March 2015 Papers - Tameside Hospital

Transcription

TAMESIDE HOSPITAL NHS FOUNDATION TRUST
Report to Public Trust Board meeting of 26 March 2015
Agenda Item
6b
Title
Sponsoring Executive Director
Author (s)
Purpose
Chief Executive’s Report
Karen James
Tom Neve
To discuss and note the actions required under the
various items covered by this report.
This report has not previously been considered by
any other committee
Previously considered by
Executive Summary :
The report covers the following items:
 Morecambe Bay Report – Board should be aware that a gap analysis is being
undertaken to review compliance with the recommendations contained within the
report
 Jimmy Saville – Board should be aware that the trust is required to confirm by
Monday 15 June any actions taken as a result of the recommendations in the report
 Vanguard – New Care Models Programme – To inform board that the trust was not
successful in its application to become a Vanguard site.
 Mutuals Update – To note that the project formally concludes at the end of March
2015
 Non-Executive Director appointment – to be advised of the outcome of the recent
interviews
 If in Doubt …Speak Out – To inform board of the recently launched campaign
reminding colleagues that they have the right to speak out on any issues of concern
 Tameside Flies the Commonwealth Flag; and Visit by Tameside Advertiser – to
inform board of two recent events publicised in the local press
This report impacts on all of the Trust’s
Corporate Objectives
Relates to all aspects of Board Assurance
Framework and Significant Risk Report.
This report indirectly impacts on CQC
fundamental Standards of Care and
Monitor’s licence requirements
No direct financial implications
Related Trust Objectives
Risk Assurance – risk impacted upon
Legal implications/Regulatory
requirements
Financial Implications
Has a quality impact assessment been
undertaken?
How does this report affect
Sustainability?
No
This report does not directly affect
sustainability
Action required by the Board
The board is asked to discuss the items contained within the report and to note the
requirements for the trust to respond to the Morecambe Bay Report and the Jimmy Saville
Report
1
Morecambe Bay – Kirkup Report
The independent report commissioned by the Department of Health and written by
Dr Bill Kirkup, investigates failings in maternity care at Furness General Hospital
(FGH). It sets out at least seven missed opportunities at “almost every level” which
meant poor clinical care was not investigated and led the preventable deaths of one
mother and 11 babies.
Kirkup makes a series of recommendations, for both the University Hospitals of
Morecambe Bay NHS Foundation Trust, and the wider NHS, to prevent such failing
happening in the future.
The report helpfully acknowledges the risks inherent in healthcare and focusses on
the core importance of learning and on the core importance of learning and driving
continuous improvement, including with regard to safety. It also acknowledges the
unique features of maternity care.
In addition to specific recommendations for Morecambe Bay FT, there are some 26
recommendations aimed at other trusts, as well as national bodies within the NHS.
The Quality and Clinical Governance committee has requested that Mr Weller
conduct a gap analysis and systematically review the recommendations and report
his findings to the Quality and Governance committee. Initial assurances confirm that
the recommendations of Kirkup are consistent with the actions we have taken since
Keogh on our improvement journey
Jimmy Saville
You will know that, following the death of Jimmy Savile and subsequent allegations
of his wrongdoing at NHS organisations, the Department of Health launched an
inquiry into his activities across the NHS. In total, 44 reports have now been
published following investigations triggered by this exercise.
While many of these actions took place a long time ago and, in some cases, at
institutions that no longer exist, everyone within the NHS has a responsibility to
make sure nothing like this can ever happen again.
The Secretary of State for Health has accepted in principle 13 of these
recommendations, 10 of which apply to NHS trusts and foundation trusts. Although
the Secretary of State did not accept recommendation 6 on Disclosure and Barring
(DBS) checks, organisations are asked to consider the use of these checks
(standard or enhanced) where appropriate.
Monitor has asked trusts to read the report, assess the relevance of its
recommendations to their own organisation and take any action necessary to protect
patients, staff, visitors and volunteers. Given the severity of this issue, Monitor states
2
that it is important to be able to demonstrate the improvements made to
safeguarding across the system. Organisations are therefore asked to provide
Monitor with an overview of any necessary actions that have been taken as a result
of the recommendations in the report or, where these are in progress, the date by
which they will be completed. This response is required by 5pm Monday, 15 June
2015
Vanguard
In January the NHS invited individual organisations and partnerships, including those
with the voluntary sector to apply to become ‘vanguard’ sites for the New Care
Models Programme, one of the first steps towards delivering the Five Year Forward
View and supporting improvement and integration of services.
Board may recall that coordinated by the CCG, the local health economy submitted
an application to the Vanguard programme.
More than 260 individual organisations and health and social care partnerships
expressed an interest in developing a model in one of the areas of care, with the aim
of transforming how care is delivered locally.
On 10 March, the first wave of 29 vanguard sites was chosen. This followed a
rigorous process, involving workshops and the engagement of key partners and
patient representative groups.
Our health economy was not one of the successful applications. Whilst very
disappointing, it is perhaps not surprising given that other applications demonstrated
further progress on integration and a deeper understanding from their
commissioners on what an integrated care economy should look like.
Mutuals Update
The Mutuals project formally concludes at the end of March 2015 and the business
cases from all participant organisations in the Mutual programme will be written up
and presented to the Cabinet Office.
Board may recall that one of the key objectives of this national programme was to
consider the feasibility of the mutual model in the delivery of healthcare and to
identify any statutory or policy changes that may be required to support the use of
this model.
The learning that has been gained in terms of integrating services across a single
care pathway and the exploration of different staff engagement and ownership
models has been invaluable in the context of our journey towards an Integrated Care
Organisation (ICO).
3
With regards to the trust’s project around the heart disease pathway, no service or
staff members will be “mutualised” as a result of the trust’s involvement in the
Mutuals programme.
Non-Executive Director Appointment
Interviews for the Non-Executive Director post which becomes vacant upon the
retirement of Tony Ward our longest serving Non-Executive Director colleague were
held yesterday. Tony retires from the board at the end of April 2015 and the
dedication and enthusiasm he has demonstrated will be very difficult to follow by his
successor.
As board is aware, the appointment of Non-Executive Directors is one of the
statutory responsibilities of the Council of Governors. The three governors who sit
on the Nomination Committee, were aided by Mr Aitken external adviser, Mr
Connellan and myself.
At time of writing this report it was not known if an appointment was made but
colleagues will be advised at the board meeting.
If an appointment was made the Nomination Committee will recommend the
appointment for formal ratification at the full Council of Governors meeting on 14
April 2015.
Tameside Hospital Flies the Commonwealth flag for the NHS
The hospital was given the honour to acknowledge the diverse and different cultures
represented within its 2,600 staff and volunteers as part of the Commonwealth Day
2015 celebrations.
The hospital joined more than 730 organisations from across the world. Each was
sent a message of goodwill from Her Majesty The Queen who is Head of the
Commonwealth, and all flew the Commonwealth flag as a collective expression of
the common values the institution upholds.
A personal message from His Excellency Kamalesh Sharma, Secretary- General of
the Commonwealth – and a specially written Commonwealth Affirmation was read
out at the ceremony on Monday 11 March 2015, which took place in the hospital
grounds, before the raising of the Commonwealth flag by staff representatives.
If in Doubt …Speak Out
We recently launched a new campaign at the hospital called If in Doubt…Speak Out.
Essentially we are reminding colleagues that they have the right and protection to
speak out if they are in doubt about anything at work. This can mean issues with
colleagues, damaged equipment, a concern they might have about a patient or
anything else that might be troubling or concerning them. We want colleagues to feel
safe that what they say is taken seriously and we are always ready to listen. You
4
may have seen the leaflets, posters and floor stickers around the hospital. We are
also going round to all wards and departments asking colleagues to sign the pledge
board and in return we are giving out stickers with the If in Doubt…Speak Out logo.
Visit by the Tameside Advertiser
Last week I invited Katie Fitzpatrick from the local newspaper to the hospital to come
and see some of the improvements we have been making in all departments. Katie
met many staff, patients and visited paediatrics, outpatients, the White House and
MAU. This week (week beginning 9th March) Katie wrote her article for the
Tameside Advertiser and we got a double page spread, which is great for staff and
for the hospital. The article describes some of the excellent work we have been
doing here, not just frontline but also with our admin departments and back room
teams.
PENNA Awards
This year’s Patient Experience Awards took place in Birmingham on 12th March
2015. Karen James, chief executive, was joined by Helen Howards the matron for
patient experience and a number of other colleagues to see how we got on with our
nominations for our HALs team and patient experience. We’re pleased to say that we
were a finalist for patient experience and runners up for the work the HALs team
have been doing at the Trust and within the community.
5
Agenda Item
Title
Author (s)
Purpose
7a
Draft Operational Plan 2015-16
Karen James
Hanif Wazir
To advise board of the progress made towards
developing the annual plan for submission to Monitor
by 14 May 2015
Elements of this plan have been discussed at the
Executive planning Meeting and the Governor’s
Advisory planning Group. Planning assumptions have
been shared with the Local Healthcare Economy
(LHE)
Executive Summary :
The attached report explains the requirement for the trust to submit an operational plan for
2015-16. Given the CPT process is not yet complete, the requirement is to recommit, refresh
or recreate our strategy submission from last years which covers 5 years.
The trust’s annual plan for 2015-16 is required to be submitted to Monitor by 14 May 2015.
The final iteration of the Annual plan will be brought to the 30 April Board meeting for
discussion and approval.
The operational plan relates to all 7
Corporate Objectives
Annual planning is a regulatory requirement
of Monitor under its licencing conditions.
requirements
This report has a direct impact on the Trust’s
financial sustainability
undertaken?
No
This report has a direct impact on the
sustainability of the organisation.
Sustainability?
Board is asked to discuss and note the attached report and to note progress towards
developing the final submission that will be presented to the April 2015 board prior to
submission to Monitor on 14 May 2015.
1
Operational plan 2015 – 2016
Summary
The requirement to submit operational plans for 2015 – 2016 to Monitor remain in force
during the CPT process, however, there has been discussion with Monitor whereby we are
only requested to either recommit, refresh or recreate our strategy submission from last year
which covers 5 years. Monitor has reserved the right to request a full strategy submission
depending on the outcomes, in the coming months once the CPT process has concluded,
with 2016 -2017 counted as year 1.
Plans will need to reflect local priorities for patients, and it is expected commissioners and
providers to work together when planning. It is therefore expected that providers’ plans will
be aligned with those of the wider LHE and that key assumptions will be shared. Where
these are materially unaligned, Monitor will expect differences to be clearly explained.
The emphasis for operational planning for all FTs is around two factors:
SUSTAINABILITY - To put together, deliver and evolve a credible operational strategy for
achieving the required performance levels into the long term

How last year’s strategy has been updated (recommitted to, refreshed or recreated):
in light of:
a) the foundation trust’s 2014/15 performance
b) any changes to its internal/external environment

How the foundation trust will achieve progress against that strategy in 2015/16 with
particular reference to ‘The Forward View into action: partnership and planning for
2015/16’
RESILIENCE - Appropriate engagement with health system partners to address any
performance. This means meeting operational and financial requirements and having the
flexibility and capacity to overcome unexpected short-term difficulties along the way.
 How quality, operational and financial requirements will be met in 2015/16.
 Plans should be underpinned by strong supporting financial projections.
The final operational plan should contain:



an operational plan narrative
a redacted summary of the operational plan narrative, in a format suitable for external
publication
the full, final financial template (revised for this planning round), which requires the
completion of 1 year of detailed financial forecasts
2
Declarations
The Trust board will have to as per normal requirements make declarations as follows:

Sustainability - Boards are expected to be able to refresh the declaration of
sustainability made in the 2014/15 strategic plans based on the 2015/16 strategic
context and expected progress against the strategic agenda over the next two years.
 Resilience - Based on the analysis undertaken it is expect boards to be able make a
judgement on quality, operational and financial resilience over the next two years, as
asserted in the ‘Continuity of Services condition 7: Availability of Resources’ and
‘Interim/planned term support requirements’ declarations.
It is intended that the Board in April 2015 will be asked to recommend that the strategy is a
reaffirmed and recommitted to, since our objectives to move to an integrated model of care
remain the same. The commissioners and the regulatory intervention is moving towards this
objective. While there is debate and discussion about the future clinical model and the
sustainability of the Trust, it is agreed that a population based approach to improve
outcomes is the way forward.
Progress to Date
A Trust planning group meets weekly to progress the development of the plan. Planning
assumptions have been shared with partner organisations within the Local Healthcare
Economy (LHE)
The outline of the draft annual plan has also been discussed at the Council of Governors
Annual Planning Advisory Group. Board will be aware that there is a requirement to have
regard to the views of the Council of Governors.
The completed plan will be presented to the trust board on 30 April 2015 for formal adoption
prior to submission to Monitor on 14 May 2015.
3
Agenda Item
7b
Title
Corporate Objectives Review (2014/15 and 2015/16)
Karen James
Author (s)
Executive Team
Purpose
To advise board of the end of year position against
the 2014/15 Corporate objectives and to discuss and
agree the key themes and success criteria for the
2015/16 corporate objectives
Discussed at the Executive Management Team
Executive Summary :
There has generally been good progress made across all seven of the corporate Objectives
for the 2014/15 year.
The 2015/16 Corporate Objectives maintain the same key themes but include more
challenging success criteria in order to demonstrate the second phase of the trust’s
improvement journey.
All
The successful achievement of the trust’s
corporate objectives will ensure the
organisation complies with the legal and
regulatory requirements of all its regulators.
The corporate objectives have a material
impact on the financial sustainability of the
trust.
No
requirements
undertaken?
The achievement of the Corporate
Objectives directly impacts on the trust’s
future sustainability.
Sustainability?
Board is asked to note the achievement against the 2014/15 corporate objectives and to
discuss and agree the themes and success criteria for the 2015/16 corporate objectives.
1
Corporate Objectives end of year position 2014/15 and review of 2015/16
Corporate Objectives.
2014/15 Corporate Objectives End of Year Review
The Trust’s end of year position against the Corporate Objectives for the 2014/15
year has been reviewed by the Executive Team. Generally there has been good
progress made across all of the seven objectives in what has been a very
challenging year for the organisation
Appendix A attached provides an assessment of delivery in respect of the actions
underpinning each objective.
2015/16 Corporate Objectives
The 2015/16 corporate objectives on Appendix B maintain the key themes from the
previous year whilst incorporating more challenging success criteria to allow us to
demonstrate the second phase of the trust’s improvement journey. These are
attached
2
Corporate Objectives 2014/15
Appendix 1
Objective
1. All patients
receive harm
free care
through the
delivery of
the Trust’s
Patient
Safety
Programme
Key Outcomes
End of Year Update
All staff will be able to demonstrate an understanding of the Trust’s key safety
priorities of 2014/15.
Achieved
There will be a:
Reduction in the number of avoidable hospital acquired pressure ulcers and we
will reduce the incidence of pressure sores Grade 2 and above. We will ensure
less than 1% incidence with a 99% compliance rate.
Achieved
Reduction in catheter associated urinary tract infection ensuring 99% of patients
receive no avoidable UTI.
Achieved
Increase in the identification of deteriorating patients and a reduction in the
number of avoidable cardiac arrest calls and improved response to deterioration
triggers. We will ensure a 50% reduction from the baseline.
The implementation of the new
National Early Warning Scoring
System (NEWS) in October 2014
replaced the previous Patient at Risk
(PARs) system and will offer a
revised baseline for monitoring in
2015/16
Reduction in patient falls resulting in harm ensuring less than 1% incidence
resulting in 99% of patients receiving harm free care.
Achieved
Reduction in harm from VTE through appropriate risk assessment and
thromboprophylaxis.
Achieved
Reduction in the number of hospital acquired infections
Achieved
Improved compliance with Infection prevention standards and requirements.
Incident reporting will increase resulting in the Trust being in the upper quartile
of comparable similar sized Trusts using NRLS data.
Achieved
1
The number of incidents causing harm will reduce resulting in a reduction in
harm per 1000 patient incidents when compared to similar sized Trusts using
NRLS data.
The percentage of harm free care will increase from the current baseline of
95% with the aim of harm free care for every patients.
2. To improve
the quality of
patient care
through the
implementati
on of the
Trust’s
agreed
Quality
Strategy.
All staff will be able to demonstrate an understanding of the Trust’s Quality
Improvement priorities for 2014/15.
Achieved
Achieved
Achieved
There will be:
Increased participation in and improvements in performance against
national/local clinical audits
Achieved
Improved compliance with clinical care bundles and Advancing Quality markers
Compliance with Advancing Quality
markers has been inconsistent and
not achieved and is the focus of
targeted work.
Adherence to all eligible NICE Guidelines
There has been a systematic review
of all NICE guidelines. A revised
infrastructure has been developed
with divisional support in order to
achieve adherence to all eligible
guidelines.
Reduction in 30 day re-admission rates from the current baseline of 9.1% to
8.73% (75th percentile)
Not achieved and is the focus of
targeted work.
Adherence to all agreed internal standards with systematic monitoring and
assurance processes
This assessment will be based upon
the outcome of external scrutiny and
systematic monitoring by the trust
board and reported through the
Quality Account publication.
2
Reduction in mortality rates and implementation of a systematic review process Every patient death is being
to levels that are not statistically significant and show a reducing terns of the raw reviewed by a Multi-disciplinary
death rate.
Team led by the Medical Director. In
addition to this a coding review is
being undertaken. The impact of this
may not be evident for some time
owing to the time lapse in the
publication of data.
3. To improve
the patient
experience
through a
personalised,
responsive,
compassiona
te and caring
approach to
the delivery
of patient
care.
4. To develop a
continuous
quality
improvement
culture which
promotes
patient
quality,
safety,
personalised
Improved care in relation to nutrition and hydration
Achieved
Improvement in Friends & Family Test and response rates by a further 5% on
the national trajectory.
Achieved
Improvement in patient experience score and net promoter score
Achieved (not now used as a
measure)
Achieved
Reduction in the number of complaints per 1000 patient contacts to below 1.15
complaints per 1,000 patient contacts.
Increase in the number of recorded compliments per 1000 patient contacts by
25% above current baseline
Achieved
Improvement in results of the First Friday feedback
Achieved
Achievement of all access standards
Not achieved for RTT, and A&E.
The new clinical leadership model is implemented (both Medical and Nursing)
Achieved
Development programmes are in place to support the new leadership models
Achieved
The Trust’s new Values & Behaviours framework is established and all staff
appraisals and the Trust’s recruitment processes are aligned with the framework
Achieved
The new appraisal process
incorporating assessment against
our values and behaviours launched
in January with training taking place
from January through to April. The
3
and effective
care.
actual appraisal window will
commence in April.
There is evidence of employee engagement with the Trust’s Transformation
agenda
Improvements are demonstrated in the delivery of objectives one, two and three
Achieved
It is recognised in the 2015-16
objectives that further work is
required in this area.
Board to ward objectives are realised and evidenced
Achieved
An Internal Communications Strategy is implemented which supports the Trust’s
Safety/Quality and Patient Experience agenda
Achieved
The quality and safety of the Trust’s of the service provision through the
implementation of the Trust’s agreed Quality Strategy is improved.
Achieved
5. To develop a A strategic service plan is agreed with all key stakeholders and partners
Strategic
Service Plan
An engagement and change framework is agreed along with the implementation
which will
plan
secure
clinical and
financial
sustainability
for the Trust
in conjunction
with the
Trust’s
strategic
partners and
key
stakeholders.
6. To work with
our partners,
stakeholders
An Engagement and Communication Strategy is agreed and implemented for
the Trust (which targets both internal and external stakeholders) Feedback from
Tameside Listens is incorporated into the Trust’s Improvement Programme and
The Contingency planning Team
(CPT) is currently reviewing the
Local Health Economy’s plans for
integrated care
The CPT team have extended their
review period and will not now report
until July 2015.
The Trust has successfully
participated in the national Mutuals
Pathfinder programme which was
completed in March 2015. An outline
business case was developed
around the heart disease pathway
and this work supports the greater
review of the entire heart disease
pathway from primary through to
tertiary care.
Achieved
4
and the
community to
develop the
reputation of
Tameside
Hospital as a
provider of
safe, high
quality,
effective
care.
7. To deliver
against the
required local
and national
frameworks
in order to
meet all the
requirements
of the Trust’s
operating
licence and
the
commissione
rs’
requirements.
this focused piece of work becomes part of the normal business of the
organisation
An open and transparent culture around the performance of the organisation is
in operation with respect to the Trust’s performance against its agreed quality
and safety metrics
Achieved
Through feedback questionnaires, there is evidence for key stakeholders that
the Trust’s reputation has improved
Achieved
Compliance with all national and local performance standards is achieved.
These will include:Delivery of CQUIN improvements and targets
Delivery of other commissioning targets
Implementation of all national NICE guidelines.
Delivery of financial plans
Meeting current regulatory standards and requirements and any that are
imposed
The Trust is on track to deliver
revenue and capital financial plans.
The deficit has reduced from
projected deficit of £21m to £18m as
a result of additional income received
over and above that anticipated
within the plan. Monitor has been
kept fully informed of change in
position.
The final outturn will be available in
April as part of the production of the
annual accounts.
There has been a systematic review
of all NICE guidelines. A revised
infrastructure has been developed
with divisional support in order to
achieve adherence to all eligible
guidelines.
The Trust is currently meeting
regulatory standards and
requirements and a CQC inspection
is due in April 2015.
The Trust is currently under “Special
Measures”.
5
Corporate Objectives 2015/16
Appendix 2
Objective
1. All patients receive
harm free care
through the delivery
of the Trust’s
Patient Safety
Programme
Key Outcomes

We will continue to build upon and embed the reduction in harm achieved in 2014/15 and we will maintain or
exceed the end of year position against key performance metrics.

We will participate in the Haelo Patient Safety Programme and ensure external engagement is secured to meet
its expressed objectives

We will implement and deliver the Trust Safety plan for 2015/16 measuring and monitoring safety objectives
across the Trust as submitted to Haelo and the NHSLA.

A speciality level range of safety metrics are developed which will drive local quality improvement and
measurement.

We will develop in partnership with our commissioners and other providers and the local authority a system wide
metrics for at least two agreed areas of harm and collate baseline data for these.
We will develop a system for anticipating and predicting potential future harm and implement this for at least two of
the Patient Safety Patient work streams for 2015/16
2. To improve the
quality of patient
care through the
implementation of
the Trust’s agreed
Quality Strategy.
 We will achieve the identified pledges and measures as stated in the Trust Quality Strategy and meet key
indicators as attributed to each Quality Priority.
 Each speciality will have developed a suite of Quality metrics which will drive local quality improvement and
measurement.
 The Trusts mortality rates will have improved in line with expected levels.
 We will further develop our strategy for seven day services and working in partnership with other key
organisations.
 Through delivery of the Workforce and HR/OD Strategy we will ensure delivery our of Health and Wellbeing and
organisational development intentions and improve outcomes against our Values and Behaviours.
 We will review our position against appropriate NICE guidance and Quality standards ensuring these are
monitored and prioritised within service delivery
1

3. To improve the
patient experience
through a
personalised,
responsive,
compassionate and
caring approach to
the delivery of
patient care.
We will deliver Advancing Quality (AQ) improvement targets.
There is evidence of an improvement in administration processes which support responsiveness to patients and
other service users.
This will include:
 All urgent letters typed and sent within 2 working days.
 All routine letters typed and sent within 5 working days
 All areas will have agreed standard operating policies which will ensure that compliance is maintained with
these standards
We will improve our Friends & Family Test and response rates by a further 5% on the national trajectory for each
required FFT speciality published.
We will improve our reported Positive patient experience metrics and intend to be in the top 50% of Trusts when
benchmarked for each reported FFT speciality.
We will further reduce the number of KO41 complaints per 1000 patient contacts to below 1.15 complaints per 1,000
patient contacts.
We will increase in the number of recorded compliments and improve the Compliments to KO41 Complaints ratio by
20% from the Q4 2014/15 baseline.
We will continue to undertake First Friday walkrounds to receive feedback on patient and staff experience and see
on going improvement in the feedback provided and reported.
We will continue to implement our open and transparent culture around the performance of the organisation and our
performance against our agreed quality and safety metrics and include examples of improvement and patient stories.
We will publish these on the Trust Website in our “Open and honest” publications monthly
We will continue through feedback questionnaires and other systems to understand what our patients and key
stakeholders are telling us about the Trust’s Quality of service provision and reputation. We will report on this
through published performance in the “Open and Honest” publications and it visibility through the NHS choices star
ratings.
4. To foster a
continuous quality
improvement culture
which promotes
patient quality,
safety, personalised
There is evidence of a service Transformation Strategy which will focus on improving responsiveness to patients and
support the more effective use of resources.
The Strategy will support the delivery of:
 A reduction in DNA rates in Outpatients from 11% to 7.5%.
2
and effective care.




Appointment dates will be agreed in advance with 90% of patients before an appointment is provided.
The utilisation of slots in clinics will improve from 73% to 90%
All day case and inpatients being offered a choice of date for their treatment.
A reduction of cancellations of surgery on the day from 1.1% to 0.8%
Redesign across the Heart Disease Pathway in collaboration with health, social care and third sector partners will
continue. The outcome being a pathway which delivers safe and effective care.
Develop an internal engagement and service improvement programme delivered at Departmental level, which listens
to staff and empowers staff to act and along with an implementation plan ensure:
-
There is evidence of employee engagement with the Trust’s Transformation agenda – evidenced through
NHS Staff Survey results – aim to be best 20% for staff engagement scores
-
There is continued improvement with staff engagement evidenced through NHS Staff survey results at Trust
and Divisional Levels
Through the new Appraisal process Board to ward objectives are realised and evidenced – evidenced within the
Staff Survey results – aim for above average/best 20% compared with national average.
Continuation of the Leadership Development and coaching programmes to develop a distributed leadership model –
evidenced through NHS Staff Survey scores – best 20%
Development of a Learning & Development Strategy for Health Care Support workers in bands 1-4.
Achievement and maintenance of Mandatory Training Compliance 95%
Embedding of Trust Values and Behaviours through new Appraisal process. Completion of Appraisals within new
Appraisal window and compliance with the 95% target
Launch Trust Workforce Health & Wellbeing Policy - Improvement in Attendance levels – achievement of Trust
target 3.5%
Evidence of improvement in the quality and safety of the Trust’s service provision through the implementation of the
Trust’s Quality Strategy, evidenced through improved safety and quality metrics
5. To develop a
Strategic Plan which
There will be evidence of further development of the 7 day services Strategy.
3
will secure clinical
and financial
sustainability for the
trust in collaboration
with its strategic
partners, and key
stakeholders.
To develop a workforce strategy which ensures our workforce requirements support new ways of working, builds
skills and capabilities so staff are equipped to deliver community and hospital service delivery
To support and encourage team working across boundaries to enable better integration and enhance the working
experience of staff so they are able to provide truly integrated services
In pursuing our strategy of integrated care, we will collaborate with commissioners, social care, GPs and other
healthcare providers to expand patient access to health care, improve care coordination, and achieve the triple aims
of improved health outcomes (quality), lower total healthcare costs and increased patient satisfaction.
An agreed clinical model for the delivery of an Integrated Care Service, is endorsed by system stakeholders i.e.
CCG, LA and the Trust, which is deemed financially and clinically sustainable.
An organisational vehicle, for the delivery of an Integrated Care Model, is agreed.
Engagement/consultation process is agreed with the Trust’s commissioners.
There is evidence of a clear acute network plan which secures sustainability for the Trust’s future service strategy.
There is evidence of an agreed implementation plan for the delivery of Integrated Care and acute service strategy for
year 1.
An engagement strategy is agreed, for the development of secure partnership relationships, which includes the third
sector.
6. To work with our
partners,
stakeholders and
the community to
deliver more
effective safe, high
quality, effective
care.
To further develop the Governors bi-monthly training programme ensuring alignment with current regulatory
requirements and regional and Local Health Economy issues.
Enhance membership engagement by implementing a fit for purpose electronic membership engagement platform.
Enhance membership engagement by establishing a quarterly programme of health related seminars beginning with
“living with diabetes” scheduled for 9 May 2015.
Plan and deliver 2015 Open Day in September 2015 – the theme is “Tameside Hospital at the Heart of the
Community”. Work with CVAT and voluntary groups in the planning and delivery of the open day.
Develop links and build relationships with third sector partners.
4
Deliver the Health and Wellbeing programme - Making Every Contact Counts (MECC) in partnership with TMBC
Continue to develop an open and transparent culture around the performance of the organisation with respect to the
Trust’s performance against its agreed quality and safety metrics – for example If in Doubt Campaigns, Executive
walk rounds, First Friday.
To develop an engagement strategy to further enhance relationships within Primary Care; this will be evidenced
through increased joint education events, wider use of social media and specific specialty/topic engagement
activities/events.
7. To deliver against the Compliance with all national and local performance standards is achieved:
required local and
national frameworks,
 Delivery of all CQUIN targets
and to put in place
 Delivery of commissioners agreed contract and quality plans
arrangements to
 All NICE guidelines are considered and implemented into the Trust Quality Plan
secure economy,
 Financial and CIP plans are delivered against agreed improvement trajectories
efficiency and
 Key performance metrics/standards are delivered in accordance with national requirements
effectiveness in it use
of resources, in order
 The Trust’s improvement trajectories, for the following standards, are met:
to meet all the
o Referral-to-Treatment A&E Stroke Services
requirements of the
 The Trust’s information Quality Assurance Improvement plan is delivered and improvements are secured in
Trust’s operating
performance data in the following areas:
licence and the
 Mortality
commissioners’
 Length-of-stay
requirements.
 Readmissions
5
Report to Public Trust Board meeting of 26th March 2015
Agenda Item
7c
Title
Making Safety Visible
Mr John Goodenough – Director of Nursing
Mr Brendan Ryan – Medical Director
Author (s)
Peter Weller – Director of Quality & Governance
Purpose
To note/receive
n/a
Executive Summary
This paper outlines the Trust’s commitment and action in response to the Haelo
initiative. The paper outlines the launch of Year 2 of the Tameside Patient Safety
Programme and our Trust plans to further improve the measurement and monitoring
of patient safety
The paper outlines the action we are taking with partner organisations to understand
how we can further develop further the measurement and monitoring of Patient
Safety aligned to the Measurement and Monitoring of Safety Framework.
1,2,3 4,5,6 & 7
Potentially impacts on all
requirements
Compliance with regulatory requirement and
operating licences
None identified
Has a quality impact assessment
been undertaken?
Not applicable – within existing developments
Sustainability?
The Trust is required to ensure safety and harm
free care underpin its core services.
The Trust Board are requested to receive this update and note the Trust’s
commitment and action in response to the Haelo initiative. The Board is asked to
note the launch of Year 2 of the Tameside Patient Safety Programme and our Trust
plans to further improve the measurement and monitoring of patient safety.
Page 1 of 4
.
1. BACKGROUND
As Board members are aware, Making Safety Visible is a Board level programme that is
aiming to increase the knowledge of Boards around the measurement and monitoring of
safety. It aims to help the organisations taking part become safer. The Trust is committed to
the programme, its aims and objectives.
The programme is based around the ‘Measurement and Monitoring of Safety’ paper
authored by Prof Charles Vincent, Susan Burnett and Dr Jane Carthey.
Making Safety Visible is funded by The Health Foundation and aims to improve the capacity
on the Boards of the 22 organisations taking part.
The purpose of this paper is to outline the action taken since Workshop 1 and the next steps.
2. CURRENT POSITION
We will be launching Year 2 of our Tameside Hospital Patient Safety Programme on the 1st
April 2015 under the banner of: ‘Signed up to Safety – It’s no Joke!’
Coordinated as a Trust wide event; with partner organisations joining us, we will be working
with Clinical and Corporate teams to understand how they can further develop their
measurement and monitoring of Patient Safety aligned to the Measurement and Monitoring
of Safety Framework as shown in Appendix 1. Haelo will be joining us.
A baseline assessment has been carried out and focus groups with key stakeholders have
informed our current position. It was reassuring to note that the work we have taken as part
of our improvement programme had adopted many of the principles and measures identified
in the programme. The baseline assessment has identified our position against Learning
from Past Harms and has identified areas of measurement where reliability could be further
explored in order to adopt a more predictive and integrated approach to potential harm and
safety sensitivities. This is being coordinated by the Patient Safety Programme Board and is
overseen by the Quality and Governance Committee.
Further work is scheduled with the CCG, Social Care, Primary Care and other Providers to
ascertain how work could be enhanced against specific work streams. Falls and Pressure
Care are an initial focus as agreed at the Haelo event by the Tameside contingent. We are
undertaking PDSA’s of new approaches to past harm and reliability.
Our Patient Safety Programme continues to be an overarching enabler for the Trust. Our aim
is to keep our patients safe and reduce harm using the Tameside Patient Safety Programme.
Overall Lead: Mr Brendan Ryan, Medical Director
Executive Nursing Lead: Mr John Goodenough, Director of Nursing
Programme Lead: Mr Peter Weller, Director of Quality & Governance
Patient Safety Lead Nurse: Amanda Dooley, Head of Patient Safety & Risk Management
Page 2 of 4
Our Priorities for Safety Improvement are :
Reducing harm through:









