480.5 1524 600 600 620 580 96.1% 102.9%

2 RBN01 WHISTON HOSPITAL - RBN01 3C 110 - TRAUMA & ORTHOPAEDICS 1652 1554.5 1699 1758 900 880 900 890 94.1% 103.5%

0 RBN01 WHISTON HOSPITAL - RBN01 3D 301 - GASTROENTEROLOGY 300 - GENERAL MEDICINE 1749 1670 1418 1366 733.5 703.5 830 830 95.5% 96.3%

0 RBN01 WHISTON HOSPITAL - RBN01 3E 502 - GYNAECOLOGY 1372.5 1327.5 802.5 780 600 600 300 250 96.7% 97.2%

0 RBN01 WHISTON HOSPITAL - RBN01 3F 420 - PAEDIATRICS 100 - GENERAL SURGERY 2136.5 2118 627.5 560.54 1190 1150 335 315 99.1% 89.3%

0 RBN01 WHISTON HOSPITAL - RBN01 4A 101 - UROLOGY 100 - GENERAL SURGERY 1784.5 1779.5 1286 1249 900 880 880 870 99.7% 97.1%

2 RBN01 WHISTON HOSPITAL - RBN01 4B 100 - GENERAL SURGERY 101 - UROLOGY 2337.25 2324.75 1704.5 1618.75 1080 1080 420 471.5 99.5% 95.0%

2 RBN01 WHISTON HOSPITAL - RBN01 4C 100 - GENERAL SURGERY 2098.5 2106.5 1418 1383.5 900 890 900 900 100.4% 97.6%

2 RBN01 WHISTON HOSPITAL - RBN01 4D 160 - PLASTIC SURGERY 1598.5 1561 637.5 600 600 590 300 310 97.7% 94.1%

0 RBN01 WHISTON HOSPITAL - RBN01 4E 192 - CRITICAL CARE MEDICINE 5354 5228.5 809.5 785.5 3600 3450 440 440 97.7% 97.0%

0 RBN01 WHISTON HOSPITAL - RBN01 4F 420 - PAEDIATRICS 1689.5 1648.5 639 579.5 600 580 300 280 97.6% 90.7%

2 RBN01 WHISTON HOSPITAL - RBN01 5A 300 - GENERAL MEDICINE 430 - GERIATRIC MEDICINE 1796 1788.5 2127 2219.5 900 860 900 930 99.6% 104.3%

2 RBN01 WHISTON HOSPITAL - RBN01 5B 430 - GERIATRIC MEDICINE 1534.5 1542 2189.5 2223.7 830 810 860 900 100.5% 101.6%

2 RBN01 WHISTON HOSPITAL - RBN01 5C 430 - GERIATRIC MEDICINE 2485.5 2468.5 1746 1730 1210 1190 810 830 99.3% 99.1%

2 RBN01 WHISTON HOSPITAL - RBN01 5D 430 - GERIATRIC MEDICINE 1503 1513 1485.5 1485.5 600 600 600 570 100.7% 100.0%

2 RBN02 ST HELENS HOSPITAL - RBN02 Duffy Ward 300 - GENERAL MEDICINE 430 - GERIATRIC MEDICINE 1290 1290 1631.25 1721.25 600 600 610 610 100.0% 105.5%

2 RBN01 WHISTON HOSPITAL - RBN01 SCBU 420 - PAEDIATRICS 1411.5 1370.5 642 642.1 960 960 250 250 97.1% 100.0%0 RBN01 WHISTON HOSPITAL - RBN01 Delivery Suite 501 - OBSTETRICS 3041.5 2966.5 834.5 718.5 2100 2050 540 530 97.5% 86.1%0 RBN02 ST HELENS HOSPITAL - RBN02 Seddon 314 - REHABILITATION 1312.5 1297.5 1680 1650 600 600 630 610 98.9% 98.2%00000000000000000000

Day

Average fill rate - care staff

(%)

Average fill rate -

registered nurses/midwiv

es (%)

Please provide the URL to the page on your trust website where your staffing information is available

Day

Care StaffMain 2 Specialties on each ward

Night

http://www.sthk.nhs.uk/pages/AboutUs.aspx?iPageId=17467

Validation alerts (see control panel)

Hospital Site Details

Ward name

Registered midwives/nurses Registered midwives/nursesCare Staff



Comments









hours


hours


hours


hours


hours


hours


1734 1659 1935 1972.5 900 860 760 750 95.7% 101.9%

Day


(%)

Average fill rate -


es (%)


Day


Night




Ward name


0000000000000000000000000000000000000000000000000000000000000000000000



Comments









hours


hours


hours


hours


hours


hours


1734 1659 1935 1972.5 900 860 760 750 95.7% 101.9%

Day


(%)

Average fill rate -


es (%)


Day


Night




Ward name


000000000

Total 60933.25 59879.25 40711.25 40288.34 30043.5 29083.5 18175 18236.5

Trust Board (29-07-15) – FT Progress Report including Self-Certification Page 1

TRUST BOARD PAPER


Title of paper: Foundation Trust Application Programme Report

Purpose: To escalate issues from the Executive Committee items for assurance or which require Trust Board consideration and direction.

Summary: The FT Application Strategic Delivery Governance Council (SDGC) is a sub group of the Executive Committee, this report is providing assurance from the Executive Committee that the FT Application Programme is progressing as planned and is escalating to the Board recommendations for key FT application deliverables. The issues for consideration in this report are;

1. TDA Integrated Delivery Meeting (IDM) – July 2. Monthly Board statements and self-certifications 3. Well Led Framework Action Plan Progress Report 4. Well Led Framework Self-Assessment 5. CQC Inspection Preparation update

Corporate objectives met or risks addressed: Contributes directly to developing the Trust’s Corporate and Quality Governance arrangements. Supports the corporate objective to become a sustainable Foundation Trust.

Financial implications: None directly from this report

Stakeholders: NHSTDA, Commissioners, Trust Staff, Service Users, the Public.

Recommendation(s): Members are asked to: 1. Note the expected requirement to revise and resubmit the 2015/16 operational plan

2. Approve the monthly Board statement and self-certification submission

3. Note the progress in delivering the Well Led Framework action plan

4. Review and approve the second self –assessment against the final Monitor Well Led Framework published in April 2015

5. Note the CQC inspection preparation progress report.

Presenting officer: Damien Finn, Director of Finance and Information



FOUNDATION TRUST APPLICATION PROGRAMME MONTHLY REPORT 1. Background and Context

1.1. The Foundation Trust (FT) application process is managed as a programme of work, led by the Director of Finance and Information, and involving the whole of the Board and others.

1.2. The governance for the FT Application Programme is from the Strategic Delivery Governance Council (SDGC) to the Executive Committee. The Executive Committee provides assurance to the Trust Board.

2. Integrated Delivery Meeting (IDM) – 7th July 2015 2.1. At the IDM the Trust was informed that the NHSTDA had been tasked with

reducing the NHS Trust sector planned deficit by 1/3 for 2015/16. The process of allocating financial “stretch” targets to each Trust would be completed and notified by 24th July. Trusts will then have until 30th September to submit a revised 2015/16 financial plan.

2.2. Formal feedback on the TDA’s mock CQC inspection was also given. This was generally very positive, but there were a small number of important actions identified by the team. These were all issues that had already been identified by the Trust own mock assessment process and actions have been put in place to address them.

2.3. A detailed briefing on actions to achieve and sustain the A&E four hour access target was also required, and this will continue to be monitored closely.

2.4. The Trust continues to be assessed at Escalation Level 3. 3. TDA Accountability Framework – Monthly Board Statement and Self-Certificates

3.1. The recommended statements and self-certificates for June are attached (appendix 1). There is no proposed change from the May statements, as performance other than the Emergency Access Targets is being maintained and financial performance is an improvement against plan.

4. Well Led Framework Self-Assessment Action Plan 4.1. The Board agreed the action plan resulting from the draft Well Led Framework

Self-Assessment that was undertaken in October 2014. 4.2. The table provides a summary of the progress to the end of June. The majority

of actions have now been completed or are in progress. A small number of the actions are not due (because of the Board cycle) until later in the year.

Domain

Tota

l Ac

tions

Due

Com

plet

e (G

reen

)

Ong

oing

(A

mbe

r)

Ove

rdue

(R

ed)

Mitigation Plan

Planning and Strategy 23 21 15 7 0 Two not due until Sept 2015

Capability and Culture 19 18 17 1 0 One not due until Nov 2015

Process and Structure 13 13 11 2 0

Measurement 8 8 8 0 0

Total 63 60 51 10 0

4.3. Due to section 5 below it is proposed that this action plan in now closed, as it is superseded by the latest self-assessment. Any outstanding action will be


transferred to the new action plan, if they are have not already been identified via the new self-assessment.

5. Monitor Well Led Framework 5.1. Monitor has published the final Well Led Assessment Framework in April. This

has now replaced the Board Governance Assurance Framework (BGAF) and Quality Governance Assurance Framework (QGAF), and provides a single governance assurance standard for existing Foundation Trusts and aspirant Foundation Trusts.

5.2. There are some changes to the final framework compared to the consultation version, but not to the key governance domains and questions.

5.3. It is recommended good practice for Trusts to undertake a self-assessment against the framework annually and to commission an independent governance review, using the Well Led Framework at least every 3 years.

5.4. In line with this best practice advice a working group was established consisting of Bill Hobden (NED, FT Lead), Sue Redfern (Director of Nursing, Midwifery and Governance), Peter Williams (Director of Corporate Services), Nicola Bunce (FT Programme Director), and Anne Rosbotham-Williams (CQC Project Manager).

5.5. This group undertook a self-assessment review against the revised well led framework on 3rd July. The report of self-assessment is presented (appendix 2), if this assessment is accepted by the Board a next stage action plan will be developed to be delivered over the next 6 months.

5.6. The overall assessment demonstrates progress since the previous self-assessment;

Self-Assessment Ratings

Domain October 2014 July 2015

1. Strategy and Planning

2. Capability and Culture

3. Process and Structures

4. Measurement

Overall Assessment

6. CQC Inspection Preparation 6.1. The CQC Provider Information Pack was submitted on the 23rd June, and the

data pack received by the Trust on the 9th July. Factual accuracy comments are to be submitted to the CQC by 21st July.

6.2. On 21st July there is a meeting with the Inspection Manager to review the arrangements for the inspection.

6.3. The CQC has launched its comments and engagement page, for the public, staff and patients to give their feedback on the Trust.

http://www.cqc.org.uk/syesthelensandknowsley 6.4. Two public engagement and listening events have been organised by the CQC

on 11th August, in Knowsley and St Helens. 6.5. By early August posters and comments boxes will be located in public areas

around the Trusts sites, and formal notification of the inspection and the staff focus groups given to staff.

http://www.cqc.org.uk/syesthelensandknowsley


6.6. The individual interview schedule is being finalised, but all interviews will take place in the Learning and Development Centre in Nightingale House, where the CQC inspection team will be based during the inspection.

6.7. The CQC have notified us that they plan to be on site for two days, the 19th and 20th August. The briefing day will take place on the 18th August and this is when the CEO presentation is given.

6.8. The mock inspection schedule is now coming to an end, with all areas having undergone a mock assessment. The action plans identified as a result of the mock inspections are being completed by the services, and the organisation wide issues, such as Junior Doctors induction are being addressed at a corporate level.

6.9. Iain McInnes the TDA Portfolio Director undertook mock interviews with Board members to be interviewed on 28th July.

END


Appendix 1

1. Board Statements – June 2015 No Statement Compliance

Yes/No/Risk Comment

1 The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight model (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

Yes

2 The board is satisfied that plans in place are sufficient to ensure on-going compliance with the Care Quality Commission’s registration requirements.

Yes

3 The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements.

Yes

4 The board is satisfied that the trust shall at all times remain a going concern, as defined by the most up to date accounting standards in force from time to time.

Yes

5 The board will ensure that the trust remains at all times compliant with the NTDA accountability framework and shows regard to the NHS Constitution at all times.

Yes

6 All current key risks to compliance with the NTDA's Accountability Framework have been identified (raised either internally or by external audit and assessment bodies) and addressed – or there are appropriate action plans in place to address the issues in a timely manner.

Yes

7 The board has considered all likely future risks to compliance with the NTDA Accountability Framework and has reviewed appropriate evidence regarding the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued compliance.

Yes

8 The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliver the annual operating plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily.