Pressure Ulcer Prevention
Earlier Recognition of the deteriorating patient and the management of the acutely
unwell (including improved communication and handover)
Reduction in the Number of falls and falls with injury
Improved nutritional care and hydration
Reduction in harm from Venous Thrombosis
Reducing harm from high risk medicines and providing safe and effective medicines
management
Improving peri-operative outcomes through safer surgery
Infection Prevention
Maternity Governance
Results Governance
3. Haelo Next Steps
We will progress the Haelo programme by hosting a site visit by a partner Trust and CCG
site visit. This will be attended by an expert faculty member from Haelo and other
organisations to share good practice and challenges. Each visit will require two nonexecutives and two executives as a minimum.
We will attend 2 Trust and CCG site visits hosted by another member of the collaborative.
Four representatives of the board / CCG governing body are required to attend each visit.
This will be coordinated and communicated to Board members via the Quality and
Governance Unit.
We will deliver our plan for measuring and monitoring safety across the health economy
linked to our Signed up to Safety plans
Haelo also offer the opportunity to undertake a board to board executive coaching session
which is being explored
Learning Session 2 is the 6-7th May 2015
4. Recommendations
The Trust Board are requested to receive this update and note the Trust’s commitment and
action in response to the Haelo initiative. The Board is asked to note the launch of Year 2 of
the Tameside Patient Safety Programme and our Trust plans to further improve the
measurement and monitoring of patient safety
Page 3 of 4
APPENDIX 1
Page 4 of 4
Agenda Item
7d
Title
Draft Revenue and Capital budgets 2015/16
Claire Yarwood, Director of Finance
Author (s)
Jeremy Cook , Interim Operational Director of
Finance
Purpose
To update the Trust Board on the draft revenue and
capital budgets for 2015/16
Finance & Performance Committee
Executive Summary
The draft revenue budgets show a £25.75m deficit and together with a draft capital plan of
£2.7m will require a cash loan of £25m.
5 – Develop a strategic plan to secure
clinical and financial sustainability for the
Trust in conjunction with the Trust’s strategic
partners and key stakeholders
7 – to deliver against local and national
frameworks in order to meet all the
requirements of the Trust’s operating licence
and the commissioners’ requirements.
723 – Failure to meet, deliver the Trust’s
financial plan
requirements
In breach of Licence
None
undertaken?
No
Sustainability?
Sustainability is subject to the outcome of the
system wide review by the CPT
The Board is asked to discuss and approve the draft revenue and capital budgets. Final
budgets will be brought back to the April Board pending conclusion of the contract with T&G
CCG
DRAFT REVENUE AND CAPITAL BUDGET 2015/16
1.
Financial strategy
Introduction
1.1 The Board are required to approve the revenue and capital budgets for the financial year
2015/16.
1.2 The contracting process has been delayed this year due to the national rejection of the
proposed tariff. Therefore signing contracts has been extended from 11 March to 31
March, draft plans from 27 February to 7 April and final plans from 10 April to 14 May.
1.3 The contract with T&G CCG has not yet been agreed. The revenue budgets are therefore
draft at this stage. A revised budget will be taken to the April Trust Board and which will
form the basis of the final annual plan submitted to Monitor on 14 May. This will also
incorporate the final pay awards which were only agreed this week.
Background
1.4 Last year the Trust prepared a 5 year financial plan which was submitted to Monitor which
excluded strategic change.
1.5 In addition an alternative financial plan was prepared, and also submitted to Monitor, which
reflected strategic change by incorporating activity levels based on the Care Together plan
adjusted to include non- complex activity and additional non-elective activity to optimise
the usage of the hospital estate. This also reflected an emergency care integrated model
and in 2017/18 income and expenditure relating to an integrated care organisation.
1.6 The financial plans referred to in 1.4 and 1.5 are summarised in Table 1 below:
Table 1 – 14/15 5 year financial plan
2014/15 2015/16 2016/17 2017/18 2018/19
£m
£m
£m
£m
£m
Monitor plan with no strategic savings
-17.50
Alternative plan including strategic
savings
-17.50
-25.76
-23.96
-23.35
-22.63
-15.47
-11.81
4.06
6.26
1.7 The alternative plan including strategic savings assumed £10m of strategic support in
2017/18 and £5m in 2018/19 which left a small underlying surplus by year 5 of the plan.
Principle objectives
1.8 Within the corporate objectives set for 2015/16, and going forward, the Trust is aiming to
develop a strategic service plan that will secure clinical and financial sustainability for the
Trust in conjunction with the Trust’s strategic partners and key stakeholders.
1.9 This has seen the appointment by Monitor of Price Waterhouse Coopers as the
Contingency Planning Team in November 2014 to support the development of this
strategy. This work is ongoing and is not due to report until July 2015.
1.10 The financial plan for 2015/16 (£25.75m deficit)reflects a similar position to that shown in
year 2 of the 2014/15 Monitor plan with no strategic savings as it is not believed at this
Page | 1
point that any material changes will take place in 2015/16 (£25.76m deficit as shown in the
table above).
2014/15 projected outturn
1.11 The original plan for 2014/15 assumed a deficit of £17.5m. During October the Trust
reforecast the deficit to £21.03m due to an under performance on activity especially on
elective activity , higher than expected nursing costs and the continuation of contract staff
to manage the Lorenzo implementation. This revised forecast was approved by Monitor as
a revised in year plan.
1.12 Based on the Month 10 results for January the Trust submitted a revised forecast to
Monitor of £19m. This was based on additional winter resilience funding, an increase in the
underlying activity and income including additional elective activity to achieve Referral to
Treatment (RTT) targets that were included within the year end settlement with Tameside
& Glossop CCG.
1.13 The forecast has improved by a further £0.8m to £18.2m in February (Month 11). This is
due to the following:
 A further review of accruals and provisions
 A benefit in moving to the new funding arrangements from Public Dividend Capital
(PDC) attracting interest at 3.5% to a loan which will only attract interest at 1.5% for 9
days in 2014/15.
1.14 The budget setting process was based on the forecast outturn of £18.8m. The change to
the current forecast of £18.2m is due to recurrent movements and this benefit has been
utilised within the 2015/16 budgets to reduce the FYE of the 14/15 CIP’s to £5.5m. In
addition £0.2m of contingency reserve has been utilised to reduce the FYE CIP to £5.3m
which is the value forecast at Month 11. This has therefore reduced the risk of unidentified
full year effect CIP’s impacting on the 2015/16 budgets.
2.
Activity plan
2.1 The activity plans for 2015/16 have been arrived at by taking forecast outturn for 2014/15
based on Month 7 activity extrapolated for non- emergency non elective and outpatients,
day case, elective and outpatients. A 12 month rolling average at Month 7 has been used
for emergency activity to reflect seasonal variations.
2.2 Activity for non T&G CCG commissioners reflects forecast outturn only. Activity for T&G
CCG reflects agreed service changes which are analysed in Table 3 below and which
include the new Stroke pathway and incorporation of the Orthopaedics business case. In
addition the plan reflects the impact of demographic growth and CCG QIPP including the
impact of the better care fund.
2.3 The overall high level activity plans for 2015/16 are shown in Table 2 below:
Page | 2
Table 2 – Activity plan 2015/16
Total Cardiac Cross Non
Forecast Demographic Service QIPP/ Activity
SLA's rehab border contract Overseas Specialist outturn 14/15 Growth develop'ts BCF plan 15/16
Elective
3,505
Elective Excess Beddays
1,142
Non Elective
24,040
Non Elective Excess Beddays
23,166
OP
222,464
A&E
80,534
PBR excluded drugs & devices
8,014
Other
1,087,828
Daycase
17,029
Grand Total
1,467,720
Analysis of other
Ambulatory Care
Audiology
Cardiac Rehab Contract
Chemotherapy
Critical Care
Direct Access
Other
Telephone Contacts
Unbundled Diagnostics
Grand Total
0
0
0
0
0
0
0
1,027
0
1,027
0
0
38
211
51
0
2
12
0
315
22
55
305
133
1,344
1,704
34
413
111
4,122
0
72
0
0
14
234
4
197
31 10,795
21
0
0 2,462
0 5,966
2 1,385
72 21,111
3,599
1,197
24,631
23,711
234,685
82,259
10,512
1,095,247
18,527
1,494,366
25
17
728
708
2,508
2,411
0
37,719
195
44,311
66
0
0
0
5,133
0
0
0
322
5,521
0
3,690
0
1,214
-536 24,823
-1,029 23,390
-824 241,502
-1,986 82,684
0 10,512
0 1,132,966
0 19,044
-4,375 1,539,823
Total Cardiac Cross Non
Forecast Demographic Capacity QIPP/ Activity
SLA's rehab border contract Overseas Specialist outturn 14/15 Growth specific BCF plan 15/16
3,696
0
2
41
0
0
3,739
118
0
0
3,857
19,649
0
0
10
0
0
19,659
652
0
0 20,311
0 1,027
0
0
0
0
1,027
0
0
0
1,027
0
0
0
0
0
78
78
0
0
0
78
3,701
0
2
44
0 5,320
9,067
123
0
0
9,190
1,021,776
0
2
77
0
0 1,021,854
35,659
0
0 1,057,513
7,029
0
0
66
0
568
7,663
187
0
0
7,850
2,493
0
0
17
0
0
2,510
48
0
0
2,558
29,486
0
7
158
0
0
29,650
932
0
0 30,582
1,087,828 1,027
12
413
0 5,966 1,095,247
37,719
0
0 1,132,966
2.4 Planned activity movements for 2015/16 all relate to T&G CCG. All other SLA’s are
planned at 2014/15 outturn.
2.5 A bridge between the 2014/15 forecast outturn and the 2015/16 plan for T&G CCG is set
out in Table 3 below:
Page | 3
Table 3 – T&G CCG Activity Bridge 2014/15 to 2015/16
Remove Add new
2014/15 Demographic Non
current stroke Service Maternity Local
SSIU Lorenzo
outurn growth recurrent Stroke model model develop's adjustment prices adjustment changes
Emergency
Non elective
Ambulatory care
Non elective same day
Non elective short stay
Non elective excesss bed days
16,929
3,377
922
1,298
20,801
43,327
583
118
34
58
698
1,493
0
0
0
0
0
0
-317
0
0
-115
-2,013
-2,446
113
0
0
0
0
113
0
0
0
0
0
0
3,106
2,556
411
2,217
8,290
109
53
10
78
249
0
0
0
0
0
0
-28
-43
0
-71
0
288
1,480
0
1,768
0
0
0
0
0
-477
0
0
0
-477
15,095
2,971
1,051
19,117
195
25
17
238
0
0
0
0
-14
-14
0
-28
0
0
0
0
322
66
0
388
Outpatients
Diagnostic imaging
26,618
Outpatient first appointment
59,275
Outopatient follow up procedure 111,497
Outpatient procedure
17,959
Telephone consultation
2,151
Year of care payment
108
217,608
932
797
1,527
179
48
4
3,486
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2,411
0
652
35,659
123
38,845
0
179
0
0
0
179
0
0
0
0
0
0
0
0
0
0
0
0
Non Emergency
Antenatal
Non elective
Non elective excess bed days
Postnatal
Elective
Day case
Elective
Elective excess bed days
Other
Accident & Emergrncy
Adhoc
Audiology
Direct access
Critical care
71,156
9,174
18,638
1,018,818
3,507
1,121,293
0
0
0
0
0
0
0
0
0 -1,842
0 -1,842
CCG QIPP
Stroke
Activity
LoS Cardiology plan 15/16
BCF
772
0
0
0
0
772
21
0
1
0
211
233
-467
0
0
0
-26
0
-44
0
0 -1,029
-536 -1,029
0
0
0
0
0
0
17,635
3,495
931
1,197
16,826
40,085
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-7
0
0
-7
0
0
0
0
0
0
0
0
0
0
2,738
2,863
1,858
2,294
9,753
0
0
0
0
0
0
0
0
0
0
0
0
-518
0
0
-518
0
0
0
0
0
0
0
0
0
0
0
0
15,081
3,049
1,068
19,197
0
4,678
455
0
0
0
5,133
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
518
0
0
519
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 27,551
-540 64,211
0 113,480
-284 18,371
0 2,199
0
112
-824 225,923
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 -1,986
0
0
0
0
0
0
1
0
1 -1,986
0
0
0
0
0
0
0 71,581
0 9,353
0 19,290
0 1,054,477
0 3,631
0 1,158,332
2.6 The summary financial plan which delivers this planned level of activity is explained in
Section 3 below.
Page | 4
3.
Summary financial plan
3.1 The financial plans for 2015/16 show a deficit of £25.75m after the delivery of a CIP plan of
£6.1m and generating a continuity of services risk rating (CoSRR) of 1. Additional cash
support of £25m will be sought from Monitor/DoH during 2015/6 which will be drawn down
to allow the Trust to hold at each month end two days operating expenditure based on the
13/14 accounts (circa £0.9m).
3.2 The summary financial plan for 2015/16 is shown in Table 4 below:
Table 4 – Summary financial plan
15/16 plan
£'000
Income
Clinical income
142,710
Non NHS clinical income
903
Non clinical income
9,893
153,506
Operating expenses
Employee expenses
Non pay expenses
CIP 15/16
EBITDA
Finance costs
Depreciation and amortisation
Finance income
Interest expense
PDC expense
Other finance costs
Loss for the year
3.3
14/15 forecast
£'000
142,990
934
10,435
154,359
119,097
56,552
-6,100
169,549
-16,043
112,024
52,443
0
164,467
-10.5%
-10,108
-5,226
25
-3,215
-1,274
-19
-9,709
-4,730
25
-3,235
-958
-19
-8,917
-25,752
-19,025
-6.5%
The bridge between the 2014/15 forecast deficit of £18,229k and the 2015/16 deficit of
£25,752k is shown in Table 5 below. In addition the bridge for year 2 of the 14/15 plan is
shown for comparison purposes:
Page | 5
Table 5 – Bridge from forecast outturn
15/16 plan
£'000
-18,229
15/16 per
14/15 plan
£'000
-17,500
Non recurrent income
Non recurrent expenditure
Non recurrent CIP
Full year effect CIP
Underlying deficit
-3,514
4,344
-1,953
1,766
-17,586
0
0
0
0
-17,500
Vacant posts
Full year effect of new posts 14/15
Reinstate non pay underspends
Contract changes
Baseline budgets
-2,312
-686
-1,022
1,046
-20,560
0
0
0
0
-17,500
-798
-1,252
-702
-2,752
-3,800
-760
-1,540
-6,100
6,100
6,100
-2,996
-4,600
-7,596
-2,500
-3,432
-5,932
2,628
-1,460
-1,168
0
2,720
-5,100
50
-2,330
-1,143
0
1,200
-1,000
200
0
0
0
-25,751
-25,762
Planned deficit 14/15
Cost Inflation and tariff deflation
Pay inflation
Non pay inflation
Tariff deflation
Cost improvement plans
Cost pressures
CNST
Other cost pressures
Clinical income
Demographic growth
CCG QIPP
Net cost movement associated with the above
Contingency
Non recurrent
Income - transitional support T&G CCG
Expenditure - Project support
Forecast deficit
Page | 6
3.4 The Trust changed its budget setting approach for 2015/16 by rebasing the budgets based
on recurrent forecast outturn. A budget book will be prepared on finalisation of the budgets
in April following conclusion of the contract negotiations. Draft budgets have been signed
off by budget holders and the lead Executive Directors. The new budget setting process
can be explained by going through the component elements of the bridge:
Underlying deficit
3.5 The underlying deficit of £17.6m was arrived at as follows:
 Forecast outturn
 Adjust for non-recurrent income (adverse)
 Adjust for non-recurrent expenditure (favourable)
 Adjust for non-recurrent CIP (adverse)
 Adjust for the full year effect of CIP’s (favourable)
Baseline budgets
3.6 The baseline budgets of £20.56m were arrived at by adding the following to the underlying
deficit:
 Substantive posts which have been vacant for the whole or part of the year and
are not reflected within the forecast outturn.
 The full year effect of new posts which have been recruited to in 2014/15.
 Reinstate any approved non-pay underspends. These are largely to do with
maintaining the utilities budgets at their historic level, due to the uncertainty
over the winter weather, and retaining budgets at their historic level where they
are linked to a business case or CIP initiative.
 Incorporates contract changes which are primarily the orthopaedic business
case.
3.7 As the above process was not considered during the 2014/15 financial plan this explains
why the baseline budget and forecast outturn were both £17.5m for 2015/16 within the
2014/15 plan.
Cost inflation and deflation
Pay inflation
3.8 The pay awards, superannuation increase and incremental drift have been calculated
using staff in post and in accordance with the estimated pay uplifts. This also includes
£150k for additional discretionary points for medical staff.
3.9 Pay inflation is significantly less than the 2014/15plan as at that time it was anticipated that
there was going to be a significant increase in employer’s superannuation of 4%.
Non pay inflation
3.10 Non pay budgets have been uplifted by 1.9% or £760k which is in line with Monitor
guidance.
3.11 Drug budgets have been uplifted by £150k for new NICE approved drugs.
3.12 Inflation on the PFI contract has been calculated in accordance with the contract (£342k).
3.13 Non pay inflation is higher than that shown in the 2014/15 plan as £632k of drug and PFI
inflation were included within other cost pressures.
Page | 7
Tariff deflation
3.14 The original tariff deflator for 2015/16 was 1.9%. However as the additional cost of CNST
was not appropriately reflected within the price inflation the tariffs were amended which
reduced the deflator by 1.1% to 0.8%. As a result of the tariff being rejected two options
were proposed the Enhanced Tariff Option and the Default Tariff Rollover. The Trust opted
for the Enhanced Tariff Option which resulted in a 0.3% reduction in the tariff deflator
bringing the deflator down to 0.5% which is reflected within the plan.
3.15 The deflator used for 2015/16 in the 2014/15 plan was 1%.
Cost pressures
CNST
3.16
The cost pressure for CNST is £2,996k and is based on the notification of premium by
the NHS Litigation Authority. The significant increase in premium is due to a change in
the basis of setting the premium which is now a weighted average of 3 elements:
 A risk based contribution based on size and activity levels.
 A contribution based on paid claims over 5 years to 31 March 2014.
 A contribution based on known outstanding claims as at 31 March 2014.
3.17 Nationally the uplift in the CNST premium for 2015/16 is 35%. The Trusts increase in
contribution to £8,936k represents an increase of 55% or 39% excluding the £663k
transitional benefit in 2014/15.
Other cost pressures
3.18 An updated business planning process is in the process of implementation which will result
in any gross cost/service pressure, service development going through the following
process:
 <£10k – authorised by the Director of Finance
 £10k - £50k – mini business case authorised by the Executive Team
 >£50k – business case approved by the Executive Team
3.19 The cost pressures have therefore been put into budgets or reserves based on the above
criteria and is shown in Table 6 below:
Table 6 – Analysis of other cost pressures
To budgets
Miscellaneous items < £10k
Vacancy approved
Business case approved
Revaluation of estate at 9%
To reserves
Mini business case required £10k - £50k
Busines case required >£50k
Total
£'000
64
158
106
560
888
569
3,143
3,712
4,600
Page | 8
3.20 The detailed list of proposals, which have been put forward by the divisions, and is
included within the £3,712k within reserves includes the following:
 Patient quality related developments including compliance with NICE
guidelines on Nursing and external recommendations by Keogh, CQC or the
Deanery.
 Service pressures relating to demand.
 The cost of provide an absence management service to all employees within
the Trust.
 A business case to provide a private ambulance service as the service
specification of the CCG commissioned contract, as provided to the Trust, is
not responsive enough.
 The managed service contract for the endoscopy service.
Income
3.21 The Bridge between the 20134/15 forecast outturn and the 2015/16 budget is shown in
Table 7 below:
Table 7 – Income bridge 2014/15 to 2015/16
Forecast Non recurrent Non recurrent
outturn 14/15
income
CIP
£'000
£'000
£'000
Clinical income
Non NHS clinical income
Non clinical income
142,990
934
10,435
154,359
-3,061
-1
-502
-3,564
-57
-1
-131
-189
FYE
CIP
£'000
0
0
36
36
Contract Demographic/
Other
adjustments
QIPP
adjustments
£'000
£'000
£'000
1,212
-29
-6
1,177
1,168
0
0
1,168
458
0
61
519
Budget
15/16
£'000
142,710
903
9,893
153,506
3.22 Non recurrent income includes resilience funding, funding for the RTT validation team plus
the bonus payment and CCG transitional funding.
3.23 Contract adjustments include the incorporation of the Orthopaedic business case for 3
additional orthopaedic consultants to address capacity issues.
3.24 Demographic growth is £2,628k offset by QIPP of £1,460k which includes Better Care
Fund £1,090k which represents a 2.7% reduction in Emergency Admissions and A&E
attendance plus QIPP of £370k for reduced length of stay in Stroke and the Cardiology
diagnostic scheme.
3.25 Other adjustments reflect the tariff deflator at 0.5% offset by CCG transitional support.
3.26 The contract with T&G CCG has not been agreed. Any updates will be reflected in the
revised budget taken to the April Trust Board.
Commissioning for Quality and Innovation (’CQUIN’)
3.27 Income of £3m is included within the income budgets for achieving a range of national,
regional and local quality initiatives. The schemes have recently been agreed but will be
subject to finalising the value which is dependent on finalising the contracts.
3.28 The income assumption is that the Trust achieves 97% of the CQUIN target similar to
2014/15.
Marginal rate tariff
3.29 The Trust did not suffer the 30% marginal rate tariff in 2014/15 as the threshold was
rebased on 2013/14 outturn. This gave the Trust headroom of £3.3m before the marginal
Page | 9
rate would be applied. No application of the marginal rate was applied in 2014/15. As the
Trust has opted for the Enhanced Tariff any marginal rate that would apply in 2015/16
would be at 70%.
Readmissions
3.30 Similar to 2014/15 the readmissions penalty has been set at £2.2m of which 50% (£1.1m)
has been re-invested with the Trust.
Penalties
3.31 The budget includes an assumption for penalties of £1.1m. The T&G CCG financial plan
does not include any income assumption from penalties and therefore there is an
opportunity to discuss whether any penalties levied under the contract can be reinvested
with the Trust.
Contingency
3.32 The financial plan for 2015/16 has a contingency of £1,143k which is made up, of a
contingency of £2,143k offset by an anticipated reduction in cost pressures and
uncommitted costs of £1m. Until this has been identified this will sit against the
contingency reserve.
Non recurrent
3.33 The financial plans for 2015/16 are predicated on £1.2m of non-recurrent transitional
support being made available by T&G CCG. This is still under discussion.
3.34 A sum of £1m has been included in the plan for non-recurrent project support for
supporting the delivery of cost improvement plans, service redesign and supporting
strategic initiatives around integration.
4. Cost Improvement Plans
4.1 A summary of the cost improvement plans is set out in Table 8 below:
Table 8 – Summary of CIP plan
Recurrent
£'000
Non
recurrent
£'000
Pay
2,511
305
2,816
2,725
Non pay
Drugs
Clinical supplies
Non clinical supplies
Other non pay
Total non pay
300
647
239
257
1,443
0
187
0
558
745
300
834
239
815
2,188
300
757
241
210
1,508
Income
1,096
0
1,096
1,867
Total
5,050
1,050
6,100
6,100
Total
£'000
FYE
£'000
Page | 10
4.2
4.3
4.4
Of the expenditure CIP’s of £5m (£4.3m FYE) detailed plans exist for £3m (£3.2m FYE)
with outline plans for £2m (£1.1m FYE). Work is ongoing to prepare detailed plans for all
schemes.
Quality impact assessments are currently being prepared and will be signed off by the
Medical Director and Director of Nursing and then discussed with T&G CCG.
Income CIP’s include new SLA’s currently under discussion, better achievement of best
practice tariffs within the elective Division and the Medicine and Urgent Care division and a
small amount for coding changes.
5. Asset values and capital charges
5.1 The movement in fixed assets is shown in Table 9 below:
Table 9 – Analysis of movement in fixed assets
Property plant and equipment
Property plant and equipment - PFI
5.2
Forecast NBV
31/03/2015
£'000
74,205
39,185
113,390
Additions
£'000
2,727
Depreciation
£'000
-4,295
-931
-5,226
2,727
Closing NBV
31/03/2016
£'000
72,637
38,254
110,891
A 9% uplift was reflected in the asset value with effect from 31 March 2015 (£8.8m). This
has had an impact of increasing the depreciation by £243k and PDC by £316k. This has
still to be confirmed by the district valuer.
6. Monitor Continuity of Services Risk Rating
6.1
As set out in the risk assessment Framework Monitor has the statutory role to ensure the
continued provision of key NHS services. In considering the level of risk to the continued
provision of those services, financial plans are assessed against the Continuity of Services
(CoSRR) rating. This rating incorporates two measures of financial robustness:

6.2
Liquidity – this measure considers the Ability of the Trust to cover its day to day
operating expenditure commitments.
 Capital servicing – this measure considers the ability of the Trust to cover off its
financing obligations for example interest payable on loans and leases and PDC.
There are four rating categories from 1 (highest risk) to 4 (lowest risk). Table 9 below
shows the history of the risk rating including the rating for 2015/16 based on the planned
budget.
Table 9 – History of Continuity of Service Risk rating
Actual
12/13
Capital servicing cover metric
Capital service cover rating
Liquidity metric
Liquidity rating
Continuituy of service rating
Actual
13/14
Forecast Budget
14/15
15/16
1.77
3
1.16
1
-1.39
1
-2.09
1
-23.12
1
-26.72
1
-33.39
1
-32.5
1
2
1
1
1
Page | 11
6.3 Overall the Trust will remain a 1 with a deteriorating metric on capital servicing and a slight
improvement on the liquidity metric.
7. Key risks and mitigation – revenue plan
POTENTIAL RISK/IMPACT
1. Failure to achieve the recurrent
CIP target of £6.1m and in
particular £2m of schemes (FYE
£1.1m) for which only outline
plans are in place.
MITIGATION
Risk
The Trust has asked the divisions to plan for a
contingency of 20% of their annual CIP plan in
order to provide contingency against any 12
slippage.
The Trust has a number of additional CIP
schemes that are not currently reflected within
the plan. These schemes require to be worked
up at the earliest opportunity to either provide
resilience against slippage contribute towards
the 2016/17 CIP plan.
2.
In addition income schemes
include an assumption of clinical
income CIP’s of £854k which Ongoing review of action plans to:
includes achievement of best
 increase achievement of best practice
practice tariffs and improved
tariffs
coding
 review of coding processes and
procedures to ensure all activity is being
counted and tis being charged at the
appropriate tariff. Track coding changes
to ensure any improvement in income
associated with coding is taken as CIP
Overspends
on
delegated Budgets have been rebased to recurrent
budgets and in particular on forecast outturn which should mitigate against
nursing and medical budgets overspends.
through appointing agency staff
to fill vacancies not able to fill The new business case process whereby
through bank or locum.
business cases will be discussed and approved
by the Executive team will provide greater
In
addition
if
increased controls over commitments against new spend. 12
investment in nurse staffing is
filled through agency there will A review will be undertaken of the current
be an agency premium that is controls over agency staff and where nurse
not budgeted for.
staffing levels are set above the agreed rota
with a view to further strengthening controls.
A control has been implemented to ensure that
no bank or agency budget can be converted to
a substantive post(s) without approval by the
Director of Finance. This will mitigate the risk
whereby the newly created substantive posts
cannot be recruited to and are subsequently
filled by agency staff at premium rates.
3.
The budgets have assumed a Quantification of the likely level of penalties to
level of penalties of £1.1 and identify whether there is likely to be any risk
Page | 12
9
that CQUIN achievement is 97% above that budgeted for.
(the same as 14/15)
There is a detailed contract risk schedule with
mitigating actions that can be monitored.
As the CCG has not planned for receiving
penalties there is the opportunity to discuss
whether there is the opportunity to reinvest the
penalties
4.
5
6
7
8
Under-performance of contract
activity as a result of:
 Patient choice
 Success of investment
in primary and social
care
 Inability to deliver the
Orthopaedic
business
case as the consultants
has not yet been
appointed.
 Ward unavailability due
to infection control
 Capacity to clear the
RTT backlog
That the recommendations from
an external review or new
guidance will place an additional
cost pressure into the system
that is not budgeted for.
Resilience funding may only be
restricted to the first Tranche
that was received in 14/15 and
now built into CCG baselines
(£820k) and not the 2nd Tranche
£955k. This could result in either
a financial or operational
pressure or both.
The contract has not yet been
agreed with the CCG. As a
result there are a number of
risks which are not yet resolved.
The Trust requires a cash loan
of £25m in 2015/16 which has
not yet been agreed.
Regular monitoring of contract activity against 9
plan and developing action plans to address
any variances from plan.
The financial plan includes the expenditure
budgets associated with the Orthopaedic
business case and therefore the risk is the £80k
included within the CIP plan.
All known issues have been reflected as a
potential cost pressure and included within the 9
financial plan.
The CCG have a total resilience budget of
£1.6m which will be monitored through the 6
System Resilience Group. The Trust will need
to put forward a strong case to secure the
funding it needs to ensure resilience and deliver
the key performance targets.
Discussions are ongoing to ensure contracts 6
can be agreed by the 31 March deadline
Board resolutions have been signed to allow the
Trust to sign up to a loan and access a working
capital facility.
6
Page | 13
8. Capital plan
8.1 The Trust plans to minimise its capital expenditure below the level of internally generated
funds in order to improve liquidity as much as possible while maintaining a safe estate.
The planned capital expenditure for 2015/16 is £2,727k which compares to depreciation of
£5,226k.
8.2 The Trust was required to submit a 5 year capital plan to the DoH in January 2015. The
plan was co-ordinated through the Capital Planning & Estates Committee who reviews the
prioritisation of bids for capital funds.
8.3 The proposed 5 year capital plan which has a £2.7m capital spend in 2015/16 and £2.6m
in each of years 2 to 5 together with the funding requested is shown in Table 10 below:
Table 10 – Proposed capital v requested capital
2015/16 2016/17 2017/18 2018/19 2019/20
£'000
£'000
£'000
£'000
£'000
Estates
Requested
Proposed
Condition and statutory
Requested
Proposed
IM&T
Requested
Proposed
Medical equipment
Requested
Proposed
Total
Requested
Proposed
Total
£'000
1,111
1,111
500
500
400
400
189
180
600
600
2,800
2,791
555
425
345
450
400
400
520
520
470
445
2,290
2,240
1,354
548
3,350
836
1,800
834
1,330
800
876
1,000
8,710
4,018
843
643
1,139
814
1,016
966
949
1,100
1,606
555
5,553
4,078
3,863
2,727
5,334
2,600
3,616
2,600
2,988
2,600
3,552
2,600
19,353
13,127
9. Key risks and mitigation – capital plan
POTENTIAL RISK/IMPACT
1.
That the bid for IM&T for
2015/16 was £806k greater
than the capital allocated
including £607k amber risks
MITIGATION
If there was an unavoidable capital pressure on IM&T
then the following options would need to be looked at
 Reviewing priorities
 Slipping the timescale of some schemes
 Increasing the capital plan
2.
The capital plan has been risk assessed by category
and also between categories so this should have
mitigated against this risk.
That an unexpected capital
request is needed which is not
on the capital plan
Risk
6
6
If there was an unavoidable capital pressure on IM&T
then the following options would need to be looked at
 Reviewing priorities
 Slipping the timescale of some schemes
 Increasing the capital plan
Page | 14
3.
That there is slippage in the
capital plan
Re-forecasting capital spend requires to be undertaken
on a regular basis.
6
Alternative schemes require to be identified to absorb
any slippage by bringing forward schemes from next
year or rephrasing the plan
10. Cash flow
10.1 In order to fund a deficit of £25.75m and a capital plan of £2.7m cash of £25m will be
required.
10.2 Whereas this has previously been funded through PDC the new arrangements will require
the Trust to fund this through a loan. Repayment of the loan in whole, part or not at all will
be on a case by case basis with reference to ‘ability to pay’ and on submission of a
business case following the outcome of the CPT work. This will require to be submitted
within 5 years or 4 years in order to avoid the loan being shown as a current liability.
11. Summary
11.1 A new budget setting process has been adopted in 2015/16 which uses recurrent forecast
outturn, adjusted for vacancies and protected non pay budgets, and the full year effect of
new posts recruited to in 2014/15 to set baseline budgets.
11.2 The contract with T&G CCG has not yet been concluded therefore the budgets are draft
and will be finalised for the April Trust Board.
11.3 The proposed draft revenue budget shows a deficit of £25.75m for 2015/16 after delivery
of £6.1m of CIP’s.
11.4 The key risks to achieving the budget deficit is achievement of the £6.1m CIP target and
overspends on delegated budgets.
11.5 The proposed draft capital plan is for a capital spend of £2.7m
11.6 The Monitor Continuity of Service Risk rating is 1
12. Recommendation
12.1 The Board is asked to discuss and approve the draft revenue and capital budgets for
2015/16. Final budgets will be brought to the April Board pending conclusion of the
contract with T&G CCG.
Page | 15
Agenda Item
Title
Author (s)
Purpose
8a
Improvement Update
Karen James
Peter Weller – Director of Quality and Governance
Angela Brierley – Head of Service Transformation
John Fletcher – Head of Assurance and Governance
To note/receive
Elements of this paper have been considered by the
following groups, in line with agreed governance:
 Performance and Service Improvement Group
 Operational Board
 Service Quality and Operational Governance
group
 Quality and Governance Committee
Executive Summary
The Board receives a monthly report detailing progress of all actions detailed in the Revised
Improvement Central Action Plan (RICAP). Historic actions are reported through the Board
Assurance Framework and Significant Risk Report.
In line with the improvement plan the actions have been implemented by December 2014.
The Trust will now focus on ensuring that change is embedded by monitoring trends in Key
Performance Indicators and gathering evidence of change to provide assurance.
Impacts on all Objectives
requirements
The Trust is currently in Special Measures.
Delivery of the actions within the RICAP, as
assess by the Chief Inspector of Hospitals
will be central to the regulators decision on
Rating of Services
£6.027m is included in the 2014/15 plan for
this Keogh.
undertaken?
Quality Impact Assessments will be
undertaken within each individual work
stream that feeds into the Improvement
Report
Sustainability?
This report is central to sustainability
The Board is asked to ratify the assurance submitted to confirm the improvement actions
have been delivered.
Page 1 of 23
Tameside Hospital NHS Foundation Trust
1.
Background
The RICAP (Revised Central Improvement Action Plan) was presented to the Board in
August 2014. The RICAP has been created to allow the Trust to articulate the Improvement
Strategy, in response to the reviews listed below, and to align business to that strategy.

CQC Chief Inspector of Hospital’s Inspection “Must & Should Do
recommendations”. May 2014

Post Graduate Education Monitoring Visit (Deanery). May 2014

Emergency Care Intensive Support Team Review. June 2014

Breast Review. June 2014

Cardiology Peer Review. September 2014
To ensure that improvements are sustained, actions from the historic action plan (ICAP)
have been mapped to the RICAP where appropriate and all have been mapped to the Board
Assurance Framework and Risk Registers, to allow assurance through the Significant Risk
Report.
2. Reporting
Appendix 1 contains the current version of the RICAP.
The Trust has been working since early summer 2014 to deliver the actions outlined in the
RICAP and embed improvement. Delivery against RICAP timescales are rated using
Monitor’s Blue, Green, Amber & Red (BRAG rating system)
3. Delivery of actions
Actions are BRAG rated in line with Monitor guidance. Movement between the BRAG
colours is based delivery against timescale.
Page 2 of 23
Current performance:
Delivered and fully embedded
Blue
54
On Track to deliver
Green
11
Some issues – narrative disclosure
Amber
0
Not on track to deliver
Red
0
Total
65
The total number of actions has reduced by 1, as action 1.25 has been removed. This was a
duplicate of 1.24 and in previous versions 1.21 from when the action plan was generated.
4. Exception Reporting
4.1 Movements and changes since last reporting period
Green to Blue
CQC Actions 1.1, 1.4, 1.7, 1.11, 1.12, 1.13, 1.15, 1.17, 1.18, 1.19, 1.20,
1.21, 1.22, 1.23, 1.24
Green to Blue
Critical care Actions 2.1, 2.2, 2.5
Green to Blue
Patient flow Actions 3.1, 3.2
Green to Blue
Cardiology Actions 6.1, 6.2, 6.3, 6.4
Green to Blue
Deanery Actions 7.1, 7.2, 7.4, 7.5, 7.6, 7.8.
Details of the rationale presented in the tables below.
Page 3 of 23
CQC Recommendations
RICAP Ref
Source
Detail
Current Delivery Date
1.1
CQC
Ensure there are at all times, enough appropriately skilled staff in all areas or Dec-14
on call to meet people's needs.
Current BRAG Rating
Update: Evidence presented to Quality and Governance Committee considered that these actions were systematically monitored through Quality and
Governance Committee and Trust Board. Evidence provided included

















Major review of nursing establishments following Keogh review and CQC recommendation: investment to support front line nursing teams - increases
to Bands 2 – Band 6 staffing.
Additional investment to support additional staffing in view of issues relating to ward environmental layout and patient mix on Elective Unit, Trauma
Unit, Ward 45 and Ward 46.
Increase in supporting specialist nursing & safety infrastructure – VTE Specialist Nurse, Dementia & Frail Elderly Specialist nurse.
6-monthly Acuity & Dependency Review undertaken:
Acts as a ‘sense check’ to assess whether current staffing levels are adequate and appropriate.
Triangulated against Nurse Sensitive Indicators and professional judgement.
Report to Trust Board
Increase to staff numbers and skill mix in A&E. Investment following a review and remodelling of the Healthcare Assistant role in A&E.
Gap Analysis undertaken against ‘Hard Truth’s’ commitments and Action plan to meet requirements.
Commenced monthly reporting of ‘Planned’ v ‘Actual’ staffing levels
Reported publically via NHS Choices and Trust public website
Monthly Board reporting commenced of staffing levels
Public display of Planned & Actual staffing at ward level
Escalation process for staffing concerns revised and re-launched
Gap analysis undertaken against NICE guidance and action planning commenced to meet guidance standards. Reported to Trust Board.
Additional Ward Clerk support provided on the wards at weekends to nursing teams with additional admin & clerical support.
Business case developed to meet NICE guidance re: Nurse: Patient ratios: investment agreed by Board to meet NICE recommendations .
Page 4 of 23
CQC Recommendations
RICAP Ref
Source
Detail
1.4
CQC
Take action to ensure they adequately safeguard patient information.
Dec-14
Current BRAG Rating
Update: Evidence presented to Quality and Governance Committee considered that these actions were systematically monitored through Governance
structures and the meeting..









Implementation of Confidentiality and Disclosure of Information policy and Information security policies
Robust recruitment and selection processes implemented
Systems access policies implemented at a system level with role based access and user authentication for issue of SMART card access
IG training part of Induction and Mandatory training requirement.
IG training reported through Monthly dashboard circulated to managers
Baseline audit and review of all white board content and locations and information handling of these
Unannounced walk round reviewed the security of Patient information and reported no issues identified
Systematic Incident reporting of patient information breaches of confidentiality and monitoring to ensure these are discussed and learning evidenced in
the divisions.
Third party review and walkround as part of the MIAA audit on Information Governance
RICAP Ref
Source
Detail
1.7
CQC
Take action to ensure that suitable infection prevention and control measures
are in place, to reduce the number of surgical site infections.
Current BRAG Rating
Update: Evidence presented to Quality and Governance Committee considered that these actions were systematically monitored through the meeting, but
was the sum of many parts of the action plan requirements.







Infection control policy suite in place and systematically monitored
Trust Antibiotic formulary
Statutory monitoring of SSI done for a quarter annually and reported through Infection prevention committee to HPA. RCA's undertaken of all SSI's
identified.
Additional surveillance nurse appointed to provide full year surveillance for SSI and continuous monitoring and action to be reported to IPC
Systematic reporting on IPC to IPC committee and through to Patient safety Programme board
Elective division to systematically explore potential for using the Patient Safety First SSI compliance bundle and undertake a gap analysis against this
by the end of September 2014
Infection prevention team have a suite of metrics that are regularly reviewed and reported to Board
Page 5 of 23
CQC Recommendations
RICAP Ref
Source
Detail
1.11
CQC
Ensure they share accurate information in a timely way with patients or people
acting on their behalf.
Dec-14
Current BRAG Rating











Values and behaviours published on Trust website
Admission and Discharge policy in place and implemented which identifies the information provision
Patient Information Service in place.
Patient information leaflets available on the intranet
Everyone Matters philosophy, patient and carers engagement work plan, professional communication standards communicated to all staff
Implementation of Patient, Family and Carer Experience Strategy through Patient Experience group
Bedside folder developed and continuous implementation of values and behaviour work.
Patient Safety Booklet being launched as part of Re launch of Patient safety Programme
Patient Experience group minutes demonstrate evidence of implementation and learning
First Friday Walkrounds provide direct feedback on provision of care and information
Unannounced walk rounds used to triangulate and confirm this.
RICAP Ref
Source
Detail
1.12
CQC
Ensure there are robust systems in place to safeguard staff who handle patient
records against workplace injury.
Dec-14
Current BRAG Rating








Risk Management and Health & Safety programme in place
Mandatory and statutory training in place Training policy and TNA matrix identifies required training an awareness
Systematic monitoring of compliance with training requirements.
Health and safety audit of record storage systems to be undertaken
Review of records storage in the Whitehouse with transformation project implemented
Health records teams have implemented trust standards with regard to Size of casenote volumes to ensure the size is effectively managed Trust
Guidance.
Records management group agreed revised archiving strategy and delivery of current volumes only to wards to minimise handling requirement
Strategy developed to Increase in use of electronic patient records - Scanning of Large volumes commenced
Page 6 of 23
CQC Recommendations



Communication to remind all staff of their obligations in relation to moving and handling and records management
Unannounced walkrounds demonstrating no observed concerns
Systematic monitoring of incident reports and rate for moving and handling issues - demonstrates no increase in from Jan - March 14 baseline
RICAP Ref
Source
Detail
1.13
CQC
Consider how they promote patient engagement methods, such as the
inpatient survey or the Friends and Family Test, in wards or units with low
response rates, such as the day case or endoscopy unit.(linked to 1.24)
Dec-14
Current BRAG Rating
Update: Evidence presented to Quality and Governance Committee considered that these actions were systematically monitored through the meeting, and
that assurance was the sum of many parts of the action plan requirements.










Implementation of Patient, Family and Carer Experience Strategy
Meridian Survey tool in place and systematically rolled out to provide locality and speciality patient experience surveys in addition to the Friends and
family test
Successful Trust JAG accreditation for Endoscopy includes requirement for monitoring and acting on patient feedback
Web based access to survey results on line for ward managers to access
Monthly provision of FFT survey results posters to be displayed in ward areas.
Sample Checklist for January demonstrates this
Results reviewed systematically at Patient Experience Group and Service Quality and Operational Governance Group and Quality and Governance
Committee
Use of Patient experience information in wards and departments and Governance Fora with demonstration of sharing across the division evident in
ward and departmental areas and meetings. This is tested in Service reviews and walkround processes.
Matron for Patient Experience has undertaken a full review of the patient engagement methods used in all services trust wide and report on this
Evidence of Divisional action on findings of patient experience surveys reported through patient stories on Opne and honest publication and shared at
Learning from Experience group.
RICAP Ref
Source
Detail
1.15
CQC
Take action to ensure staff accurately and regularly check equipment such as Dec 14
resuscitation trolleys across all areas of the Trusts building on the good
practice in many areas.
Current BRAG Rating
Page 7 of 23
CQC Recommendations






Resuscitation policy in place and implemented - includes requirement
Ward accreditation programme - includes requirement Monitored through the Wards accreditation reviews systematically
Reviewed as part of senior nurse walk rounds and resuscitation officer monitoring programme.
Systematic monitoring and audit of implementation reported back through Patient Safety Programme reports
Resuscitation trolley monitoring audits are systematically produced by the Resuscitation Officer and presented to the responsible committee and to
Deteriorating Patient work stream
Ward visits and unannounced checks will monitor checking on a periodic testing basis and report on this
RICAP Ref
Source
Detail
1.17
CQC
Ensure that all staff, patients and visitors know how to respond to any allegation of
abuse.
Current BRAG Rating
 Safeguarding policies, system and process in place
 Comprehensive Safeguarding training and monitoring in place and monitored
 Safeguarding Dashboard reported
 Integrated annual safeguarding report produced and reported to Trust Board
 Increase in staff trained in safeguarding awareness in centrally recorded data reported
 Safeguarding web page on intranet to increase in accessibility and availability of information
 increase in DOLS and safeguarding referrals against 2013/14 baseline
 production of weekly dashboard on adult safeguarding to Director of Quality and Governance
 MIAA Audit report providing significant Assurance on safeguarding policy, process and monitoring system.
RICAP Ref
Source
Detail
1.18
CQC
Ensure that staff (particularly in medical care services) have adequate plans in
place to care for people with mental health conditions, including dementia, or
challenging behaviour.
Dec-14
Current BRAG Rating

Safeguarding policies, system and process in place
Page 8 of 23
CQC Recommendations








Comprehensive Safeguarding training and monitoring in place and monitored
Safeguarding Dashboard reported
Integrated annual safeguarding report produced and reported to Trust Board
Increase in staff trained in safeguarding awareness in centrally recorded data reported
Safeguarding web page on intranet to increase in accessibility and availability of information
increase in DOLS and safeguarding referrals against 2013/14 baseline
production of weekly dashboard on adult safeguarding to Director of Quality and Governance
MIAA Audit report providing significant Assurance on safeguarding policy, process and monitoring system.
RICAP Ref
Source
Detail
1.19
CQC
Consider how they support staff to quickly identify clean versus dirty equipment;
particularly in maternity, children's services and medical care services.
Dec-14
Current BRAG Rating





Decontamination policy in place
Infection Prevention and control policies in place monitored and audited
Reviewed as part of senior nurse walk rounds and resuscitation officer monitoring programme.
Ward accreditation standards include compliance with this. Reviews of these standards reported and systematically monitored at SQOGG and Quality
and Governance meetings
Ward visits and unannounced checks will monitor checking on a periodic testing basis and report on this.
RICAP Ref
Source
Detail
1.20
CQC
Take action to ensure that staff promptly assess all patients and ensure their welfare Dec-14
and safety, particularly in A&E. (Linked to Ref 8.4 already blue)
Current BRAG Rating
Update: Evidence presented to Quality and Governance Committee considered that these actions were systematically monitored through the meeting, and
that assurance was the sum of many parts of the action plan requirements.



Monitor and improve the use of the current “Track and Trigger system”- Patient at Risk Score (PARS)
Plan a measured transition to National Early Warning Score system (NEWS)
Using PARs the Trust was compliant with Nice Clinical Guideline 50: Acutely ill patients in hospital. However in order to comply with recommendation
from the Royal Colleague of Physicians and ensure standardisation of the assessment of acute-illness severity in the NHS, the Trust need to move to
the National Early Warning Score (NEWS) track and trigger system.
Page 9 of 23
CQC Recommendations









Multiprofessional working group to facilitate the deployment and management of the NEWS system across the hospital. This group was also
responsible for monitoring and ensuring use and compliance with track and trigger systems. The group has overseen the following:
Trust wide implementation of the NEWS track and trigger system, took place on 1st October 2014.
Trust wide training on management of deteriorating patients and NEWS system
NEWS form & escalation processes redesigned by Multidisciplinary team
Outreach Service policy updated to incorporate NEWS
Enhanced audit tool designed
More in-depth audit approach is being developed.
Monitoring includes triangulation with cardiac arrest calls/incidents/failure to rescue and the ward accreditation scheme.
Demonstrated improvement this has been reported as sustained in Patient Safety Programme Board
RICAP Ref
Source
Detail
1.22
CQC
Ensure that all staff (particularly in medical care services and A&E) receive suitable
structured supervision building on the work already in place.
Dec-14
Current BRAG Rating











See also Deanery HENW recommendations 7.1
Implementation of PDR and Mandatory training policy.
Educational Governance committee to undertake a Trust wide review of Clinical supervision and report with recommendations.
Training needs analysis in place and available on the intranet.
Revised and updated appraisal process.
Monitoring of Training undertaken centrally.
Monitoring information and RAG rated dashboard monitored in Division and sent to Divisional and departmental leads monthly for review.
PDR/appraisal rates demonstrated in weekly performance report.
Compliance monitored monthly at Trust board.
Minutes of Divisional Governance meeting monitored at SQOGG.
Continuous focussed implementation of PDR and Mandatory Training Policies.
Page 10 of 23
CQC Recommendations
RICAP Ref
Source
Detail
1.23
CQC
Ensure that staff provide external identification for patients, such as a wristband,
when patients arrive in the A&E department.
Dec-14
Current BRAG Rating





Patient ID policy in place
Systematic Audit and monitoring of implementation in place
Ward Accreditation scheme includes the requirement. Monitoring of the ward accreditation process reported to SQOGG and Quality and Governance
committee
Communication re policy to be strengthened:
Spot checks and unannounced monitoring introduced in A&E and feedback provided
RICAP Ref
Source
Detail
1.24
CQC
Ensure there are robust systems in place to obtain the views of patients and carers
regarding care at the end of life and bereavement support. (Linked to 1.13)
Dec-14
Current BRAG Rating
 Implementation of Patient, Family and Carer Experience Strategy
 Meridian Survey tool in place and systematically rolled out to provide locality and speciality patient experience surveys in addition to the Friends and
family test
 Successful Trust JAG accreditation for Endoscopy includes requirement for monitoring and acting on patient feedback
 Web based access to survey results on line for ward managers to access
 Monthly provision of FFT survey results posters to be displayed in ward areas.
 Sample Checklist for January demonstrates this
 Results reviewed systematically at Patient Experience Group and Service Quality and Operational Governance Group and Quality and Governance
Committee
 Use of Patient experience information in wards and departments and Governance Fora with demonstration of sharing across the division evident in
ward and departmental areas and meetings. This is tested in Service reviews and walk round processes.
 Matron for Patient Experience has undertaken a full review of the patient engagement methods used in all services trust wide and report on this
 Evidence of Divisional action on findings of patient experience surveys reported through patient stories on Open and honest publication and shared at
Learning from Experience group.
Page 11 of 23
CQC Recommendations
Rational for BRAG rating change:
Quality and Governance committee members’ recommendation following review of the evidence presented and discussion of progress with respect to RICAP
action plan at 5th March 2015 meeting and routinely reported through the committee.
Executive Director
Responsible
Director of Nursing,
Director Of Quality
and
Governance,
Medical
Director,
Director
of
Operations
and
Director of Estate
and Facilities
Governance
Ward meetings, Divisional Governance meetings, Learning from Experience Group, Service
Quality and Operational Governance and progress monitored through Quality and Governance
committee.
Page 12 of 23
Critical Care Recommendations
RICAP Ref
Source
Detail
2.1
CQC
Take action to ensure that within critical care they have safely stored adequate supplies of
medication and that staff regularly check this.
Dec-14
Current BRAG Rating
Update: Evidence presented to Quality and Governance Committee considered that these actions had been evidenced and were systematically monitored
through the Operational Management systems.



The Trust has an effective system in place for ensuring that there are adequate stocks of medicines available on wards and that the respective
responsibilities of pharmacy and nursing, in terms of maintaining those stocks of medicines are clear and well established, and documented in the
Medicines management policy.
Any variation in appropriate practice is therefore due to individual error or omission and not as a result of system failures.
Reinforcement of those policies has been actioned, specifically in terms of the disposal of medicines and disseminated through the Nursing and
midwifery forum in discussion on PGD’s and medicines management.
Monitoring of Incident reporting shows no areas of concern related to safe storage and adequate supplies of medication.
The system have been reviewed as part of the Unannounced walk round inspections.


Audit
 The Pharmacy Team undertook an audit of medicine compliance in September 2014
 The November 2014 Audit showed ITU to have one minor concern, and re audit being done in January 2015
 The most recent audit in January 2015 identified that all issues are now resolved and that they were fully compliant
RICAP Ref
Source
Detail
2.2
CQC
Ensure that the Intensive Care National Audit & Research Centre data is kept up to date and
used proactively to help monitor the safety, effectiveness and responsiveness of the service.
Dec-14
Current BRAG Rating





ICNARC data has always been collected on ITU in line with requirements, but the timely use of this data was not evident of demonstrable
Systems are in place to ensure this does not recur with resilience in the process for submission and follow-up
Audits carried out by the lead clinician have shown that submissions have been accurate in timely.
Widened ICNARC to include Medical HDU, operating a closed model for Critical Care where ITU, MHDU and SHDU admission rights are controlled by
intensivist.
ICNARC data has informed the planning for the reconfigured Critical Care Units- supporting bed number calculations and determination of
improvement schemes to reduce length of stay
Page 13 of 23
Critical Care Recommendations

ICNARC data displayed for all staff with action plans for areas where the Unit falls below levels with Greater Manchester peers
RICAP Ref
Source
Detail
2.5
CQC
Consider how their plans for re-developing the critical care service meet the needs of staff
and patients.
Dec-14
Current BRAG Rating





A Critical Care Steering Group has been established to oversee the delivery of the Critical Action Plan, by the three critical care working groups
Process, Place & People. Ensuring that the clinical and operational, Estate and Facilities and People processes within the Trust adequately support the
effective management of the critically ill patient.
The Critical Care Process Project Team has been developed in order to improve the quality of care to patients who require critical care within TGH. Its
focus on the delivery of actions to meet the standards and recommendations
The membership includes operational staff from the wards to ensure the refurbishments meets the requirement of staff:
Patient & carer survey complete, display board in place in visitors area for feedback
Open and honest improvement video produced demonstrating staff engagement and improvement achieved
Members’ recommendation following review of the evidence presented and discussion of progress at the February 2015 Performance and Service
Improvement board, and subsequently at Quality and Governance committee on 5th March. This identified that the RICAP action had been completed but
acknowledged that further work with regard to the ongoing improvement programme.
Executive Director
Responsible
Director Of
Operations
Governance
Implementation of systematic processes and monitoring within the Emergency Department.
Reported through Daily performance meetings, Performance reports and Speciality Governance
Groups, and at Operational Board.
Page 14 of 23
Patient flow Recommendations
RICAP Ref
Source
Detail
3.1
CQC
Consider how they work together with the local community to facilitate safe and prompt
discharges. Focus on discharge planning to minimise extended lengths of stay and the
associated increased staffing demand.
Dec-14
Current BRAG Rating














A robust action plan is in place which is being delivered through Patient Flow and Discharge Group, with assurances on delivery sought through the
Performance and Service Improvement Group.
A Health Economy wide “Perfect Week” rapid improvement even was held in October and 2 weeks in January 2015. The major success of this event
was the development of relationships across the Health and Social Care economy and joint learning on areas for improvement.
System Resilience Manager in place for 6 months initially to review systems and process and make recommendations for service change. Post now
made substantive to implement agreed actions
Patient Flow List implemented to focus and monitor discharge processes.
Identification & Monitoring of LOS and potential/actual lost bed days in a patient journey.
Patient Flow Meetings embedded and supporting paperwork revised
Sharing of lost bed days identified at Patient Flow Meetings and actions required with Partners.
Log of Intermediate Care referrals to enable progress monitoring
Overview of Social Care referral activity
Bed management process and meeting revised
Right Patient... Right Bed... Right Place... First Time monitoring. Implementation of ward moves and reallocations
Declaration of Wards predicting discharge activity day before and issues affecting confirmation
We can demonstrate that we are reducing patients with long lengths of stay
Working with Partners we have developed a Transitional Care Unit with a local nursing home to enable flow of medically stable patients
RICAP Ref
Source
Detail
3.2
CQC
Ensure they adequately monitor the quality of their bed management.
Dec-14
Current BRAG Rating



Implemented standards and attendance monitoring at capacity meetings
Implemented a suite of KPIs have been developed to monitor the Trends in these areas
Daily audits wards declaration of beds and times.
Page 15 of 23
Patient flow Recommendations




Use data for ward managers and matrons to target wards with delayed discharges
Reduction in outliers from all specialities and ensuring prompt senior clinical review.
Reduction in late transfers across the hospital at night.
Reduction in cancelled surgery and underutilisation of theatre resources.
Improvement board, and subsequently at Service quality and operational Governance group and in summary to Quality and Governance committee on 5 th
March. This identified that the RICAP action had been completed but acknowledged that further work with regard to the ongoing improvement programme.
Executive Director
Responsible
Director Of
Operations
Governance
Page 16 of 23
Cardiology Review Recommendations
RICAP Ref
Source
Detail
6.1
Cardiology
review
Ensure a robust on-call rota for temporary wire insertion out of hours
Dec-14
Current BRAG Rating


Robust Cardiologists on – call rota in place for out of hours temporary wire insertion
Evidenced to Third party unannounced assurance walk round by CCG
RICAP Ref
Source
Detail
6.2
Cardiology
review
Ensure provision of isolation facilities for patients admitted to CCU/HDU who currently are
or who are subsequently recognised as being of a high infectious risk
Dec-14
Current BRAG Rating



The current configuration of the CCU does not provide a side room facility to provide isolation. The plan is to relocate this facility planned for Mid-March
2015 to Ward 5 where isolation facilities will be available. A plan of the revised bed spaces provided.
Currently- Standard Operating procedure implemented for CCU/MHDU to manage patients if isolation is required agreed with IPC team where adjacent
bed space is vacated to reduce risk of cross infection and cross contamination.
RICAP Ref
Source
Detail
6.3
Cardiology
review
Ensure there is interventional Consultant Cardiology support for MDT discussions
regarding revascularisation
Dec-14
Current BRAG Rating




The Trust has made a joint appointment of an interventional cardiologist with University Hospitals of South Manchester.
This clinician will provide expert input to the MDT in respect of patients who require discussions regarding revascularisation.
Page 17 of 23
Cardiology Review Recommendations
RICAP Ref
Source
Detail
6.4
Cardiology
review
Ensure appropriate support for CRI department staff both with regard to recruitment, but
also personal development, career progression.
Dec-14
Current BRAG Rating





Successfully recruited Echo physiologist from another Recruitment of Band 6 cardiac physiologist. Upgrade of existing Band 6 cardiac physiologist to
add capacity to Pacemaker Implant service
Recruitment of ATO (0.61WTE) to ECG.
Mandatory training compliant.
Personal development programmes in place
Improvement board, and subsequently at Quality and Governance committee on 5th March. This identified that the RICAP action had been completed but
Executive Director
Responsible
Director Of
Operations
Governance
Reported through Daily performance meetings, Performance reports and Speciality
Governance Groups, and at Operational Board.
Page 18 of 23
Deanery Review Recommendations
RICAP Ref
Source
Detail
7.1
Deanery
review
Supervision: Ensure that all staff (particularly in medical care services and A&E) receive
suitable structured supervision building on the work already in place. The Trust must ensure
that the core medical trainees are appropriately supervised and able to access senior
support at all times.
Dec-14
Current BRAG Rating
Update: Evidence presented to Service Quality and Operational Governance group and reported in summary to Quality and Governance Committee
considered that these actions had been evidenced and were systematically monitored through the Human Resources, Medical staffing, PGME and Operational
Management systems.
.
Full and comprehensive action plan has been submitted to the Deanery with evidence portfolio for each Speciality report action requirement.
in summary for this action that includes evidence of











Improved supervision– evaluated by survey
Additional shifts to reduce workload
Clear information regarding accessing senior assistance
Trainee Issues Project Group set up
Recruitment of additional acute physicians
Doctors in Difficulty Policy reviewed
Additional shadowing for trainees away from main site
Constant evaluation and monitoring of changes & improvement
Continue to receive and act on feedback from trainees
Embed our Trust Values & Behaviours into everything we do
Ongoing programme of improvements following on from the HENW report recommendations to ensure future trainees value their learning experiences
at Tameside
RICAP Ref
Source
Detail
7.2
Deanery
review
Housekeeping : Ensure term SHO is not used, timely issue of ID badges, timely induction
Dec-14
Current BRAG Rating
Management systems.
Page 19 of 23










Screensavers & posters
Scrutiny of documents
Coloured Lanyard Project
Instant access to ID badge, SMART card, LORENZO training and Life Support Skills training
Audit of life support skills
Clinical Induction evaluated and improved across all specialties
at Tameside
RICAP Ref
Source
Detail
7.4
Deanery
review
The Trust must continue its work to improve the educational environment within some of the
medical specialties, seeking to further increase consultant presence and clinical support for
the trainees.
Dec-14
Current BRAG Rating
Management systems.







Wi-Fi available 24/7 in certain parts of hospital and most ward areas
New Director of Performance and IM&T appointed to review IT systems
Hospital wide WiFi on future agenda
at Tameside
Page 20 of 23
RICAP Ref
Source
Detail
7.5
Deanery
review
The Trust must ensure that the senior medical trainees have access to appropriate senior
support when working on the ICU and when managing acutely unwell patients on other
wards.
Dec-14
Current BRAG Rating
Management systems.
















Improved supervision– evaluated by survey
Additional shifts to reduce workload
Clear information regarding accessing senior assistance
Trainee Issues Project Group set up
Fully compliant rota
Break room within theatre complex
Access to Doctors Mess with kitchen, toilet, shower, entertainment and areas to rest
Vending machines
Emergency snack boxes
Wi-Fi available 24/7 in certain parts of hospital and most ward areas
New Director of Performance and IM&T appointed to review IT systems
Hospital wide WiFi on future agenda
at Tameside
RICAP Ref
Source
Detail
7.6
Deanery
review
Handover: The Trust must continue its work to improve handover, particularly in medicine,
and ensure that trainees are able to handover the care of their patients safely. Handover of
patients should be timetabled for all trainees and should take place under the supervision of
a senior doctor, ideally a consultant, and trainees should have the opportunity to learn from
Dec-14
Page 21 of 23
Current BRAG Rating
their work.
Management systems.
In summary for this action that includes evidence of
 Medical & ITU handover reviewed & formalised
 NEWS system adopted
 Electronic information system widely available
 New staff recruited
 Constant evaluation and monitoring of changes & improvement
 Continue to receive and act on feedback from trainees
 Embed our Trust Values & Behaviours into everything we do
 Ongoing programme of improvements following on from the HENW report recommendations to ensure future trainees value their learning experiences
at Tameside
RICAP Ref
Source
Detail
7.7
Deanery
review
Supervision: The Trust must review the supervision arrangements for, and the educational
value of, the solo lists undertaken by the anaesthetics trainees
Dec-14
Current BRAG Rating
Management systems.
 Medical & ITU handover reviewed & formalised
 NEWS system adopted
 Electronic information system widely available
 New staff recruited
 Constant evaluation and monitoring of changes & improvement
 Continue to receive and act on feedback from trainees
 Embed our Trust Values & Behaviours into everything we do
Page 22 of 23

at Tameside
RICAP Ref
Source
Detail
7.8
Deanery
review
The Trust must continue its work to improve the clinical leadership of the emergency
medicine department, including the work on referral systems.
Dec-14
Current BRAG Rating
Management systems.