Yes

9 An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk).

Yes

10 The Board is satisfied that plans in place are sufficient to ensure on-going compliance with all existing targets as set out in the NTDA oversight model; and a commitment to comply with all known targets going forward.

Risk

The Trust has in place robust performance management and governance processes to monitor the achievement of all targets. The Emergency Access Standard continues to be extremely challenging as a result of the record levels of activity and the acuity of patients presenting at the Trust. The Trust is


implementing a recovery plan, which includes working with health economy partners to support the earlier discharge of medically optimised patients.

11 The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit.

Yes

12 The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests, ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or plans are in place to fill any vacancies.

Yes

13 The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.

Yes

14 The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the annual operating plan; and the management structure in place is adequate to deliver the annual operating plan.

Yes

2. Self-Certification – June 2015 No Statement Compliance

Yes/No/Risk Comment

1 Condition G4 Fit and proper persons as Governors and Directors

Yes

2 Condition G5 Having regard to monitor Guidance.

Yes

3 Condition G7 Registration with the Care Quality Commission.

Yes

4 Condition G8 Patient eligibility and selection criteria.

Yes

5 Condition P1 Recording of information. Yes 6 Condition P2 Provision of information. Yes 7 Condition P3 Assurance report on submissions

to Monitor. Yes

8 Condition P4 Compliance with the National Tariff.

Yes

9 Condition P5 Constructive engagement concerning local tariff modifications.

Yes

10 Condition C1 The right of patients to make choices.

Yes

11 Condition C2 Competition oversight. Yes 12 Condition IC1 Provision of integrated care. Yes

Appendix 2

Well Led Framework Final Self Assessment

Well Led Framework Final version

Board Governance Self - Assessment

July 2015 – Bill Hobden, Sue Redfern, Peter Williams,

Nicola Bunce, Anne Rosbotham-Williams

Well Led Framework

• Replaces BGAF and QGAF • To be used as Board Governance Assessment

tool for all future FT applicants • Will be undertaken as part of the TDA

approval stage • Requires authorised FTs to undertake the

Assessment at least every 3 years, with a review by an independent 3rd party and declaration to Monitor

The Four Governance Domains

Board Self Assessment

Stage Action

1 Review and initial assessment by Sue Redfern, Peter Williams and Nicola Bunce

2 Review by Trust Board and agreement of ratings

3 Development of an improvement of an action plan

4 Re- assessment once action plan delivered

Review and Assessment by the TDA and an Independent Assessor will occur during the development and assurance phase of the Foundation Trust application process. This will include interviews with directors, a review of the evidence portfolio, board and committee minutes/papers and discussions with stakeholders – staff, commissioners, patients etc.

Scoring

Domain 1 – Strategy and Planning (1) Q1 – Does the Board have a credible strategy to provide high quality, sustainable services to patients and is there a robust plan to deliver?

Criteria Good Practice StHK Evidence/Gaps in Assurance

Self Assessment Next Steps

There is a clear statement of vision and values, driven by quality and safety. It has been translated into a credible strategy and well-defined objectives that are regularly reviewed to ensure that they remain achievable and relevant.

The trust has developed a comprehensive and sustainable picture of how its services will look in the future and its strategy is clear and well thought out. The strategy includes: specific aims that steer the organisation towards its vision a small number of ambitious trust-wide quality improvement goals or objectives a set of values and behaviours supporting and underpinning the strategy. There is likely to be a narrative about how the trust is planning to respond to the Five Year Forward View, aligned with its vision and values. Quality goals: cover safety, clinical outcomes and patient experience support continuous improvement comprise local as well as national priorities, reflecting what is relevant to patients and staff. The organisation has been informed by an analysis of its performance on key quality indicators when identifying the strategic goals; and overall trust-wide quality goals link directly to goals in divisions/services, suitably tailored to the specific service. The board can explain how the quality goals have been selected to have the highest possible impact across the overall trust. There is evidence of patient, service user and carer engagement in determining the quality goals. There is a clear action plan for achieving the quality goals, with designated leads and timeframes.

• IBP/LTFM – but does not yet deliver long term sustainability or response to FYFV

• Values and behaviours are clear • Quality strategy and goals • Quality improvement goals

determined annually

Need to agree a financial recovery plan. Need to finalise a long term service strategy with health economy partners that is clinically and financially sustainable


Criteria Good Practice StHK Evidence/Gaps in assurance

Self Assessment

Next Steps

The vision, values and strategy have been developed through a structured planning process with regular engagement from internal and external stakeholders, including people who use the service, staff, commissioners and others.

The board has self-assessed its approach to strategy development using a suitable framework, such as Monitor’s strategy development toolkit, or equivalent. There is clear evidence that the trust: understands its external opportunities and challenges and its internal strengths and weaknesses has robust solutions to address the opportunities and challenges in light of its strengths and weaknesses has the capability and a credible plan to deliver the strategy (see also the section on capability below). In examining the internal and external challenges facing services, boards should consider whether services are financially, operationally and clinically sustainable in 3 to 5 years time. In examining the solutions to address the challenges, boards should consider whether transformation is required to achieve long-term sustainability − such as reconfiguration of services, moving to new care models and/or changes to organisational form. There should be clear evidence of the trust having mechanisms in place to suitably engage with local health economy partners to address critical issues impacting on long term sustainability. The planning process reflects: current and future priorities of local commissioners evidence-based forecast changes in the local environment regarding public health, socio-demographic and economic factors local and national policy developments and an appropriately thorough market assessment for each of the key service lines, including competitive opportunities and threats and how the trust plans to respond. The strategic planning process takes account of relevant internal factors, for example: the organisation’s capabilities and weaknesses costs and cost reduction priorities previous performance and delivery of plans operational issues such as people and resources, estates and facilities clinical issues of scope and scale of services (are volumes sufficient to support high quality care) whether the people strategy fits the needs of the organisation and workforce plans and projections. The board should be able to demonstrate: who their main stakeholders are; that they have an understanding of those stakeholders’ views; and that those stakeholders have been suitably engaged in the development of its vision and strategy. Stakeholders would normally include: patient groups and the council of governors staff (who are clear about the organisation's vision and strategy and how their work supports this) commissioners and other local health economy stakeholders (such as other providers, local Healthwatch, local politicians and MPs). The board identifies its main stakeholders based on criteria such as who will have the greatest impact on the delivery of the organisation's particular services.

Draft Strategic Planning toolkit assessment has been completed – next step to review with whole Board and develop an action plan to address the gaps. Need to repeat strategic planning cycle e.g. SWOT, Policy Review, options appraisal, Market assessment, to develop a future strategy that is fit for purpose in light of the challenges facing the Trust and the wider NHS. Formal engagement with CCGs and other partners is improving but has not yet settled into a routine where issues of long term sustainability are discussed. Need to repeat and formalise stakeholder mapping and agreement of stakeholder engagement strategies to support strategic planning.

Develop structured strategic planning cycle Develop structured stakeholder engagement, involvement and consultation cycle to support strategic planning.



Self Assessment

Next Steps

The challenges to achieving the strategy, including relevant local health economy factors, are understood and an action plan is in place.

The board demonstrates that it has effective, timely horizon scanning and reporting processes in place, so that it is sufficiently aware of changes in the internal and external environment which may impact on the delivery of the strategy/plan and/or impact on clinical and financial sustainability. Processes are in place to monitor and manage the delivery of the plan.

Future developments and changes to the health care environment nationally and locally are reported ad hoc at Board (CEO report). Need to be more formally brought together and their impact reviewed and response agreed and performance managed

Build horizon scanning and reporting into the strategic planning cycle.

Strategic objectives are supported by quantifiable and measurable outcomes which are cascaded through the organisation.

The organisational objectives in the plan are linked through to the performance targets of business units. The trust has detailed delivery plans for each of its strategic initiatives that lay out milestones, resource requirements, dependencies and risk mitigations. The development of the quality improvement strategy includes: analysis of the organisation’s performance on key quality indicators directly linking the quality accounts with the quality improvement strategy. The quality strategy is supported by clear, specific, measurable, achievable and time-bound action plans, with leads and delivery dates to achieve the specific and ambitious goals. The board monitors action plans relating to the quality strategy or quality account and takes action where performance is off trajectory.

The Trust has detail annual objectives, but cannot demonstrate the KPIs for achieving its strategic objectives. Quality Strategy in place with supporting action plan Quality performance and improvement monitored via the IPR Quality Account identifies the improvement targets for following year

To identify KPIs and trajectories for achievement for the Trusts strategic objectives, which then need to inform the annual objectives



Self Assessment

Next Steps

Staff in all areas know and understand the vision, values and strategic goals.

The board can demonstrate that the strategic vision, values and goals (including quality goals) are effectively communicated through an implemented plan, across the trust and its sites. The goals are well understood and the board can demonstrate how staff at all major sites have been informed of the goals. The non executive directors and the trust divisional management should be able to articulate the trust’s quality goals. The quality strategy is supported by a communication plan and there is evidence that this plan is being implemented.

The Clinical and Quality Strategy has a 5 year implementation plan. The Trusts Vision, Values and Strategic Goals are widely publicised and discussed

The strategic goals need to be more widely discussed and understood and then translated into service level business and improvement plans

Domain 1 – Strategy and Planning (5) Q2 – Is the Board sufficiently aware of potential risks to quality, sustainability and delivery of current and future services?


Self Assessment

Next Steps

There is an effective and comprehensive process in place to identify, understand, monitor and address current and future risks.

Board members can comprehensively describe the same set of risks facing the organisation. Dynamic risk registers and a board assurance framework are in place and assessed by the board at least quarterly, reflecting risks to the initiatives in the strategic plan. These are considered and reviewed regularly. The board regularly assesses and understands current and future risks to quality and performance and is taking steps to address them. The board regularly reviews quality risks in an up-to-date risk register. The risk register is supported and fed by quality issues captured in directorate/service risk registers. The risk register covers potential future external risks to quality (eg new techniques/technologies, competitive landscape, demographics, policy change, funding, regulatory landscape) as well as internal risks. There is clear evidence of action to mitigate risks to quality. Management and reporting The board has clear risk management plans (including quality risks) and there is evidence of action being taken to mitigate risks to quality and performance – for example, key risks and issues being escalated from relevant sub-committees on a consistent basis. As part of these plans: risk-related reporting lines should be in place from ward to board (eg to ensure overall risk is managed) responsibility for each risk flagged in the board assurance framework is owned by an executive lead responsibilities for maintaining an oversight of risk mitigation are clearly attributed to board members/sub committees risk scenarios and contingency plans are in place and are subject to regular updates and reviews. Training Appropriate training is provided to staff and managers on risk and assurance and, as a consequence, the organisation can evidence that risks are owned and managed at all levels of the organisation. Evaluation and review The board has reviewed lessons learned from inquiries, internal and external reviews and has considered the impact on the trust. Actions arising from this exercise are captured and progress is followed up.

The Board needs to increase the frequency of BAF reviews to 4 times a year. Recent review of the Trusts risk management policy and processes by the Institute of Risk Management and MIAA. There is a Ward to Board escalation route for risk. The BAF identifies the Committee/Governance Council which is responsible for each of the strategic risks

Further Risk management training for Board Members Increased frequency of BAF review by the Board Increase discussion and challenge of risks and the controls and assurances required to be recorded in Board and committee minutes

Domain 1 – Strategy and Planning (6) Q2 – Is the Board sufficiently aware of potential risks to quality, sustainability and delivery of current and future services?


Self Assessment

Next Steps

Service developments and efficiency changes are developed and assessed with input from clinicians to understand their impact on the quality of care. Their impact on quality and financial sustainability is monitored effectively. Financial pressures are managed so that they do not compromise the quality of care.

The board is assured that proposed initiatives are assessed according to their potential impact on quality (eg clinical staff cuts would likely receive a high risk assessment). There is a quality impact assessment approach that is consistently applied. Initiatives are developed with clinicians; have a clinician as a sponsor or a consultation has been held by clinicians. Schemes have been modified or rejected where concerns have been raised. Initiatives with significant potential to impact quality are supported by a detailed assessment that could include: ‘bottom-up’ analysis of where waste exists in current processes and how it can be reduced without impacting quality (eg lean) internal and external benchmarking of relevant operational efficiency metrics (of which nurse−bed ratio, average length of stay, bed occupancy, bed density and doctors−bed ratio are examples that can be markers of quality) historical evidence illustrating prior experience in making operational changes without negatively impacting quality (eg impact of previous changes to nurse−bed ratio on patient complaints). Measures of quality and early warning indicators are identified for each initiative. Quality measures are monitored before and after implementation and there is clear ownership of risk (for example, the relevant clinical director). Post-implementation, the impact of initiatives on quality is monitored on an ongoing basis. Mitigating action is taken where necessary.

CIP processes and QIA’s. Investment in PMO and Lean practitioners Regular benchmarking reports IPR with tolerances that act as early warning indicators

To ensure the F&P Chairs reports gives sufficient assurance regarding financial and performance risk. Implementation of post project reviews and benefits realisation tracking.

Domain 1 - Summary Criteria Self

Assessment Board

Assessment Director

Lead

Q1 – Does the Board have a credible strategy to provide high quality, sustainable services to patients and is there a robust plan to deliver?

There is a clear statement of vision and values, driven by quality and safety. It has been translated into a credible strategy and well-defined objectives that are regularly reviewed to ensure that they remain achievable and relevant.

DoF

The vision, values and strategy have been developed through a structured planning process with regular engagement from internal and external stakeholders, including people who use the service, staff, commissioners and others.

Deputy CEO/DoHR

The challenges to achieving the strategy, including relevant local health economy factors, are understood and an action plan is in place

DoMod

Strategic objectives are supported by quantifiable and measurable outcomes which are cascaded through the organisation.

DoF

Staff in all areas know and understand the vision, values and strategic goals.

Deputy CEO/DoHR

Q2 – Is the Board sufficiently aware of potential risks to quality, sustainability and delivery of current and future services?

There is an effective and comprehensive process in place to identify, understand, monitor and address current and future risks.

DoN

Service developments and efficiency changes are developed and assessed with input from clinicians to understand their impact on the quality of care. Their impact on quality and financial sustainability is monitored effectively. Financial pressures are managed so that they do not compromise the quality of care.

DoF

Overall Assessment Domain 1

Domain 2 – Capability and Culture(1) Q3 – Does the Board have the skills and capability to lead the organisation?


Self Assessment

Next Steps

The board has the experience, capacity and capability to ensure that the strategy can be delivered.

The board has assured itself that the capabilities, experience and capacity are in place within the senior management team and workforce to develop and deliver the strategy. One or more individuals on the board have strategic planning skills and background and have led the development and implementation of a strategic plan in the last 2 to 3 years in an organisation of similar complexity and challenges. Board members can clearly explain why the current balance of skills, experience and knowledge on the board is appropriate to effectively govern the trust. The capabilities required in relation to delivering good quality governance are reflected in the make-up of the board. Board members: have insight into the organisation are aware of the organisation's impact on its environment have clarity on their role demonstrate personal values and style that are aligned with the interests of patients and carers are effective communicators seek personal development and learning. Trusts are able to give specific examples of when the board has had a significant impact on improving quality performance (for example, providing evidence of the board’s role in leading on quality). Board reviews The board uses reviews to measure its performance, governance and impact across the organisation. Key findings are openly shared with patients, the public and staff and acted on. The board also reviews the effectiveness of board relationships regularly, with specific focus on board working relationships: between the chair and chief executive between executive and non executive directors between the board and the senior management team/divisional managers between the council of governors and the board.

Board skills audit Completion of Strategic Planning Assessment toolkit Board annual effectiveness review Talent management and succession planning for senior management and Directors

Agreement and delivery of Strategic Planning toolkit action plan



Self Assessment

Next Steps

The appropriate experience and skills to lead are maintained through effective selection, development and succession processes.

The board has a development programme and succession plan to ensure that its skills and capabilities are appropriate and maintained (including in relation to quality governance). It conducts regular self-assessments to test its skills and capabilities. Governors are supported (with training as appropriate) on how to make judgements about the appointment/re-appointment of the non executive directors and the chair. When vacancies arise, the selection process considers the skills of the existing non executive directors, to ensure that the recruitment process delivers the blend and balance of skills and experience to complement the existing board. All members of the board, both executive and non-executive, are appropriately inducted into their role as a board member in a timely fashion. The board takes time out to identify and act upon successes and failures. The board has put in place a leadership development programme for clinical leadership and non-clinical management that: demonstrates learning and impact on behaviours encourages and trains clinical leadership and non-clinical management to participate in setting the quality agenda. The audit committee (as a group) has the appropriate skills and experience to fulfil its responsibilities: the audit committee carries out an annual self-assessment of its effectiveness and at least one member of the audit committee has recent and relevant financial experience.

CD Development programme Board effectiveness reviews, which includes a review of the ToRs of all the Board committees. Policy for the composition of the Board* currently agreed with TDA rather than Council of Governors Director induction and orientation programme Audit Committee Chair has a financial background

Major risk to continuity of Board due to all NEDs terms of office ending during 2016. Chair and Company Secretary to discuss staggered terms of office with the TDA.



Self Assessment

Next Steps

The leadership is knowledgeable about quality issues and priorities, understands what the challenges are and takes action to address them.

Board members are able to: describe the trust’s top quality-related priorities identify well − and poorly − performing services in relation to quality, and actions the trust is taking to address them explain how it uses external benchmarks to assess quality in the organisation (eg National Institute for Health and Care Excellence guidelines, recognised Royal College or faculty measures) understand the purpose of each metric they review, be able to interpret them and draw conclusions from them be clear about basic processes and structures of quality governance feel they have the information and confidence to challenge data be clear about when it is necessary to seek external assurances on quality, eg, how and when they will access independent advice on clinical matters. The board is assured that quality governance is subject to rigorous challenge, including full non executive director engagement and review (either through participation in audit committee or relevant quality-focused committees and sub-committees). The board can demonstrate how it has provided challenge to the executive on clinical quality.

Quality metric reported every month via the IPR. SLR/SLM reports to each F&P Committee 6 monthly benchmarking reports Challenge and external independent scrutiny from internal and external audit, commissioners contract monitoring, Royal College reviews and accreditation etc. TDA advice and support for Infection Control and A&E Access targets Challenges include Complaints Responses, VTE and Staffing.

Improve the recording of challenge and debate in Board, Committee and Council minutes. Benchmarking reports to be presented at Board on a regular basis. Mortality reports to be presented to Board every 6 months. Action plans are presented and monitored via Board and committees and this is evidenced in the minutes.

Domain 2 – Capability and Culture(4) Q4 – Does the Board shape an open, transparent and quality focused culture?

Criteria Good Practice StHK Evidence Self Assessment

Next Steps

Leaders at every level prioritise safe, high quality, compassionate care and promote equality and diversity.

There is evidence of leaders at every level asserting safe, high quality, compassionate care as top priority. Their behaviour demonstrably emulates that of a strong safety culture. Staff at all levels of the organisation are subject to an appraisal process in which goals are aligned with the vision and values of the organisation. The organisation has an effective and robust diversity and equality strategy. A comprehensive induction programme is in place for all staff groups (including junior doctors and agency staff) derived from the organisation’s vision, values and strategy.

Nursing Strategy Speak Out Safely Policy Equality and Diversity Policy and Scheme Appraisal Performance in 2014/15 achieved 85% Clinical and non-clinical induction and mandatory training. Induction policy with local induction checklists

Completion of ED scheme for 2015 Review the effectives of induction for clinical staff and Jnr Doctors

Candour, openness, honesty and transparency and challenges to poor practice are the norm. Behaviour and performance inconsistent with the values is identified and dealt with swiftly and effectively, regardless of seniority

The trust can demonstrate that challenges to poor practice made by board and committee members are delivered, received and acted on positively. The trust has a senior independent director. Board behaviours should be consistent with the identified trust values. The board is aware of any behaviours contrary to the trust’s vision and values and is taking active steps to manage these, wherever they exist in the organisation. Examples can be provided of how management has responded to staff that have not behaved consistently with the trust’s stated values and behaviours (for example, demonstrably effective HR policies are in place to address the areas where poor behaviours have been identified). There are comparable processes to manage non executive director and governor behaviours – for example through a standards committee. The organisation has reflected on the findings of internal and external sources that provide insight into its safety culture (staff survey, patient surveys, NRLS, CQC IMR and any formal cultural assessments).

There is a SID and a NED Speaking Out Safely Guardian ACE Behavioural Standards Staff Survey action plan Francis Action Plan Implemented duty of candour for all staff, with amendments to contract and guidance Briefed Board re CQC fundamental standards


Criteria Good Practice StHK Evidence Self Assessment

Next Steps

The leadership actively shapes the culture through effective engagement with staff, people who use the services, their representatives and stakeholders. Leaders model and encourage co-operative, supportive relationships among staff so that they feel respected, valued and supported.

The board responds to challenges in a positive manner with inquiry about the root causes as opposed to, for example, questioning the data as a first resort. The board is visible and can be challenged by staff through different channels (eg surveys, focus groups, workshops, patient safety walkabouts and approaches such as the 15 steps challenge)4 to identify and address blocks to improvement. The board demonstrably listens to patients (complaints and other feedback, governors, patient groups and Healthwatch) to identify deficiencies in organisational quality culture and actively takes steps to address these and improve. Board members spend time developing the relationship with the governors. Governors are trained and supported in holding non executive directors to account and asking them the right questions to check they are in turn holding the executive directors to account for quality and operational delivery. Governors consider that they receive sufficient information in a timely fashion to carry out their role. The board co-operates with third parties with roles in relation to the trust – for example, there is a constructive relationship with commissioners and other providers which, as a minimum, involves: discussing and sharing the overall strategy of the organisation sharing information on specific services and care pathways contract/performance issues are addressed and resolved quickly without recourse to arbitration and regular reviews and discussions to resolve any lessons learnt. Where appropriate, the board uses external support networks and expertise to support ideas for development and quality improvement, for example: use of benchmarking, working with patient groups, linking with healthcare providers and other improvement interventions and tools.

Board visibility via internet, News and Views, Posters, Team Talks, back to the floor, big conversations, Quality Ward Rounds Patient Stories Complaints and incident reports Governors N/A at this stage for StHK Board to Board meetings with CCGs Board member attends St Helens CCG Board Membership of Stroke and other clinical pathway/service boards. H&WBB membership Contract Monitoring Board and CQPG

Ensure all plans in place to make Council of Governors effective and productive when elected. Continue to develop relationships with commissioners and partners to promote collaborative working.



Self Assessment

Next Steps

Mechanisms are in place to support staff and promote their positive wellbeing.

The board can demonstrate how the organisational development strategy addresses staff support and wellbeing. The board discusses the results of staff feedback on a regular basis to understand if staff feel valued, supported and developed. An action plan is put in place effectively to address any major issues emerging. The results of staff surveys and organisational action plans are shared with staff.

Staff Survey action plan – violence and aggression, stress Staff Health, Work and Well Being Strategy

There is a culture of collective responsibility between teams and services.

The board can demonstrate it has mechanisms in place so that teams work collectively to resolve conflict quickly and constructively and share responsibility to deliver good quality care. Staff are aware of and understand how the organisation is performing overall, their part in that, and how this is being measured. The trust can demonstrate it has an approach to recognising staff achievements, such as best practice awards.

IPR Care Group and Service performance reports Service line reporting Ward quality dashboards

The leadership actively promotes staff empowerment to drive improvement and a culture where the benefit of raising concerns is valued.

There is a demonstrable commitment to improvement and evidence of its achievement. There is appropriate devolution of decision-making, and use of approaches such as service line management. Staff are supported to deliver the quality improvement initiatives they have identified: for example, staff are provided with quality improvement training to embed quality initiatives; and the board regularly commits resources (time and money) to delivering quality initiatives. The reporting of harm and error is encouraged as a means of learning from experience, including how the trust learns from incidents, complaints and feedback from patients.

Scheme of delegation and budget setting SLR and action plan to move to SLM Increase in incident reporting Patient Safety Bulletin Track record of investment in quality improvement

Domain 2 – Capability and Culture(7) Q5 – Does the Board help support continuous learning and development across the organisation?


Self Assessment

Next Steps

Information and analysis are used proactively to identify opportunities to drive improvement in care.