New & increased management
Revised teaching programmes
Full local induction
Improved handover project
Peak time workload addressed by additional experienced staffing
at Tameside
Members’ recommendation following review of the evidence presented and discussion of progress at the February 2015 Service Quality and Operational
Governance group, and subsequently at Quality and Governance committee on 5th March. This identified that the RICAP actions had been completed but
Executive Director
Responsible
Medical Director
and Director of HR
Governance
Page 23 of 23
1
Tameside Hospital NHS Foundation Trust Consolidated Action Plan July 2014
Inadequate
54
Good
On Track to deliver
Green
11
Some issues – narrative disclosure
Amber
Red
0
0
Total
65
x Lead reporting area
Not on track to deliver
In CQC action Plan
V36 5/3/15
1
BRAG Status
Revised Date of
Completion
Expected Date of
Completion
Surgical Division
Medical Division
Cardiology Group
Urgent Care
Junior issues Group
Deteriorating Patient
Patient Flows
Critical Care Group
Elective Patients Access
Concern
CQC Action Plan
Deanery
Cardiology Peer Review
Breast Review
ECIST
CQC
Keogh Legacy
Reporting Responsibility
Governance &
Reporting
Blue
Lead Officers
Delivered and fully embedded
Director Responsible
Requires Improvement
CQC Actions
1.1
*S5
Ensure there are at all times, enough appropriately skilled staff in all x
areas or on call to meet people's needs.
1.2
E1
take action to ensure that care and treatment reflects published
research evidence and guidance issued by the appropriate
professional and expert bodies.
x
1.3
E3
take action to ensure staff are adequately trained and regularly
appraised.
x
1.4
S3
take action to ensure they adequately safeguard patient information. x
1.5
S2
take action to ensure that staff continue to report and learn from
incidents.
Blue
Director of Nursing
Divisional General
Managers/ Heads of
Nursing/ Clinical
Directors
Daily at Bed meeting
Deputy director of
Nursing - daily Trust
board - 6 monthly report,
EMT weekly Monthly
hard truths paper
Blue
Director Nursing ,
Medical Director
Divisional General
Managers/ Heads of
Nursing/ Clinical
Directors
Green
Director of Human
Resources
Divisional General
Managers/ Heads of
Nursing/ Clinical
Directors
Blue
Director Of Nursing ,
Director of Operations
Blue
Director of Quality and
Governance
Divisional General
Managers/ Heads of
Nursing/ Clinical
Directors
Divisional General
Managers/ Heads of
Nursing/ Clinical
Directors
Divisional Governance
meetings - Clinical audit
and effectiveness group Monthly
Quality Account progress
monitored through
Quality and Governance
committee and
subcommittees
Trust board , Divisional
Governance groups ,
Operational Board and
Performance meetings,
Ward level dashboards
Information Governance
Group
Dec-14
Dec-14
Dec-14
Dec-14
x
Dec-14
1
Service Quality and
Operational Governance
Group
1.6
R4
take action to ensure that they learn from complaints and concerns. x
1.7
S4
take action to ensure that suitable infection prevention and control
measures are in place, to reduce the number of surgical site
infections.
x
1.9
S5
ensure that they regularly update policies and procedures.
x
1.10
S2
R4
ensure there is a robust system for disseminating information, such x
as learning from complaints or incidents, amongst all staff.
1.11
R3
ensure they share accurate information in a timely way with patients x
or people acting on their behalf.
1.12
S4
ensure there are robust systems in place to safeguard staff who
handle patient records against workplace injury.
x
1.13
R3
x
1.14
S3
1.15
S4
E3
consider how they promote patient engagement methods, such as
the inpatient survey or the Friends and Family Test, in wards or
units with low response rates, such as the day case or endoscopy
unit.
Take action to ensure that patient records, such as nursing
assessments, procedure books, patient group directives or
discharge letters, are accurate and fit for purpose.
Take action to ensure staff accurately and regularly check
equipment such as resuscitation trolleys across all areas of the
Trusts building on the good practice in many areas.
1.16
R4
1.17
S3
1.18
S4
E1
Blue
Governance
Blue
Governance &
Reporting
Lead Officers
BRAG Status
Revised Date of
Completion
Expected Date of
Completion
Surgical Division
Medical Division
Cardiology Group
Urgent Care
Junior issues Group
Patient Flows
Critical Care Group
Concern
CQC Action Plan
Deanery
Breast Review
ECIST
CQC
Keogh Legacy
2
Service Quality and
Group
Director of Nursing
/DIPC,
Medical
Director
Divisional General
Managers/ Heads of
Nursing/ Clinical
Directors
Clinical Lead, Infection
Prevention,
Clinical Lead Surgery
Green
Governance
Head of Assurance and
Governance
Blue
Governance
Blue
Divisional General
Managers/ Heads of
Nursing/ Clinical
Directors
Divisional General
Manager(s) and Heads
of Nursing and Midwifery
Risk Management
Committee, Quality and
Governance Committee
Learning from
Experience group,
Quality and Governance
Committee
Patient Experience
Group.
Blue
Governance
Blue
Director of Nursing
Green
Director Nursing
Deputy Director of
Nursing /Matrons
SQOGG, Operational
Board
Blue
Director Nursing
Deputy Director of
Nursing /Matrons
Management of Acutely
unwell and deteriorating
Patients group (includes
Life support and Resus)
Blue
Governance
Service Quality and
Group
Blue
Governance
Blue
Governance
Divisional General
Managers/ Heads of
Nursing/ Clinical
Directors
Head of Adult
Safeguarding, Children's
Safeguarding lead
Head of Nursing
/Matrons, DGMs and
Clinical Directors
Dec-14
Elective Governance
structures,
Committee, Service
Quality and Operational
Governance committee
and Trust Board annually
Dec-14
Dec-14
Dec-14
Dec-14
Dec-14
Operationally:
DGMs, Clinical Directors,
Business Managers,
Heads of Nursing
Health and Safety
Committee report to the
Quality and Risk
Management and Quality
and Governance
Head of Patient
Patient Experience
Experience and Heads of Group and Divisional
Nursing
Governance For a
Dec-14
x
Dec-14
x
Dec-14
Take action to ensure that the practice of learning from complaints x
is embedded across the trust, building on the good practice already
in place in some areas as they learn from complaints and concerns
.
Ensure that all staff, patients and visitors know how to respond to
x
any allegation of abuse.
Dec-14
Dec-14
Ensure that staff (particularly in medical care services) have
adequate plans in place to care for people with mental health
conditions, including dementia, or challenging behaviour.
x
Dec-14
2
Trust Internal
Safeguarding Board
Trust Internal
Safeguarding Board
1.19
S3
1.20
S3
1.21
E3
1.22
S5
1.23
S4
E1
Ensure that staff provide external identification for patients, such as
a wristband, when patients arrive in the A&E department.
1.24
W4
ensure there are robust systems in place to obtain the views of
patients and carers regarding care at the end of life and
bereavement support.
Consider how they support staff to quickly identify clean versus dirty x
equipment; particularly in maternity, children's services and medical
care services.
Take action to ensure that staff promptly assess all patients and
x
ensure their welfare and safety, particularly in A&E.
Blue
Director of Estate and
Facilities
Blue
Medical Director
DGMs, HoN, Matrons,
Clinical Directors
Governance &
Reporting
Lead Officers
BRAG Status
Revised Date of
Completion
Expected Date of
Completion
Surgical Division
Medical Division
Cardiology Group
Urgent Care
Junior issues Group
Patient Flows
Critical Care Group
Concern
CQC Action Plan
Deanery
Breast Review
ECIST
CQC
Keogh Legacy
3
Decontamination group
Dec-14
x
Dec-14
Blue
take action to ensure staff, particularly in maternity safely store
x
adequate supplies of medication, that staff accurately record this ,
and that staff regularly check these records
Ensure that all staff (particularly in medical care services and A&E)
receive suitable structured supervision building on the work already
in place.
Deputy Director of
Nursing /Matrons,
Clinical Directors
Medical Director, Director Chief Pharmacist, Head
of Nursing
of Midwifery
x Medics
X Nursing
Dec-14
x
Service Quality and
Group
Drug and therapeutic
committee/ Medicines
Safety group
Educational Governance
Blue
Director of HR
Blue
Governance
Head of Patient Safety
and Risk
Blue
Director of Nursing
Head of Patient
Patient Experience
Experience,
Group and SQOGG
Bereavement Office and
End of Life team
Blue
Blue
Blue
Facilities
Blue
Blue
Facilities
Blue
Director of Estates and
Facilities
Blue
Chief Pharmacist, Head of Critical Care steering
Group through to Quality
Nursing (Elective)
& Governance
Dr.Gourishankar
Critical Care steering
& Governance
Divisional General
Manager (Elective )
& Governance
Dr.Gourishankar
& Governance
Divisional General
Manager (Elective )
& Governance
Medical Devices Lead
& Governance
Head of Nursing
/Matrons
& Governance
Blue
Dec-14
x
Patient Safety
Programme Board
Dec-14
x
Dec-14
2
Critical Care
2.1
E3
Take action to ensure that within critical care they have safely
stored adequate supplies of medication and that staff regularly
check this.
Ensure that the Intensive Care National Audit & Research Centre
data is kept up to date and used proactively to help monitor the
safety, effectiveness and responsiveness of the service.
x
2.2
S5
E3
2.3
E3
Take action to ensure that the environment for interventional
procedures in coronary care are safe and suitable for treatment.
x
2.4
R1
x
2.5
S5
E3
R1
S5
E3
take action to ensure that they seek and have regard for appropriate
professional and expert advice when planning their critical care
services.
Consider how their plans for re-developing the critical care service
meets the needs of staff and patients.
Take action to ensure that the appropriate equipment in critical care
is available and promptly repaired when broken.
x
Consider how staff in the MHDU/CCU adequately monitor the
weight of patients who cannot easily stand.
x
Dec-14
x
Dec-14
Dec-14
2.6
Dec-14
x
Dec-14
Dec-14
2.7
S4
Dec-14
3
3.1
Patient Flows
E3 x
consider how they work together with the local community to
facilitate safe and prompt discharges. Focus on discharge planning
to minimise extended lengths of stay and the associated increased
staffing demand.
3
Head of Patient Flow and Operational Board
Directorate General
Manager
3.2
S4
R2
ensure they adequately monitor the quality of their bed
management.
x
Governance &
Reporting
Lead Officers
BRAG Status
Revised Date of
Completion
Expected Date of
Completion
Surgical Division
Medical Division
Cardiology Group
Urgent Care
Junior issues Group
Patient Flows
Critical Care Group
Concern
CQC Action Plan
Deanery
Breast Review
ECIST
CQC
Keogh Legacy
4
Blue
Head of Patient Flow and Operational Board
Directorate General
Manager
Blue
Medical Director
Deputy Director of
Nursing /Matrons,
Clinical Directors
Acutely unwell and
deteriorating patient
programme
Dec-14
4
4.1
5
Deteriorating patient
S4
Take action to ensure that staff adequately assess and respond to
changes in patient condition or risk.
Elective Access
5.1
E3
take action to ensure that they appropriately prioritise patients
waiting for surgery.
Green
Divisional General
Manager (elective)
Performance and Service
Improvement Board
5.2
E1
Consider the impact of having nurses with combined anaesthetic
and recovery responsibilities .
Blue
Director of Nursing
Head of Nursing
/Matrons
Nursing and Midwifery
leaders forum
Blue
Divisional General
Manager Medicine
Improvement Board
Blue
Divisional General
Manager Medicine
Improvement Board
Blue
Divisional General
Manager Medicine
Improvement Board
Blue
Divisional General
Manager Medicine
Improvement Board
Green
Divisional General
Manager Medicine
Improvement Board
Green
Divisional General
Manager Medicine
Improvement Board
Blue
Director of HR Medical
Director
Head of Medical
Education
Group
Blue
Director
Director
Director
Head of Medical
Education
Head of Medical
Education
Head of Medical
Education
Group
Group
Group
6
Cardiology Review
6.1
x
Ensure a robust on-call rota for temporary wire insertion out of
hours
x
Nov-14
6.2
x
Ensure provision of isolation facilities for patients admitted to
CCU/HDU who currently are or who are subsequently recognised
as being of a high infectious risk
x
6.3
x
Ensure there is interventional Consultant Cardiology support for
MDT discussions regarding revascularisation
x
6.4
x
Ensure appropriate support for CRI department staff both with
regard to recruitment, but also personal development, career
progression.
x
6.5
x
MDT for Echocardiography and case discussion to be
implementation immediately
x
6.6
x
Timeslots for investigations to be reviewed and over-reading of a
percentage of investigations to provide a Quality Assurance to be
implemented.
x
Apr-15
Jan-15
Mar-15
Dec-14
7.2
7.3
7.4
Deanery Review
S5
x
x
x
x
Supervision: Ensure that all staff (particularly in medical care
services and A&E) receive suitable structured supervision building
on the work already in place. The Trust must ensure that the core
medical trainees are appropriately supervised and able to access
senior support at all times.
Housekeeping : Ensure term SHO is not used, timely issue of ID
badges, timely induction
Training: The Trust must ensure it has a systematic process to
check and audit life support skills.
The Trust must continue its work to improve the educational
environment within some of the medical specialties, seeking to
further increase consultant presence and clinical support for the
trainees.
x Medics
7
7.1
Dec-14
Dec-14
x
Dec-14
x
Dec-14
Green
Blue
x
Dec-14
4
7.5
x
7.6
7.7
x
x
7.8
x
8
The Trust must ensure that the senior medical trainees have access
to appropriate senior support when working on the ICU and when
managing acutely unwell patients on other wards.
Handover: The Trust must continue its work to improve handover,
particularly in medicine, and ensure that trainees are able to
handover the care of their patients safely. Handover of patients
should be timetabled for all trainees and should take place under
the supervision of a senior doctor, ideally a consultant, and trainees
should have the opportunity to learn from their work.
x
Medical Director
Blue
Medical Director
Group
Clinical Directors
Dec-14
Group
Clinical Directors
Blue
x
Dec-14
Blue
x
Governance &
Reporting
Lead Officers
Revised Date of
Completion
Expected Date of
Completion
Surgical Division
Medical Division
BRAG Status
Blue
Dec-14
x
Supervision: The Trust must review the supervision arrangements
for, and the educational value of, the solo lists undertaken by the
anaesthetics trainees
The Trust must continue its work to improve the clinical leadership
of the emergency medicine department, including the work on
referral systems.
Cardiology Group
Urgent Care
Junior issues Group
Patient Flows
Critical Care Group
Concern
CQC Action Plan
Deanery
Breast Review
ECIST
CQC
Keogh Legacy
5
Group
Medical Director
Medical Director
Dec-14
Clinical Directors
Group
Clinical Directors
Urgent Care
8.1
x
Continue to monitor ED capacity & demand and any delays in
transferring out of the ED.
x
8.2
x
Introduce a full capacity protocol approach in A&E
x
8.3
x
Monitor ED consultant presence and leadership
x
8.4
x
Monitor how and when ED board rounds are undertaken
x
8.5
x
Implement standardised operating procedures for REACT and
ensure these are and monitored to minimise variation within the
consultant led service
x
8.6
x
Develop a more robust nurse led rapid assessment service out of
hours
x
8.7
x
Prioritise the implementation of twelve hour consultant cover at the
weekend
x
8.8
x
Ensure short stay patients are identified at the earliest opportunity
and streamed short stay
x
Blue
ED Manager
Blue
ED Manager
Blue
ED Manager
Blue
ED Manager
Blue
ED Manager
Blue
ED Manager
Blue
ED Manager
Blue
ED Manager
Dec-14
Dec-14
Dec-14
Dec-14
Dec-14
Dec-14
Dec-14
Dec-14
5
Performance & Service
Improvement Board
through to Quality &
Governance
Improvement Board
Governance
Improvement Board
Governance
Improvement Board
Governance
Improvement Board
Governance
Improvement Board
Governance
Improvement Board
Governance
Improvement Board
Governance
8.9
x
Increase continuity and reduce handoffs to maximise the number of
patients managed within short stay
x
8.10
x
introduce a frailty pathway close to Acute Medicine to maximise
short stay and ambulatory pathways for older people
x
8.11
x
IPS are implemented, monitored and escalated to support early
resolution of any issues highlighted.
x
8.12
x
Work with ECIST to reduce unplanned attendances
x
8.13
x
continue to monitor multi-disciplinary working and consider the
potential for further development as vacancies reduce
Governance &
Reporting
Lead Officers
BRAG Status
Revised Date of
Completion
Expected Date of
Completion
Surgical Division
Medical Division
Cardiology Group
Urgent Care
Junior issues Group
Patient Flows
Critical Care Group
Concern
CQC Action Plan
Deanery
Breast Review
ECIST
CQC
Keogh Legacy
6
Blue
ED Manager
Green
ED Manager
Blue
ED Manager
Green
ED Manager
Blue
Divisional General
Manager Elective
Blue
DGMs
Improvement Board
Governance
Improvement Board
Governance
Operational Board
Green
Divisional General
Manager Elective &
Radiology Manager
Operational Board
Governance
Green
Divisional General
Manager Elective &
Radiology Manager
Operational Board
Governance
Dec-14
Dec-14
Improvement Board
Governance
Improvement Board
Governance
Improvement Board
Governance
Dec-14
x
Dec-14
8.14
S4
E1
Ensure that the trust improve the routine monitoring of the care and
treatment of patients in A&E dep
9
Breast Services
9.1
x
9.2
x
Ensure there are two substantive imaging posts to support the
breast service at Tameside; and could be provided by two
radiologists or a radiologist and a consultant radiography
practitioner.
Ensure joint MDT governance arrangements are overhauled and
formalised in a funded Service Level Agreement to ensure face to
face discussions take place with the whole team from both Trusts.
Joint MDT should work towards a set of shared protocols and
policies as part of the agreed SLA. Consideration should be given
to the reintroduction of face-to-face MDT sessions between the
sites, or alternatively increased discussion to include screening
cases originating from the Tameside area which would improve joint
working between the teams and allow shared learning from these
cases.
x
Dec-14
Aug-15
x
Dec-14
6
Apr-15
Agenda Item
8b
Title
Integrated Quality Report : February 2015
Author (s)
Purpose
Trish Cavanagh, Director of Operations
Brendan Ryan, Medical Director
John Goodenough, Director of Nursing
Amanda Bromley, Director of HR
Claire Yarwood, Director of Finance
Peter Nuttall Director of Performance & Informatics
Kay Holland Deputy Director of Operations
To note/receive
Executive Summary
The Trust failed to achieve a number of national and local key performance indicators during
the month of February. The Trust reported failure of four targets included in Monitor’s Risk
Assessment Framework: A&E four-hour waits; and three Referral-to-Treatment standards
(non-admitted, admitted and incomplete pathways). In addition, the Trust reported that 24
patients were waiting longer than 52 weeks for treatment, at the end of February.
Objective 1 - All patients receive harm-free care
through the delivery of the Trust’s Patient Safety
Programme.
Objective 2 - To improve the quality of patient care
through the implementation of the Trust’s agreed
Quality Strategy.
Objective 3 - To improve the patient experience
through a personalised, responsive, compassionate
and caring approach to the delivery of patient care.
Objective 7 - To deliver against the required local
and national frameworks in order to meet all the
requirements of the Trust’s operating licence and the
commissioners’ requirements.
Risk Assurance – risk impacted
AF3446
upon
requirements
been undertaken?
Sustainability?
Tameside and Glossop CCG may apply financial
penalties for failing to achieve specific performance
targets as detailed in the Contract.
This is the Medical Director and Chief Nurse view on
the impact of any service change
The Board is asked to review the quality and performance standards noted in the Quality
Account.
This page is intentionally blank
QUALITY ACCOUNT: March 2015 Board (February 2015 performance)
Page 2
Board of Director’s Meeting: 26th March 2015
Quality Account 2014/15
Contents
Introduction
4
List of Acronyms
5
Quality Dashboard December 2014/15
6
Exception Reports
Medical Director
SHMI/HSMR
7
4-hour Wait
RTT
Stroke
62-Day Cancer
Readmissions within 30 Days
Outpatient Utilisation
Outpatient DNA Rate
Cancelled Operations
8
9
10
11
12
13
13
14
Director of Human Resources
Appraisals
Trust Induction
Mandatory Training
15
15
15
Page 3
Quality Account Report – February 2015 Performance
Introduction
This report provides the Trust Board with: an overview of the Trust’s performance across a range of quality
and operational indicators for the month of February 2015; and year-to-date performance, along with a RAG
rating, to support the Board in evaluating performance against each indicator.
Exception Reports
Alongside the Quality and Performance Dashboard, the report includes exception reports which respond to
the performance data and allow the Executive Team and Trust Board to be assured of, and contribute to,
plans to rectify performance and quality issues. All serious incidents are reported to Trust Board in Part 2 of
the meeting for patient confidentiality reasons; therefore, no exception report is provided for this indicator
within the report.
February’s Performance
The Trust failed to achieve a number of national and local key performance indicators during the month of
January. The Trust reported failure of four targets included in Monitor’s Risk Assessment Framework: A&E
four-hour waits; and three Referral-to-Treatment standards (non-admitted, admitted and incomplete
pathways). In addition, the Trust reported that 24 patients were waiting longer than 52 weeks for treatment,
at the end of February.
This report includes an exception report concerning mortality, as both national measures (SHMI and HSMR)
continue to trend negatively.
Recommendation
The Trust Board is asked to review the quality and performance standards noted in the Quality Account.
Page 4
List of Acronyms
ADT
C DIFF
CIP
CQC
CT
CWT
DNA
DPH
FFT
GMCCN
HSMR
HAS
MRSA
MSA
RAMI
RCA
RIDDOR
ROSIER
RTT
SHMI
STAR
StEIS
TIA
TNA
VTE
YTD
Admission, Discharge, Transfer
Clostridium difficile
Cost Improvement Plan
Care Quality Commission
Computerised Tomography
Cancer Waiting Times
Did-not-Attend
Director of Public Health
Friends & Family Test
Greater Manchester & Cheshire Cancer Network
Hospital Standardised Mortality Ratio
Hospital Arrival Screen
Methicillin-resistant staphylococcus aureus
Mixed-sex Accommodation
Risk-adjusted Mortality Index
Root Cause Analysis
Reporting of Injuries, Diseases and DangerousOccurrences Regulations
Rule Out Stroke In the Emergency Room
Referral-to-Treatment
Summary Hospital-level Mortality Indicator
Staff Accident Rate
Strategic Executive Information System
Transient Ischaemic Attack
Training Needs Analysis
Venous Thromboembolism
Year-to-Date
Page 5
THFT QUALITY ACCOUNT 2014/15
Quality Dashboard
February 2015
* Governance indicators, which appear in Monitor's Risk Assessment Framework
Actual year-to-date (YTD) is upto February 2015 unless otherwise indicated. # identifies indicators reporting on previous months' data
Overall Clinical Quality
Target
14/15
Actual
YTD
4-mth
Trend
Actual
Month
Current
Period
1-mth
F'cast
≤100
106.9
NA
NA
SHMI (rolling 12 months) (Mar 14)
≤100
115.8
NA
NA
Infection Prevention & Control
C-difficile - avoidable cases YTD*
NHS Safety Thermometer
Harm-free care (all harms)
Harm-free care (new harms)
Patient Safety
VTE risk assessments
Medicines reconciled
on admission (Oct-Dec 14)
Nutrition risk assessment
Emergency re-admissions within
30 days #
Failure of safer-surgery process
Serious Incidents reported (StEIS)
'Duty of Candour' breaches
Never Events reported (StEIS)
Regulation 28 reports (inquests)
Moves after 11pm (% of Admissions)
Target
14/15
Actual
YTD
4-mth Actual Current 1-mth
Trend Month Period F'cast
≥80%
41.45%
12.50%
≥80%
64.76%
37.50%
≥60%
25.50%
25.00%
Target
14/15
Actual
Stroke
Mortality
HSMR # (rolling 12 months)(August 14)
MRSA - actual cases YTD*
Specialty Clinical Quality
4
0
41
12
0
N/A
94.56%
90.76%
≥95%
98.53%
96.68%
from arrival (<4 hours)#
≥95%
96.64%
95.70%
≥94%
-
86.50%
High-risk TIA cases treated
within 24 hours #
NA
NA
Staff Health & Safety
RIDDOR incidents reported
Consecutive safe days
N/A
Lost-time accidents
Calendar days lost
due to staff accidents
Staff accident rate#
(STAR)
≥90%
93.72%
96.55%
<10%
13.59%
13.33%
0
0
0.00%
0
0
36
0
0
0
People
0
0
2
8
0
1
Staff attendance
Appraisals - rolling 12 mths
0%
1.84%
2.22%
Trust induction
Safer Staffing
0
>28
0
YTD
10
4-mth
Trend
Actual
Month
18-week admitted*
18-week non-admitted*
18-week incomplete*
RTT waits- incompletes (>52 weeks)
Current 1-mth
Period F'cast
0
No Data Provided
No Data Provided
TBC
95.21%
94.73%
NA
NA
Recommend Treatment
HCA hrs on shift (% of planned)
TBC
118.33%
127.47%
NA
NA
Recommend Work
FFT positive responses
FFT response rate (excludes maternity)
Complaints received
Complaints responded to within
Target
Actual
4-mth
Actual
Current
1-mth
E-learming Info Gov
14/15
YTD
Trend
Month
Period
F'cast
E-learming SG Children
0
0
85.39%
0
88.21%
NA
NA
NA
20%
467
33
80.69%
90.91%
E-learming E-MH
E-learming E &D
NA
NA
E-learming SG Adults
E-learming H&S
Mandatory training (Overall)
agreed timescale
Ombudsman cases upheld
E-learming Infection Control
43.40%
N/A
≥90%
0
2
Regulatory
Governance Risk Rating*
Financial Risk Rating*
CQC Rating*
Trolley waits in A&E (>12 hrs)
HAS compliance
Cancer
2-week referral*
2-week breast symptomatic*
31-day treatment*#
31-day surgery*#
31-day drug treatment*#
62-day from referral*#
62-day from upgrade of urgency*#
82.47%
85.94%
95.13%
88.19%
≥92%
0
82.51%
84.43%
≤1%
0.66%
0.60%
≥95%
0
≥85%
93.43%
92.61%
0
77.85%
0
73.09%
93%
93%
96%
94%
98%
85%
96.83%
97.15%
98.92%
100.0%
100.0%
90.00%
97.09%
100.00%
100.00%
100.00%
81.90%
85%
89.19%
84.62%
Actual
YTD
70.86%
106
Current
Period
1-mth
F'cast
24
<10
0.35
0.00
Target
14/15
Actual
YTD
≥96.6%
≥95%
95.18%
N/A
95.17%
68.00%
Operational Efficiency
≥95%
N/A
83.00%
Outpatient slot utilisation
Target
14/15
≥85%
Outpatient DNA rate
≤7.5%
11.41%
10.42%
≥67 %
≥61 %
72.00%
-
Theatre utilisation (capped)
≥85%
83.96%
83.70%
68.00%
-
Cancelled operations (last-minute)
≤0.8%
1.08%
1.07%
0
0
0
4-mth
Trend
NA
Actual
Month
NA
Diagnostic wait time, 6 weeks
A&E
4-hour wait*
≥90%
≥95%
0
Current 1-mth
period F'cast
Urgent operations cancelled
≥95%
≥95%
N/A
77.90%
N/A
77.80%
≥95%
≥95%
N/A
76.00%
N/A
77.80%
for second time
Finance
-1420
-18229
163.9%
100%
53
3175
97.0%
97.0%
97%
≥95%
≥95%
Cum. Capital (£k)
N/A
80.40%
Cum. CQUIN (% of plan) ≥70 % of plan
Target
Actual
4-mth
Actual
Current 1-mth
14/15
YTD
Trend
Month
Period F'cast
Green
R
NA
R
-
3
1
-
NA
1
-
-
Inadequate (Special Measures)
strong improvement
improvement
no change
deterioration
strong deterioration
Page 6
Yr-end
F'cast
2158
Cum. CIP (% of plan)
88.60%
-
Current
Period
-15563
Cum. Net surplus (£'m)
77.80%
4-month trend
1-mth
F'cast
106.7%
90.50%
N/A
Trend
Actual
Month
Current
Period
Actual
YTD
N/A
4-mth
Actual
Month
72.76%
Target
14/15
N/A
1-month forecast
The one-month forecast is an informed prediction of the
next month's performance, which may be based on partmonth data, operational intelligence and historical
trends.
4-mth
Trend
-
≤-£17500
≥100% of plan
≥95%
≥95%
0
QUALITY ACCOUNT: March 2015 Board (February 2015 performance)
Actual
Month
163
Mandatory Training
MSA breaches
4-mth
Trend
NA
FFT- Staff Survey (quarterly)
RN/RM hrs on shift (% of planned)
Patient Experience
Actual
YTD
Waiting times
Time to stroke bed
% time on Stroke Unit#
0
Target
14/15
Patient Access
QUALITY ACCOUNT EXCEPTION REPORTS: Medical Director (1/1)
Mortality
SHMI (Reporting Period: Jul 13 – Jun 14)
HSMR (Reporting Period: Dec 13 – Nov 14)
Target
4 Month Trend
≤100
≤100
ISSUE:
The latest figures for HSMR & SHMI are above the ‘expected’ level.
ACTIONS COMPLETED:





Trust Mortality Steering Group in place;
Mortality review process reviews the care provided for all inpatient deaths in
hospital;
National benchmarking tools used to flag areas of concern reported to
Mortality Steering Group and Service Quality and Operational Governance
Group;
Engagement with Dr Foster to review areas identified as Mortality outliers;
Participation in the AQuA mortality collaborative programme.
FUTURE ACTIONS:



Implementation of the Trust’s Quality Improvement Strategy and Patient
Safety Programme;
Systematic review of data quality, clinical information capture and recording
is being undertaken;
Coding improvement analysis shared with commissioners, Monitor and staff
at Haelo.
ASSESSING IMPROVEMENT:
Improvement will be tracked through monthly performance monitoring via the
Mortality Steering Group and governance structures.
Expected date to meet
target
2015-16
Signed off by
Brendan Ryan
Signed
off by
Peter Nuttall
Note: HSMR was re-based in December
Page 7
Performance
Current Period
115.8
106.9
Forecast
QUALITY ACCOUNT EXCEPTION REPORTS: Director of Operations (1/7)
Patient Access
A&E
4-hour wait (Reporting Period: February 2015)
Target
95%
ISSUES:
The Trust did not achieve the four- hour emergency access standard in February
and will not meet the target for Quarter 4. The most significant factor affecting
performance, during this reporting period, was the availability of inpatient beds.
Delayed Transfers of Care (DTOC), of around 15 per day, contributed to
compromised bed capacity during the period. Attendance and admission rates
had less of an impact than in January.
ACTIONS:
 The Transitional Care Unit has now begun its phased opening, which will
provide greater flexibility of patient flow and earlier availability of beds.
 The Trust’s clinical leadership team is to develop plans to reduce delays
caused by waits for specialty doctors.
 A health-economy plan, for four-hour target recovery, is being developed
as a work stream of the Systems Resilience Group.
 Full Time HALO officer is assigned to ED for the tracking and monitoring
of ambulance- handover compliance. The Trust is to re-site one of the
HAS screens to a more prominent position on the corridor.
 Improvement will be assessed by the daily monitoring of the performance
access standard.
Expected date to meet target
Q1 2015
Signed off by
Trish Cavanagh
Signed off
by
Mike
Griffiths
Page 8
4 Month Trend
Performance
92.61%
Forecast
Patient Access Waiting Times
Target
4 Month Trend
Performance
18 Week Admitted Pathways (Reporting Period: February 2015)
90%
85.94%
18 week Non-Admitted Pathways (Reporting Period: February 2015)
95%
88.19%
18 week Incomplete Pathways (Reporting Period: February 2015)
92%
84.43%
0
24
52-Week Waiters (Reporting Period: February 2015)
ISSUE:
The Trust failed all RTT standards in February 2015 and reported that 24 patients were
waiting longer than 52 weeks at the end of the month (reduced from 34 at the end of
January).
 As expected, performance against the non-admitted standard deteriorated
(91.9% to 88.2%) as a consequence of the Trust treating more ‘backlog’ patients.
 Performance against the admitted standard improved from 84.5% to 85.9%.
 Performance against the ‘incomplete pathway’ standard improved by a further
1.1%, having improved by 3% between January and December 2014. This is a
particularly important and positive change, and shows that improvements to
booking processes and waiting-list management are beginning to take effect.
 The Trust reduced its backlog of patients, waiting more than 18 weeks, from
2756 to 2344, which equates to a 15% improvement since the end of January.
Since December 2014, the Trust’s backlog has reduced from 3714, a reduction of
37%. The Trust’s total waiting list reduced by 9% from the January position, and
by 20% since the end of December (a reduction of 3749 patients).
PROPOSED ACTIONS:
 The Trust’s action plan/ improvement trajectory has been shared with
stakeholders and is being managed through weekly RTT meetings.
Delivery of all standards in line with agreed trajectories.
target
Q3 2015-15
Signed off by
Trish Cavanagh
Signed off by
Peter Nuttall
Page 9
Forecast
Specialty Clinical Quality (Stroke)
Target
Stroke – time to stroke bed from arrival (4hr target) (Reporting Period: January
2015)
Stroke - % of time on Stroke unit (Reporting Period: January 2015)
80%
12.5%
80%
37.5%
TIA – high risk TIAs treated within 24hrs (Reporting Period: January 2015)
ISSUE: Time on Stroke Ward / Direct Admission
Early identification of stroke patients in ED remains a focus of clinical teams although,
as highlighted previously, the high number of locums adversely affects consistency of
diagnosis. ROSIER scoring remains in place as part of the REACT processes, which
should aid diagnosis and identification of appropriate patients. The TIA pathway
continues to be adversely affected by referral patterns, despite communication with
GPs.
60%
25%
PROPOSED ACTIONS
It was agreed that beds on the Acute Stroke Unit would be ‘ring fenced’ and, in
general, this occurs during the day, but becomes problematic in the evenings and at
weekends. The issue is that when there is a shortage of bed capacity, on-call
managers, Bed Managers and the Executive-on-call may require the use of stroke
beds to ease emergency pressures, which adversely affects stroke performance.
Dialogue continues with the CCG to allow stroke patients, whose rehab potential has
been reached, but are awaiting a package of care or nursing assessment, to be
moved to Intermediate Care. This is currently not part of the intermediate-care
contract, thus these patients remain in hospital.
ASSESSING IMPROVEMENT
st
It should be noted that from 1 April 2015, all new acute strokes will go directly to
one of the hyper-acute stroke units across Greater Manchester. This will also
mean a change to a number of the stroke targets for THFT in 2015-16.
Q1 2015-16 (new
targets)
Signed off by
Trish Cavanagh
Signed off
by
John
Turner
Page 10
4 Month Trend
Performance
Forecast
Patient Access
Cancer
62-day Cancer waiting time standard (upgrade patients)
(Reporting Period: January 2015)
62-day Cancer waiting time standard (Referral to Treatment)
Target
84.62%
85%
81.9%
The 62-day RTT reallocation target of 85% was not achieved in January 2015.
There were 11 breaches, one of which was shared with CMFT. The following
provides the headline reasons for those breaches:
 internal/external capacity issues – two;
 external diagnostic delay - one;
 dual-cancer pathway - one;
 complex diagnostic pathway - three;
 patient choice - one;
 patient unfit for diagnostics/ treatment - three.
The local 62-day target for ‘upgrades’ of 85% was not achieved in January 2015.
There were two ‘complex- diagnostic pathway’ breaches.
ACTIONS:
The following actions have been taken:
 extra weekly Cancer PTL meeting with all key operational managers;
 new e-PTLs allow for daily reports to be sent to the diagnostic support
services for action;
 bi-weekly monitoring of the 42-day PTL by the Cancer Services
management team.
Both targets were achieved for February 2015.
February 2015
Signed off by
Trish Cavanagh
Signed
off by
Performance
85%
ISSUE:
4 Month Trend
Janet
Smart
Page 11
Forecast
Target
4 Month Trend
Performance
10%
Emergency Readmissions within 30 days
Forecast
13.3%
ISSUE:
The 30-day readmission rate remains above the target level of 10%.
ACTIONS COMPLETED:
 The Trust has commissioned a detailed analysis of the data relating to
the target.
 Initial analysis suggests that more detailed interrogation of the data,
pertaining to the specialty of General Medicine, is required.
 The Trust is working with the third-party to determine which subspecialties of the General Medicine grouping are contributing to the
Trust’s poor performance, by analysing the data by diagnosis code.
FUTURE ACTIONS:
 The Trust will receive the final report in April 2015.
 The final report will provide the basis for a readmissions improvement
plan.
 Reduced readmissions in 2015-16.
May14
14.1%
target
Signed off by
2015-16
Signed off by
Jun14
13.7%
Jul14
14.4%
Peter Nuttall
Trish Cavanagh
Page 12
Aug14
12.0%
Sep14
14.4%
Oct14
12.6%
Nov14
12.7%
Dec14
14.3%
Jan15
13.3%
YTD
13.6%
Operational Efficiency (Outpatients)
Target
4 Month Trend
Performance
Outpatient Slot Utilisation (Reporting Period: February 2015)
85%
72.76%
Outpatient DNA Rate (Reporting Period: February 2015)
7.5%
10.42%
ISSUE:
The Outpatient Department requires review, and significant change, in both
process and structure in order to achieve the operational targets. Improvements
in operational performance will form a key element of the outpatient project,
which is aimed at improving the Trust’s responsiveness to patients and promoting
efficiency.
The DNA rate for February reduced by 1.5%, compared to the previous month,
whilst slot utilisation remained unchanged from January.
Actions:




Implement appointment-confirmation service across all specialties;
Choice of appointment, date and time for first outpatient attendance;
Amend outpatient letters to include patient responsibilities and the importance
of attending appointments;
Review clinics with 0% slot utilisation to determine whether they can be
removed from the system.




Increased outpatient-slot utilisation;
Reduction in the DNA Rate;
Increase in OP appointment availability;
Reduction in OP waiting time.
2015-16
Signed off by
Trish Cavanagh
Signed off
by
Anthony
Edwards
Page 13
Forecast
Operational Efficiency (Theatre Utilisation)
Target
Last Minute Cancelled Operations (Reporting Period: February 2015)
0.8%
ISSUE:
Last- minute cancellations were greater than the 0.8% standard. Increased cancellations
correlate with periods of bed pressures at the Trust. The Trust is developing a valid, and
consistent, method of data collection for cancellations.
ACTIONS:
Actions to improve theatre utilisation are expected to reduce the rate of cancellation:
 Theatre utilisation (capped) has improved a little over past three months as a
result of implementing weekly scheduling meetings with input from theatre staff,
day-case staff, and speciality managers.
 It is also anticipated that the utilisation rate will improve further with
implementation of the centralised booking team in April 2015.
 Whilst there has been an upward trend in utilisation, the percentage of late starts
i.e. sessions which start > 15 minutes after scheduled start time has increased.
The main reason for a significant increase in late starts is the introduction of the
Team Briefing. Data is to be reviewed by recently re-launched Theatre User
Group with a view to develop a work stream to resolve this issue, based partly on
learning from other trusts.
Improvement in KPIs (i.e. theatre utilisation, productivity, reduction in last-minute
cancellations, reduction in waiting list initiatives); development of KPI dashboard for
Theatre User Group, against which work streams can be developed and monitored;
wider dissemination of KPIs; and stakeholder engagement.
target
April 2015
Signed off by
Trish Cavanagh
Signed off by
Lynda
Handley
Page 14
4 Month Trend
Performance
1.07%
Forecast
QUALITY ACCOUNT EXCEPTION REPORTS: Director of Human Resources (1/1)
People
Target
4 Month Trend
Performance
Appraisals - Rolling 12-month (Reporting Period: March 2014- February 2015)
95%
68%
Trust Induction (Reporting Period: February 2015)
95%
83%
Mandatory Training (Reporting Period: February 2015)
95%
80.4%
ISSUE:
Performance for the following is below the Trust targets: induction, mandatory training
and appraisal compliance. It should be noted that the decline in appraisal rates has been
predicted, as the Trust is moving to an ‘appraisal window’ (April – August). All appraisals
are currently on hold for this reason.
PROPOSED ACTIONS:
There is a particular focus on the e-learning element of mandatory training. Urgent action
is being taken as follows:
 E-learning support sessions are being run several times a month, with laptops
able to be loaned to clinical areas.
 Additional face-to-face training sessions have been arranged, both centrally and
departmentally, to help achieve compliance rates, whilst the issues with the elearning system are being rectified.
 HR is working closely with IT to resolve the technical issues with the e-learning
system.
 A review of the Mandatory Training TNA has been undertaken to streamline the
frequency and methods of training, to bring the Trust in line with other trusts and
the Core Skills Framework.
The above will be monitored on a monthly basis.
target
2015-16
Signed off by
Amanda Bromley
Signed off by
Page 15
Forecast
Agenda Item
8c
Title
Safe Staffing Report
Author (s)
Anne Allison, E-Rostering Project Manager
Purpose
To note/receive
n/a
Executive Summary
In-line with the ‘Hard Truths Commitments regarding the publishing of Staffing Data’, the Trust Board
are required to review staffing data on a monthly basis. The aim of this report is to provide the
monthly update on the continuing actions and developments to support safe staffing.
1. All patients receive harm free care through the
Trust’s Patient Safety Programme.
2. To improve the quality of patient care through the
implementation of the Trust’s agreed Quality
Strategy.
3. To improve the patient experience through a
personalised, responsive, compassionate and
caring approach to the delivery of patient care.
CR734: Nurse vacancies, leadership and Nursing
staffing recruitment across medicine and the ability to
provide safe care.
AF3480: Failure to meet CQC registration
requirements relating to staffing.
AF3482: Failure to ensure adequate staffing levels to
ensure patient safety and quality of services
requirements
NHS England monthly requirement to publish and
report Staffing Data
None
been undertaken?
Yes – where applicable in plans
Sustainability?
The Trust are required to ensure staffing levels are
adequate to meet patient safety and quality.
The Trust Board are requested to receive this update and note the assertive monitoring of staffing
levels that are in place for quality & safety.
Page 1 of 7
Purpose
In-line with the ‘Hard Truths Commitments regarding the publishing of Staffing Data’, the
Trust Board are required to review staffing data on a monthly basis. The aim of this report is
to provide the monthly update on the continuing actions and developments to support safe
staffing.
1. Safe Staffing Update – February 2015 Data
Each month the data collection compares the number of staff hours ‘Planned’ against the
number of staff hours used ‘Actual’. This is collected by ward, by shift, and is reported by
calendar month as a % fill rate by day and by night: Appendix 1 Provides a summary of the
February position.
The overall Trust position for February is:
Day
Night
RN/RM Average Fill
rate
93.7%
96.2%
Care Staff Average Fill
rate
114%
153.1%
This is the UNIFY upload of February’s Staffing Data; and the information is published via
NHS Choices. This data is currently available via our public website in a specific designated
section ‘Safe Staffing’:
Tameside Hospital - Nurse Staffing (www.tamesidehospital.nhs.uk/nurse-staffing.htm)
Monthly Submission Trend
160
150
140
130
120
110
100
90
80
70
RN Fill DAY
RN Fill NIGHT
Feb-15
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
Care Staff Fill
DAY
May-14
% Fill Rate
Average Fill Rates
Care Staff Fill
NIGHT
Overall, RN fill-rates remain fairly constant month on month, but Care Staff fill rates have
seen an increase due to increasing levels of enhanced care (1:1’s) and additional support for
RN shortfalls.
Page 2 of 7
2. Exception Report
The submission only represents monthly aggregated data and percentages, which have
limited benefit. Robust conclusions cannot be deducted from this information alone. The data
gives a summary and aggregated overview of how frequently the Trust met its planned
requirements.
NHS England have suggested that greater scrutiny should be given to any area reporting
<80% fill rates. This month there were 2 areas reporting <80% fill rates.
The table below gives further detail regarding reasons for this:
January 2015
Area
Surgical
Unit
Fill (%)
RN Staff Days
75.1%
Comments
These wards within the Elective Division were
reconfigured during February. ‘Planned’ staffing
varied during this period and each area worked
together to provide safe staffing on a shift by shift
basis. Real-time staff moves were not fully captured
within roster reports.
However, the average monthly fill for Division:
Shift
Day
Night
Ward 5
RN Staff Days
77.6%
CCU
Care Staff Days
76.6%
RN
91.7%
110.4%
Care Staff
118.7%
191.7%
Staff moves and reallocations overseen by Matron &
Head of Nursing.
AP in-post who bridges the gap between RN and
Care Staff, but reported in Care Staff figures.
RN:Patient ratio’s maintained 1:10
NA vacancy 1.74wte. Shifts adjusted from long day to
9 – 5pm to bridge period of greatest workload.
3. Actions to Address Shortfalls
Short-term sickness and vacancy continue to be the main reasons for shortfalls in
substantive staffing, with additional pressures due to escalation areas.
To address these shortfalls the Trust are/have:
 A further ‘Recruitment Day’ for RN/RM staff is being planned for May 2015.
 Internal adverts to recruit HCA staff who have been on placement from NHSP.
 Utilising non-clinically based nursing staff to support the clinical areas e.g. specialist
and Corporate nurses working within the wards.
 Ward Manager’s and Matron’s providing increased direct support to the clinical teams
 Increased HR support to ensure improved efficiency in the management of sickness.
Temporary Staffing
When required; additional staff are requested through our temporary staffing provider NHSP, to meet any shortfalls in RN or Care Staff. Whilst reliance and temporary staffing
costs remain high, the new NHSP contract is driving significant change to improve efficiency
and reduce current expenditure.
A monthly dashboard has been produced and gives an overview of usage and actions being
taken: (Appendix 2).
Page 3 of 7
4. Summary
Getting the right numbers of nurses, midwives and care staff in place is essential for the
delivery of safe and effective patient care. This paper shows that the Executive Nurse
Director is providing scrutiny, leadership and oversight of this essential area of quality and
safety.
The latest Acuity & Dependency review is reported in a separate report/board paper.
5. Recommendations
The Trust Board are requested to receive this update and note the assertive monitoring of
nurse staffing that is in place.
Page 4 of 7
APPENDIX 1.
Planned Staff Vs Actual
%
January-15
WARD
SPECIALTY
Elective
Unit
General
Surgery
Surgical
Unit
General
Surgery
Trauma
Unit
Trauma &
Orthopaedics
ITU
Critical Care
Medicine
Ward 5
Ward 30
Ward 31
MAU
CCU
Ward 40
General
Medicine
General
Medicine
General
Medicine
General
Medicine
General
Medicine
General
Medicine
SHIFT
Registered
Staff
Care Staff
Day
97.4
109.3
Night
86.9
130.6
Day
105.4
122.9
Night
118.6
166.3
Day
96.8
124.3
Night
99.2
122.5
Day
99.6
91.9
Night
94.2
n/a
Day
78.6
112.3
Night
101.7
101.0
Day
99.2
110.8
Night
95.7
106.9
Day
87.7
103.0
Night
95.9
119.8
Day
98.8
92.0
Night
84.5
119.1
Day
96.3
60.4
Night
101.2
n/a
Day
94.3
115.9
Night
94.6
116.4
Page 5 of 7
Comments
AP in-post who bridges the gap
between RN and Care Staff, but
reported in Care Staff figures.
NA vacancy 1.74wte. Shifts
adjusted from long day to 9 – 5pm
to bridge period of greatest
workload.
APPENDIX 1 continued
Planned Staff Vs Actual
%
January-15
Comments
WARD
SPECIALTY
SHIFT
Registered
Staff
Care Staff
General
Medicine
Day
93.6
120.6
Ward 41
Night
88.2
192.1
Day
94.9
121.4
Night
93.5
166.3
Day
100.2
151.5
Night
102.6
173.3
Day
100.2
137.9
Night
103.4
162.4
Day
83.3
114.9
Night
103.9
114.2
Day
91.4
116.2
Night
96.5
117.1
Day
89.4
99.6
Night
93.0
84.4
Day
87.8
96.0
Night
115.6
n/a
Day
97.5
81.4
Night
105.2
n/a
Day
81.0
84.3
Night
95.7
n/a
Ward 42
Ward 43
Ward 44
Ward 45
Ward 46
Maternity
Ward 27
General
Medicine
General
Medicine
General
Medicine
General
Medicine
General
Medicine
Obstetrics
Women’s
Health Unit
Gynaecology
NICU
Obstetrics
Children’s
Ward
Paediatrics
Trust Average Fill Rates
RN/RM Average Fill rate
Care Staff Average Fill rate
Day
Night
94.0%
96.7%
111.9%
134%
Page 6 of 7
APPENDIX 2
Page 7 of 7
Agenda Item
8c Appendix A
Title
6 Month Acuity & Dependency Review
Author (s)
Anne Allison, E-Rostering Project Manager
Purpose
To note/receive
n/a
Executive Summary
In-line with the ‘Hard Truths Commitments regarding the publishing of Staffing Data’, and
NICE Guidance, the Trust Board are required to receive and review a 6-monthly Acuity and
Dependency Report. The aim of this report is to provide the 6-monthly review of data
collected during January 2015.
1. All patients receive harm free care through the
Trust’s Patient Safety Programme.
2. To improve the quality of patient care through the
implementation of the Trust’s agreed Quality
Strategy.
3. To improve the patient experience through a
personalised, responsive, compassionate and
caring approach to the delivery of patient care.
CR734: Nurse vacancies, leadership and Nursing
staffing recruitment across medicine and the ability to
provide safe care.
AF3480: Failure to meet CQC registration
requirements relating to staffing.
AF3482: Failure to ensure adequate staffing levels to
ensure patient safety and quality of services
requirements
NHS England monthly requirement to publish
and report Staffing Data
None
been undertaken?
Yes – where applicable in plans
Sustainability?
The Trust are required to ensure staffing levels
are adequate to meet patient safety and quality.
The Trust Board are requested to receive this update
Page 1 of 12
1. Purpose
In-line with the ‘Hard Truths Commitments regarding the publishing of Staffing Data’, and NICE
Guidance, the Trust Board are required to receive and review a 6-monthly Acuity & Dependency
Staffing Report.
2. Background/Introduction
The National Quality Board (NQB) issued guidance in November 2013 to optimise nursing,
midwifery and care staffing capacity and capability: “How to ensure the right people, with the right
skills, are in the right place at the right time: A guide to nursing, midwifery and care staffing capacity
and capability”. This was in response to the Robert Francis QC Report, and also encompassed the
findings of Sir Bruce Keogh’s review of hospitals with high adjusted mortality rates, the review of
safety by Don Berwick and other similar sentinel national reports.
The guidance clearly sets out the expectations and requirements of Trust’s to meet the ‘Hard Truth’s
commitments’, with clear guidance from the Chief Nursing Officer for England – Jane Cummings,
and Professor Sir Mike Richards. In addition to this, NICE (National Institute for Health and Care
Excellence) published further guidance in July 2014 with regard to staffing levels in adult inpatient
wards: ‘Safe Staffing for nursing in adult inpatient wards in acute hospitals’.
Undeniably there is world-wide evidence within the literature that ensuring the appropriate numbers
of skilled staff safeguards a safe, quality, caring experience for patients.
3. Current Position
At Tameside Hospital, a significant amount of work has been undertaken to ensure we meet the
requirements set out within ‘Hard Truths’ and can provide assurance to our patients, our staff, the
Trust Board, our regulators and the general public of Tameside & Glossop.
The journey has been huge, both in terms of organisational change, staff effort and financial
investment, despite significant overarching operational and financial pressures.
The table below summarises our journey to-date:
Date
Sept ‘13
Action Taken
Major review of nursing establishments following Keogh review and CQC
recommendation:
£440,499 investment to support front line nursing teams - increases to Bands 2
– Band 6 staffing.
Significant increase in supporting specialist nursing & governance infrastructure
– VTE Specialist Nurse, Dementia & Frail Elderly Specialist nurse, 3 x band 7
Patient Safety Officers, 2 x band 7 Divisional Governance Lead posts and
Clinical Effectiveness - £325,000
Nov ‘13
Dec ‘13
Additional investment of £388,883 to support additional staffing in view of issues
relating to ward environmental layout and patient mix on Elective Unit, Trauma
Unit, Ward 45 and Ward 46
Corporate Matron post created for Patient Experience & Quality - £43,822
Jan ‘14
£279,020 investment to create additional Band 7 posts and facilitate Ward
Manager ‘supervisory’ time
Jan ‘14
6-monthly Acuity & Dependency Review undertaken
2014
£789,611 investment to increase staff numbers and skill mix in A&E.
£156,182 investment following a review and remodelling of the Healthcare
Assistant role in A&E
May ‘14
Gap Analysis undertaken against ‘Hard Truth’s’ commitments and Action plan to
Page 2 of 12
meet requirements.
Commenced monthly reporting of ‘Planned’ v ‘Actual’ staffing levels
 Reported publically via NHS Choices and Trust public website
 Monthly Board reporting commenced of staffing levels
 Public display of Planned & Actual staffing at ward level
 Escalation process for staffing concerns revised and re-launched
June ‘14
6-monthly Acuity & Dependency Review undertaken:
 Acts as a ‘sense check’ to assess whether current staffing levels are
adequate and appropriate.
 Triangulated against Nurse Sensitive Indicators and professional judgement.
 Report to Trust Board
Aug/Sept Gap analysis undertaken against NICE guidance and action planning
2014
commenced to meet guidance standards.
 Report to Trust Board
Nov ‘14
Additional Ward Clerk support provided on the wards at weekends to nursing
teams with additional admin & clerical support - £ 13,000
Jan ‘14
Business case developed to meet NICE guidance re: Nurse: Patient ratios:
£500,000 investment agreed to meet NICE recommendations
4. Acuity & Dependency Review January 2015
The review of nursing establishments is complex and any method of determining staffing has
limitations. There is no one solution to determine safe staffing and therefore triangulation of
methods is essential. Using the combination approach will provide greater confidence in the
decisions taken. The setting of establishments should triangulate from different sources:




Workload measurement based information (acuity/dependency and activity) using a
validated tool.
Analysis in conjunction with patient safety & quality indicators
Benchmarking with other organisations.
Professional consultation/judgment by senior nurses and Chief Nurse/Head of Midwifery.
The Trust is currently utilising the Safer Nursing Care Acuity & Dependency tool to further
understand what the optimal staffing levels are for individual areas. This tool has been endorsed by
NICE following the publication of their guidance ‘Safer Staffing for nursing in adult inpatient wards in
acute hospitals’ July 2014). The tool, when allied to Nurse Sensitive Indicators (NSIs), also offers
nurses a reliable method against which to deliver evidence-based workforce plans to support
existing services or the development of new services.
The Acuity & Dependency Review is undertaken twice yearly (January and June) to enable the
identification of trends across seasons and in response to changing demographics and healthcare
needs. During January 2015 we carried out data collection on each ward for a period of 20 days in
order to ensure a consistent approach.
Utilising the Safer Nursing Care Tool, multipliers are used to calculate recommended staffing levels
according to actual patient acuity and dependency. The results of this review are illustrated in
Appendix 1, 2, 3 and 4, and are for the 15 adult inpatient areas detailed in the reports.
Page 3 of 12
4.1 Results
The results for each ward are illustrated in Appendix 1 – 4:
Appendix 1: Shows the reported dependency levels for each ward
Appendix 2: Illustrates the number of staff required according to patient
Acuity ‘v’ the Funded establishment, by ward.
Appendix 3: Shows the variance between funded staffing and staffing
required according to dependency.
Appendix 4: ‘HeatMap’ illustrating staffing variance and mapped against
nursing care indicators and incidents.
4.2 Analysis (Appendix 3) identified:

4 areas are within an acceptable 10% variance (Ward 30, 43, MAU and WHU)

5 areas sit with a 10.1 – 20% variance

6 areas have a variance >20%

No areas demonstrate staffing above 10% variance
These results highlight areas where a more detailed analysis and review needs to take place by
triangulating the data against other risks, complaints and patient care indicators.
4.3 Triangulation of Data
A HeatMap has been produced (Appendix 5) to map patient care indicators against ward staffing
and dependency data. The table below summarises the findings for the areas who sit outside of the
10% variance:
Key:
Ward/Dept
Ward 41
Ward 31
Elective
Unit
Surgical
Unit
Ward 45
Ward 40
‘+’ = Over staffed
‘ – ‘ = Under staffed
Variance
- 10.6%
- 11.8%
- 12.7%
- 14.4%
- 18.0%
- 20.5%
Comment
RN staffing at night <90% of planned levels during review period.
Number of falls & drug errors higher than average
RN staffing on day’s <90% of planned levels during review period
1 incident of C-Diff
RN staffing at night <90% of planned levels during review period.
1 incident of C-Diff
No significant issues identified
Average number of complaints during review period (2)
‘Moderate’ number of complaints, drug errors and falls
No significant issues identified
Average number of complaints during review period (2)
Page 4 of 12
Ward 5
-21.5%
Trauma
Unit
- 25.0%
Ward 42
-29.3%
Ward 44
- 31.7%
Ward 46
-37.5%
Number of complaints during review period high (5) and this area was
one of only 2 areas reporting the development of a grade 2 pressure
ulcer during this period.
Planned staffing levels good during review period
High number of falls reported (9), but no other significant issues.
High number of falls reported (8), 2 complaints & 1 drug error.
This area reported the highest number of falls during the review period
(11).
The only incident of MRSA was reported in this area, plus 1 grade 2
Pressure Ulcer (a total of 2 were reported in all areas during review).
No complaints reported
4.4 Discussion
The analysis has demonstrated that a significant number of our ward areas did not have the
budgeted staffing levels to meet the acuity and dependency of the patients they provided care to
during the review period. These reviews are undertaken at a point in time, it is therefore important to
consider the findings over a longer period to determine the prevalence of increased patient
dependencies.
The table below shows the changes to patient dependency over the past 12-months based on all
patients assessed during each review period:
Review Date
Level 0
Level 1a
Level 1b
Level 2
Level 3
Jan 2014
45%
19%
36%
<0.1%
-
June 2014
48%
16%
36%
<0.1%
-
Jan 2015
35%
16%
48%
1%
-
The above illustrates a reduction in the number of Level 0 patients and an increase in Level 1b and
Level 2 patients. This suggests the patient mix admitted to our wards in Jan 2015 were significantly
more acute and/or dependent, requiring higher levels of nursing care, intervention and support than
previous reviews had identified.
When reviewing the Nursing Care Indicators, there has been little change when comparing results
between studies, although there has been a significant increase in the number of complaints
reported (see below). This needs to be considered however; against the assertive work we have
done to accurately capture these against incident reporting.
Date
Complaints
Drug
Errors
Falls
MRSA
C.Diff
Grade 2
Pressure
Ulcers
June 2014
9
12
81
0
2
2
Jan 2015
39
13
79
1
2
2
Page 5 of 12
Further work is required Divisionally to review the areas that sit outside of the +/- 10% variance and
triangulate with other safety metric data to identify any risks to patient care. The outcomes from this
work will be reported through Divisional Governance structures and via Senior Nursing and Staffing
Forums in order to provide further Board assurance.
4.5 Impact of NICE Guidelines
In July 2014 the National Institute for Health and Care Excellence (NIC) published guidance in
relation to nurse staffing levels: ‘Safe Staffing for nursing in adult inpatient wards in acute hospitals.
This report highlighted that patient care may be compromised in areas where nursing staff were
required to care for more than 8 patients during the day and 10 patients at night.
Further analysis of the acuity and dependency data has been undertaken to map the trust’s position
against NICE guidelines, and illustrate the impact; should these recommended ‘minimum’ staffing
levels/ratio’s be applied across our inpatient areas. The results of this remapping are shown in
Appendix 5 & 6.
If staffing establishments were increased to meet NICE guidance only 5 areas would sit outside the
+/- 10% variance for understaffing, and 10 would be satisfactory, whereas currently only 4 areas are
satisfactory.
4.6 Recommendations
The table below outlines the recommendations and required action as a result of this latest Acuity &
Dependency review:
Recommendation
Action
Review ward areas who sit outside
of the +/- 10% variance.
Triangulate with safety data
to determine actual/potential
risks.
Develop action plans to
mitigate/address known risks
Divisional
Teams
Gap analysis of NICE guidance
completed:
Trust Board to be appraised of
quality, safety and cost
implications and potential options
for implementation.
Consider implications of
implementing NICE
Guidelines.
Decide whether any increase
to nursing establishments is
required.
Trust Board
April 2015
Further analysis of additional
staffing data/information in-line
with NHS England ‘Hard Truths’
Reporting requirements and NICE
guidance recommendations.
Report to be provided to
Trust Board and
disseminated Divisionally to
ward teams
Anne Allison
May 2015
Further establishment reviews
required for those areas not
captured during this review.
Establishment reviews to be
undertaken in:
 Critical Care
 Maternity
 Children’s Unit
Divisional
Teams
June 2015
Page 6 of 12
Responsibility
Completion
Date
May 2015
Appendix 1
Dependency Levels by Ward
January 2015
700
600
Patient Beddays
500
400
300
200
100
0
00
0 0
Acute Stroke Elective Unit
and Short
Stay Unit
30
MAU
0
0
00
Surgical Unit Trauma Unit
00
Ward 30
00
Ward 31
10
Ward 40
00
Ward 41
00
Ward 42
Ward
Level0
Level1a
Level1b
Page 7 of 12
Level2
Level3
00
Ward 43
520
Ward 44
00
Ward 45 and
Stroke Rehab
Unit
00
Ward 46
20
Womens
Health Unit
Appendix 2
Dependency vs Current Staffing - January 2015
80
70
60
50
40
30
20
10
0
Dependency
Current Staffing
Acute
Stroke and
Short Stay
Unit
24.537
20.2
Elective
Unit
MAU
Surgical
Unit
Trauma
Unit
Ward 30
Ward 31
Ward 40
Ward 41
Ward 42
Ward 43
Ward 44
Ward 45
and Stroke
Rehab Unit
Ward 46
Womens
Health Unit
28.481
70.659
29.745
56.732
19.656
35.091
39.757
35.96
42.167
24.698
35.156
38.01
35.795
17.506
25.28
67.8
26
45.4
20.7
31.4
33
32.5
32.6
26.6
26.7
32.2
26.04
16.3
Dependency
Current Staffing
Page 8 of 12
Appendix 3
% Variance - January 2015
(Current Staffing-Dependency)/
Current Staffing
100.0%
75.0%
50.0%
25.0%
5.0%
7.2%
0.0%
-4.2%
-12.7%
-25.0%
-11.8%
-14.4%
-21.5%
-7.4%
-10.6%
-20.5%
-18.0%
-25.0%
-29.3%
-31.7%
-37.5%
-50.0%
-75.0%
-100.0%
Acute Stroke Elective Unit
and Short
Stay Unit
MAU
Surgical Unit Trauma Unit
Ward 30
Ward 31
Ward 40
Page 9 of 12
Ward 41
Ward 42
Ward 43
Ward 44
Ward 45 and
Stroke
Rehab Unit
Ward 46
Womens
Health Unit
Appendix 4
Acuity & Dependency - January 2015
FundedDependency
Elective Unit
Surgical Unit
Trauma Unit
Ward 30
Ward 31
Ward 40
Ward 41
Ward 42
Ward 43
Ward 44
Ward 45
Ward 46
MAU
Ward 5
CCU
ITU
Women's Health Unit
Total
-12.7%
-14.4%
-25.0%
5.0%
-11.8%
-20.5%
-10.6%
-29.3%
7.2%
-31.7%
-18.0%
-37.5%
-4.2%
-21.5%
N/A
N/A
-7.4%
Complaints
Drug Errors
2
3
5
3
2
2
2
2
2
2
1
0
8
1
0
0
4
39
2
0
1
0
0
0
2
0
1
1
1
1
3
1
0
0
0
13
Falls
MRSA
7
3
4
3
0
3
6
9
4
8
5
11
6
7
0
0
3
79
Pressure Ulcers (Grade 2 only)
C.Diff
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
1
1
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
1
0
0
0
0
0
0
0
0
1
0
0
0
0
0
2
Registered
Staff - Day
Shift
97.4%
105.4%
96.8%
99.2%
87.7%
94.3%
93.6%
94.9%
100.2%
100.2%
83.3%
91.4%
98.8%
78.6%
96.3%
99.6%
87.8%
Registered
Staff - Night
Shift
Care Staff Day Shift
Care Staff Night Shift
86.9%
118.6%
99.2%
95.7%
95.9%
94.6%
88.2%
93.5%
102.6%
103.4%
103.9%
96.5%
84.5%
101.7%
101.2%
94.2%
115.6%
109.3%
122.9%
124.3%
110.8%
103.0%
115.9%
120.6%
121.4%
151.5%
137.9%
114.9%
116.2%
92.0%
112.3%
60.4%
91.9%
96.0%
130.6%
166.3%
122.5%
106.9%
119.8%
116.4%
192.1%
166.3%
173.3%
162.4%
114.2%
117.1%
119.1%
101.0%
N/A
N/A
N/A
Key:
Funded – Dependency
+/- 10% = Green
+/- 10% - 20% = Amber
+/- 20% = Red
Complaints
0 = Green
1 = Amber
2 = Red
Drug Error
0 = Green
1 = Amber
2 = Red
Falls
<4 = Green
5 – 7 = Amber
>8 = Red
MRSA
0 = Green
1 = Amber
2 = Red
C Diff
0 = Green
1 = Amber
2 = Red
Pressure Ulcer
0 = Green
1 = Amber
2 = Red
Staff Fill Rates
>90% = Green
80% - 90% = Amber
<80% = Red
Page 10 of 12
Appendix 5
% Variance - January 2015
(Proposed Staffing-Dependency)/
Proposed Staffing
100.0%
75.0%
50.0%
25.0%
9.8%
17.4%
8.7%
4.7%
4.6%
0.0%
-2.3%
-4.2%
-14.8%
-25.0%
-4.8%
-7.4%
-7.7%
-15.9%
-17.6%
-22.9%
-19.7%
-50.0%
-75.0%
-100.0%
Acute Elective Unit
Stroke and
Short Stay
Unit
MAU
Surgical Trauma Unit
Unit
Ward 30
Ward 31
Ward 40
Page 11 of 12
Ward 41
Ward 42
Ward 43
Ward 44 Ward 45 and Ward 46
Stroke
Rehab Unit
Womens
Health Unit
Appendix 6
% Variance Comparison - January 2015
100.0%
75.0%
50.0%
25.0%
0.0%
-25.0%
-50.0%
-75.0%
-100.0%
Acute
Elective
Stroke and Unit
Short Stay
Unit
MAU
Surgical
Unit
Trauma
Unit
Ward 30
% Variance
Ward 31
Ward 40
Ward 41
Ward 42
% Variance (Proposed Staffing)
Page 12 of 12
Ward 43
Ward 44
Ward 45 Ward 46 Womens
and Stroke
Health
Rehab Unit
Unit
Agenda Item
8d
Title
Finance & Activity Report – February 2015
Claire Yarwood – Director of Finance
Author (s)
Suzanne Holroyd – Deputy Director of Finance
Purpose
To update the Finance & Performance Committee on
the financial position at the end of February 2015 (
Month 11)
Finance and Performance Committee on 24/03/15
Executive Summary
The Trust remains in financial deficit with the forecast deficit estimated to be circa £18.23m,
an increase above the planned deficit of £17.5m. At the end of February the actual deficit
stands at £16.98m.
5 – Develop a strategic plan to secure clinical and financial
sustainability for the Trust in conjunction with the Trust’s
strategic partners and key stakeholders
7 – to deliver against local and national frameworks in order
to meet all the requirements of the Trust’s operating licence
Risk Assurance – risk
impacted upon
723 – Failure to meet, deliver Trust’s financial plan
Legal
implications/Regulatory
requirements
None
Has a quality impact
assessment been
undertaken?
Sustainability?
No
Sustainability is subject to the outcome of the system wide
review by the CPT
The Board is requested to discuss and recognise the change in the forecast outturn
to £18.23m.
1
Summary Financial Position
As a result of a request from Monitor this paper will now also report against the reforecast plan submitted to Monitor. The Trust will however continue to report against
its original plan in order to understand where there has been non-delivery against
agreed income and expenditure budgets.
Original Plan Performance
Key Financial Metrics: Month 11 – February 2015
YTD Plan
YTD
Actual
YTD
Variance
FY Plan
Forecast
Outturn @
February
2014
£'000
£'000
£'000
£'000
£'000
868
127,825
130,916
3,091
140,021
144,499
1,469
566
10,000
10,910
910
10,921
11,511
(13,157)
(14,389)
(1,231)
(145,756)
(150,584)
(4,827)
(159,057)
(165,388)
EBITDA
(889)
(686)
203
(7,931)
(8,758)
(827)
(8,115)
(9,378)
Financing
Net (Deficit)
Surplus
Exceptional
Items
Normalised
(Deficit)Surplus
(775)
(733)
(41)
(8,583)
(8,225)
358
(9,385)
(8,851)
(1,664)
(1,420)
(244)
(16,514)
(16,983)
(469)
(17,500)
(18,229)
0
0
(16,514)
(16,983)
1
1
0
1
1
2,211
772
3,175
3,175
Income –
Clinical activity
Income - Other
Expenditure
Current
Month
Plan
Current
Month
Actual
Current
Month
Variance
£'000
£'000
£'000
11,365
12,233
903
0
(1,664)
0
(1,420)
0
(244)
0
0
(469)
3,235
(17,500)
(14,994)
CoSRR
Capital
expenditure
Cash
163
53
110
2,983
500
513
13
500
500
CIP
617
1,011
394
5,450
6,168
718
6,100
6,800
The tables below compare the financial planned position to the actual position both
year to date and in month.
Cumulative Planned Deficit v Actual Deficit
5,000
Surplus (Deficit)
£'000
0
(5,000)
(10,000)
(15,000)
(20,000)
£'000
Planned
Deficit
Clinical
Income
Other
Income
Pay Costs
Non Pay
Costs
Financing &
Dep'n
Actual
Deficit
(16,514)
3,091
910
(4,302)
(526)
358
(16,983)
2
In Month Planned Deficit
v Actual Deficit
1,000
Surplus(Deficit)
£'000
500
0
(500)
(1,000)
(1,500)
(2,000)
£'000
Planned
Deficit
Clinical
Income
Other
Income
Pay Costs
Non Pay
Costs
Financing /
Dep'n
Actual
Deficit
(1,664)
868
566
(673)
(558)
41
(1,420)

Financial Position–The Trust is reporting a cumulative deficit of £16.98m at
the end of February, against a planned deficit of £16.51m, £469k behind plan
and a Continuity of Service Risk Rating of 1 against an expected rating of 1.
In month, the Trust is £244k ahead of plan with an in month deficit of £1,420k.

The main driver of the cumulative deficit is above planned levels of pay
expenditure, with an underlying income under-performance, as explained
below.

In month £451k has been released from the balance sheet into other clinical
and other non-clinical income (£451k cumulatively). This relates to clinical
income provisions for penalties no longer required.

Cumulatively EBITDA is behind plan by £827k.

Forecast Outturn – is reported within the key financial metrics table above,
and is currently estimated to be a forecast deficit of £18.23m prior to technical
items. The revaluation of the estate is estimated to reduce this to £14.99m.

Income – Clinical income is over-performing cumulatively by £3,091k against
the original plan, this however masks the fact that income is being received
for winter resilience (£1,473k) and RTT (£2,347k) that is not in the plan.
February RTT activity has again shown an in increase on last month up from
143 admitted patients to 173, with no non admitted patients being seen. If this
income is stripped out income would show a cumulative under-performance of
£729k with regard to the baseline contracts, based on RTT activity being in
addition to contract. This reflects a continuation of the improving underlying
position.
Clinical income is above plan in February by £868k, driven by income overperformance in other clinical income of £1,620k and elective of £129k, offset
by under-performance on non-elective of £825k, outpatients £48k and A&E of
3
£8k. It should be noted however, that in month performance has been
reduced by £61k relating to the previous months income movements. If
previous months losses, and RTT (£242k) and resilience funding (£299k)
were excluded the in month position would be an over-performance of £388k,
again reflecting an improving position.
Appendix B1 now incorporates revised baseline income and activity plans to
show performance against budget had the income and activity budgets been
increased for RTT and resilience funding. In this scenario in month income
over-performance would be £569k, with a cumulative under-performance of
£406k.

Cumulatively activity is above plan with the exception of outpatients and
combined non-elective and ambulatory care which is below plan. However, if
the plan were increased to include RTT additional activity elective activity
would now be above plan due to the in month performance. Compared with
activity levels this time last year activity is now ahead of those levels, but it
should be remembered that activity levels fell in 2013/14 with the introduction
of Lorenzo, such that all points of delivery were underperforming by
December 2013.
February – Original Activity (Spells / attendances)
Activity
Elective
Non
Elective
Ambulatory
Care
Outpatients
A&E
Plan
Month
Actual
Month
Variance
1,853
2,052
199
19,887
Actual
Cum
20,664
Variance
777
2,304
1,735
(569)
25,291
22,327
(2,965)
51
330
279
604
3,193
2,589
19,335
19,362
27
217,838
216,147
(1,691)
6,060

Plan
Cum
5,968
(92)
72,291
74,770
2,479
Variance if
plan
increased
for RTT
February
2014 YTD
Actual
67
18,906
(2,965)
2,589
24,815
462
(2,469)
213,794
2,479
70,446
Expenditure Costs are overspending by £1,231k in the month, and £4,827k
year to date. The table below tracks the causes of the overspend. Further
information can be found in Appendix C. The main cause of the deterioration
both in month and year to date is pay costs.
Planned Costs
Pay Costs
Drugs
Clinical Supplies & Services
General Supplies & Services
Establishment Expenses &
Costs
Premises & Fixed Plant
Other Costs
Actual Costs
(145,756)
(4,302)
(144)
(505)
595
(657)
(1,073)
1,258
(150,584)
4
Analysis of pay variance – Year to February
Variance
£’000
(1,624)
(1,694)
(985)
(4,303)
Medical Pay
Nursing Pay
Other Pay
Total
Comment
Use of agency staff,
Over- establishment & agency
Lorenzo, IT and Information, UHSM recharge
The graph below shows actual WTE compared with budgeted WTE for the main staff
categories. The over-establishment on nursing is 141wte (120wte in January). This is
related to non-delivery of CIP (reducing length of stay/beds) (85wte February / 85wte
January), unfunded escalation beds (2wte in February / January 9wte), and ward
staffing above approved levels in many of the wards (54wte in February / 26wte in
January).
Current month budget v actual wte Trust Total
1,400
1,200
1,000
800
600
1,108
1,249
400
200
342
1,020
981
328
WTE Medical
WTE Nursing
Wte Budget

WTE Other
Wte Actual
CIP – CIP performance is above plan in February by £394k, taking the total in
year savings identified and actioned to £6.17m against a plan of £5.45m. Of
the savings identified, £2.43m has been achieved non-recurrently and £3.74m
is recurrent. Appendix F provides additional CIP information.
Recurrently, the full year effect of identified savings is £4.91m.
The CIP delivery to the year end is £6.76m, and is forecast to be £6.8m. The
Trust has reassessed the operational CIP targets and has allocated all targets
to a divisional level to ensure delivery of the recurrent target of £6.1m for the
year. In addition a 1% stretch /contingency target has also been introduced.

Cash - Cash balances are just above plan at £513k. In order to comply with
the DoH requirement to ensure that no more than £500k is held in the bank at
month end the Trust will manage its PDC drawdown based on projected in
month cash requirements. Cash flow performance information can be found in
Appendices E1 to E3. The Trust has called down £661k of PDC in February.
The total PDC received to date is £9.007m. The Trust has just received
notification that no new PDC will be issued going forward and all temporary
PDC received to date will have to be re-paid in March, and will be replaced by
two year loan agreements.
5
Monitor Re-Forecast Plan Performance
Financial Metrics: Month 11 – February 2015
YTD Actual
YTD
Variance
Forecast
Outturn @
February
2014
£'000
£'000
£'000
£'000
Current
Month
Plan
Current
Month
Actual
Current
Month
Variance
YTD Plan
£'000
£'000
£'000
Income –
Clinical activity
11,674
12,233
559
127,980
130,916
2,936
144,499
Income - Other
992
1,469
477
10,637
10,910
273
11,511
(13,778)
(14,389)
(611)
(150,307)
(150,584)
(277)
(165,388)
(1,113)
(686)
426
(11,689)
(8,758)
2,932
(9,378)
(727)
(733)
(6)
(8,160)
(8,225)
(65)
(8,851)
(1,840)
(1,420)
420
(19,850)
(16,983)
2,867
(18,229)
Expenditure
EBITDA
Financing
Net (Deficit)
Surplus
Exceptional
Items
Normalised
(Deficit)Surplus
0
(1,840)
(1,420)
0
420
(19,850)
0
(16,983)
0
2,867
3,235
(14,994)
The table above details the Trust performance against the revised forecast outturn
deficit of £21.03m submitted to Monitor.

Financial Position–The Trust is reporting a cumulative deficit of £16.98m at
the end of February, against a planned deficit of £19.85m, £2.87m ahead of
plan and a Continuity of Service Risk Rating of 1 against an expected rating of
1. In month, the Trust is £420k ahead of plan with an in month deficit of
£1.42m.

The main driver of the above plan performance is higher than planned levels
of income. Of the in-month income over-performance £61k relates to
previous months positions. Also within the in-month income over-performance
is the receipt of £159k(£796k YTD) of resilience funding agreed with Monitor
after the revised plan was submitted. The other key driver of the income overperformance relates to the actual delivery of RTT against the RTT profiling in
the revised plan. The actual RTT is behind plan by £146k in February and
£28k behind plan cumulative to the end of February.
If the above items are adjusted for the in-month income position would be an
over-performance of £607k in January and a cumulative income overperformance of £2,268k.

In month £451k has been released from the balance sheet into other clinical
and other non-clinical income (£451k cumulatively). This relates to clinical
income provisions for penalties no longer required.