The board takes a proactive and self-challenging approach to improving quality and actively looks at how to do this in ways relevant to its context – through adopting or setting sector best practice, setting stretching performance objectives for the trust and using peer/external review. The board challenges itself on whether objectives are sufficiently stretching. The board seeks to further improve services by looking at best practice across the healthcare sector and, where appropriate, uses benchmarking as a way of evaluating the services being delivered. It seeks to apply lessons learned in other trusts, organisations and industries. Information in quality reports is displayed clearly and consistently. The board has sufficient information derived from, for example, ward or service line quality data, service line management/service line reporting to identify areas of underperformance or good practice; and is able to demonstrate how reviewing quality information has resulted in actions which have successfully improved quality performance. The organisation has a way of measuring the success or the progress of quality improvement, including innovation, and sees failure not as a negative but as a learning experience. Lessons are learned and embedded in practice from failures to deliver performance improvement.

Clinical and Quality Strategy Trust annual objectives IPR and Ward Quality Reporting Benchmarking Commercial assessment matrix Post project reviews of CIP schemes

There is a strong focus on continuous learning and improvement at all levels of the organisation. Safe innovation is supported and staff have objectives focused on improvement and learning.

The trust’s vision sets out a focus on continuous improvement and ambitions towards being a learning organisation or system. The trust’s strategy contains a number of trust-wide ambitious quality improvement goals. The board can articulate the trust’s quality and other improvement initiatives and is actively engaged in their delivery (some initiatives could be led personally by board members). Governance structures and controls exist in order to support the generation and implementation of new ideas to drive innovation and organisational development. The board has a clear corporate methodology that it uses to drive improvement across the organisation. Quality/continuous improvement training and development is offered to staff at all levels. Quality is communicated effectively across the organisation (for example, newsletters, intranet, noticeboards regularly feature articles on quality).

Clinical and Quality Strategy BAF PMO – Lean Methodology Quality Account

Domain 2 – Capability and Culture(8) Q5 – Does the Board help support continuous learning and development across the organisation?


Self Assessment

Next Steps

Staff are encouraged to use information and regularly take time out to review performance and make improvement

Arrangements are in place for leadership to review performance against targets and then update targets for continual improvement on an on-going basis. Across the organisation arrangements appropriate to particular roles are in place for frontline staff to identify and report areas for improvement. Operational performance improvement processes are in place and the board reviews the outcomes of this work, actively encouraging staff to look at how they can continually improve the way that they work (processes, pathway deployment, etc).

F&P Committee deep dive Team to Team meetings Operational meetings Care Group Governance Meetings Monthly IPR

Improve the explicit development and monitoring of improvement plans which translate into clear targets for each clinical and service area


Assessment Board

Assessment Director

Lead

Q3 – Does the Board have the skills and capability to lead the organisation?

The board has the experience, capacity and capability to ensure that the strategy can be delivered. Chair and CEO

The appropriate experience and skills to lead are maintained through effective selection, development and succession processes.

Chair and CEO

The leadership is knowledgeable about quality issues and priorities, understands what the challenges are and takes action to address them.

DoN

Q4 – Does the Board shape an open, transparent and quality focused culture?

Leaders at every level prioritise safe, high quality, compassionate care and promote equality and diversity. MD and DoN

Candour, openness, honesty and transparency and challenges to poor practice are the norm. Behaviour and performance inconsistent with the values is identified and dealt with swiftly and effectively, regardless of seniority

Deputy CEO/DoHR

The leadership actively shapes the culture through effective engagement with staff, people who use the services, their representatives and stakeholders. Leaders model and encourage co-operative, supportive relationships among staff so that they feel respected, valued and supported.

Deputy CEO/DoHR

Mechanisms are in place to support staff and promote their positive wellbeing. Deputy CEO/DoHR

There is a culture of collective responsibility between teams and services. MD/ DoN

The leadership actively promotes staff empowerment to drive improvement and a culture where the benefit of raising concerns is valued.

Deputy CEO/DoHR

Q5 – Does the Board help support continuous learning and development across the organisation?

Information and analysis are used proactively to identify opportunities to drive improvement in care. DoF

There is a strong focus on continuous learning and improvement at all levels of the organisation. Safe innovation is supported and staff have objectives focused on improvement and learning.

DoOps

Staff are encouraged to use information and regularly take time out to review performance and make improvement

DoOps


Domain 3 – Process and Structure(1) Q6 – Are there clear roles and accountabilities in relation to Board governance (including Quality governance)?


Self Assessment

Next Steps

The board and other levels of governance within the organisation function effectively and interact with each other appropriately

The board operates as an effective unitary board, demonstrating corporate leadership and a good balance between challenge and support. The board is assured that the size of the board (including voting and non-voting members) is appropriate for the requirements of the organisation. There is clarity on the functions of the board of directors and how it will exercise those functions. A formal statement is in place that specifies the types of strategic decisions, including levels of investment and those representing significant service changes that are expressly reserved for the board, and those that are delegated to committees or the executive. There are defined lines of accountability into directorates and services. Information flows (between the board and its committees and between senior management, non-executive directors and the governors) support decision-making and the rapid resolution of risks and issues. Board sub-committees have a stable, regularly attending membership and operate within their terms of reference. The board’s agenda is appropriately balanced and focused between: strategy and current performance quality finance making decisions and noting/receiving information matters internal to the organisation and external considerations business conducted at public board meetings and that done in confidential sessions. The council of governors are actively involved in holding the non executive directors to account for their work at the board.

Annual Governance statement SFI’s and Scheme of delegation reviewed annually Not an FT so Governors are not involved in holding the Board to account

Quality of the Board, Committee and Council minutes and papers is not consistent and do not always record decisions, actions, assurance and challenge – training for minute takers Training for Chairs of Councils and Care Group and Service Governance meetings Attendance of non-voting members at full Board meetings, has been questioned via BGAF etc. in past.



Self Assessment

Next Steps

Structures, processes and systems of accountability, including the governance and management of partnerships, joint working arrangements and shared services, are clearly set out, understood and effective.

The trust’s senior leadership is clear about who is responsible for making decisions about the provision, safety and adequacy of services. Every board member understands their ultimate accountability for quality. The board is assured that levels of delegation are in place and is working to support the delivery of the plan and management of risks and issues throughout the organisation and ensure that these delegation processes are monitored and decisions captured and escalated to the appropriate committees, divisions and teams. There is a clear organisational structure that cascades responsibility for delivering quality performance from ‘board to front line to board’ (and there are specified owners in post and actively fulfilling their responsibilities). The board is assured that a sound system of internal control to safeguard investment, the trust’s assets, patient safety and service quality is in place and that board sub-committees are set up to focus on these areas. The board is assured that governance and management of any partnerships, joint ventures and shared services are clearly set out and understood, for example: all parties are clear about their roles clarity and rules are in place to govern the use of any pooled budgets, and appropriate management structures exist to support and enforce the agreed practice parties are clear and use the protocols for escalation and resolution of issues between parties a process for dealing with overspends and underspends exists and is reviewed regularly. If any issues/concerns have been raised by either internal or external audit, recommendations have been implemented in a timely and robust manner. If the trust has encountered any serious fraud in the last two years, procedures and controls are now in place and the trust has received assurance that they are effective.

Scheme of delegation and statement of internal control Board, Committee and Council annual ToR review Investment not currently included in F&P ToRs PFI partnership arrangements are robust Other partnership arrangements may not be as robust as necessary e.g. HIS, Sexual Health

Increase the assurance provided to the Board of the probity and risk mitigation for joint ventures and partnerships Performance management of audit report action plans



Self Assessment

Next Steps

Quality receives sufficient coverage in board meetings and in other relevant meetings below board level.

Quality is a core part of main board meetings, both as a standing agenda item and as an integrated element of all major discussions and decisions. Quality performance is discussed in more detail by a quality-focused board sub-committee with a stable, regularly attending membership. Discussions suitably interrogate issues to locality/clinical business unit level.

Board minutes and papers Quality Committee and supporting Councils Board effectives reviews F&P – Care Group Deep Dive

Domain 3 – Process and Structure(3) Q 7 – Are there clearly defined, well understood processes for escalating and resolving issues and managing performance?


Self Assessment

Next Steps

The organisation has the processes and information to manage current and future performance.

The board has agreed and implemented a performance management system which comprises: a set of appropriate performance measures covering financial, quality and other areas which are defined, subject to appropriate targets and monitored appropriate reporting lines to manage overall performance against these targets in a transparent and timely fashion clinical governance policies for addressing under-performance and recognising and incentivising good performance at individual, team and service line levels means of addressing underperformance across the full range of the trust’s operations. In particular, arrangements are in place to manage/respond to adverse performance in: finance clinical and other operations organisation/HR and long-term strategy. Lessons from performance issues are well documented and shared across the trust on a regular, timely basis, leading to rapid implementation at scale of good practice.

IPR Action and improvement plans e.g. A&E access targets, complaints response times

Improve monitoring of the delivery of the Trusts long term strategy

Domain 3 – Process and Structure(4) Q 7 – Are there clearly defined, well understood processes for escalating and resolving issues and managing performance?


Self Assessment

Next Steps

Performance issues are escalated to the relevant committees and the board through clear structures and processes.

The trust is clear about the processes for escalating both quality and financial performance issues to the board: processes are documented there are agreed rules determining which issues should be escalated (in respect of quality, for example, these cover escalation of serious incidents, complaints and matters related to legal and audit) there is a defined procedure for bringing significant issues to the board’s attention outside monthly meetings. The board is assured that the processes are working and that the appropriate person/management level is aware of the issues and are managing these through to resolution. The board is aware of the most frequent issues being flagged by the workforce to analyse which barriers need to be removed in order to drive improvement. Robust action plans are put in place to address performance issues (across quality, finance and operations). Actions have: designated owners and timeframes and regular follow-ups at subsequent board meetings.

IPR and tolerances for variation and exception reporting SUI reports to each Board Workforce Council reports via the Quality Committee and workforce dashboard included as part of the IPR

Do we have a formal process for “flash reports” of significant issues that occur between board meetings? Follow up of agreed action is evidenced in Board minutes and this is followed through until actions are delivered

Clinical and internal audit processes function well and have a positive impact in relation to quality governance, with clear evidence of action to resolve concerns

There is a continuous rolling programme that measures and improves quality. The board actively oversees a co-ordinated programme of clinical audit, peer review and internal audit which is aligned with identified risks and/or gaps in other assurance. Action plans are completed from audit; and re-audits are undertaken to assess improvement.

Internal and external audit programmes agreed by the Board. Participation in national clinical audits. Peer review visits. Effective Audit Committee

Monitor and record the completion of all audit action plans, with escalation if beyond agreed timescales. Need to clarify the role of CEC in reviewing the delivery of audit action plans

Domain 3 – Process and Structure(5) Q 8 – Does the Board actively engage patients, staff, governors and other key stakeholders on quality, operational and financial performance?


Self Assessment

Next Steps

A full and diverse range of people’s views and concerns are encouraged, heard and acted on. Information on people’s experience is reported and reviewed alongside other performance data.

The board is assured that patient and public views are heard and acted on, complementing other means of assessing performance. For example: Patient feedback is actively solicited. The process to give feedback is well publicised, feedback is easy to give and based on validated tools. Patient views are proactively sought during the design of new pathways and processes. Patient feedback is reviewed on an ongoing basis, with summary reports reviewed regularly and intelligently by the board. The board regularly reviews and interrogates complaints and serious untoward incident data. The board uses a range of approaches to engage with individual patients (eg face-to-face discussions, video diaries, ward rounds, patient shadowing, patient stories). Feedback from external representatives, eg Healthwatch, is considered alongside the views of current patients and service users, members and governors.

F&FT Patient Power Groups Health Watch (x 3) Patient Experience Council reports to Quality Committee Complaints and serious incident reports to Board NED reviews of Complaints and RCAs Quality Ward Rounds Patient Stories NEDs have “buddy” wards

The service proactively engages and involves all staff and assures that the voices of all staff are heard and acted on.

The board can demonstrate a variety of methods to capture the views of staff. Staff are encouraged to provide feedback on an ongoing basis, as well as through specific mechanisms (for example, monthly ‘temperature gauge’ plus annual staff survey). All staff feedback is reviewed on an ongoing basis with summary reports reviewed regularly and intelligently by the board.

Staff Survey and action plan Staff F&FT Workforce Council – monitors delivery of actions and reports to Quality Committee Union recognition and consultation and engagement

Domain 3 – Process and Structure(6) Q 8 – Does the Board actively engage patients, staff, governors and other key stakeholders on quality, operational and financial performance?