Cumulatively EBITDA is ahead of plan by £2.93m.
6
Underlying Financial Position
The table below details the underlying financial position. The table identifies the
position reported to Board and then restates it for the underlying income position
when movements in the month relate to previous months. There is currently a
backlog in coding of seven weeks, and as coding is caught up with this will change
previous months’ income figures. This income restatement is currently being re-done
to reflect the changes in the way the maternity pathway is being recalculated, and to
reflect an agreed year end settlement, in agreement with Tameside & Glossop CCG,
and as such the position has not been restated since January. This restated position
has then been adjusted for non-recurrent income and expenditure, which once
adjusted for reduces the underlying deficit by £920k to a deficit of £16,063k.
April May June July Aug Sept Oct Nov Dec
REPORTEDFINANCIALPOSITION -2,427 -2,108 -2,626 -1,254 -1,179 -1,645 -1,216 -824 -1,114
Re-StatedSurplus/(Deficit)for
IncomeRe-Profiling
-2,572 -1,772 -1,816 -1,225 -2,087 -1,093 -1,199 -751 -911
Re-StatedSurplus/(Deficit) for
Income Re-Profilingand
excludingnon-recurrentincome
&expenditure
-2,123 -1,503 -1,496 -1,069 -1,867 -953 -1,210 -996 -982
MovementinSurplus/(deficit) -304 -605 -1,130 -185 688 -692 -6 172 -133
Note:- (Movement- minusfigure=improvementplusfigure=deteriorationonthepositionreportedtoBoard)
Jan Feb Total
-1,169 -1,420 -16,983
-2,136 -1,420 -16,984
-2,163 -1,701 -16,063
994 281 -920
Conclusion
At the end of February the Trust is cumulatively behind is original plan by £469k, and
ahead of the revised plan by £2.86m with a deficit of £16.98m.
The factors driving the position against the original plan are below planned levels of
activity and continued high levels of pay expenditure at premium rates and overestablishments. The performance against the revised plan is due to above planned
levels of clinical income.
Cumulatively, the Trust is ahead of its CIP trajectory (13.19%) and it is essential this
is maintained going forward. There continue to be risks around the full year effect of
CIP’s as a further £1.19m of schemes are required to be in place by 1 April 2015.
Executive Directors continue to hold a weekly meeting with Divisions on finance,
manpower and activity performance to reinforce the Tier 1 & 2 reviews that are one
of the core actions within the turnaround process. Weekly monitoring of elective
performance against a revised trajectory is expected to ensure that activity levels are
recovered for the remainder of the year.
7
Recommendation
The Board is requested to discuss and recognise the change in the forecast outturn
to £18.23m.
8
FINANCE DASHBOARD AS AT 28 FEBRUARY 15
Capital Programme
1,500
1,400
1,000
1,200
500
1,000
0
(500)
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb March
£000
Surplus/(Deficit)£000
Normalised Monthly Surplus/(Deficit)
800
600
(1,000)
400
(1,500)
200
(2,000)
-
(2,500)
(3,000)
Actual 14/15
Key Measures
EBITDA
Net Surplus/(Deficit)
Net Surplus/(Deficit) before Exceptional Items
CIP
EBITDA Margin %
EBITDA % Achieved of Plan
I&E Surplus Margin %
COSRR
Plan
Actual 13/14
Cumulative
Plan
£000
(7,931)
(16,514)
(16,514)
5,450
Annual Plan
%
-5.38%
99.40%
1.10%
Cumulative
Actual
£000
(8,758)
(16,983)
(16,983)
6,168
Cumulative
Actual
%
-6.17%
110.43%
-11.97%
Annual Plan
Cumulative
Actual
1
1
Variance
£000
(827)
(469)
(469)
718
Variance
%
-0.80%
11.03%
-13.07%
Actual
Cash Balances
£000
Plan
Margins
Month
Month
7,000
6,000
5,000
4,000
3,000
2,000
1,000
-
Month
Plan
Key Risks
1. Key risk is the non-delivery of CIP, and its associated impact on achieving financial recovery.
2. Activity underperformance.
3. In year cost pressures.
Actual
Appendix A
INCOME & EXPENDITURE REPORT FEBRUARY 15
In Month
Year to Date
Budget
Actual
Variance
Budget
Actual
Variance
£000
£000
£000
£000
£000
£000
Annual
budget
£000
Income
Clinical Income
Research & Development
Education & Training
Other Clinical & other non-clinical income
PFI Specific Income (transitional)
11,365
11
309
583
0
12,233
34
385
1,049
1
868
23
75
466
1
127,825
119
3,404
6,477
0
130,916
353
3,745
6,697
116
3,091
234
341
219
116
140,021
129
3,714
7,078
0
Total Income
12,268
13,702
1,434
137,825
141,826
4,001
150,942
(9,005)
(3,930)
(222)
0
(9,679)
(4,487)
(222)
(1)
(673)
(557)
0
(1)
(98,801)
(44,312)
(2,644)
0
(103,103)
(44,721)
(2,644)
(116)
(4,302)
(410)
0
(116)
(107,785)
(48,379)
(2,893)
0
(13,157)
(14,389)
(1,231)
(145,756)
(150,584)
(4,827)
(159,057)
(889)
-7.25%
(686)
-5.01%
203
2.24%
(7,931)
-5.75%
(8,758)
-6.17%
(827)
-0.42%
(8,115)
-5.38%
(398)
2
(187)
(60)
(2)
(89)
0
0
0
0
0
(4,770)
18
(2,230)
(709)
(14)
(880)
(3)
0
0
0
40
(4,347)
21
(2,230)
(712)
(18)
(976)
(3)
0
0
0
40
423
3
(0)
(4)
(4)
(97)
0
(449)
2
(187)
(59)
(1)
(80)
0
0
0
0
0
51
0
(0)
(0)
(1)
(9)
(5,219)
20
(2,437)
(775)
(15)
(960)
Net Surplus/(deficit)
(1,664)
(1,420)
244
(16,514)
(16,983)
(469)
(17,500)
For Information
Net Surplus/(deficit) before exceptional items
(1,664)
(1,420)
244
(16,514)
(16,983)
(469)
(17,500)
Expenditure
Pay Costs
Non-pay cost (incl internal recharges)
PFI Specific Expenditure - UP
PFI Specific Expenditure - transitional
Total Costs
EBITDA
EBITDA as a % of Income
Technical Items
Profit/(loss) on asset disposal
Exceptional income ( fixed asset impairment)
Exceptional costs ( fixed asset impairment)
Restructuring Costs
Plus Income from Donated Assets
Less Total Depreciation
Plus Total Interest Receivable
Less Total Interest payable on loans and leases - PFI
PFI Contingent Rent
Less Other Finance Cost - Unwinding Discount
Less PDC Dividend
Appendix A2
PERFORMANCE AGAINST RE-FORECAST MONITOR PLAN
INCOME & EXPENDITURE REPORT FEBRUARY 15
In Month
Year to Date
Budget
Actual
Variance
Budget
Actual
Variance
£000
£000
£000
£000
£000
£000
Annual
budget
£000
Income
Clinical Income
Other Clinical & other non-clinical income
PFI Specific Income (transitional)
11,674
37
325
630
0
12,233
34
385
1,049
1
559
(3)
60
419
1
127,980
403
3,572
6,662
0
130,916
353
3,745
6,697
116
2,936
(50)
173
34
116
140,168
438
3,898
7,311
0
Total Income
12,665
13,702
1,037
138,617
141,826
3,209
151,815
(9,436)
(4,105)
(237)
0
(9,679)
(4,487)
(222)
(1)
(243)
(382)
16
(1)
(103,026)
(44,570)
(2,652)
(59)
(103,103)
(44,721)
(2,644)
(116)
(77)
(151)
8
(57)
(112,392)
(48,588)
(2,889)
(59)
(13,778)
(14,389)
(611)
(150,307)
(150,584)
(277)
(163,928)
(1,113)
-8.78%
(686)
-5.01%
426
3.77%
(11,689)
-8.43%
(8,758)
-6.17%
2,932
2.26%
(12,113)
-7.98%
0
0
0
0
0
(399)
2
0
(190)
(59)
(2)
(80)
0
0
0
0
0
(398)
2
0
(187)
(60)
(2)
(89)
0
0
0
0
0
1
(0)
0
3
(0)
(1)
(9)
0
0
0
0
0
(4,330)
23
0
(2,248)
(711)
(17)
(878)
(3)
0
0
0
40
(4,347)
21
0
(2,230)
(712)
(18)
(976)
(3)
0
0
0
40
(17)
(2)
0
18
(2)
(1)
(98)
0
0
0
0
4
(4,729)
25
0
(2,458)
(777)
(19)
(958)
Net Surplus/(deficit)
(1,840)
(1,420)
420
(19,850)
(16,983)
2,867
(21,025)
For Information
Net Surplus/(deficit) before exceptional items
(1,840)
(1,420)
420
(19,850)
(16,983)
2,867
(21,025)
Expenditure
Pay Costs
Non-pay cost (incl internal recharges)
PFI Specific Expenditure - UP
PFI Specific Expenditure - transitional
Total Costs
EBITDA
EBITDA as a % of Income
Technical Items
Profit/(loss) on asset disposal
Exceptional income ( fixed asset impairment)
Exceptional costs ( fixed asset impairment)
Restructuring Costs
Plus Income from Donated Assets
Less Total Depreciation
Plus Total Interest Receivable
Plus income from Impairment
Less Total Interest payable on loans and leases - PFI
PFI Contingent Rent
Less Other Finance Cost - Unwinding Discount
Less PDC Dividend
Appendix B1
INCOME REPORT FEBRUARY 15
In Month
Clinical Income by type
Elective
Non-Elective
Outpatient
A&E
Other
Year to Date
Budget
Actual
Variance
Budget
Actual
Variance
£000
£000
£000
£000
£000
£000
Annual
budget
£000
1,931
3,892
2,115
649
2,779
2,059
3,067
2,067
641
4,399
129
(825)
(48)
(8)
1,620
21,272
43,209
23,820
7,737
31,788
20,755
41,117
23,666
7,948
37,430
(517)
(2,092)
(154)
211
5,642
23,363
47,371
26,065
8,455
34,767
11,365
12,233
868
127,825
130,916
3,091
140,021
9,752
428
589
90
537
(30)
8,600
334
525
145
690
1,939
(1,152)
(94)
(64)
56
152
1,969
109,561
4,808
6,619
1,007
6,300
(470)
111,304
4,823
6,346
967
6,182
1,293
1,743
16
(273)
(40)
(118)
1,763
119,985
5,265
7,250
1,103
6,908
(490)
11,365
12,233
868
127,825
130,916
3,091
140,021
Other clinical & other non-clinical income
PFI Specific Income - Transitional
11
309
583
0
34
385
1,049
1
23
75
466
1
119
3,404
6,477
0
353
3,745
6,697
116
234
341
219
116
129
3,714
7,078
0
Total
903
1,469
566
10,000
10,910
910
10,921
12,268
13,702
1,434
137,825
141,826
4,001
150,942
1,853
2,304
51
19,335
6,060
2,052
1,735
330
19,362
5,968
199
(569)
279
27
(92)
19,887
25,291
604
217,838
72,291
20,664
22,327
3,193
216,147
74,770
777
(2,965)
2,589
(1,691)
2,479
22,785
27,775
660
238,370
78,999
29,603
29,447
(156)
335,911
337,101
1,189
368,589
Total
Clinical Income by Commissioner
Tameside CCG
Manchester CCG
Oldham CCG
Stockport CCG
Specialised Services
All other income contracts and CIP
Total
Other income:
Total Income
Activity (Spells/ attendances)
Elective
Non Elective
Ambulatory Care
Outpatients (inc OPPROC)
A&E Attendances
Performance against revised plans adjusted for
RTT and winter resilience
In Month
Clinical Income by type
Elective
Non-Elective
Outpatient
A&E
Other
Total
Year to Date
Budget
Actual
Variance
Budget
Actual
Variance
Annual
budget
£000
£000
£000
£000
£000
£000
£000
1,931
3,892
2,115
649
3,078
2,059
3,067
2,067
641
4,399
129
(825)
(48)
(8)
1,321
22,727
43,209
23,958
7,737
33,691
20,755
41,117
23,666
7,948
37,430
(1,973)
(2,092)
(292)
211
3,739
24,819
47,371
26,203
8,455
36,968
11,664
12,233
569
131,322
130,916
(406)
143,816
1,853
2,304
51
19,335
6,060
2,052
1,735
330
19,362
5,968
199
(569)
279
27
(92)
20,597
25,291
604
218,616
72,291
20,664
22,327
3,193
216,147
74,770
67
(2,965)
2,589
(2,469)
2,479
23,495
27,775
660
239,148
78,999
29,603
29,447
(157)
337,399
337,101
(299)
370,077
Activity (Spells/ attendances)
Elective
Non Elective
Ambulatory Care
Outpatients (inc OPPROC)
A&E Attendances
EXPENDITURE REPORT FEBRUARY 15
APPENDIX C
ANALYSIS OF EXPENDITURE
Budget
wte
In Month
Budget
£000's
Actuals
wte
Actuals
£000's
Variance
£000's
Budget
£000's
Year-to-Date
Actuals
£000's
Variance
£000's
Annual
Budget
£000's
Expenditure
Pay Costs:Medical
Medical Agency
Nursing
Nursing Agency
Other
Other Agency
Total Pay Costs
341.53
0.27
1,108.17
1,009.02
10.98
279.91
47.94
1,217.36
32.07
980.74
0.00
(2,568)
(166)
(3,643)
(0)
(2,606)
(22)
(2,423)
(636)
(3,660)
(228)
(2,561)
(170)
2,469.97
2,558.02
(9,005)
(597)
(986)
(526)
(106)
(605)
(599)
(511)
(222)
0
Non-Pay Costs:Drugs
Clinical Supplies & Services
General Supplies & Services
Establishment Expenses
Other Establishment Costs
Premises & Fixed Plant
Other
PFI - UP
PFI - Transitional Costs
Total Non-Pay Costs
Total Expenditure
0
2,469.97
0
2,558.02
(28,448)
(1,787)
(39,589)
(3)
(28,734)
(240)
(25,750)
(6,108)
(39,205)
(2,081)
(27,640)
(2,319)
2,699
(4,322)
383
(2,077)
1,094
(2,079)
(30,992)
(1,953)
(43,233)
(3)
(31,341)
(262)
(9,679)
145
(470)
(18)
(228)
45
(148)
0
(673)
(98,801)
(103,103)
(4,302)
(107,785)
(722)
(1,063)
(502)
(148)
(737)
(749)
(566)
(222)
(1)
(124)
(78)
23
(42)
(131)
(149)
(56)
0
(1)
(7,203)
(11,202)
(5,918)
(1,260)
(6,686)
(6,408)
(5,634)
(2,644)
0
(7,347)
(11,707)
(5,323)
(1,627)
(6,976)
(7,481)
(4,260)
(2,644)
(116)
(144)
(505)
595
(367)
(290)
(1,073)
1,374
0
(116)
(7,853)
(12,243)
(6,458)
(1,370)
(7,292)
(7,017)
(6,145)
(2,893)
0
(4,152)
(4,710)
(558)
(46,956)
(47,481)
(525)
(51,272)
(13,157)
(14,389)
(1,231)
(145,756)
(150,584)
(4,827)
(159,057)
The above table excludes expenditure on technical items as detailed in Appendix A such as depreciation, dividends and exceptional items.
Appendix D1
STATEMENT OF POSITION 2014/15
Column A
Column B
Period Ending
31 March
2014
£'000s
Period Ending
31 January
2015
£'000s
Column C
Column D
Period Ending
28 February
2015
£'000s
Movement in
the month
January February
2015
£'000s
Non Current Assets
Property, plant and equipment
PFI: Property, plant and equipment
69,396
36,798
68,349
36,091
68,075
36,020
(275)
(71)
203
2,309
280
2,869
319
2,920
40
51
108,707
107,588
107,334
(255)
Current Assets
Inventories - Stock - Finished Goods
1,300
1,377
1,415
38
Trade & Other Receivables:> NHS Trade Receivables
> Non NHS Trade Receivables
> Other Receivables
> Accrued Income
> Prepayments - Non PFI Related
1,432
730
531
2,105
740
1,035
123
489
3,536
1,582
1,285
79
479
3,595
1,075
250
(44)
(10)
59
(507)
0
Trade and Other Receivables
> Accrued Income (CRU Income grt than 1 yr)
> Prepayments - PFI Related
Total Non Current Assets
Non-Current Assets held for sale and
assets in disposal groups
0
2,586
2,000
500
0
513
0
0
0
12
0
Total Current Assets
11,424
8,643
8,442
(201)
Current Liabilities
Trade & Other Payables:> NHS Trade Creditors
> Non NHS Trade Creditors
> Other Creditors
> Capital Creditors
(1,501)
(2,548)
(3,105)
(491)
(884)
(1,637)
(4,658)
(931)
(1,147)
(2,518)
(4,744)
(920)
(263)
(881)
(86)
11
(10,808)
(1,880)
(1,428)
(40)
(13,477)
(1,943)
(1,428)
(409)
(12,673)
(1,839)
(1,428)
(497)
804
104
0
(89)
(190)
(591)
(605)
(14)
Total Current Liabilities
(21,991)
(25,958)
(26,370)
(412)
Net Current Assets/Liabilities
(10,567)
(17,315)
(17,928)
(614)
Non Current Liabilities
Other Financial Liabilities:> Deferred Income
> PFI Leases
(312)
(57,440)
(698)
(56,243)
(698)
(56,134)
0
110
(638)
(800)
(800)
0
Total Non Current Liabilities
(58,390)
(57,742)
(57,632)
110
TOTAL ASSETS EMPLOYED
39,749
32,532
31,774
(759)
Financed By Taxpayers Equity
PDC
Revaluation Reserve
I&E Reserve
I&E Reserve 2013/14
I&E reserve 2014/15
53,168
19,347
(33,895)
1,130
0
61,514
19,347
(33,895)
1,130
(15,563)
62,175
19,347
(33,895)
1,130
(16,983)
661
0
0
0
(1,420)
TOTAL TAXPAYERS EQUITY
39,749
32,532
31,774
(759)
Cash
Investments
Other Liabilities:> Accruals
> Deferred Income
>PFI Leases
>PDC Dividend Creditor
Provisions
Provisions
Cashflow Statement 2014/15
Actual April
2014 £'000
Actual
May 2014
£'000
Actual
June 2014
£'000
Actual
Q1
2014/15
£'000
Actual
Q2
2014/15
£'000
Actual
Q3
2014/15
£'000
Actual
January
2015
£'000
Actual
February
2015
£'000
(2,427)
(2,109)
(2,625)
(7,161)
(4,077)
(3,156)
(1,169)
(1,420)
Gain/loss on disposal of property, plant and equipment
394
0
80
0
394
0
80
0
396
0
80
0
1,184
0
240
0
1,181
0
240
0
1,187
0
239
3
398
0
169
0
Other increases/(decreases) to reconcile to profit/(loss) from operation items
262
272
262
796
804
765
271
Operating Surplus/(deficit) after tax
Depreciation and Amortimisation
Impairment losses/(reversals)
PDC Dividend
YTD
Actual
£'000
YTD
Movement
to plan
£'000
Plan
March
2015
£'000
Plan
Q4
2014/15
£'000
(469)
0
0
(423)
0
138
3
2,200
(389)
398
0
89
0
(16,983)
0
0
4,348
0
976
3
398
(3,235)
(111)
0
245
2,882
(63)
Revised
Plan
2014/15
£'000
Monitor Plan
2014/15
£'000
(17,500)
1,194
(3,235)
147
0
(14,783)
0
0
4,746
(3,235)
865
3
268
784
3,149
3,212
0
5,219
0
959
0
736
746
737
2,219
2,225
2,195
839
732
8,209
(345)
(2,681)
(1,111)
5,528
9,390
(1,691)
(1,363)
(1,888)
(4,942)
(1,852)
(961)
(331)
(688)
(8,773)
(813)
(481)
(1,500)
(9,254)
(8,110)
(62)
11
573
66
(316)
(346)
0
677
0
1,292
1,264
615
(99)
(232)
59
(153)
(42)
(85)
0
(193)
0
56
655
(246)
103
464
(19)
147
165
(229)
(124)
379
(47)
(54)
(128)
(225)
0
1,323
0
4
(2,068)
(160)
170
(688)
77
61
(628)
112
0
(1,182)
0
142
442
(15)
(65)
462
(36)
(25)
(481)
(71)
(38)
(250)
44
10
(59)
507
(1,397)
0
28
1,691
(343)
(58)
243
613
60
(193)
(660)
0
(913)
0
1,376
3,610
27
(758)
0
31
685
598
1,143
0
86
(804)
(104)
(115)
147
650
51
(1,490)
(335)
0
(385)
0
1,639
1,864
346
56
853
75
(64)
(1,430)
109
0
(3,135)
0
1,348
5,925
(244)
0
(1,050)
0
(533)
1,000
422
0
(500)
0
(2,950)
622
(279)
(103)
(838)
7
(549)
459
859
0
(114)
0
(2,834)
502
215
(115)
(903)
650
(482)
(490)
87
0
(885)
0
(1,311)
2,486
67
0
0
542
0
0
0
0
608
0
1,148
(2,695)
0
Increase/(Decrease) in working capital total
(16)
3,758
1
(279)
(7)
604
(22)
4,083
155
(944)
(35)
(1,544)
465
804
14
548
576
2,947
447
3,939
0
(3,268)
479
(1,916)
576
(321)
0
(397)
Net cash inflow/(outflow) from operating activities
2,067
(1,642)
(1,284)
(859)
(2,796)
(2,505)
473
(140)
(5,826)
3,125
(3,749)
(3,416)
(9,575)
(8,507)
Net cash inflow/(outflow) from Investing activies - Total
(71)
(304)
(375)
(41)
(54)
(95)
(25)
(22)
(47)
(137)
(380)
(517)
(331)
193
(138)
(1,594)
1,046
(548)
(96)
(419)
(515)
(53)
(11)
(64)
(2,211)
429
(1,782)
991
669
1,660
(692)
(158)
(850)
(841)
(588)
(1,429)
(2,903)
271
(2,632)
(3,175)
(365)
(3,540)
Net cash inflow/(outflow) before financing
1,692
(1,736)
(1,331)
(1,375)
(2,934)
(3,053)
(42)
(204)
(7,608)
4,785
(4,599)
(4,845)
(12,207)
(12,047)
0
0
0
(264)
(172)
2
0
0
0
(273)
(178)
2
662
0
0
(264)
(172)
3
(44)
(493)
(39)
190
2,535
0
0
(810)
(528)
5
0
(60)
1,141
661
0
0
(247)
(161)
2
177
(257)
4,675
0
(519)
(810)
(528)
5
0
(86)
2,737
474
0
0
(273)
(178)
2
Net cash inflow/(outflow) from Financing activities - Total
662
0
0
(801)
(522)
7
0
94
(560)
(24)
1
(40)
216
9,007
0
(519)
(2,942)
(1,917)
21
0
(116)
3,534
(4,592)
0
(40)
(7)
6
2
0
(141)
(4,772)
0
(9,007)
(585)
(281)
(174)
3
14,650
(19)
4,587
1,135
(9,007)
(585)
(801)
(513)
6
14,650
(82)
4,804
9,007
(9,007)
(1,104)
(3,223)
(2,091)
24
14,650
(135)
8,121
14,300
0
(959)
(3,212)
(2,102)
20
0
0
8,047
Net increase/(decrease) in cash and cash equivalents
1,435
(2,229)
(1,141)
(1,936)
(197)
(1,911)
(41)
12
(4,073)
12
(13)
(41)
(4,086)
(4,000)
Opening cash and cash equivalents
4,586
6,021
3,792
4,586
2,650
2,453
542
500
4,586
0
513
542
4,586
4,500
Closing cash and cash equivalents
6,021
3,792
2,650
2,650
2,453
542
500
513
513
13
500
500
500
500
Monitor Plan 14/15
Variance to Monitor Plan 14/15
4,370
1,651
3,178
614
500
2,150
500
2,150
500
1,953
500
42
500
0
500
13
500
13
12
0
500
(0)
500
0
500
0
500
(0)
Non-Cash flows in operating surplus/(deficit) total
Operating Cash Flows before movement in working capital
Increase/(Decrease) in working capital
(Increase)/Decrease in inventories
(Increase)/Decrease in NHS Trade Receivables
(Increase)/Decrease in Non NHS Trade Receivables
(Increase)/Decrease in other receivables
(Increase)/Decrease in accrued income
(Increase)/Decrease in prepayments
(Increase)/Decrease in Non Current Assets held for sale
Increase/(Decrease) in Trade Creditors
Increase of creditors due to insufficient PDC funding
Increase/(Decrease) in Other Creditors
Increase/(Decrease) in accruals
Increase/(Decrease) in Deferred Income (exl Donated Assets)
Increase/(Decrease) in provisions
Net cash inflow/(outflow) from Investing activies
Property, plant and equipment - maintenance expenditure
Increase/(decrease) in Capital Creditor
Net cash inflow/(outflow) from Financing activities
Public Dividend Capital Received
Public Dividend Capital Repaid
PDC Dividends paid
Interest element of finance lease rentals on balance sheet
Capital element of finance lease rental payments - on balance sheet
Interest received on cash and cash equivalent
Increase/(decrease) in non-current payables - Loan from DOH
(Increase)/decrease in non-current receivables
Appendix E2
Rolling 12 Month Cashflow Statement March 2015 - February 2016
2014/15
Plan
March
2015
£'000
Plan
Q4
2014/15
£'000
Plan
May
2015
£'000
Plan
June
2015
£'000
Plan
July
2015
£'000
Plan
August
2015
£'000
Plan
September
2015
£'000
Plan
October
2015
£'000
Plan
November
2015
£'000
Plan
December
2015
£'000
Plan
January
2016
£'000
Plan
February
2016
£'000
(1,882)
(2,181)
(1,777)
(2,034)
(2,144)
(1,926)
(2,003)
(2,641)
(1,637)
(2,381)
1,194
(3,235)
147
0
423
0
80
0
423
0
80
0
423
0
80
0
422
0
80
0
422
0
80
0
422
0
80
0
445
0
80
0
445
0
80
0
445
0
80
0
450
0
80
0
450
0
80
0
268
784
3,149
263
263
263
266
266
266
267
267
267
263
263
(2,681)
(1,111)
5,528
766
766
766
768
768
768
792
792
792
793
(481)
(1,500)
(9,254)
(2,261)
(1,116)
(1,415)
(1,008)
(1,265)
(1,376)
(1,134)
(1,211)
(1,849)
(844)
(1,588)
0
(1,050)
0
(533)
1,000
422
(500)
(2,950)
622
(279)
(103)
(838)
7
(549)
459
859
(114)
(2,834)
502
215
(115)
(903)
650
(482)
(490)
87
(885)
(1,311)
2,486
67
0
1,223
0
500
0
(319)
653
1,250
650
600
0
100
0
(500)
(319)
0
1,800
202
0
0
0
0
0
(35)
(319)
(216)
0
0
0
0
0
0
0
(26)
(155)
(16)
0
0
0
0
(100)
0
0
(26)
(155)
0
0
0
0
0
0
0
0
(26)
(155)
0
0
0
0
0
0
0
0
(57)
17
0
0
0
0
0
0
0
0
(57)
17
0
0
0
0
0
(200)
0
0
(57)
17
0
0
(200)
0
0
0
0
0
117
458
(200)
0
(200)
0
0
0
0
0
117
458
(400)
0
(200)
0
Increase/(Decrease) in working capital total
0
(3,268)
479
(1,916)
576
(321)
0
4,557
0
1,283
0
(570)
0
(197)
0
(281)
0
(181)
0
(40)
0
(40)
0
(440)
0
175
0
(25)
Net cash inflow/(outflow) from operating activities
(3,749)
(3,416)
(9,575)
2,296
167
(1,985)
(1,205)
(1,546)
(1,557)
(1,174)
(1,252)
(2,290)
(668)
(1,613)
(692)
(158)
(850)
(841)
(588)
(1,429)
(2,903)
271
(2,632)
(54)
0
(54)
(54)
0
(54)
(54)
0
(54)
(108)
0
(108)
(108)
0
(108)
(108)
0
(108)
(530)
0
(530)
(530)
0
(530)
(530)
0
(530)
(174)
0
(174)
(174)
0
(174)
(4,599)
(4,845)
(12,207)
2,242
113
(2,039)
(1,314)
(1,655)
(1,665)
(1,704)
(1,782)
(2,820)
(842)
(1,787)
0
(9,007)
(585)
(281)
(174)
3
14,650
(19)
4,587
1,135
(9,007)
(585)
(801)
(513)
6
14,650
(82)
4,804
9,007
(9,007)
(1,104)
(3,223)
(2,091)
24
14,650
(135)
8,121
0
0
0
(264)
(157)
2
0
0
(419)
0
0
0
(264)
(157)
2
0
0
(419)
0
0
0
(264)
(157)
2
1,814
0
1,395
0
0
0
(266)
(159)
2
1,737
0
1,313
0
0
0
(266)
(159)
2
2,078
0
1,654
0
0
(480)
(266)
(159)
2
2,570
0
1,666
0
0
0
(264)
(159)
2
2,125
0
1,704
0
0
0
(264)
(159)
2
2,203
0
1,782
0
0
0
(264)
(159)
2
3,240
0
2,819
0
0
0
(264)
(157)
2
1,261
0
842
Net increase/(decrease) in cash and cash equivalents
(13)
(41)
(4,086)
1,822
(307)
(645)
(0)
0
(0)
(0)
0
(0)
(0)
(1)
Opening cash and cash equivalents
513
542
4,586
13
1,835
1,528
884
884
884
884
884
884
884
884
Closing cash and cash equivalents
500
500
500
1,835
1,528
884
884
884
884
884
884
884
884
884
Monitor Plan
Variance to Monitor Plan
500
(0)
500
0
500
0
1,835
(0)
1,529
(0)
884
(0)
884
0
884
(0)
884
0
884
0
884
0
884
0
884
(0)
884
0
Impairment losses/(reversals)
PDC Dividend
Gain/loss on disposal of property, plant and equipment
Other increases/(decreases) to reconcile to profit/(loss) from operation items
Non-Cash flows in operating surplus/(deficit) total
Operating Cash Flows before movement in working capital
398
(3,235)
(111)
0
Plan
April
2015
£'000
(3,027)
Depreciation and Amortimisation
(389)
Revised
Plan
2014/15
£'000
(14,783)
0
0
4,746
(3,235)
865
3
Operating Surplus/(deficit) after tax
2,200
2015/16
793
Increase/(Decrease) in working capital
(Increase)/Decrease in inventories
(Increase)/Decrease in NHS Trade Receivables
(Increase)/Decrease in Non NHS Trade Receivables
(Increase)/Decrease in other receivables
(Increase)/Decrease in accrued income
(Increase)/Decrease in prepayments
Increase/(Decrease) in Trade Creditors
Increase/(Decrease) in Other Creditors
Increase/(Decrease) in accruals
Increase/(Decrease) in Deferred Income (exl Donated Assets)
Increase/(Decrease) in provisions
Net cash inflow/(outflow) from Investing activies
Property, plant and equipment - maintenance expenditure
Increase/(decrease) in Capital Creditor
Net cash inflow/(outflow) from Investing activies - Total
Net cash inflow/(outflow) before financing
Net cash inflow/(outflow) from Financing activities
Public Dividend Capital Received
Public Dividend Capital Repaid
PDC Dividends paid
Interest element of finance lease rentals on balance sheet
Capital element of finance lease rental payments - on balance sheet
Interest received on cash and cash equivalent
Increase/(decrease) in non-current payables - Loan from DOH
(Increase)/decrease in non-current receivables
Net cash inflow/(outflow) from Financing activities - Total
0
0
0
(264)
(157)
2
2,205
0
1,786
Appendix E3
Summary Monthly Cash Plan Forecast
Actual
Month
Actual
April
14
Actual
May
14
Actual
June
14
Actual
July
14
Actual
August
14
£'000
£'000
£'000
£'000
£'000
Actual
Actual
September October
14
14
£'000
£'000
Actual
Actual
Actual
Actual
November December January February
14
14
15
15
£'000
£'000
£'000
£'000
Total
YTD
2014/15
£'000
Variance
YTD
Variance
Plan
Total
To Plan March 15 2014/15
2014/15
£'000
£'000
£'000
15 Week Cashflow Forecast
Plan
April 15
Plan
May 15
Plan
June 15
£'000
£'000
£'000
Bank Accounts
Current Account (RBS/Lloyds/Citi)
Patient Monies
Petty Cash
National Loans Fund
Total Cash Balance
2,558
(2)
8
2,000
4,565
4,514
(2)
8
1,500
6,021
3,772
(2)
8
0
3,779
2,643
(2)
8
0
2,650
1,184
(2)
8
0
2,691
2,545
(2)
8
0
2,552
2,446
(2)
8
0
2,453
1,562
(2)
8
0
1,569
545
(2)
8
0
552
535
(2)
8
0
542
493
(2)
8
0
500
65
506
(2)
8
0
513
4,565
506
(2)
8
0
500
1,828
(2)
8
0
1,835
1,522
(2)
8
0
1,529
4,565
11,334
11,791
11,706
12,170
11,746
11,629
12,051
11,857
11,504
12,091
11,280
62
0
7
43
7
0
(696)
(507)
423
462
439
129,158
2,017
239
1,508
12,436
141,594
11,731
12,122
11,731
824
1,063
0
0
73
744
12,212
54
712
12,557
109
1,411
13,232
94
989
13,296
38
607
12,398
67
724
12,421
82
866
12,303
87
542
11,979
102
885
12,914
40
1,060
13,652
48
497
12,265
794
9,038
139,229
(198)
215
3,542
0
166
536
13,962
960
9,574
153,191
180
1,127
13,038
150
534
12,806
170
412
12,313
(4,375)
(1,784)
(1,321)
(479)
(7,959)
(4,515)
(3,051)
(1,024)
(551)
(9,141)
(4,517)
(3,083)
(958)
(830)
(9,388)
(4,412)
(3,050)
(1,084)
(722)
(9,266)
(4,371)
(3,015)
(814)
(865)
(9,065)
(4,484)
(2,936)
(1,079)
(598)
(9,097)
(4,459)
(3,018)
(1,118)
(848)
(9,443)
(4,492)
(3,177)
(1,123)
(678)
(9,470)
(4,529)
(2,861)
(1,171)
(123)
(8,683)
(4,544)
(3,038)
(1,093)
(696)
(9,371)
(4,584)
(3,082)
(756)
(521)
(8,943)
(49,281)
(32,094)
(11,541)
(6,911)
(99,827)
(397)
(4,502) (53,783)
498
(6,160) (38,254)
1,737
(1,257) (12,797)
(285)
(792)
(7,703)
1,553 (12,710) (112,537)
(4,545)
(1,868)
(1,211)
(200)
(7,824)
(4,545)
(1,212)
(1,086)
(600)
(7,443)
(4,545)
(3,080)
(966)
(600)
(9,191)
Non Pay Revenue
(3,212)
PFI Payment, all monthly outgoing inc VAT (821)
PDC Dividend
0
Reduce Creditor Payment
0
Total Non Pay
(4,032)
Total Expenditure
(11,991)
(5,309)
(679)
0
0
(5,988)
(15,129)
(5,213)
(851)
0
0
(6,065)
(15,452)
(4,305)
(875)
0
0
(5,180)
(14,446)
(5,079)
(875)
0
0
(5,954)
(15,020)
(5,319)
(841)
(519)
0
(6,679)
(15,776)
(4,469)
(876)
0
0
(5,345)
(14,788)
(4,924)
(847)
0
0
(5,771)
(15,241)
(3,540) (49,692)
(794)
(9,214)
0
(519)
0
0
(4,334) (59,425)
(13,277) (159,252)
(777)
(4,112) (53,803)
(446)
(1,000) (10,214)
1
(585)
(1,104)
0
0
0
(1,222)
(5,697) (65,122)
331 (18,407) (177,659)
(4,164)
(862)
0
0
(5,025)
(12,850)
(6,047)
(671)
0
0
(6,717)
(14,160)
(5,265)
(865)
0
0
(6,129)
(15,320)
221
(2,572)
(2,220)
(1,150)
(2,622)
(3,355)
(2,485)
(3,262)
(306)
(1,260)
(1,012)
(20,023)
3,873
(4,445)
(24,468)
188
(1,354)
(3,008)
(375)
518
(95)
437
(47)
529
(43)
451
(55)
523
(40)
509
(27)
441
(249)
480
(273)
432
(515)
426
(64)
444
(1,782)
5,191
1,571
(246)
(850)
0
(2,633)
5,191
(54)
500
(54)
1,000
(54)
500
Cash Income Receipts
NHS Contract Income
Overe/(Under) performance &
Winter Monies/SRG
NCA Income
Other Income
Total Income
Cash Expenditure Payments
Payroll
Tax, NI & Superannuation
Agency/Other Pay
NHSP
Total Pay
(3,656) (4,667)
(881)
(875)
0
0
0
0
(4,537) (5,542)
(13,220) (14,913)
Income/Expenditure
Other cash receipts/payments
Capital
VAT Debtor
Recharges/Payroll
Deductions/Prepayments
Deferred Income
Interim Revenue Support Loan
PDC Repaid
PDC Drawdown
Total Other
Cash Movement in the month
448
(13)
(53)
115
(38)
(16)
(1)
(52)
136
185
(17)
693
(1,120)
(360)
333
102
102
102
645
0
0
0
1,236
1,456
0
0
0
0
330
(2,242)
0
0
0
662
1,091
(1,129)
602
0
0
66
1,191
41
0
0
0
2,053
2,483
(139)
248
0
0
2,556
3,257
(98)
798
0
0
389
1,599
(884)
(81)
0
0
2,146
2,244
(1,017)
0
0
0
0
296
(10)
648
0
0
474
1,219
(42)
0
0
0
661
1,024
14
2,860
0
0
9,007
15,969
(4,052)
460
0
0
(4,592)
(3,927)
(52)
0
14,650
(9,007)
0
4,432
(13)
2,860
14,650
(9,007)
9,007
20,401
(4,061)
600
0
0
0
1,148
1,335
0
0
0
0
1,048
(306)
0
1,814
0
0
2,362
(645)
Opening cash Balance
4,565
6,021
3,779
2,650
2,691
2,552
2,453
1,569
552
542
500
4,565
65
513
4,565
500
1,835
1,529
Closing Monthly Cash Balance
Monitor Plan
Movement to Monitor Plan
6,021
4,370
1,651
3,779
3,178
601
2,650
500
2,150
2,691
500
2,191
2,552
500
2,052
2,453
500
1,953
1,569
500
1,069
552
500
52
542
500
42
500
500
0
513
500
13
513
500
13
13
0
13
500
500
0
500
500
0
1,835
1,835
0
1,529
1,529
(0)
884
884
0
Appendix F
In Year
Achieved to
date £'000
CYE Plan
2014/15 £'000
Recurrent
achieved to
date £'000
Revised Plan
FYE £'000
2014/15 CIP Programme
Scheme Category
Project
Income
Ambulatory Care
307.6
307.6
307.6
307.6
Income
Income (Paediatrics)
383.2
383.2
383.2
383.2
Income
Income
Income (other)
Coding EPS
Productivity
Coding - Orthopaedics
Readmissions
Theatre Productivity
Productivity
Outpatients
Productivity
Radiology
Productivity
RLOS - close 8 further beds on ward 30 (7/12 months)
Income
Income
Productivity
RLOS - closure of ward 30 in totality at the end of Winter 14/15.
RLOS - Elective
Productivity
Pathology Divisional
Productivity
Productivity
Controls
Transitional Care Unit
Reduction in premium and pay expenditure
0.0
304.6
304.6
308.1
41.9
304.6
304.6
291.1
41.9
58.9
58.9
106.0
0.0
300.0
0.0
300.0
0.0
325.0
0.0
325.0
0.0
272.0
0.0
272.4
0.0
0.0
0.0
46.0
46.0
288.0
0.0
216.0
0.0
352.0
0.0
0.0
0.0
100.0
0.0
44.0
0.0
18.7
18.7
18.7
0.0
0.0
300.0
350.0
53.0
0.0
18.7
26.0
150.8
150.8
246.0
324.7
20.3
324.7
324.7
324.7
30.8
30.8
22.0
22.0
0.0
0.0
0.0
160.0
119.2
Collaboration
Non-Ward based clinical staff
Collaboration
Collaboration
Collaboration - pathology
0.0
0.0
0.0
Collaboration
Collaboration - radiology
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
32.5
Productivity
Collaboration
Collaboration
Collaboration
Collaboration
Collaboration
Collaboration - Pharmacy
Collaboration - HR
Collaboration - IM&T
Collaboration - Clinical
Collaboration - Procurement
69.1
Tactical
Collaboration - Procurement stretch
Dermatology SLA
Tactical
Pharmacy
Collaboration
Tactical
Review of divisional support services (Inc E-Rostering benefits)
Tactical
Correspondance (patient letters/electronic comms)
Correspondance (trust members/electronic comms)
CQUIN Benefit (Digital by Design)
Review of legal costs
Tactical
Procurement Schemes
Tactical
Estate and Facilities (Divisional)
Tactical
Tactical
Tactical
Tactical
Physiotherapy (Divisional)
Infection Control
Tactical
Divional 2% Tactical schemes & - Vacancy Factor - Local regrading
Tactical
Contingency reserve
Non recurrent HIT allocation
Over delivery to off-set RED risk schemes
160.0
65.0
160.0
98.7
160.0
0.0
160.0
65.0
65.0
238.9
190.8
190.8
81.1
81.1
86.0
86.0
85.0
0.0
48.0
0.0
45.0
0.0
35.4
0.0
15.0
15.0
15.0
15.0
34.0
34.0
34.0
34.0
586.0
586.0
412.2
412.2
64.6
64.6
508.8
508.8
16.0
16.0
16.0
16.0
0.0
0.0
3.0
0.0
0.0
238.9
65.0
0.0
0.0
126.0
0.0
0.0
790.0
979.7
1,109.7
2,700.2
979.7
1,109.7
-2,913.4
6,100.3
MONITOR FINANCIAL PLAN PROFILE
% of Plan achieved
70.0
1,109.7
2,700.2
1,109.7
-2,577.7
4,912.3
6,101.0
80.5
6,763.3
110.9
14/15 FYE (M11 position) 14/15 CYE (M11 Position)
4,912.3 R
6,763.3 R
1,188.0 R
88.5 R
0.0 R
70.0 R
0.0 R
-820.8 R
6,100.3 FYE
6,101.0 CYE
Report to Public Trust Board 26th March 2015
Agenda Item
8e
Title
Significant Risk Report
Karen James, Chief Executive
Author (s)
Peter Weller, Director of Quality and Governance
Purpose
For discussion and agreement of future actions
For approval
To note/receive
Risk Management Group, Service Quality and
Operational Governance Group, Quality and
Executive Summary
The Significant Risk Register report provides details on all identified significant risk exposure
through the Risk Register and Board Assurance Framework across Tameside Hospital NHS
Foundation Trust. This report also provides the Annual Review of Risk Management
Strategy. Understanding, recognising and addressing the significant risks to the organisation
is a key component of well led governance services.
Impact on all Trust Objectives
Impacts on all BAF and Risk Registers
requirements
Referred to if necessary in the paper
undertaken?
Sustainability?
Reflects current risks to the Trust’s business
and strategic objectives
Action required by the Group
The Trust Board is asked to discuss and consider the current position in relation to
significant risks and receive the update report of the Annual Review of Risk Management
Strategy. This has been received by the Risk Management Group.
Page 1 of 42
Annual Review of Risk Management Strategy
Background
Risk management is the key system through which strategic, clinical, operational, corporate
and financial risks are managed by all staff to their reasonable best for the benefit for
patients, staff, visitors and other key stakeholders. Risk management involves a planned and
systematic approach to the identification, assessment and mitigation of the risks which could
hinder the achievement of strategic objectives.
The Trust has a legal requirement to give assurance that all risks in the organisation are
prioritised and managed. The methodology adopted by Tameside Hospital NHS Foundation
Trust in order to both identify and deal with risk is set out in the Trust’s Risk Management
Strategy, Plan and Policy. The identification and management of risk is an ongoing process
linked with the achievement of the Trust’s objectives. The main focus of risk management
within the Trust focuses on the fulfilment of objectives and delivery of beneficial outcome in
the public interest.
The Trust is required to carry out an annual review of the Risk Management Strategy and this
paper outlines the findings of the annual review and identifies the amendments needed to the
strategy. This review has been informed by the extensive improvement programme, scrutiny.
Internal and external auditing and the monitoring processes that have taken place in the
preceding twelve months in relation to the Risk Management process.
Trust Risk Management Strategy review findings
The format of the strategy and policy is comprehensive and clear. The risk management
policy includes details of the system, supporting systems and training in this regard.
The Trust received confirmation following the Deloittes Review and CQC Inspection process
that its revised Strategy and Plan post Keogh is reflective of an appropriate risk management
system and approach.
There have been no material changes in the Trust Risk Management policies and procedures
since these assessments were carried out.
Page 2 of 42
The appropriateness and implementation of the current risk management strategy has been
validated through continuous external scrutiny. It is therefore concluded that it is not
necessary to amend or revise the risk management process or the strategic direction and risk
management objectives outlined in the strategy.
In light of ongoing organisational developments and to ensure that the strategy remains an
iterative policy and plan the following changes will need to be made to the document:

Titles and roles have been amended and updated to reflect the current organisational
configuration. All material roles and responsibilities have been be updated to reflect
current portfolios of activity.