Self Assessment

Next Steps

Staff actively raise concerns and those who do (including external whistleblowers) are supported. Concerns are investigated in a sensitive and confidential manner, and lessons are shared and acted on.

There is an appropriate mechanism in place for capturing frontline staff concerns. This includes a defined ‘whistleblower’ policy/error reporting process which is defined and communicated to staff; and staff are prepared if necessary to blow the whistle. Organisations have considered and implemented the recommendations of the ‘Freedom to speak up’ review into creating an open and honest reporting culture in the NHS.

Speaking Out Safely Policy Staff suggestion schemes Duty of candour Freedom to speak out action plan in place CQC reported Whistle blowers on Intelligent Monitoring report – May 2015

Complete the delivery of the freedom to speak out action plan

The service is transparent, collaborative and open with all relevant stakeholders about performance.

The board ensures that its decision-making is transparent. There are processes in place that enable stakeholders to find out easily how and why the board has made key decisions without reverting to freedom of information requests. The board works with the council of governors on communicating fully the decisions taken and the reasons that the board reached them, recognising its accountability to the council as the representatives of service users and the public. The board is clear about governors’ involvement in quality governance. The board actively engages with the public and stakeholders on significant policy developments. Performance outcomes are made public (and accessible) regularly, and include objective coverage of both good and bad performance. The board actively engages all other major stakeholders on quality: for example, quality performance is clearly communicated to commissioners to enable them to make informed decisions For care pathways involving GP and community care, discussions are held with all providers to identify potential performance issues and ensure overall quality along the pathway.

Publication of Board papers and minutes. Council of Governors – N/A at this stage Healthwatch, CCGs etc. involved in Quality improvements Annual Report and Accounts Quality Account

Increase stakeholder engagement and involvement in developing future plans, including patient and carer groups.


Assessment Board

Assessment Director

Lead

Q6 – Are there clear roles and accountabilities in relation to Board governance (including Quality governance)?

The board and other levels of governance within the organisation function effectively and interact with each other appropriately

DoCS

Structures, processes and systems of accountability, including the governance and management of partnerships, joint working arrangements and shared services, are clearly set out, understood and effective.

DoF/ DoCS

Quality receives sufficient coverage in board meetings and in other relevant meetings below board level DoN

Q 7 – Are there clearly defined, well understood processes for escalating and resolving issues and managing performance?

The organisation has the processes and information to manage current and future performance.

DoF

Performance issues are escalated to the relevant committees and the board through clear structures and processes.

DoOps

Clinical and internal audit processes function well and have a positive impact in relation to quality governance, with clear evidence of action to resolve concerns

MD/DoN

Q 8 – Does the Board actively engage patients, staff, governors and other key stakeholders on quality, operational and financial performance?

A full and diverse range of people’s views and concerns are encouraged, heard and acted on. Information on people’s experience is reported and reviewed alongside other performance data.

Deputy CEO/DoHR

The service proactively engages and involves all staff and assures that the voices of all staff are heard and acted on.

Deputy CEO/DoHR

Staff actively raise concerns and those who do (including external whistleblowers) are supported. Concerns are investigated in a sensitive and confidential manner, and lessons are shared and acted on.

Deputy CEO/DoHR

The service is transparent, collaborative and open with all relevant stakeholders about performance. Deputy CEO/DoHR


Domain 4 – Measurement(1) Q 9 – Is appropriate information on organisational and operational performance being analysed and challenged?


Self Assessment

Next Steps

Integrated reporting supports effective decision-making.

An integrated reporting approach, appropriate to the size and complexity of the trust, is used by the board to ensure that the impact on all areas of the organisation is understood before decisions are made. Dashboards Monthly reporting is supported by a ‘dashboard’ of the most important metrics. The board is able to justify the selected metrics as being: relevant to the organisation given the context within which it is operating and what it is trying to achieve linked to the trust’s overall strategy and priorities covering all the trust’s major focus areas the best available ones to use useful to review. The board’s information ‘dashboard’ is frequently reviewed and updated to maximise effectiveness of decisions; and in areas lacking useful metrics, the board commits time and resources to developing new metrics. The board dashboard is backed up by a ‘pyramid’ of more granular reports reviewed by sub-committees, divisional leads and individual service lines. Supporting performance detail is broken down by service line so members can understand which services are high and low performing from a financial and quality perspective. Quality information is analysed and challenged at the individual consultant level. Information is compared with target levels of performance (in conjunction with a red-amber-green rating), historic own performance and external benchmarks (where available and helpful). Information being reviewed must be the most recent available, and recent enough to be relevant. ‘On demand’ data is available for the highest priority metrics. Information is ‘humanised’/personalised where possible (eg, unexpected deaths shown as an absolute number not embedded in a mortality rate). Good practice quality dashboards might include: performance against relevant national standards and regulatory requirements selection of other metrics covering safety, clinical effectiveness and patient experience selected ‘advance warning’ indicators • adverse event reports/serious incident reports/ patterns of complaints measures of instances of harm Monitor’s risk ratings (with risks to future scores highlighted) where possible/appropriate, percentage compliance to agreed best-practice pathways and qualitative descriptions and commentary to back up quantitative information. A balanced policy exists for data sharing which demonstrates safe and effective sharing of information to facilitate integrated patient care. The board is willing to use ‘soft’ information, for example: use of questionnaires and focus groups throughout the organisation and tools for assessing impact with patients, council of governors and other major stakeholders. Board reports reflect the issues and themes that board members are picking up through other channels of information, for example talking to staff, patients and other external stakeholders. Internal audit of data takes place on a regular basis.

Monthly IPR IPR refreshed annually to take account of TDA accountability framework, annual operational plan and Trust objectives. Including Quality, Patient Experience and HR information. Qlick View provides real time data Key metrics are reported more frequently to Board members e.g. A&E access targets.

Domain 4 – Measurement(2) Q 9 – Is appropriate information on organisational and operational performance being analysed and challenged?


Self Assessment

Next Steps

Performance information is used to hold management and staff to account.

Information is clearly aligned to priorities/elements of the trust plan and its delivery. The board can measure the impact of the organisation’s strategy through the use of agreed key performance indicators (eg productivity and efficiency measures), national and local indicator sets, etc. There is robust narrative text/qualitative analysis of outliers/poor performance. Board reporting provides assurance that patients are receiving person-centred co-ordinated care. Boards also review the performance of patient pathways rather than purely reviewing metrics of the performance of divisions and/or clinical units. The trust has established financial reporting procedures which provide robust information on organisational performance and enable key risks to be identified and managed, in both operational and strategic terms. Information includes relevant indicators in relation to the people or HR strategy, eg: workforce capacity and capability to deliver the future strategy intelligence on values, behaviours and attitudes HR health indicators, including information on equality and diversity performance appraisal, training and development; and leadership.

IPR aligned to Trust annual objectives HR dashboard and metrics reported every month. Safer Staffing report every month.

Domain 4 – Measurement(4) Q 10 – Is the Board assured of the robustness of information?


Self Assessment

Next Steps

The information used in reporting, performance management and delivering quality care is accurate, valid, reliable, timely and relevant.

The board assures itself that information it receives is from reliable and suitable sources and covers an appropriate mix of intelligence (qualitative and quantitative). There is assurance covering the data collection, checking and reporting processes in place for producing the information and testing the systems and controls. The following dimensions of data quality could be used to assess the processes and data quality: accuracy: data is recorded correctly and is in line with the methodology for calculation validity: data has been produced in compliance with relevant requirements reliability: data has been collected using a stable process in a consistent manner over a period of time timeliness: data is captured as close to the associated event as possible and is available for use within a reasonable time period relevance: data is used to generate indicators that meet eligibility requirements as defined by guidance. The board regularly reviews their arrangements for supporting how they prepare and report performance indicators. There are clearly documented, robust controls to assure the board on the accuracy, validity and comprehensiveness of information. Local operating procedures are in place to ensure the consistency of data handling and processing, for example : Each directorate/service has a well-documented, well- functioning process for clinical governance that assures the board of the quality of its data. The clinical audit programme is driven by national audits, with processes for initiating additional audits as a result of identification of local risks (eg, incidents). Electronic systems are used where possible, generating reliable reports with minimal ongoing effort. Information can be traced to source and is signed off by owners. There is clear evidence of action to resolve audit concerns: Action plans are completed from audit (and subject to regular follow-up reviews). Re-audits are undertaken to assess performance improvement. There are no major concerns with coding accuracy performance

DQ checks Audit plan checks information and DQ IG toolkit Care Group Governance meetings

Increase use of electronic systems for; recording and monitoring of complaints, safer staffing reporting (e -Rostering), VTE monitoring. Improve the consistency and quality of minutes and papers for meetings at care group and service level. Develop comprehensive business cycle for Board and all committees and Councils, which is mapped to the ToRs and the BAF.


Assessment Board

Assessment Director

Lead

Q 9 – Is appropriate information on organisational and operational performance being analysed and challenged?

Integrated reporting supports effective decision-making.

DoF

Performance information is used to hold management and staff to account DoOps

Q 10 – Is the Board assured of the robustness of information?

The information used in reporting, performance management and delivering quality care is accurate, valid, reliable, timely and relevant.

DoF


Self Assessment Summary Domain Self

Assessment Timescale to

address issues Review date

1. Strategy and Planning November 2015

January 2016

2. Capability and Culture December 2015

January 2016

3. Process and Structures September 2015

January 2016

4. Measurement September 2016

January 2016

Overall Assessment

Next Steps • Develop Phase 4 Action Plan – with agreed leads and target

completion dates • Monitor delivery via the SDGC • Report progress monthly via the Executive Team to the Trust

Board

Trust Board (29-07-15) – Board Assurance Framework Page 1

TRUST BOARD PAPER


Title of paper: Board Assurance Framework (BAF)

Purpose: For the Trust Board to review the BAF and approve the changes recommended by the Executive Committee.

Summary: 1. The BAF has been updated to reflect the 2015/16 operational plan and financial

position. The Executive Committee has reviewed both the risks and the risk scores to ensure that they reflect the current level of strategic risk. The Executive Committee have also reviewed and revised the control measures and methods of assurance to the Board, to reflect the changes that have been put in place since the last review in March 2015.

2. A significant proposal is to change the BAF with respect to Risk 9 – Impact of the Better Care Fund on the sustainability of hospital services. It is felt that this is no longer reflective of the challenge facing the Trust and should be amended to embrace the wider NHS Policy developments including those contained in the Five Year Forward View, and the associated proposals to review organisational form. Actions to finalise this change are ongoing.

3. A further recommendation, reflecting Monitor’s good practice requirements that the BAF should be reviewed by the Trust Board at least four times a year, is that the Board calendar should be amended accordingly.

4. The Board are asked to review these changes and determine if they are sufficient to mitigate the strategic risks being managed by the Trust, to the level of risk appetite agreed by the Board.

Corporate objective met or risk addressed: To ensure that the Board has put in place sufficient controls to assure itself that risk to the delivery of its strategic objectives can be effectively managed.

Financial implications: None arising directly from this report

Stakeholders: Trust Board, TDA, CQC

Recommendation(s): Board members are asked to: 1. To review the BAF and identify any additional controls or assurance required 2. To approve the recommended changes to the BAF 3. To agree that the BAF should be reviewed by the Trust Board 4 times a year.