Reporting schedules and timings will need to be amended to reflect current reporting
and TORs of the Sub Committees to the Board

Any relevant References will be updated to reflect and demonstrate adherence to
current guidance and requirements

Monitoring arrangements will be updated to reflect alignment with current
organisational configuration

Current regulatory mechanism will be reflective of NHS Transitional changes. Updates
to other regulatory and statutory functions will be included.
Conclusion – There are no changes to risk management processes or systems and the
risk management process remains extant.
.
Recommendation:
Members are asked to note and accept the findings of the annual review and the actions
taken.
Page 3 of 42
March 2015 - Significant Risk Register Report
Summary Narrative
1.0
The Significant Risk Register report provides details on all identified significant risk
exposure through the Risk Register and Board Assurance Framework throughout
Tameside Hospital NHS Foundation Trust. These risks were subject to review by
the Quality and Governance Unit following discussion with responsible Directors.
The risks have been fully reviewed in light of the RICAP in response to the CQC
regulatory inspection report published in July 2014 and mapped against the Trust’s
Improvement plan. The Treatment Plans for these risks have been reviewed by
responsible Directors and Leads to ensure reflection of the assertive improvement
work and current mitigations. Horizon scanning for future risks is continually taking
place facilitating systematic examination of information to identify potential threats,
and risks, and detect opportunities and options to reduce existing risks. Where
applicable necessary third party assurances are referred to.
1.1
The Trust has identified a range of significant risks, which are currently being
mitigated, whose impact could have a direct bearing on compliance with Monitor’s
Provider Licence, CQC registration or the achievement of corporate objectives in
the following areas should the mitigation plans be ineffective. Currently, the
significant risks relate to the following areas:
 Infection Prevention (C. difficile target)
 Finance (Cost control, CIP delivery and liquidity)
 Compliance (Monitors Provider Licence and CQC Registration )
 Lorenzo ( Lorenzo related implementation issues, IM&T infrastructure)
 Discharge Processes
 Recruitment and Training
 Emergency Department Pressures
 Data Quality
 Referral To Treatment pathway (RTT)
1.2
The main controls and action plans for each significant risk in each area have been
reviewed and collated in the Trust’s Risk Register. The programme has
incorporated the Corporate Risks and aligned them to the Board Assurance
Framework. Appendix 1 summarises the current significant risks. Appendix 2
provides the Board with the controls and mitigation for the significant risk analysis.
Detailed and focussed work is taking place within the Divisions to ensure risk
registers are updated and monitored. All risk handlers and risk owners are
systematically meeting with the Quality and Governance Unit Senior Staff to review
their risks for assurance and controls. The responsible Committees are identified
where relevant on the report.
Page 4 of 42
1.3
New Significant Risks
At the time of writing this report no newly identified risks have been discussed and
agreed at the sub-group for escalation in risk score.
1.4
1.5
Increased Risk Scores
Risk AF 3486 has been increased from 20 to 25 as a result of assertive
investigations and review in relation to data quality and information under the
direction of the Director of Performance and Informatics. Head of Data Assurance
now in post however until further action taken score increased.
Downgraded Risks
 Following assertive actions in relation to Risk CR734 relating to nursing
vacancies, leadership and recruitment the risk score has been reduced from
20 to 15.

AF 3476 relating to patient discharge and safety has been reduced from 25
to 20 following implementation of mitigations and the continuous work that is
progressing..

Risk AF3464 Failure to contain and prevent Healthcare Associated Infection
has been reduced from 20 to 15 as a result of continued focus on monitoring
and mitigation strategies. It is expected that this will reduce further in the new
financial year as trajectories are set.
Mapping is taking place with the new revised RICAP ratings and scores will be
reduced commensurately.
1.6
Other Notable Changes / Update
Appendix 2 of the significant risk report includes more detailed information on
notable actions.
1.7
The BAF is in the process of being reviewed and aligned to strategic plans for
2015/16. Updates against the BAF significant risks are included in Appendix 1.
Page 5 of 42
Appendix 1
CORPORATE SUMMARY – SIGNIFICANT RISK THFT SHOWING RISKS 15 OR ABOVE
 Residual Risk Score (Current Risk)
 (Target Risk / Risk Appetite Threshold)
Risk Trend
 Reducing
* New Risk Score
 Increasing
 Static
Risks scoring 25 on the Corporate Risk Register and Assurance Framework
Description
Risk
AF3485
CORPORATE
Failure to deliver cost efficiency
savings and deliver financial
plans in line with FT compliance
framework
Description
Risk
AF3486
Risk
CR718
Risk
AF3488
Responsible
Committee
1
Responsible
Committee
Data Quality and Information
accuracy and completion
Description
Responsible
Committee
Quality and
Governance
Committee
Description
Responsible
Committee
Description
Failure to deliver the 4 hour
Emergency Access Standard.
Demand outstrips capacity.
5
6
8
9
Very Low Risk
2
3
Medium
Risk
Low Risk
4
5
6
8
9
10
12
15
16
20
25

High
Risk
10
12
Significant Risk
15
16
20
25



Very Low Risk
2
3
Medium
Risk
Low Risk
4
5
6
8
9
High
Risk
10
12
Significant Risk
15
16
20

25


Very Low Risk
1
2
3
Medium
Risk
Low Risk
4
5
6
8
9
Trust Board
High
Risk
10
12
Significant Risk
15
16
20

25


Responsible
Committee
E&CC DIVISIONAL
Risk
CR3618
4
Significant Risk

1
Continuing implementation of
Lorenzo (risks to patient safety
quality, information governance
and performance trajectories)
CORPORATE
3
High
Risk

1
Executive
Management
Team/Finance
and
Performance
Failure to ensure on-going
compliance with terms of FT
authorisation (Monitor
requirements)
2
Medium
Risk
Low Risk
Finance and
Performance
Committee
CORPORATE
CORPORATE
Very Low Risk
ES&CC
Divisional
Governance
Meeting
Operational
Board
Very Low
Risk
1
2
3
Low Risk
4
5
6
Mediu
m Risk
8
9
High
Risk
10 12
Significant Risk
15
16
20

25


Page 6 of 42
Risks scoring 15 - 20 on the Corporate Risk Register and Assurance Framework
Description
Risk
AF3473
CORPORATE
Risk
CR3132
Quality and
Governance
Committee
Description
Responsible
Committee
Quality and
Governance
Committee
Description
Responsible
Committee
CORPORATE
Risk
CR3509
Incomplete referral to
treatment (RTT) pathway data
submission
Description
Responsible
Committee
E&CC DIVISIONAL
The PIU environment on ward 46
is inadequate for the delivery of
planned procedures and
treatments.
Description
Failure to admit patients with a
diagnosis of Stroke directly to the
Stroke Unit therefore affecting
quality of care and access
standards.
5
6
8
9
10
Significant Risk
12
15
16
20
25

2
3
Medium
Risk
Low Risk
4
5
6
8
9
High
Risk
10
Significant Risk
12
15
16
20
25



Very Low Risk
2
3
Medium
Risk
Low Risk
4
5
6
8
9
High
Risk
10
Significant Risk
12
15
16

20
25


Very Low Risk
1
2
3
Medium
Risk
Low Risk
4
5
IM&T
Committee /
Executive
Management
Team
6
8
9
High
Risk
10
Significant Risk
12
15
16

20
25


Responsible
Committee
Very Low
Risk
1
2
3
ES&CC
Divisional
Governance
Meeting
Responsible
Committee
E&CC DIVISIONAL
Risk
CR3607
4
Very Low Risk
1
Executive
Management
Team/Finance
and
Performance
Description
3
High
Risk

1
Failure to discharge patients
safely –Potential of patients
being discharged with
inadequate information on
complications or knowledge of
medications
Trusts ability to recover all
services in the event of a data
centre loss (DC1 or DC2) due to
storage capacity within the
server infrastructure and the
supporting server capacity for
the delivery of services and
growth is reaching critical levels
2
Medium
Risk
Low Risk

CORPORATE
Risk
CR3510
Very Low Risk
1
Failure to comply with
registration requirements relating
to record keeping and have
timely information to support
patient care
CORPORATE
Risk
AF3476
Responsible
Committee
Operational
Board
Low Risk
4
5
6
Mediu
m Risk
8
9
High
Risk
10 12
Significant Risk
15
16

20
25


Very Low
Risk
1
2
3
Low Risk
4
5
6
Mediu
m Risk
8
9
High
Risk
10 12

Significant Risk
15
16
20


Page 7 of 42
25
Description
Risk
CR734
Risk
AF3460
CORPORATE
Executive
Team
Description
Responsible
Committee
CORPORATE
Failure to ensure appropriate
focus on privacy and dignity for
patient and relatives
Description
Risk
AF3464
Risk
AF3467
Risk
AF3477
CORPORATE
Risk
AF3480
Risk
AF3481
9
10
12
15
16
20
25

Medium
Risk
Low Risk
3
4
5
6
8
High
Risk
9
10
Very Low Risk
CORPORATE
2
3
4
5
6
8
High
Risk
9
Very Low
Risk
2
Medium
Risk
Low Risk
10
12
25
15
16
20
25

3
4
5
6
8
9
10
Significant Risk
12
15

16
20
25


Very Low Risk
2
3
Medium
Risk
Low Risk
4
5
6
8
9
High
Risk
10
Significant Risk
12
15


16
20
25

Very Low Risk
2
3
Medium
Risk
Low Risk
4
5
6
8
9
High
Risk
10
Significant Risk
12

15
16
20
25


Very Low Risk
1
2
3
Medium
Risk
Low Risk
4
5
6
8
9
High
Risk
10
Significant Risk
12
15

16
20
25


Very Low Risk
1
Quality and
Governance
Committee
20
Significant Risk
High
Risk
Quality and
Governance
Committee
Responsible
Committee
16

Medium
Risk
Low Risk
Quality and
Governance
Committee
CORPORATE
15

1
Responsible
Committee
12

1
Responsible
Committee
Significant Risk

1
Description
CORPORATE
8

Responsible
Committee
Executive
Management
Team / Trust
Board
Failure to ensure that staff have the
relevant skills, training, support and
supervision to ensure safe practice.
2
1
Failure to deliver services in line
with best practice relating to
NICE Guidance Trust wide and
failure to deliver the contract
quality requirements and CQUIN
Description
6
Quality and
Governance
Committee
Responsible
Committee
Failure to meet CQC registration
requirements relating to staffing
(All staff groups)
5
Very Low Risk
Responsible
Committee
Description
Description
4
Significant Risk

1
Failure to contain and prevent
Healthcare associated infection
Failure to ensure requirements
for consent to treatment
3
High
Risk
Quality and
Governance
Committee
Quality and
Governance
Committee
CORPORATE
2
Medium
Risk
Low Risk

CORPORATE
Description
Risk
AF3463
1
Nursing vacancies, leadership
and Nursing staffing
recruitment and the ability to
provide safe care
Failure to address areas of
outlying performance in
relation to the Trust HSMR
SHMI
Very Low
Risk
Responsible
Committee
2
3
Medium
Risk
Low Risk
4
5
6
8
9
High
Risk
10

Significant Risk
12
15
16
20


Page 8 of 42
25
Description
Risk
AF3482
CORPORATE
Risk
AF3484
Executive
Management
Team / Trust
Board
Description
Responsible
Committee
Increased demands beyond
predicted levels which is outside
current capacity
Description
Responsible
Committee
CORPORATE
Description
Risk
AF3487
Description
Risk
AF3490
CORPORATE
Failure to minimise delayed
transfers of care
Description
Risk
AF3491
CORPORATE
Failure to have in place a IM&T
infrastructure and Service
supporting organisational
objectives
Description
Risk
AF3495
CORPORATE
Failure to deliver agreed activity
and income plan
Medium
Risk
Low Risk
3
4
5
6
8
10
Significant Risk
12

15
16
20
25


Very Low Risk
2
Medium
Risk
Low Risk
3
4
5
6
8
High
Risk
9
10
Significant Risk
12

15
16
20
25


Very Low
Risk
1
2
Mediu
m Risk
Low Risk
3
4
5
6
8
High Risk
9
10
12

Significant Risk
15
16
20
25


Very Low
Risk
Responsible
Committee
1
2
Low Risk
3
4
5
6
Medium
Risk
High Risk
8
10
9
Quality and
Governance
Committee
12

Significant Risk
15
16
20
25


Very Low
Risk
Responsible
Committee
1
2
Medium
Risk
Low Risk
3
4
5
6
8
9
Improvement
Board
High
Risk
10
Significant Risk
12

15
16
20
25


Very Low
Risk
Responsible
Committee
1
2
Medium
Risk
Low Risk
3
4
5
Executive
Management
Team and
Board
6
8
9
High
Risk
10
Significant Risk
12

15
16
20
25


Very Low
Risk
Responsible
Committee
1
Executive
Management
Team and
Board
High
Risk
9
Quality and
Governance
Committee
CORPORATE
Failure to comply with the
regulatory requirements for
standards of Quality and Safety
2
1
Executive
Management
Team /
Finance and
Performance
Committee
Failure to fulfil regulatory
registration requirements with
management of Complaints
Very Low Risk
1
Failure to ensure adequate
staffing levels of medical, nursing
and support staff to ensure
patient safety and quality of
services.
CORPORATE
Risk
AF3483
Responsible
Committee
2
3
Medium
Risk
Low Risk
4
5

6
8
9
High
Risk
10
12
Significant Risk
15
16
20


Page 9 of 42
25
Description
Risk
CR770
DIAGNOSTIC AND
THERAPEUTIC
Reduced sustainability of
Radiology Services due to
inability to recruit to key
radiology posts
Description
Risk
CR1845
1
Failure of the Trust to have in
place a robust IT Disaster
Recovery Plan
Responsible
Committee
Description
Risk
CR3572
CORPORATE
Risk of a reduction in the
provision of services and delivery
of care due to the realisation of
industrial action
3
4
5
6
8
9
Very Low Risk
2
Medium
Risk
Low Risk
3
4
Very Low Risk
2
16
20
25

5
6
8
9
High
Risk
10
Significant Risk
12
15
16
20
25

Medium
Risk
Low Risk
3
4
5
6
8
High
Risk
9
10
Significant Risk
12
15

16
20
25


Very Low Risk
1
2
3
Medium
Risk
Low Risk
4
IM&T
Committee /
Executive
Management
Team
5
6
8
9
High
Risk
10
Significant Risk
12
15

16
20
25


Very Low Risk
1
Executive
Management
Team / Trust
Board
15

Executive
Management
Team
Responsible
Committee
12

1
Responsible
Committee
10
Significant Risk

Executive
Management
Team
Responsible
Committee
High
Risk

1
CORPORATE
SQL Microsoft Enterprise
database tool unlicensed and
used widely across the Trust
risks relating to long term
support with Microsoft
software, service and security
risk.
2
Medium
Risk
Low Risk
Executive
Management
Team/Finance
and
Performance
CORPORATE
Description
Risk
CR3512
Very Low Risk
CORPORATE
Trust fails to achieve national
best practice e.g. NICE, Bundles
of Care, NSFs, Stroke Sentinel
Audits/ TIA etc.
Description
Risk
CR3511
Responsible
Committee
2
3
Medium
Risk
Low Risk
4
5

6
8
9
High
Risk
10
Significant Risk
12
15
16
20


Page 10 of 42
25
APPENDIX 2: SIGNIFICANT RISK ANALYSIS
Regulatory | National Target | CORPORATE
Risk
AF3485
Potential Risk
Location
CORPORATE
All Clinical
and Corporate
Directorates
Failure to deliver cost
efficiency savings and
deliver financial plans
in line with FT
compliance framework
Owner/Responsible
Committee/Group
RR
Main Controls

Review Date /
Frequency
Director of Finance
Directors of all
services
Risk Review
Monthly and
Weekly EMT)
Finance and
Performance
Committee

25
RED


Continued use of
appropriate
benchmarking
information
reference costs led
by the Finance
Department and
Turnaround
Director to ensure
control and rigor of
CIP delivery
Finance Team to
work with all
budget holders to
drive down costs
and increase
income and
contribution margin
and, with clinical
teams, to exploit
opportunities and
repatriate activity
and develop new
markets
Established
Governance
structure e.g. PMO
Key Actions
Action
Overdue
not being
addressed
Risk
Source

Turnaround Director
and revised
programme
 Certify that all material
non recurrent CIP's
have also been
subject to a rigorous
QIA
 Fully develop
schemes to deliver the
Strategic
full 2014/15 CIP target
Insight and
on a recurrent basis
None
Foresight
 Commission a review
of 2015/16 CIPs.
 Develop and submit to
regulators milestones
and financial
modelling

Impact of
improvement plan
requires resources.
Action plan being
progressed.
ANTICIPATED EFFECT ON CONTROL
Continuously being monitored and reviewed.
Page 11 of 42
Potential Risk
Location
CORPORATE
Clinical and
non-clinical
Directorates
Risk
AF3486
Data Quality and
Information accuracy
and completion
Failure to recover all
patient income and
have accurate data.
Suboptimal use of
capacity and failure to
address accuracy of
data e.g. waiting lists.
Owner/Responsible
Committee
RR
Review
Date /
Frequency
Monthly

On-going and
monthly scrutiny of
data activity and
income performance.

Director of
Information post
created and
appointed to.

Director of Finance
Executive
Management Team
/ Finance and
Performance
Committee
Main Controls
25
RED
↑
Outcome reported to
board as part of
improvement delivery
board.

Increased
benchmarking and
use of metrics.

Board Report re
delivery of financial
programme.

Improved governance
programme in place
with checks
Page 12 of 42
Key Actions

Increased
benchmarking and
use of metrics

Processes for
information to be
reviewed by new
Director of
Information
Action
Overdue
not being
addressed
Risk Source
None
Performance
management
Mitigation plans are designed to achieve
compliance Data quality checks have been
impacted on by Lorenzo transition. It is anticipated
that the review and subsequent actions by the
Director of Performance and Informatics will reduce
this risk
Potential Risk
CORPORATE
Risk No:
CR718
Implementation of
Lorenzo information
system (Risks to Patient
Safety Quality,
and Performance
Trajectories)
Location
Owner/Responsible
Committee
RR
Main Controls

All Clinical
and
Corporate
Directorates
Review Date
/ Frequency



Director of
Performance &
Informatics with
Director of
Operations
Risk Review
Monthly
Executive
Management
Team
25
RED



Initial
implementation
plan complete
which involved
clinicians from
each area
Monitoring of post
implementation
performance by
the EPR team.
Live action log
On-going
monitoring of
Lorenzo reported
incidents and
triangulation of
information.
Monitoring
progress report to
Trust Board
Prioritisation of
urgent information
requests to
delivery of safe
and effective
patient care.
Key Actions





Post-implementation
issue specific plans
progressed and
monitored by the
EPR Team, Quality
and Governance
Committee and sub
committees.
Routine reporting to
Board
Assessment of issues
by maintenance and
monitoring of
Operational
Performance
All key operational
standards continue to
be monitored
Business Continuity
Plans implemented if
required to ensure
staff assisted and
able to continue
delivering their
services.
Action
Overdue
not being
addressed
Risk Source
None
Risk
Register
Incident,
Operational
Performance
It is anticipated that completion of the agreed actions and
mitigations will mitigate and reduce the risk.
Page 13 of 42
Risk
AF3488
Potential Risk
Location
CORPORATE
Corporate
Directorates
Failure to ensure ongoing compliance with
terms of FT
authorisation (monitor
provider licence
requirements)
Owner/Responsible
Committee
RR

Review Date
/ Frequency
Director of Finance
Risk Review
Monthly
Main Controls
Trust Board
25
RED

Board reporting in
line with FT
provider licence
requirements

Board Financial
reporting
procedures fit for
purpose

FT metric
performance
framework.

Regular contact
with Monitor and
Board reporting
re actions taken
to maintain
authorisation
Page 14 of 42
Key Actions
Action
Overdue
not being
addressed
Risk Source

Continuous
implementation of
required actions by all
staff at levels required
 Implementation of
action plan re CIP
None
identification and
implementation of
Trust Improvement
Programme and
Agreed Monitoring
action
Monitors
Provider
licence
requirements
and
Regulatory
Monitoring
Continually being reviewed in partnership with
Regulator
Regulatory | National Target | E&CC DIVISIONAL
Potential Risk
CORPORATE
Risk
CR3618
Failure to deliver the 4
hour Emergency
Access Standard.
Demand on the service
outstrips capacity.
Location
Owner/Responsible
Committee/Group
RR
Main Controls

ES&CC
Division

Review Date /
Frequency

Risk Review
Monthly and
Weekly EMT
Director of
Operations
Divisional General
Manager
Operational Board
25
RED



Additional ED
Management
Support.
Extended out of
hours
management
presence.
Three times daily
bed meetings.
Additional staffing
(all services)
Breach analysis.
Key Actions
Action
Overdue
not being
addressed
Risk
Source
Daily management
oversight on a patient by
patient basis.
On site management
support overnight.
None
In-reach from medical
consultants to ED
Strategic
Insight and
Foresight
See RICAP review
mitigations will mitigate and reduce the risk
Page 15 of 42
Risk
AF3473
Potential Risk
Location
CORPORATE
All Clinical
and
Corporate
Directorates
Failure to comply with
the regulatory
requirements relating to
record keeping and
ensure timely
information to support
patient care
Owner /
Responsible
Committee
RR
Main Controls




Review Date
/ Frequency


Medical
Director/
Director of
Nursing
Monthly
Quality and
Governance
Committee
20
RED









Health records standards
and policies in place.
Professional Standards
for record keeping
Clinical Coding Standards
Clinical Coding
awareness training for
Clinicians.
Monitoring of coding
completeness and data
quality
Electronic access to
“intelligence” on best
practice.
Electronic access to
Policies and Protocols.
Development of EPR
Committee
Health Records
Committee
IM&T Committee
Clinical audit and
Effectiveness programme
Case note tracking and
availability monitoring
Electronic test requests
and results reporting
Dr foster system
Page 16 of 42
Key Actions
Action
Overdue
not being
addressed
Risk Source

Assurance via
Clinical leads and
Senior Nurse walk
round/visits
 Assurance from First
Friday visit
programme
 Executive Walk
round programme
 NED Walk round
programme.
 Audit programme
and related activity
None
 Consistent
application of all
policies and
processes to be
applied by all clinical
divisions and staff at
all levels to prevent
decisions being
made on inadequate
or incomplete clinical
information as a
result of weaknesses
in the system
Operational
Performance
Incidents
Complaints
and Claims
Assertive monitoring and focussed work including
walk rounds to monitor impact and risk control
alongside systematic review processes will further
inform the risk score.
Risk
AF
3476
Potential Risk
Location
CORPORATE
All Clinical
and
Corporate
Directorates
Failure to discharge
patients safely –Potential
of patients being
discharged with
inadequate information on
complications or
knowledge of medications
Owner /
Responsible
Committee
RR
Main Controls


Review Date
/ Frequency
Director of
Operations
supported
professionally by
the Director of
Nursing and
Medical Director
Risk review
Monthly and
Weekly EMT
Quality and
Governance
Committee

20
RED
↓


Discharge policy
and procedures in
place
Monitoring of
operational
performance
activity and review
of discharge and
transfer services
undertaken.
Pre - printed
discharge
summaries given
to each patient,
addressing all the
discharge issues
Audit programme
Key Metrics
monitored
Risk
Management
Group
Key Actions





Implementation of
processes to support
ward based intervention
and reconciliation.
Monitoring of the ongoing usage of Care
Bundles through Patient
Safety Programme
Discharge and Patient
Flow Work Stream
Implementation of the
Urgent Care Recovery
Plan.
A revised discharge
summary has been
developed for delivery
via Lorenzo which it is
expected will improve
the quality of discharge
summaries
Action
Overdue
not being
addressed
None
Risk
Source
Third party
reviews
Patient
feedback
Incidents
complaints
and claims
Improvement Programme in place to address and
monitor continual improvement, closely aligned to
Lorenzo work
Page 17 of 42
Risk No:
CR3132
Potential Risk
Location
CORPORATE
All Clinical
Directorates
Incomplete Referral To
Treatment pathway
(RTT) data submission
Owner /
Responsible
Committee
RR
Review Date
/ Frequency
Risk
Reviewed
Monthly
Daily by
Improvement
Team
Director of
Performance &
Informatics /
Director of
Operations
Executive
Management
Team / Finance
and Performance
20
RED

Main Controls
Key Actions
A dedicated validation
team has been
established to validate
each and every patient on
an incomplete pathway in
order to be able to report
our incomplete pathway
performance accurately.
The Trust:
 Has developed a
comprehensive
recovery plan within
a clear project
management and
governance
structure to ensure
this problem is
rectified
appropriately within
agreed timescales
Developed all appropriate
waiting list reports
(outpatients non admitted
and admitted) to support
management of patients
and data reporting.
Action
Overdue
not being
addressed
Risk Source
None
External
Monitoring,
National
reports,
Operational
performance
Incidents
inquests
complaints
and claims
The completion of the agreed implementation plan
and mitigations will result in RTT pathway
completeness.
Page 18 of 42
Risk No:
CR3510
Potential Risk
Location
CORPORATE
All Clinical
Directorates
Trusts ability to recover
all services in the event
of a data centre loss
(DC1 or DC2) due to
storage capacity within
the server
infrastructure and the
supporting server
capacity for the
delivery of services
and growth is reaching
critical levels
Owner /
Responsible
Committee
RR
 The Trust has
implemented interim
controls pending
solutions.
Review
Date /
Frequency
 Regular backups of
systems are in place to
disk for 14 days.
Director of
Performance &
Informatics
Risk
Reviewed
Monthly
Main Controls
IM&T Committee
/ Executive
Management
Team
 Regular backups in
place to tape for 12
weeks.
20
RED

 Patch management
and anti-virus
programme in place.
 There is monitoring of
sufficient resilience
hardware.
Key Actions
Action
Overdue
not being
addressed
Risk Source
None
,
Operational
performance
Incidents
The Trust:
 Is monitoring the
situation closely and
reviewing SOPS and
procedures.
 Review externally
hosted solutions.
 Purchasing of
additional capacity to
provide more storage
capacity in the event of
failure of the data centre
to be commissioned
 Hardware has been
procured and is currently
being tested. Testing will
be followed by data
migration
The risk score will be reviewed following full testing
of procured hardware and migration of data.
Page 19 of 42
Regulatory | National Target | DIVISIONAL
Potential Risk
CORPORATE
Risk
CR3509
The PIU
environment
on ward 46
is
inadequate
for the
delivery of
planned
procedures
and
treatments.
Location
Owner/Responsible
Committee
RR
Main Controls
16
RED
Meetings have now started
to look at the space,
service design and review.
This is in line with the
proposed refurbishment for
a haematology and
chemotherapy unit. The
ES&CC division has
identified the business
manager who is
responsible for
Haematology and the CNS
and CSM are working with
him to address the issues.
There is a proposal that
the PIU will be relocated
ASAP either as part of the
Haematology and
Chemotherapy Unit project
or a self-contained
Haematology unit with
adequate staffing and
equipment.
ES&CC
Division
Review Date
/ Frequency
Risk Review
Monthly
ES&CC Divisional
Governance
Meeting

Page 20 of 42
Key Actions
Action
Overdue
not being
addressed
Risk Source
Review of the
environment
taking place
with the Matron
and Head of
Estates with
consideration of
Risk
all procedures
Register
currently being
None
Incident,
carried out and
Operational
with focus on
Performance
suitability of the
environment
and impact on
Ward 46
regarding foot
traffic.
It is anticipated that completion of the agreed actions
and mitigations will mitigate and reduce the risk
Regulatory | National Target | DIVISIONAL
Potential Risk
CORPORATE
Risk
CR3607
Failure to admit patients
with a diagnosis of
Stroke directly to the
Stroke Unit therefore
affecting quality of care
and access standards.
Location
Owner/Responsible
Committee
RR
Main Controls
ES&CC
Division

Review Date
/ Frequency


Operational Board
Risk Review
Monthly
Bed management
aware of right
patient right bed.
ROSIER
assessment tool in
ED.
Stroke team
contactable by
bleep.
16
RED

Key Actions
Monthly Stroke
Meetings.
Daily follow up of all
stroke admissions
By Stroke coordinator with
feedback to the
Emergency
Department
Patient by patient
level review and RCA
when patients don’t
progress through the
desired pathway.
Action
Overdue
not being
addressed
Risk Source
None
Risk
Register
Incident,
Operational
Performance
mitigations will mitigate and reduce the risk
Page 21 of 42
Potential Risk
CORPORATE
Risk No:
CR734
Nursing vacancies,
leadership and
Nursing staffing
recruitment and the
ability to provide
safe care
Location
Owner/Responsible
Committee
RR
Trust wide
Review Date
/ Frequency
Main Controls

Workforce planning
and recruitment
plans.

Nurse staffing levels
based on acuity /
NICE Guidance –
Daily close
monitoring and
management of
staffing, escalation
process and
provision of cover
by Senior Nursing
staff.
Director of Nursing
Director of Human
Resources
4 X Daily
Bed
Management
Meetings
and real time
Nursing
Reviews
using the erostering
electronic
system
Director of
Operations
Executive
Management Team
Quality and
Governance
Committee
15
RED
↓


Completion of
staffing
levels/incident
reports forms to
enable analysis of
impact.
Monitoring of KPI’s
including HR.

Monthly paper to
Trust Board.

6 Month acuity /
dependency
reviews to Trust
board
Page 22 of 42
Key Actions

Timely
recruitment in to
the vacant posts
is underway and
to continue under
monitoring.

Monitoring of
KPIs

Utilisation of a
partnership model
and secondment
opportunities from
other trusts.