St Helens and Knowsley Teaching Hospitals NHS Trust – Board Assurance Framework

Trust Board Review – July 2015

Strategic Risks - Summary Matrix

Vision: 5 Star Patient Care

Mission: To provide high quality health services and an excellent patient experience

BAF Ref

Long term Strategic Risks Strategic Objectives We will provide services that meet the highest quality and performance standards

We will work in partnership to improve health outcomes

We will be the hospital of choice for patients

We will respond to local health needs

We will attract and develop caring highly skilled staff

We will be a sustainable and efficient Foundation Trust

1 Systemic failures in the quality of care 2 Failure to agree a sustainable financial

plan with commissioners 3 Sustained failure to maintain operational

performance/deliver contracts 4 Failure to protect the reputation of the

Trust 5 Failure to work in partnership with

stakeholders

6 Failure to attract and retain staff with the skills required to deliver high quality services

7 Major and sustained failure of essential assets, infrastructure

8 Major and sustained failure of essential IT systems

9 Impact of the Better Care Fund on the sustainability of Hospital Services


Key to changes in the following BAF risks:

• Score through = proposed deletions • Blue Text = proposed additions

Impact Score

Likelihood /probability

1

Rare

2

Unlikely

3

Possible

4

Likely

5

Almost certain

5 Catastrophic 5 10 15 20 25

4 Major 4 8 12 16 20

3 Moderate 3 6 9 12 15

2 Minor 2 4 6 8 10

1 Negligible (very low) 1 2 3 4 5

Likelihood – Descriptor and definition

Almost certain - More likely to occur than not, possibly daily (>50%)

Likely - Likely to occur (21-50%)

Possible - Reasonable chance of occurring, perhaps monthly (6-20%)

Unlikely - Unlikely to occur, may occur annually (1-5%)

Rare - Will only occur in exceptional circumstances, perhaps not for years (<1%)

Impact - Descriptor and definition

Catastrophic – Serious trust wide failure possibly resulting in patient deaths / Loss of registration status/ External enquiry/ Reputation of the organisation seriously damaged- National media / Actual disruption to service delivery/ Removal of Board

Major – Significant negative change in Trust performance / Significant deterioration in financial position/ Serious reputation concerns / Potential disruption to service delivery/Conditional changes to registration status/ may be trust wide or restricted to one service

Moderate – Moderate change in Trust performance/ financial standing affected/ reputational damage likely to cause on-going concern/potential change in registration status

Minor – Small or short term performance issue/ no effect of registration status/ no persistent media interest/ transient and or slight reputational concern/little financial impact.

Negligible (very low) – No impact on Trust performance/ No financial impact/ No patient harm/ little or no media interest/ No lasting reputational damage.


BAF Ref

Risk Description

Initi

al

Sco

re

(IxP

)

Key Controls Sources of Assurance

Res

idua

l S

core

(Ix

P)

Additional Controls Required

Additional Assurance Required

Action Plan (with target completion dates) Ta

rget

S

core

(Ix

P)

Exec Lead

1 Systemic failures in the quality of care

Cause: • Failure to deliver the Clinical

and Quality Strategy • Failure to deliver CQUIN

element of contracts • Patient experience indicators

decline • Breach of CQC regulations • Unintended CIP impact on

service quality • Availability of resources to

deliver safe standards of care • Failure in operational or

clinical leadership • Failure of systems or

compliance with policies • Failure in the accuracy,

completeness or timeliness of reporting

Effects: • Poor patient experience • Poor clinical outcomes • Increase in complaints • Negative media coverage Impact: • Harm to patients • Loss of reputation • Loss of contracts/market share

5x4=

20

• Reported Quality metrics / clinical outcomes data

• Safety thermometer data • Quality Board Rounds • Patient feedback via

complaints and claims • F&FT scores • F&FT response rates • Incident reporting • IPR monitoring • Quality Governance structure • Outcomes data • Risk Assurance and

Escalation policy • Contract monitoring • CQPG meetings with lead

CCG • Accountability Framework • Appraisal and revalidation

processes • Clinical policies and guidelines • Mandatory Training • Professional development • Lessons Learnt reviews • Clinical Audit • Quality Improvement Actions

Plan • Clinical Outcomes Group • Ward Quality Dashboards • CIP Risk Assessment Process • Data Quality monitoring and

audit

To Board; • IPR • Patient Stories • Quality Board Round reports • Quality Committee and its

Councils • Audit Committee • Finance and Performance

Committee • Infection control,

Safeguarding, H&S, complaints, claims and incidents annual reports

• Staff Survey • Nursing Strategy • Mortality Review Reports • Quality Account • Internal audit • Clinical and Quality Strategy

and the Action Plan reviewed annually

Other; • National clinical audit

programme • CQC inspections • TDA quality inspections and

reviews • External independent reviews • PLACE Inspections • CQC Intelligent Monitoring

Reports

5 x2

= 1

0

CIP schemes still to be identified for a proportion of the CIP required in 20145/16 Robust Complaints Management system and performance monitoring

CQC new style inspection of the Trust - Planning and preparation for the planned CIH Inspection in August 2015.

Conduct and develop an action plan in response to the findings of the A&E patient survey (October 2014) Action plan to respond to Deanery Plan for the reduction in Junior Doctors, to ensure standards of patient care are maintained – February 2014 Review of specialist nursing workforce – October 2015

5x1

= 5

KH/ SR


BAF Ref

Risk Description

Initi

al

Sco

re

(IxP

)


Res

idua

l S

core

(Ix

P)




rget

S

core

(Ix

P)

Exec Lead

2 Failure to agree a sustainable financial plan with commissioners

Cause; • Failure to agree health

economy strategy for future sustainable healthcare delivery model

• Failure to delivery LTFM, including growth and CIP

• Failure to control costs • Failure to implement

transformational change at sufficient pace

• Failure to meet the TDA 4 tests and secure national PFI support

• Failure to respond to commissioner requirements

• Failure to respond to emerging market conditions

Effects; • Failure to meet statutory duties • TDA Escalation status

increases • Failure to progress FT

application Impact; • Unable to deliver viable

services • Loss of market share • External intervention

5 x

5 =

25

• Up to date IBP/LTFM • Business Planning process • Budget setting • CIP plans and assurances

processes • Monthly financial reporting • Service line reporting • 5 year capital programme • Productivity and efficiency

benchmarking (ref costs) • Contract monitoring and

reporting • Contract review Board and

CQPG • Activity planning and profiling • IPR • TDA monthly monitoring

submissions • GP Engagement and

Marketing • Appointment of a Turnaround

Director • Creation of a PMO to support

delivery of CIP and service transformation

• Signed Contracts with all Commissioners

To Board; • Finance and Performance

Committee • Annual financial plan • Finance report • IPR • Statement of Internal Control • Annual Accounts • Audit Committee • Grant Thornton CIP Review

and Report • SLM Reporting and

commercial assessment matrix • Medicine Redesign Impact and

progress Report. Other; • TDA Operational Plan • TDA Accountability Framework • Contract Monitoring Board • Trust involvement with CCG

BCF plan performance management

5 x

4 =2

0

Agree a shared and agreed health economy financial and sustainability strategy Development of shared health economy downside scenario/plan B Contract negotiations for 2015/16 Agree the 2015/16 CIP schemes and PMO proposals. Prepare for 2016/17 contract negotiations Develop 2016/17 detailed CIP plans St Helens CCG long term estate utilisation and efficiency plan

Commissioner engagement in joint long term financial modelling and planning Identification of schemes to deliver outstanding CIP gap for 2015/16 and assurance on delivery of high risk schemes. Resolution of financial disputes re 2014/15 and agreement of a contract settlement with CCGs

Gain agreement to establish a health economy turnaround /sustainability group Participation in the St Helen’s Strategic Estates Review (on going) Bids for resilience and sustainability funding (on going) Consideration of FYFV vanguard application Agree revised long term sustainability strategy and renew the IBP/LTFM

4 x3

= 1

2

DF

Sustained failure to maintain operational performance/deliver contracts


BAF Ref

Risk Description

Initi

al

Sco

re

(IxP

)


Res

idua

l S

core

(Ix

P)




rget

S

core

(Ix

P)

Exec Lead

3 Sustained failure to maintain operational performance/deliver contracts

Cause; • Failure to deliver against

national performance targets (ED, RTT, Cancer etc)

• Failure to reduce LoS • Failure to meet activity targets • Failures in data recording or

reporting Effects; • Reduced patient experience • Poor quality and timeliness of

care leading to poorer outcomes

• Failure of KPIs and self-certification returns

• Increases in staff workload/stress

Impact; • Potential patient harm • Loss of reputation • Loss of market

share/contracts • External intervention

4 x

4 =

16

• Care group activity profiles and work plans

• Winter Plan • Care Group Performance

Monitoring Meetings • Team to Team Meetings • ED RCA process for breaches • Medicine Redesign

Programme Implementation Plans

• Exec Team weekly performance monitoring

• Waiting list management and breach alert system

• Urgent Care Board reporting • ECIST review of A&E

performance • A&E Recovery Plan • Bids for operational and

resilience funding • Capacity and Utilisation plans • CQUIN Delivery Plans • Capacity and demand

modelling • Membership of CCG System

Resilience Groups • Internal Urgent Care Action

Group (UCAG)


Committee • IPR • Winter Plan • Annual Operational Plan • TDA Annual Operational Plan Other; • Contract review

meetings/CQPG • TDA monitoring and

escalation returns/sitreps • CCG CEO Meetings

4 x

3 =

12

SRG’ Capacity and Resilience Plans for 2015/16 Referrals recording and Triage processes to ensure correct contract activity recording and reporting

Long term AED resilience plans Capacity and demand plans for 2015/16 predicted activity

Development of actions plans to improve performance for key national targets • VTE • Stroke • Discharge • A&E/Winter • RTT • C-Diff

Implement “pull” discharge. Ensure Medicine ADO position filled with no loss of continuity UCAG work streams include; • Management of

ambulance patients (Aug)

• Frailty pathway (Oct 15)

• Morning discharge (Sep)

• Ambulatory care (Sep 15)

• Review of the Integrated Discharge Team on-going in conjunction with St Helen’s Council (Oct)

• Community Assessment Unit (Oct 15)

4 x

3 =

12

PJW


BAF Ref

Risk Description

Initi

al

Sco

re

(IxP

)


Res

idua

l S

core

(Ix

P)



Action Plan (with target completion dates)

Targ

et

Sco

re

(IxP

)

Exec Lead

4 Failure to protect the reputation of the Trust

Cause; • Failure to respond to

stakeholders e.g. Media • Single incident of poor care • Deteriorating operational

performance • Failure to promote successes

and achievements • Failure of staff engagement

and involvement • Failure to maintain CQC

registration/Good Rating • Failure to report correct or

timely information Effect; • Loss of market share/contracts • Loss of income • Loss of patient/public

confidence and community support

• Inability to recruit skilled staff • Increased external

scrutiny/review • Delay in FT application

timetable Impact; • Reduced financial viability and

sustainability • Reduced service safety and

sustainability • Reduced operational

performance • Increased intervention

4 x

4 =

16

• Communication and Engagement Strategy

• Communications and Engagement Plan

• Membership Strategy • Workforce Strategy • Communications/ Media

Relations Department • Complaints and legal

Department • Publicity and marketing

activity • Patient Involvement

Feedback • Health Watch • Annual Board effectiveness

review and action plan • Board development

programme • Internal audit • Data Quality • Scheme of delegation for

external reporting • Social Media Policy • Approval scheme for external

communication/ reports and information submissions

• Well Led framework self-assessment and action plan

• NED internal and external engagement programme

To Board; • Quality Committee • Audit Committee • Communications and

Engagement Strategy • IPR • Staff Survey • Complaints reports • Friends and Family • Staff F&F Test • Net promoter scores • PLACE Survey • National Cancer Survey • Francis action plan • Combined Governance Action

Plan progress reports • Referral Analysis Reports • Market Share Reports Other; • Health Watch • CQC • TDA Escalation Rating • CQC Intelligent Monitoring

reports

4 x

3 =

12

Regular media activity reports , including social media, to the Board

Media Activity Reports –Including monitoring of social media accounts NED internal and external engagement programme Delivery of the Well led self-assessment action plan

Media Reports currently being developed – October 2014 Review of corporate reporting and scheme of delegation for approval for external reports – October 2015 New Trust Internet to be launched July 2015 New Trust intranet to be developed and launched by December 2015

4 x

2 =

8

AMS


BAF Ref

Risk Description

Initi

al

Sco

re

(IxP

)


Res

idua

l S

core

(Ix

P)




rget

S

core

(Ix

P)

Exec Lead

5 Failure to work effectively with stakeholders

Cause; • Different priorities and strategic

agendas of multiple commissioners

• Competition amongst providers • Complex health economy • Poor staff engagement • Poor community engagement • Poor patient and public

involvement Effect; • Lack of whole system strategic

planning • Inability to secure support for

IBP/LTFM • Potential loss of market share • Loss of public support and

confidence • Loss of reputation • Inability to develop new ideas

and respond to the needs of patients and staff

Impact; • Unable to reach agreement on

collaborations to secure clinically and financially sustainable services

• Reduction in quality of care • Loss of referrals • Inability to attract and retain

staff • Failure to win new contracts • Increase in complaints and

claims

4 x

4 =

16

• Communications and Engagement Strategy

• Membership of Health and Wellbeing Boards

• Representation on Urgent Care Boards/System Resilience Groups

• JNCC/ Workforce Council • Patient and Public

Engagement and Involvement Strategy

• CCG CEO Meetings • Partnership agreements with

RLBUHT and WHHFT to support collaborative working with formal joint governance arrangements

• Staff engagement strategy and programme

• Patient power groups • Involvement of Healthwatch • CCG Board to Board Meetings • CCG Representative attending

StHK Board meetings • Membership of specialist

service networks and external working groups e.g. Stroke, Frailty, Cancer

To Board; • Quality Committee • CEO Reports • HR Performance Dashboard • Board Member feedback and

reports • Francis Action Plan • TDA IDM’s • Review of digital media trends

and trust mentions • Monitoring of and responses to

NHS Choices comments and ratings

4x 3

= 1

2

Annual programme of engagement events with key stakeholders to obtain feedback and inform strategic planning Health economy response to the Five Year Forward View report and potential vanguard application

Implementation of digital media plans to secure Trust is represented on popular communications forums and website upgrade to ensure up to date information is accessible

New Trust Internet to be launched July 2015 New Trust intranet to be developed and launched by December 2015 Quality Account to record how patients have been involved in service improvement and re-design – May 2016 Chair/CEO/MD meeting with WHHT scheduled for July

4 x2

= 8

AMS

Failure to attract and retain staff with the skills required to deliver high quality services


BAF Ref

Risk Description

Initi

al

Sco

re

(IxP

)


Res

idua

l S

core

(Ix

P)




rget

S

core

(Ix

P)

Exec Lead

6 Failure to attract and retain staff with the skills required to deliver high quality services

Cause; • Loss of good reputation as an

employer • Doubt about future

organisational form or service sustainability

• Failure of recruitment processes

• Inadequate training and support for staff to develop

• High staff turnover • Unrecognised operational

pressures leading to loss of morale and commitment

Effect; • Increasing vacancy levels • Increased difficulty to provide

safe staffing levels • Increase in absence rates

caused by stress • Increased incidents and never

events • Increased use of bank and

agency staff Impact; • Reduced quality of care and

patient experience • Increase in safety and quality

incidents • Increased difficulty in

maintaining operational performance

• Loss of reputation • Loss of market share

4 x

4 =

16

• Team Brief • Staff Newsletter • Mandatory training • Staff benefits package • Health and Wellbeing

Provision • Staff Survey action plan • JNCC/Workforce Council • Francis Report Action Plan • Education and Development

Plan • HR Policies • Exit interviews • Staff Engagement Programme

– Listening events • Action plans in respect of hard

to recruit posts • Involvement in Academic

Research Networks • Workforce Strategy

Implementation Plan • Values based recruitment • Daily nurse staffing levels

monitoring • Nursing establishment reviews • Staff F&F test snapshots • Workforce KPIs • Recruitment and Retention

Strategy action plan • Band 6 development

programme

To Board; • Quality Committee • Finance and Performance

Committee • IPR - HR Indicators • Staff Survey • Monthly Nurse safer staffing

reports • Workforce plans aligned to

strategic plan • Monitoring of bank, agency and

locum spending • Monthly monitoring of vacancy

rates and staff turnover • Staff F&FT snapshots Other • Annual workforce plans • HR benchmarking • Nurse staffing benchmarking

4 x

3 =

12

4

x 4

= 1

6

Development of a recruitment strategy and action plan Influence of the national agenda re training posts and upstream workforce planning via membership of the LWEG and LETB forums.

Junior Medical Cover following reduction in Deanery allocations Specific strategies to overcome recruitment hotspots – Therapists and scientists, Nurses and some medical specialities In depth review of exit interviews

Specialist nurse staffing review – Phase II to review the deployment, roles and responsibilities and how supporting the longer term workforce requirements (October 2015) Complete E- Rostering roll out to Nurses by August and to all Medical Staff by September 2016. Maintain/Increase influence on external agencies that are responsible national workforce policy and commissioning training places. Review of how establishment information is understood and presented consistently across the organisation (September 2015) International recruitment plan for medical and Nursing staff (March 2016).

4 x 2 = 8

AMS


BAF Ref

Risk Description

Initi

al

Sco

re

(IxP

)


Res

idua

l S

core

(Ix

P)




rget

S

core

(Ix

P)

Exec Lead

7 Major and sustained failure of essential assets or infrastructure

Cause; • Poor replacement or

maintenance planning • Poor maintenance contract

management • Major equipment or building

failure • Failure in skills or capacity of

staff or service providers • Major incident e.g. weather

events/ fire Effect; • Loss of facilities that enable or

support service delivery • Potential for harm as a result of

defective or • Increase in complaints Impact; • Inability to deliver services • Reduced quality or safety of

services • Reduced patient experience • Failure to meet KPIs • Loss of reputation • Loss of market share/contracts

4 x

4 =

16

• New Hospitals / Vinci Contract Monitoring

• Equipment replacement programme

• Equipment and Asset registers • Capital programme • Procurement Policy • PFI contract performance

reports • Regular accommodation and

occupancy reviews


Committee • Finance Report • Capital Programme • Audit Committee • I.P.R. Other; • Major Incident Plan • Business Continuity Plans • ERIC Returns • PLACE Audits • Minutes and papers from

meetings of the Liaison Committee, which capture: Strategic PFI Organisational

changes Legal, Financial and

Workforce issues Contract risk Design & construction FM performance MES performance

4 x

2 =

8

Accommodation occupancy and utilisation review of St Helens and Whiston

Delivery of the Cold Decontamination Business Case – Interim solution contract sign-off in June 2015. Working Group to develop longer-term solution taking on board the timescale for Whiston equipment replacement and risks inherent with the interim solution.

Estates & accommodation Strategy - initial document produced in April with supplementary Whiston estate utilisation data to be added for Board sign-off in September 2015 St Helens site strategy and accommodation development plan being developed alongside IBP development.

4 x

2 =

8

PW

Major and sustained failure of essential IT systems


BAF Ref

Risk Description

Initi

al

Sco

re

(IxP

)


Res

idua

l S

core

(Ix

P)




rget

S

core

(Ix

P)

Exec Lead

8 Major and sustained failure of essential IT systems

Cause; • Poor replacement or

maintenance planning • Poor contract management • Failure in skills or capacity of

staff or service providers • Major incident e.g. power

outage Effect; • Lack of appropriate or safe

systems • Poor service provision with

delays or low response rates • System availability resulting in

delays to patient care or transfer of patient data

• Inability to record activity and duplication due to reliance on back up paper or manual systems.

• Loss of data or patient related information

Impact; • Reduced quality or safety of

services • Reduced patient experience • Failure to meet KPIs • Loss of reputation • Loss of market share/contracts

4x4=

16

• HIS Management Board and Accountability Framework

• IM&T Strategy • Procurement Policy • Information Strategy • HIS performance framework

and KPIs

• HIS Board • IM&T Strategy delivery plan • Audit Committee • MITc Other; • Major Incident Plan • Business Continuity Plans

4x2=

8

Develop Trusts strategic response and project plans to the new national IT interoperability and procurement strategies Secure on-going HIS funding from CCGs

Review IT Strategy and system development /replacement plans in light of reduced national funding for IT projects

Current HIS IM&T Strategy expires in 2016, a new 3-5 year strategy needs to be developed IT systems KPI and availability reporting to be incorporated to MITc Action plans developed in response to IT audits – February 2015 • Telephone

answering • ADT/Maxims

availability • VTE recording

and reporting • OP

Appointment letters

4x2=

8

ND


BAF Ref

Risk Description

Initi

al

Sco

re

(IxP

)


Res

idua

l S

core

(Ix

P)




rget

S

core

(Ix

P)

Exec Lead

9 Impact of the Better Care Fund on the sustainability of hospital services

Cause; • 15% disinvestment in hospital

care • 15 % reduction in non-elective

activity • Uncertainty that community

schemes will deliver the predicted impact on hospital activity

Effect; • Complexity of patients admitted

to hospital increases • Viability of smaller specialities

with lower volume of activity • Increased unit costs if fixed

infrastructure /assets are under utilised

Impact; • Financial instability across the

health sector • Lack of integrated working • Double running and transitional

plans are inadequate • Poor patient care

4x4=

16

• The IPR monthly report • Contract monitoring/CQPG • IBP/LTFM

• BCF plans • Health and Wellbeing Boards • Resilience and Urgent Care

Boards

4x3

= 12

There is not yet a single strategic plan for the future delivery and development of health services, with supporting implementation plan and supporting transformational change infrastructure Five Year Forward View – Care Models Option Appraisal with local stakeholders

Development of CCG governance and assurance processes in relation to BCF. Development of clear risk sharing and financial allocation methodology, if BCF schemes do not deliver planned reduction in NEL admissions

• Health economy wide strategic integrated planning forum

• Development of a 10-15 year vision for the model of care in the local health economy

• Joint planning assumptions including demographic changes

• Detailed modelling of the impact of every proposed scheme, by speciality

• Agreement to double running and transitional costs

• Joint Transformational change programme arrangements, including contingency and mitigation plans

4 x

3= 1

2

IS

Trust Board (29-07-15) – Risk Register Report Page 1

TRUST BOARD PAPER


Title of paper: Corporate Risk Register Report

Purpose: For the Trust Board to review the risk profile of the Trust and all risks on the Corporate Risk Register (CRR). To approve the risk treatment or mitigation plans for the high and extreme risks.

Summary: An analysis of the Trusts risk register shows;

• The total number of risks on the risk register is 500

• The number of high/extreme rated risks escalated to the CRR is currently 8

• Corporate services has the highest number of risks at 223 or 44.6% of all reported risk

• 46.2% of risks are rated as moderate or high The Executive Committee reviews the risk register every month and all the high/extreme risks are “owned” by a Director and they develop and oversee the delivery of the mitigation plans.

Corporate objective met or risk addressed: To ensure that there are sufficient controls and mitigation plans in place to assure the Board there is effective management of operational risk.

Financial implications: None arising directly from this report.

Stakeholders: Trust Board, TDA, CQC.

Recommendation(s): The Board are asked to: 1. Note the Trust risk profile. 2. Note the Executive Committee review of CRR risks. 3. Approve the mitigation plans for the new high/extreme risks.




RISK REGISTER REPORT 1. Purpose

The purpose of this report is to provide an overview of the Trust’s risks and how they are distributed across the care groups. It is also to focus on those high /extreme risks which score 15 or above and are included on the Corporate Risk Register (CRR). The Board are asked to approve the risk treatments/mitigation plans for the risks on the CRR and the target risk scores. The extract for this report was taken from the Datix system on 15th July 2015.

2. Trust Risk Profile

Very Low Risk Low Risk Moderate Risk High /Extreme Risk 1 2 3 4 5 6 8 9 10 12 15 16 20 25

47 29 24 60 10 99 46 62 33 82 4 3 1 0

Number = 100 % of total = 20%

Number = 169 % of total = 33.8%



The table below shows the distribution of number of risks across the different care groups.

Care Group Very Low Low Moderate High /Extreme Tot

1 2 3 4 5 6 8 9 10 12 15 16 20 25

Medicine 4 3 1 9 2 14 10 13 15 23 3 1 0 0 98

Surgery 6 10 9 19 3 25 14 19 7 20 1 0 0 0 133

Clinical Support 4 6 0 6 0 7 4 10 4 5 0 0 0 0 46

Corporate 33 10 14 26 5 53 18 20 7 34 0 2 1 0 223

Total 47 29 24 60 10 99 46 62 33 82 4 3 1 0 500

3. The Corporate Risk Register The 8 high risks that have been escalated to the CRR are detailed in the table below. The risks in bold are new risks that have been reported as high risk or escalated as increasing risks to the risk CRR in the last month.

Ref Risk Description Risk Category

Care Group

Current Risk Score

Mitigation Plan Target Risk Score

1080 Nurse Staffing on Respiratory wards (2b/2c)

Clinical Care

Medicine 15 Recruitment and retention Strategy Daily staffing reviews and escalation Safer staffing checks

10

209 Failure to achieve statutory financial duties

Financial Corporate 20 Turnaround Director appointed PMO established

10

1337 Acuity of patients and demand for IV medications on ward 2d

Workforce Capacity

Medicine 15 Alternatives to IV drugs are being piloted to reduce pressure on nurse staff time

10


1285 DMOP/Frailty Service Nurse Staffing

Workforce Capacity

Medicine 16 Recruitment and retention Strategy Daily staffing reviews and escalation Safer staffing checks

8

1152 Increased use of bank and agency staff with risk to continuity of service and costs

Clinical Care

Corporate 16 Staffing reviews Recruitment and retention strategy Overseas recruitment Absence management controls

8

762 Generic risk re potential for staffing levels to impact on clinical care

Quality Corporate 16 Recruitment hotspots are monitored Development of the Trusts “bank” as alternative to agencies

12

1206 Capacity of Diabetes team to check all patients with COBAS readings out of control limits

Clinical Care

Medicine 15 Review of nice guidance

5

858 Community Midwifery connectivity to Medway system

IT Systems

Surgery 15 HIS reviewing options for system enhancements to improve connectivity

5

TRUST BOARD PAPER

Paper No: NHST(15)068 Title of paper:

A framework of Quality Assurance for Responsible Officers and Revalidation.

Annual Board Report July 2015.

Purpose: To provide assurance to the Board that the arrangements for Medical Staff Appraisal and Revalidation have been operating effectively since the regulations came into effect in 2012.

Summary: This paper is presented to provide assurance to the Board that the arrangements for Medical Staff Appraisal and Revalidation have been operating effectively since the regulations came into effect in 2012. The format follows the Annual Board Report Template provided by NHS England. The Board are requested to accept the Report and to Approve the ‘statement of compliance’ confirming that the organisation, as a designated body, is compliant with the regulations.

Corporate objectives met or risks addressed:

Financial implications:

Stakeholders: Medical Workforce

Recommendation(s): Members are asked to approve.

Presenting officer: Anne-Marie Stretch, Director of HR/Deputy Chief Executive.


A framework of Quality Assurance for Responsible Officers and Revalidation Annual Board Report July 2015

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Contents Contents .................................................................................................................... 3 1. Executive summary: .......................................................................................... 4 2. Purpose of the Paper: ....................................................................................... 4 3. Background:....................................................................................................... 4 4. Governance Arrangements ............................................................................... 5

4.7 Policy and Guidance ................................................................................... 6 4.8 Systems ....................................................................................................... 6

5. Medical Appraisal .............................................................................................. 7 5.a Appraisal and Revalidation Performance Data ......................................... 7 5.b Appraisers ................................................................................................... 7 5.c Quality Assurance ....................................................................................... 7 5.d Access, Security and Confidentiality ........................................................ 8 5.e Clinical Governance .................................................................................... 8

6. Revalidation Recommendations ...................................................................... 8 7. Recruitment and engagement background checks ........................................ 8 9. Responding to Concerns and Remediation .................................................... 9 10. Risk and Issues .............................................................................................. 9 11. Board Reflections …………………………………………………………………9 12. Corrective Actions, Improvement Plan and Next Steps .............................. 9 13. Summary ……………………………………………………………………………9 14. Recommendations ......................................................................................... 9

1. Executive summary:

Revalidation for all doctors practicing in the UK became a statutory obligation in December 2012. Revalidation is the process of renewing a doctor’s license to practice and this occurs on a 5 year cycle. To ensure a doctor is up to date and fit to practice, they must take part in annual appraisals and be part of a governed system to ensure the quality of their practice. NHS England has the ultimate responsibility for the quality and delivery of Revalidation in England. In 2014/15 there were 293 doctors with prescribed connection to St Helens & Knowsley Hospitals NHS Trust’s Responsible Officer. Of these 279 were fully appraised by the 31st March 2015 (98.6%). Doctors for whom there are legitimate reasons why their appraisal was delayed, deferred or postponed can have this agreed with the Responsible Officer and not receive any sanctions or GMC referral. Such reasons are sickness, maternity leave, logistical issues arising from employment change, appraiser sickness.

2. Purpose of the Paper:

This paper is presented to provide assurance to the Board that the arrangements for Medical Appraisal and Revalidation have been operating effectively since the regulations came into effect. The format follows the Annual Board Report Template provided by NHS England.

3. Background:

Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system.

Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations1 and it is expected that the Trust Board will oversee compliance by:

• monitoring the frequency and quality of medical appraisals in their organisations;

• checking there are effective systems in place for monitoring the conduct and performance of their doctors;

• confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and

• Ensuring that appropriate pre-employment background checks (including pre-engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.

As a Designated Body, St Helens & Knowsley NHS Trust has appointed the Deputy

1 The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012’

Medical Director as the Responsible Officer. A key role of the Responsible Officer is to make revalidation recommendations to the General Medical Council for each doctor with a prescribed connection.

4. Governance Arrangements

4.1: Individual doctors Individual doctors are expected to take part in annual appraisal, the process whereby they:

• Reflect on their practice (and in particular complaints and RCA’s) • Reflect on the supporting information they have gathered and what that

information demonstrates about their practice • Identify areas of practice where they could make improvements or undertake

further development • Demonstrate that they are up to date and fit to practice

This must encompass the whole scope of their medical practice. There are six types of supporting information that doctors will be expected to provide and discuss at their appraisal at least once in each five year cycle. They are:

• Continuing professional development (CPD)

• Quality improvement activity

• Significant events

• Feedback from colleagues

• Feedback from patients

• Review of complaints and compliments

4.2: Appraisers A medical appraiser will normally be a licensed doctor with knowledge of the context in which the doctor works. An appraiser will

• Be the most appropriate appraiser for the doctor, taking into account their full scope of work

• Understand the professional obligations placed on doctors by the GMC • Understand the importance of appraisal for the doctor’s professional • Have suitable skills and training for the context in which the appraisal is taking

place.

4.3 Responsible Officer (RO) The Responsible Officer is accountable to the Trust Board for Medical Revalidation and appraisal, and for ensuring consistent quality assurance processes in line with national guidelines. The Responsible Officer must ensure that appraisals are

carried out by the Trust in line with the most recent GMC guidelines, and are fit for the purpose of Medical Revalidation. The Responsible Officer will be required to attend any recommended training to develop and maintain their skills within the role of Responsible Officer. The Responsible Officer will undertake an annual report to the Board to provide assurance to the Board that the Trust is compliant. 4.4 Clinical Appraisal Lead The Clinical Appraisal Lead provides guidance and assurance to appraisers from within the Trust and chairs the Appraisal Support Group. The Clinical Appraisal Lead’s objectives include:

• Lead the on-going development and improvement of medical appraisal within the Trust and identify and implement good practice

• Develop the skills of the Medical Appraisers

• Represent the Trust at regional Lead Appraiser network meetings

• Quality assure medical appraisals and coordinate appraisal audits 4.5 Medical HR Manager The Medical Workforce Professional Standards Manager supports the Responsible Officer in the management and quality assurance of the Trust’s Medical Revalidation and appraisal policy and guidelines. 4.6 Revalidation Officer

The Revalidation Officer provides administrative support to the Medical HR Manager and co-ordinates the process of appraisal and revalidation.

4.7 Policy and Guidance The Trust has a Medical Revalidation and Appraisal Policy which is up to date and in line with the NHS England Framework of Quality Assurance. The policy includes guidance on appraiser recruitment, allocation and support as well as clearly defining the non-participation process. The Organisational Readiness Self-Assessment (ORSA) has been replaced by an Annual Organisational Audit (AOA). The AOA was completed on time and submitted to NHS England in May 2015.

4.8 Systems A new computer system for appraisal and revalidation, called ‘PReP’ was introduced to doctors within the Trust from January 2014. The rollout of this new system was supported by training which continues on a monthly basis for new doctor’s joining the Trust. Feedback and take up has been encouraging.

This system is secure and encrypted, and allows for documents to be uploaded by the doctor and linked with the relevant GMC standards. The system keeps appraisal records for consecutive years and will enable the Responsible Officer to review and sign off the required assurance statements with regards to revalidation.

5. Medical Appraisal

5.a Appraisal and Revalidation Performance Data Of 293 doctors within the Trust, 279 successfully completed medical appraisals within the 2014 – 2015 appraisal years (98.6%). The reasons for non- completion of Appraisals were due to maternity leave, sickness absence, unplanned absence of the appraiser and electronic information system problems.

5.b Appraisers Within the appraisal year 2014 – 2015, the Trust had 77 trained appraisers, each averaging 4 appraisals each. Funding has been identified to train 20 new appraisers over the next 2 years and to provide refresher’ training for current appraisers over the next 3 years.

5.c Quality Assurance

For the appraisal portfolio:

• The doctor is expected to complete the electronic appraisal portfolio in a timely manner to allow the appraiser sufficient time to review the content and if necessary request additional supporting evidence.

• Review of appraisal folders provides assurance that the appraisal outputs: PDP, summary and sign offs are complete and to an appropriate standard.

• Review of appraisal outputs by the Responsible Officer provides assurances that any key items identified pre-appraisal as needing discussion during the appraisal are included.

For the individual appraiser:

• An annual record of the appraiser’s participation in appraisal calibration events such as reflection on ASG (Appraisal Support Group) meetings is kept by the revalidation team

• Feedback from doctors for each individual appraiser is collected at the end of each appraisal meeting.

For the organisation:

• The PReP system allows the Revalidation team to track timescales for appraisals from the setting of appropriate appraisal dates to completion of the process and a system of prompts and reminders culminating in a letter from the RO

• Trust Information Governance policies apply. Doctors are responsible for ensuring no patient identifiable information appears in their appraisal portfolio

• The appraisal process is confidential to the Responsible Officer, the Clinical Appraisal Lead and the Appraiser except significant concerns arise as part of the appraisal and revalidation process or otherwise which relate to fitness to practice, or where patient safety is a concern.

5.d Access, Security and Confidentiality Trust Information Governance policies apply. Doctors are responsible for ensuring no patient identifiable information appears in their appraisal portfolio. No breaches were identified in the year 2014 to 2015.

5.e Clinical Governance Doctors are required to include reflection on any significant incidents and complaints within their appraisal portfolio. In addition, a pre-revalidation check of each doctor against the Trust risk management system ensures that the Responsible Officer has access to the relevant clinical governance information when making a recommendation.

6. Revalidation Recommendations

• Number of recommendations between April 14 – March 15: 109 • Recommendations completed on time: 106 • Positive recommendations: 109 • Deferrals requests: 12 (9 people) • Non engagement notifications: 0

7. Recruitment and engagement background checks

Policies are in place to govern the recruitment process for permanent and temporary staff, including the pre-employment checks that form part of these processes as per NHS Employer guidance to include the Revalidation Reference Check.

8. Monitoring Performance

Monitoring performance from a ‘fitness to practice point’ of view remains one of the most challenging aspects of the Responsible Officers role. At STHK we are developing systems to gather ‘intelligence’ from a variety of Governance Sources such as-

• Patient complaints • Colleagues and allied staff • Datix Incidents • Medical Directors litigation report • Claims • Claims outcome form • External Reports e.g. Health Service Ombudsman • SUI/ RCA

We plan to have an integrated system in place before the next board report to provide assurances to the Responsible Officer and the Board that we are capturing all relevant governance information regarding a Drs Practice.

9. Responding to Concerns and Remediation

All concerns raised in relation to medical staff are managed in line with Trust Policy ‘Handling Medical Concerns’ and national guidance ‘Maintaining High Professional Standard’s in the Modern NHS’. A robust framework is in place to ensure that all concerns are managed appropriately and in a timely manner to include:

• Weekly case reviews with Medical HR Manager, HR Advisor (Case Review). Responsible Officer and Director of HR;

• Monthly case reviews with Chief Executive Officer, Responsible Officer and Director of HR

• Monthly Professional Standards meetings with the Head of HR, Responsible Officer, Medical Education Lead and Divisional Medical Directors

Were appropriate, concerns relating to medical staff are managed within the Trust remediation policy.

10. Risk and Issues

There are no risks and issues currently identified for reporting to the Board/Executive Team.

11. Board Reflections

A significant advance would be to add a governance section to our electronic appraisal portfolios to collate for each Dr relevant information on their practice generated through complaints/datix etc. as outlined in section 8 above.

12. Corrective Actions, Improvement Plan and Next Steps

The focus for the next 12 months is further strengthening the quality assurance process to ensure this is robust as possible.

13. Summary

The Responsible Officer, Dr T Hankin can provide assurances to the Board that the Trust has effective systems in place to support revalidation to include appraisal and clinical governance systems.

14. Recommendations

The Board are asked to accept the Report and to approve the ‘statement of compliance’ confirming that the organisation, as a designated body, is compliant with the regulations. This report will be shared with the Higher Responsible Officer as part of the Trusts Annual Organisation Audit submission.

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