Recruitment from
abroad

Return to Nursing
pre nursing care
Support Worker
programme.
Action Overdue
not being
addressed
Risk Source
Big time
recruitment
events. Use of
media to
increase
responsiveness
Operational
Performance
Risk register
Incident and
Complaint
Monthly Staffing (Hard Truth) Board Report to Trust
Board informs this risk score.
Risk No:
AF3460
Owner /
Responsible
Committee
Potential Risk
Location
CORPORATE
All Clinical
Directorates

Review
Date /
Frequency


Failure to address
outlying areas of
performance in relation
to HSMR and Trust
SHMI
RR
Main Controls


Medical Director
and Director of
Performance &
Informatics
Monthly
Quality and
Governance
Committee
15
RED






Trust Mortality
Steering group in
place
Internal mortality plan.
Patient Safety
Programme developed
with work streams and
identified KPI’s
Use of National
benchmarking tools
Reports on Mortality
To Quality and
Governance
Committee
Systematic monitoring
and analysis of all
hospital deaths via
Mortality reviews
Systems for identifying
Dr foster ‘red bell’
outliers
Systematic analysis of
SHMI and HSMR
Use of Dr foster real
time monitoring and
report
AQUA Mortality
Collaborative
participation
Key Actions




Trust agreed
strategies and
actions associated
with their
implementation and
monitoring
Detailed drill downs
and mortality
analysis of alerts Dr
Foster and mortality
reviews
CQC Intelligence
Monitoring to be
systematically
reviewed
Director of
Performance &
Informatics and
Lead have begun to
review coding and
an initial review
report is expected
in late March early
April. The report will
inform the actions
and timescales
Action
Overdue
not being
addressed
Risk Source
None
External
Monitoring,
National
reports,
Operational
performance
Incidents
inquests
complaints
and claims
Further data quality work and mortality collaborative
input expected to further positively influence our risk
reductions
Page 23 of 42
Potential Risk
CORPORATE
Risk
AF3463
Failure to
ensure
appropriate
focus on
privacy and
dignity for
patient and
relatives
Location
Owner /
Responsible
Committee
RR
Main Controls

All Clinical and
Corporate
Directorates

Review Date /
Frequency



Director of
Nursing/Medical
Director
Monthly
Quality and
Governance
Committee

15
RED







Revised Quality and Governance
committee and reporting
structure in place
Programme developed with key
work streams and KPI’s
Reported to Service Quality and
Operational Governance group
Key risk related areas are built
into the clinical audit forward
plan.
Constituent quality and safety
reports to Board and Board Sub
Committees – provide
assurance
Patient experience monitoring
and reporting
Mandatory training and induction
programmes
CQUIN measures monitoring
First Friday visit programme
Senior Nursing reviews and
unannounced visits
Values and Behaviours work
programme
Board Reports Assurance
Reports
Quality Account
Key Actions








Constituent action
plan
revised and
strengthened
Governance
Systems
Organisational
Leadership and
Staffing structures
Patient Safety
programme
Patient Experience
programme
Values and
Behaviour work
streams.
Oversight by the
Improvement board
and Quality and
Governance
Committee Structure
Ward Accreditation
framework in use
and challenge in
system
Action
Overdue
not being
addressed
None
Risk Source
Third party
review/
inspection
Operational
Performance,
Incidents,
Complaints,
Claims,
Inquests
external
reviews
The risk remains 15 as the CQC inspection of May 2014
found issues regarding critical care and surgical waiting
areas. Action plan and mitigations in place risk will
remain 15 until assured by further visit.
Page 24 of 42
Potential Risk
CORPORATE
Risk
Failure to
No:
prevent
and / or
AF3464 control
Healthcare
associated
infection
Location
Owner /
Responsible
Committee
RR
Main Controls

All clinical and
Corporate
Directorates

Review Date /
Frequency


Director of
Nursing/Director
of Infection
Prevention and
Control



Daily
monitoring of
surveillance
Monthly
Trust Board
review
Weekly EMT
review
Director of
Operations (for
Delivery)

15
RED

↓

Quality and
Governance
Committee



Systematic monitoring of
performance by the
Infection Prevention Team
Performance Dashboard
Provider services contract /
service specification
Assurance dashboard
RCA process used in every
case of C. difficile (includes
internal Consultant review
rd
and 3 party CCG review)
CREAM – Consultant
Review and Executive
Assurance Meeting
PIR process used in every
case of MRSA
bacteraemia – PIR
document submitted to
PHE
Extended surveillance
process used in every case
of MSSA and E Coli
bacteraemia
HCAI Improvement plan
and monitoring report
presented monthly to
Board
Borough wide Health
Protection Group reviews
HCAI’s
Hospital Infection
Prevention Committee
meetings.
Page 25 of 42
Key Actions
Action
Overdue
not being
addressed
Risk Source

Systematic
monitoring
determines
actions to
be taken.
 Trust
 Operational
working to
performance
HCAI
 Patient Safety
Improveme
 Quality
nt Plan and None
 Incidents
CPE
complaints and
Manageme
claims
nt Plan

Alerts
agreed with
CCG and
regulators.
 Assurance
Dashboard
actions
Current risk score reduced to 15 and it is anticipated
that this risk will reduce further in the new financial
year as new trajectories are set.
Detailed HCAI Improvement Plan and CPE
Management Plan in place and monitored to ensure
mitigation.




Zero tolerance approach to
HCAI
Infection Prevention and
control policies and
procedures
Antimicrobial Policy
framework and prescribing
guidance and stewardship
CPE Management Plan
and associated protocols
(Policy, Care plan,
Information leaflets,
Isolation Facilities Risk
Assessment & Treatment
Plan
Page 26 of 42
Risk
AF3467
Potential Risk
Location
CORPORATE
All Clinical
Directorates
Failure to develop services in
line with best practice relating
to NICE Guidance Trust wide
and Failure to deliver the
Contract Quality requirements
and CQUIN.
Owner
RR
Main Controls

Review
Date /
Frequency

Executive
Team
Monthly
Quality and
Governance
Committee

15
RED


AQ, Safety
Thermometer ,
clinical work
streams , NSF and
Cancer
Implementation
Groups and action
plans
Trust is participant
in NHS North
West “Advancing
Quality Strategy”
CQUIN Contract
Monitoring
process
Key
subcommittees
and individuals
have designated
responsibilities for
Quality metrics
and CQUIN
targets identified
in the Contract
which are
supported by
standards and
processes.
Key Actions
Action
Overdue
not being
addressed
Risk
Source

Regular
progress
reports to
Service Quality
and
Operational
Governance
External
group and sub
third party
committees
review ,
against
patient
Contract
None
feedback
Quality
and
and CQUIN
incidents
metrics
complaints
 Finance and
and claims
Performance
Committee
monitoring
going forward
Improvement
Board
monitoring
and mitigations will mitigate and reduce the risk to
an organisationally acceptable level.
Review process based on regulator assessment
Page 27 of 42
Risk
AF3477
Potential Risk
Location
CORPORATE
All Clinical
Directorates
Failure to ensure
requirements for consent to
treatment
Owner
RR
Main Controls


Review
Date /
Frequency

Medical
Director
Monthly
Quality and
Governance
Committee

15
RED



Clear procedure and
training in place
Policies and
guidelines outline
expected standards
and process of audit
enables monitoring
of these
Consultant Staff
required to appraise
Juniors on skills and
knowledge
Medical Director’s
annual appraisal of
senior medical staff
Professional staff
where delegated
consent in place
required to have
appropriate
competency checks
and supervision
Clinical Audit
Programme
Key Actions

Increased staff
awareness of
safeguarding
concerns

Increase utilisation
of DOLS

Review of systems
for implementation
of Mental Health Act
has taken place

Action
Overdue
not being
addressed
None
Focussed consent
programme to be
redeveloped via
Patient safety
officers. Task and
finish work stream
reporting through to
Quality and
Governance
Risk
Source
External
third party
review ,
patient
feedback
and
incidents
complaints
and claims
and mitigations will mitigate and reduce the risk to
an organisationally acceptable level.
Review process based on regulator assessment
Page 28 of 42
Potential Risk
Location
CORPORATE
All Clinical
and
Corporate
Directorates
Review
Date /
Frequency
Risk
Failure to meet CQC
AF3480 registration requirements
relating to staffing
And to achieve full recruitment
of all staff groups to maximise
the benefits of the new working
environments
- Shortage of staff especially in
difficult to recruit disciplines.
Owner /
Responsible
Committee
RR
Medical
Director
Nursing
Director
Director of
Human
Resources
Director of
Operations
and
Performance
Monthly
Trust Board
Trust
Executive
Group
Trust
Medical
Education
Leads
15
RED

Main Controls
 Improvement Plan
Deanery review action
plan and processes
underpinning this.
 Advanced Practitioner
and Assistant
Practitioner schemes
and recruitment.
 Locum arrangements.
 Strategic plan
implementation and
monitoring Progression
of E-Rostering
programme.
 Progression of strategic
plans and alternative
staffing options where
clinical care is not
compromised.
 Divisional specific
business plans.
 Rotas monitoring and
review.
 Duty and on call senior
clinical and
management support to
address any deficits as
they arise Duty Senior
Nurses monitoring.
Page 29 of 42
Key Actions
Action
Overdue
not being
addressed
Risk
Source
 Reports to Board and
Executive Team
 Reports to Service
Governance group and
sub committees
reporting to Quality and
 Safety Walk rounds
identify real time
processes and levels
None
 First Friday visits
Feedback through
Incident reports,
complaints, PALS
External
review
and
feedback
internal
monitoring
 Third party
assessments and visits
 Ward Hot spot and
Dash Boards.
Staffing Reports to Board Report which inform risk
score.
Potential Risk
Location
CORPORATE
All Clinical
and
Corporate
Directorates
Risk
Failure to ensure that staff
AF3481 have the relevant skills,
training support and
supervision to ensure safe
practice and meet registration
requirements.
Owner /
Responsible
Committee
RR
Main Controls


Review
Date /
Frequency

Director of
Human
Resources
Executive
Team
15
RED



monthly


All key policies and
procedures held on
Intranet. - Document
control system. –
Mandatory Training
requirements and
review annually of
training needs
analysis. –
Educational
Governance Group to
coordinate and
systematically apply
educational
governance. –
Deanery action and
requirements.
Leadership Courses
for Nurse Leaders
Revised appraisal
system to be
implemented in 2015
to strengthen the
systems for
development and skill
identification
Equipment trainer
and monitoring of
competencies
Page 30 of 42
Key Actions



Action
Overdue
not being
addressed
Risk Source
None
Third party
review and
internal
monitoring
Incidents
complaints
Claims and
Operational
performance
and impact
Divisional monitoring
and actions to
ensure mandatory
training and
development needs
are met.
Monitoring of KPI’s
Bespoke training to
deliver skills where
staff identify
additional training
needs
Third party assurance received from MIAA Audit
regarding the medical staff revalidation process
provides assurance around the revalidation element.
It is anticipated that further implementation of the
agreed action plan and mitigations will mitigate and
reduce the risk to an organisationally acceptable
level.
Potential Risk
Location
CORPORATE
All Clinical
and
Corporate
Directorates
Risk
Failure to ensure adequate
AF3482 nursing, medical and support
staffing levels to ensure
patient safety and quality of
services
Owner /
Responsible
Committee
RR
Main Controls


Review
Date /
Frequency
Executive
Team
monthly
NHSP
Contract
Monitoring
Meetings

15
RED




Workforce planning
and recruitment
strategy.
Nurse staffing
levels based on
acuity – Daily close
monitoring and
management of
staffing, escalation
process and
provision of cover
by Senior Nursing
staff.
Completion of
staffing
levels/incident
reports forms to
enable analysis of
impact.
Introduction of
Divisional
Governance
support.
Recruitment from
abroad has
informed our plans
Implementation of
the Consolidated
action plan and
oversight by
Improvement board
Page 31 of 42
Key Actions




Trust wide
Consolidated action
plan and
implementation
monitored through
Improvement board
Recruitment in to the
vacant posts is
underway and to
continue under
monitoring.
Weekly monitoring of
KPI’s
Utilisation of a
partnership and
secondment
opportunities from
other trusts.
Action
Overdue
not being
addressed
Risk Source
None
Third party
review and
internal
monitoring
Incidents
complaints
Claims and
Operational
performance
and impact
agreed action plan and mitigations will mitigate and
reduce the risk to an organisationally acceptable level.
Potential Risk
Location
CORPORATE
All Clinical
Directorates
and
Divisions
Review
Date /
Frequency
Risk
Increased demands beyond
AF3483 predicted levels which is
outside current capacity
Owner /
Responsible
Committee
RR



Director of
Operations
Monthly
Main Controls
Executive
Management
Team
Finance and
Performance
Committee

15
RED




Capacity Plans in
place
Demand
Management
implications are
being implemented.
Regular meetings
with CCG and other
partners to improve
availability of, and
access to,
intermediate care
beds.
Risk assessments
are completed for
any areas used for
escalation.
Patients are required
to be appropriately
risk assessed before
being admitted to
escalation areas.
Partnership working
with other providers
to ensure a long term
strategy is in place
regarding
sustainability and
service provision.
Capacity Protocol in
place in the
Emergency
Department
Page 32 of 42
Key Actions

Development of
integration strategy in
key partners

Implementation of
workforce action s in
consolidated action
plan monitored by
Operational Board
Action
Overdue
not being
addressed
Risk Source
None
Third party
review and
internal
monitoring
Incidents
complaints
Claims and
Operational
performance
agreed plan and mitigations will mitigate and reduce
the risk to an organisationally acceptable level.
Risk
AF3484
Owner /
Responsible
Committee
Potential Risk
Location
CORPORATE
All Clinical
and
corporate
Directorates

Review
Date /
Frequency

Failure to fulfil regulatory
registration requirements
with management of
Complaints
Main Controls

Director of
Nursing
Monthly
RR
Quality and
Governance
Committee
15
RED






Complaints procedure
is in place and widely
publicised and available
– positive and negative
feedback is encouraged
Complaints sign off by
CEO
Complaints and PALS
processes are
divisionally supportive
and operationally
managed centrally in
the Trust Quality and
Governance Unit
Routine Board reporting
Detailed reports to
Quality and
Divisions routinely
receive detailed
information re
complaints and issues
identified
Service Quality and
operational Committee
receives assurance and
aggregated learning
reports
Quality and
receives assurance and
aggregated learning
reports.
Page 33 of 42
Key Actions
Action
Overdue
not being
addressed
Risk Source

Internal Complaints
review continuously
taking place.
 Independent review
of complex
complaints.
Third party
 Complaints
review and
management and
internal
investigation
monitoring
training package is
None
Incidents
being delivered to
complaints
patient-facing
Claims and
managers / senior
Operational
clinicians Additional
performance
resources
addressing
historical
outstanding issues
 Revised process
and actions to be
implemented
It is anticipated that further implementation of the agreed
plan and mitigations will mitigate and reduce the risk to an
organisationally acceptable level.
Potential Risk
Location
CORPORATE
All Clinical
And
Corporate
Directorates
Risk
Failure to comply with the
AF3487 regulatory requirements for
standards of Quality and
Safety
Owner /
Responsible
Committee
RR
Main Controls


Review
Date /
Frequency


Trust Board
Quality and
Governance
Committee
Monthly
15
RED








Trust Governance and
reporting arrangements
Review and analysis of
CQC Intelligence
monitoring - risk areas
identified and action taken
to understand if not
already aware
Reported to Service
Governance group
Key risk related areas are
built into the clinical
audit/audit forward plan.
Constituent quality and
safety reports to Board
and Board Sub
Committees – provide
assurance
Patient experience
monitoring and reporting
Mandatory training and
induction programmes
CQUIN and key standards
measures monitoring
First Friday visit
programme
Senior Nursing/Senior
Clinical reviews and
unannounced visits
Systematic Programme to
address essential
standards.
Page 34 of 42
Key Actions
Action
Overdue
not being
addressed
Risk Source
None
Regulatory
rd
3 Party
assessment
Patient
feedback
Operational
Performance
Incidents
Complaints
and Claims
Implementation of:
Trust agreed
strategies and
actions associated
with their
implementation
and monitoring
The implementation of the agreed
implementation plan and mitigations has
resulted in a reduced risk score in some areas.
Owner /
Responsible
Committee
Potential Risk
Location
CORPORATE
All Clinical
and
Corporate
Directorates

Review
Date /
Frequency

Risk
Failure to minimise delayed
AF3490 transfers of care
RR
Main Controls

Director of
Operations
Improvement
Board
15
RED



Monthly

Capacity Plans in
place
Demand Management
implications are being
implemented.
Regular meetings with
CCG and other
partners to improve
availability of, and
access to, intermediate
care beds.
Risk assessments are
completed for any
areas used for
escalation.
Patients are to be
appropriately risk
assessed before being
admitted to escalation
areas.
Partnership working to
ensure a long term
strategy is in place
regarding sustainability
and service provision.
Page 35 of 42
Key Actions


Development of
integration
strategy in
conjunction with
Key partners
Implementation of
workforce action s
in consolidated
action plan
monitored by
Improvement
board
Action
Overdue
not being
addressed
Risk Source
None
Operational
performance
Agreed implementation plans in place however as
seasonal planning approaches the ability of
partner organisations to support this agenda will
impact on the trust. Therefore this risk has been
increased to reflect this.
Risk No:
AF3491
Potential Risk
Location
CORPORATE
All Clinical
and
corporate
Directorates
Review
Date /
Frequency
Failure to have in place a
IM&T infrastructure and
Service supporting
organisational objectives
Owner /
Responsible
Committee
RR
Main Controls


Director of
Performance
& Informatics
Monthly
Executive
Management
Team and
Trust Board
IM&T team reporting
the Chief Operating
Officer reporting to an
identified Executive
Director – Director of
Finance with policy
and procedures and
operating framework to
National Standards
Key Actions




Development of
technology
infrastructure through
capital programme
15
RED


Revised IM&T
strategy
Review of
resources
Consistency to
address any gaps
in controls
IM&T Committee
and supporting
Committees to be
strengthened and
re-established
post Lorenzo go
live to ensure
systematic
reporting of IM&T
assurances
through to Board
Infrastructure to
be proposed and
progressed in line
with Governance /
Committee
Review
Action
Overdue
not being
addressed
Risk Source
None
Operational
performance
agreed plan and mitigations will mitigate and
reduce the risk to an organisationally acceptable
level.
Page 36 of 42
Potential Risk
Location
CORPORATE
All Clinical
and
corporate
Directorates
Review
Date /
Frequency
Failure to deliver agreed activity
Risk
AF3495 and income plan
Owner /
Responsible
Committee
Director of
Operations
supported by
the Director
of Finance
Monthly
Executive
Management
Team and
Trust Board
RR
15
15
RED
→ED

Main Controls

Board Performance
Monitoring
framework.

Board reporting
systems and
Committees.

Divisional
Performance
Management system
and structures.

Monthly reporting.
Validation process,
PBR Coding Audits,
Third party audits
and monitoring

Finance and
Performance
Committee
Page 37 of 42
Key Actions
Action
Overdue
not being
addressed
Risk Source
Monthly
performance
meetings with all
leads.
None
Operational/Financial
performance
It is anticipated that implementation of the agreed
plan and mitigations will mitigate and reduce the risk
to an organisationally acceptable level.
Risk
CR770
Potential Risk
Location
CORPORATE
Diagnostic
and
Therapeutic
Services
impacting
on all
Clinical
Directorates

Review
Date /
Frequency

Reduced sustainability of
Radiology services due to
inability to recruit to key
Radiology posts
Monthly
Owner
RR
Main Controls

Director of
Operations
Executive
Management
Team /
Finance and
Performance
Committee
15
RED



Trust recruitment
strategy to
vacancies
Collaboration with a
Partnership to
provide a long term
strategy for
provision of
services.
The Trust has
outsourced reporting
to address service
pressures across
radiology.
Funding for further
training of
radiographers to
undertake training
for reporting
examination
Employment of a
Band 7 post who will
be a reporter of
identified
examinations
Key Actions
Action
Overdue
not being
addressed
Risk Source

Use of waiting list
initiatives for
substantive
consultants to help
address shortfall.
 Use of external
locums to support
breast service.
 Further recruitment
of a Breast
Operational
Radiologist which
Performance
has been advertised None
Incidents
Complaints
 Agency options
and Claims
being implemented.
 Consideration of
training for Breast
Surgeon to perform
breast ultrasound.
 Further training for
radiographers to
enable reporting of
identified
examinations
The Trust has an action plan to address shortfalls
however there is local and National competitive
recruitment issues impact on the Trusts ability to
meet timescales and limit the effectiveness of long
term mitigation plans
Page 38 of 42
Risk
CR1845
Potential Risk
Location
CORPORATE
All Clinical
and
Corporate
Directorates
Trust fails to achieve
national best practice
e.g. NICE, Bundles of
Care, NSFs, Stroke
Sentinel Audits/ TIA etc.
Owner/Responsible
Committee/Group
RR
Review
Date /
Frequency
Directors of all
Services
Executive
Management Team
Risk
Review
Monthly
15
RED

Main Controls
Trust regularly reviews
performance against
national standards and
monitors implementation
of care bundles through
regular spot checks and
the dashboard and
intelligence reports.
Implementation of NICE
and other national audits
are via the Clinical Audit
Effectiveness Group
(CAEG) and Advancing
Quality requirements are
in place for this
speciality. CAEG also
monitors Doctor Foster
performance data. E.g.
Strokes are reviewed by
Executive Team.
SQOGG oversight. This
Links closely with our
Mortality action plan and
clinical safety work and
assurance
Page 39 of 42
Key Actions


Continued review
and drill down in
relation to patient
flow, stroke review
team processes
and engagement
of clinicians
Consider need for
ensuring
availability
/allocation of
specialised beds
Action
Overdue
not being
addressed
None
Risk
Source
Internal
monitoring
and
metrics
reported
externally
It is anticipated that the completion of the agreed
actions and implementation plan will reduce the
risk and provide mitigations by the end of
Risk
CR3511
Potential Risk
Location
CORPORATE
All Clinical
Directorates
Failure of the Trust to
have in place a robust
IT Disaster Recovery
Plan
Owner /
Responsible
Committee
RR
The Trust:
Has developed and
recruited a Head of
Information and
Performance to support
the service.
Review
Date /
Frequency
Director of
Performance and
Informatics
Risk
Reviewed
Monthly
Main Controls
Executive
Management
Team
15
RED

The Service is closely
monitoring the situation
and actions to mitigate
the risk are taking place.
Information Management
and Technology
Committee in place
Key Actions
Action
Overdue
not being
addressed
Risk Source
None
,
Operational
performance
Incidents
The Trust is developing
and agreeing DR
recovery plans based
upon the business need
and patient care
The Head of IT is in
discussion with the
regarding the
prioritisation of the
disaster recovery plan.
Requested Desktop DR
exercise via EPRR.
Date to be confirmed.
The risk score has been reviewed in February and
remains at 15. It is anticipated that the completion of
the agreed actions and implementation plan will
reduce the risk and provide mitigations
Page 40 of 42
Risk
CR3512
Potential Risk
Location
CORPORATE
All Clinical
Directorates
SQL is a Microsoft Enterprise
Database Tool used widely
across the Trust services.
The SQL server estate is
using unlicensed Microsoft
software.
Numerous versions of SQL
are in use, including those
that are no longer in support
with Microsoft. This is a
service and security risk.
Owner /
Responsible
Committee
RR
Information Management
and Technology
Committee in place.
Head of Information and
Performance recruited to
support the service.
Review
Date /
Frequency
Director of
Performance
and
Informatics
Risk
Reviewed
Monthly
Main Controls
IM&T
Committee /
Executive
Management
Team
15
RED

The Trust:
 Is cataloguing the
use of unsupported
SQL version
 Is migrating to
newer versions
 Cataloguing all SQL
estate
 Is migrating to robust
warehouse
architecture
 Is establishing &
implementing a Trust
wide data policy,
warehouse
processes
Key Actions
Action
Overdue
not being
addressed
Risk Source
The Trust needs to
continue to progress
main controls to reduce
the risk further
Work to identify the
best method to manage
the migration and
consolidate the servers
for a more cost
effective solution.
Potential solutions
Once the licenses have
,
been procured to
Operational
reduce risk 3346 the
None
performance
Trust will need to
Incidents
commence a
programme of work as
outlined in the business
case supporting the
procurement of
licenses to align all
databases on a
standard supported
software platform. This
needs to be completed
before the end of the
ESA agreement.
actions and implementation plan will reduce the risk
and provide mitigations
Page 41 of 42
Risk
CR3572
Potential Risk
Location
CORPORATE
All Clinical
Directorates
Risk of a reduction in the
provision of services and
delivery of care due to the
realisation of industrial action
Owner /
Responsible
Committee
RR
The main controls in
place are:
Review
Date /
Frequency
Director of
Human
Resources
Risk
Reviewed
daily/weekly
Main Controls
Executive
Management
Team / Trust
Board
15
RED

Close partnership
working with staff side
and Unions to ensure
communication and
negotiation. Contingency
planning and liaison with
clinical and non-clinical
leads/Managers to
ensure a strategy to
reduce impact.
Key Actions
Action
Overdue
not being
addressed
Risk
Source
None
,
External
Regular meetings and
updates with Union
representatives
actions and implementation plan will reduce the risk
and provide mitigations
Page 42 of 42
Report to Public Trust Board meeting of 26thMarch 2015
Agenda Item
9a
Title
Interim Support Finance – March 2015
Author (s)
Sharon Hassall – Financial Accountant
Purpose
To update the Trust Board on the arrangements for
Interim Support Finance.
N/A
Executive Summary
DH have issued new guidance regarding Interim Support finance arrangements for NHS
Trusts and NHS Foundation Trusts who are currently in receipt of Interim Support from the
Department of Health.
The Trust has drawn down, to date, from the Department of Health £9m as public dividend
capital to support the projected deficit financial position. On 23rd March this will be repaid
and replaced by a Loan for £9m plus a further drawdown of £5.6m giving a total loan for
14/15 of £14.65m.
The Trust is expecting to take out a further loan for approximate £25m in 2015/16.
A full business case will need to be prepared, following on from the conclusion from the
Contingency Planning Team, to determine how much, if any, of the debt will be repayable
and over what period. The full business case needs to be submitted and be approved within
four years in order that the debt remains a long term liability rather than convert to a short
term liability.
To develop a strategic service plan which will secure
clinical and financial sustainability for the Trust in
conjunction with the Trust’s strategic partners and key
stakeholders.
Risk Assurance – risk
impacted upon
As the Trust is operating with a deficit ‘distress funding’
is required to pay staff and suppliers in order to continue
trading. The Trust will therefore need to apply for
funding from Monitor/DH in order to mitigate against the
adverse cash flow.
requirements
Has a quality impact
assessment been undertaken?
As stated above
No
Sustainability?
Will ensure the Trust has sufficient cash to fund
operating expenditure.
Action required by the Board The Board is asked to note the contents of the report.
1
INTERIM SUPPORT FINANCE ARRANGMENTS
MARCH 2015
PURPOSE
1.
The purpose of this report is to advise the Trust Board of the change of the Interim
Support Finance Arrangements from the Department of Health (DH).
Background
2.
During 2014/15 financial year the Trust has been drawing down temporary Public
Dividend Capital (PDC), to support the cash position. In each month the repayment date
has been extended to the following month. It was believed the temporary funding would
become permanent funding. The 2012 legislation allocated the PDC to Trust based on
the risk pool. It was decided this should reviewed in 2013, as there were no detailed
policy with regards to funding providers. PDC was being distributed to Trusts to fund the
deficits. This however, was potentially being seen as “free” money, with no incentive to
the Trust’s to reduce the funding requirements. There has also been resentment from
solvent Trusts not requiring this additional funding, of the Financial Distressed Trust’s
receiving, the “free” money.
3.
Due to these factors, the DoH have reviewed the funding structures and have introduced
the following mechanisms to provide cash funding to the Trusts.
Name
Interim Revolving Working
Capital Support Facility
Interim Capital Support Loan
Description
Extendable revolving maturity loan provided
pending the development of Recovery Plan
Extendable maturity loan provided pending
the development of Recovery Plan
Capital Loan repayable by equal instalments
of principal pending the development of
Recovery Plan
4.
At the end of February the Trust had drawdown temporary PDC of £9m, with an
expectation of drawing down a further £5.6m, giving a total cash drawdown of £14.65m.
5.
Due to the changes of the funding, all temporary borrowing limits (TBL), are now required
to be repaid by the 23rd March 2015 as these cannot be extend past the 31st March 2015.
The funding to the Trust is to be replaced with an Interim Revenue Support Loan.
6.
The Trust will now be required to repay £9m PDC to the DoH on the 23rd March 2015,
and will take out a loan for £14.6m, which will consist of the £9m funding already
received and the additional £5.6m March cash requirement.
7.
This Loan will be a Non Current Liability to the Trust being a long term loan which is be
expected to be repaid in 2 years. However, as the Trust is currently working with the
Contingency Planning Team (CPT), it is expect the Trust will produce a Full Business
Case and the loan could be extended for a further 3 years, up to 5 years. This will be as
part of the implementation of the Financial Recovery.
2
8.
The principle of the Loan will not be repaid until the end of the loan period. The loan will
incur interest of 1.5% throughout the period and this will be required to be repaid every 6
months. The Trust is allowed to have a cash balance at the end of the month of any
drawdown from the loan of 2 days operating expenditure from 2013/14, this equates to
£884k.
9.
Attached in Appendix A, is a copy of the 13 week cashflow which is to be submitted to
Monitor and to the Department of Health. Attached in Appendix B is the Interim Revenue
Support Loan Resolution this is to be approved by the Board and signed by the
Chairman.
Interim Revolving Working Capital Support Facility
10. In 2015/16, the Trust will be planning a further loan to support the cash position of
approximately £25m. However, until the final plans have been submitted to Monitor, the
DoH will be unable to approve the issue of this loan.
11. To eliminate the risk of the Trust having insufficient cash in April and May, it is
recommended the Trust requests an Interim Revolving Working Capital Support Facility.
This will be for the value of 10 days operating expenditure, which is approximately,
£4.4m.
12. The Trust is not charged a commitment fee for this facility, but will be charged interest of
3.5% on the balance of any drawdown from the facility.
13. Currently, the 13 week cashflow detailed in Appendix A, shows the Trust will not require
this facility. However, being prudent, it is recommended the board authorise the
resolution, enabling the Interim Revolving Working Capital Support Facility, to be made
available, should there be any change in the cash position during the first two months on
the financial year.
14. Attached in Appendix C, is the Interim Revolving Working Capital Support Facility
Resolution to be approved by the Board and signed by the Chairman.
CONCLUSION
15. The Trust is expected to repay to the DoH £9m temporary PDC and receive an Interim
Revenue Support Loan of £14.65m from the DoH on the 23rd March. The Trust is
expecting a further Interim Revenue Support Loan of approximately £25m in the next
financial year. Until this has been finalised and the final plans submitted to Monitor, the
Trust will have an Interim Revolving Working Capital Support Facility.
RECOMMENDATION
The Board are requested to discuss the contents of this report and approve the actions
contained within.
The Board are request to endorse the Board Resolution attached in Appendix B and C which
were approved using Chairman’s action.
3
Appendix A
PDC funding request - cashflow summary (complete for 13 weeks)
Trust name
Week commencing
1
2
3
16 - Mar 23 - Mar 30 - Mar
Mar
£'000
£'000
£'000
£'000
4
5
6
7
06 - Apr 13 - Apr 20 - Apr 27 - Apr
£'000
£'000
£'000
£'000
8
9
10
11
04 - May 11 - May 18 - May 25 - May
£'000
£'000
£'000
£'000
Apr
£'000
12
13
14
15
01 - Jun 08 - Jun 15 - Jun 22 - Jun
£'000
£'000
£'000
£'000
May
£'000
June
£'000
Section A
Opening cash
12,796
7,330
500
12,796
540
1,299
11,509
11,558
540
1,836
2,712
14,700
13,417
1,836
1,529
1,594
1,461
10,172
1,529
40
125
165
525
174
699
20
20
40
585
319
904
30
732
762
11,781
1,325
13,106
50
125
175
30
174
204
11,891
2,356
14,247
30
732
762
12,172
525
12,697
50
125
175
20
301
321
12,272
1,683
13,955
40
105
145
50
525
575
11,781
257
12,038
30
174
204
11,901
1,061
12,962
Payroll costs
Non pay costs
PDC Dividend
Loan repayments and interest
NHS Creditors
Non NHS Creditors
Other payments
Capex
PFI capex
Capital creditors
Total payments
-3,760
-1,019
0
0
-8,722
-4,109
0
-270
0
0
0
0
-120
117
0
0
-2,294
-602
0
0
-126
0
0
0
-5,285
-4,270
0
-270
-120
-588
0
0
-1,638
179
0
0
-5,685
-6,152
0
-270
-120
-588
0
0
-3,506
179
0
0
-5,565
-5,370
0
-270
0
0
0
0
0
0
0
0
-47
-54
0
0
0
0
0
0
-47
-54
0
0
0
0
0
0
-47
-54
-5,631
-13,171
0
-3
-2,896
-126
-9,926
114
-708
-1,459
-12,208
-7,443
-6,447
0
-270
0
0
-47
-54
0
0
-14,261
0
-80
0
0
-70
-0
-7,824
-4,755
0
-270
0
0
-47
-54
0
0
-12,951
0
114
0
0
-2
-850
-12,482
-5,128
0
-270
0
0
-72
-850
0
0
-18,802
-80
-708
-3,327
-11,306
-9,191
-5,859
0
-270
0
0
-47
-54
0
0
-15,421
Net payments/receipts (before PDC funding)
-5,466
-12,473
40
-17,898
759
10,210
49
-9,722
1,296
876
11,989
-1,284
-11,887
-306
65
-133
8,711
-11,102
-2,460
7,330
-5,143
540
-5,103
1,299
11,509
11,558
1,836
1,836
2,712
14,700
13,417
1,529
1,529
1,594
1,461
10,172
-930
-930
0
5,643
0
5,643
0
0
0
0
0
0
0
0
0
0
0
0
0
1,814
1,814
7,330
500
540
540
1,299
11,509
11,558
1,836
1,836
2,712
14,700
13,417
1,529
1,529
1,594
1,461
10,172
884
884
81
81
81
243
0
-107
-107
-107
-107
-427
0
-107
-107
-107
-107
-427
0
-107
-107
-107
-107
-427
0
Clinical income
Other receipts
Total receipts
Closing cash (before PDC funding)
Section B
PDC funding (1)
Closing cash (after PDC funding)
Depreciation (2)
Other capex funding source
Memo lines:
Capital funding requirement
Revenue funding requirement
(1)
PDC funding should be drawn down once per month. The
minimum cash balance in any month in which PDC
funding is drawn should not exceed £500k.
(2) For the purpose of the template the monthly
depreciation value should be spread evenly across each
week in the month.
1,093
4,550
0
0
0
0
0
1,814
Appendix B
Interim Revenue Support Loan 2014/15
This is the Board of Director’s Resolution for the Interim Revenue Support
Loan from the Department of Health to Tameside Hospital NHS Foundation
Trust to be received on 23rd March 2015.
The Board of Director’s authorise as the borrowers of the Interim Revenue
Support Loan the following:a.
approving the terms of, and the transactions contemplated by the
Finance Documents to which it is a party and resolves to execute the
Finance Documents to which it is a party.
b.
authorise the Finance Director to execute the Finance Documents on
behalf of the Board of Directors.
c.
authorise the Finance Director to sign and/or dispatch all documents
and notices including any Utilisation Requests to be signed and/or
dispatched in connection to the Finance Documents.
d.
confirm as borrowers to comply with the Additional Terms and
Conditions.
e.
a certificate of the authorised signature of the Finance Director will be
provided prior to the issue of the Interim Revenue Support Loan.
f.
updated financial statements will be provided, as required.
g.
agreement for the Interim Revenue Support Loan to be completed as
the Lender shall require and any other Finance Documents not list
above.
h.
a copy of any other documents, opinions or assurance which the lender
considers necessary or desirable in connection with the transaction will
be provided, as requested.
i.
evidence that fees, costs and expenses due from the borrower to the
lender relating to enforcement costs will be provided of having been
paid or will be paid by the first Utilisation Date.
This resolution is approved on behalf of the board by:
__________________________________
Paul Connellan
Chairman
1
18th March 2015
Appendix C
Interim Revolving Working Capital Support Facility 2015/16
This is the Board of Director’s Resolution for the Interim Revolving Working Capital
Facility from the Department of Health to Tameside Hospital NHS Foundation, to be
utilised in the period 1st April 2015 to 31st March 2016
The Board of Director’s authorise as the borrowers of the Interim Revolving Working
Capital Support Facility the following:a.
approving the terms of, and the transactions contemplated by the Finance
Documents to which it is a party and resolves to execute the Finance
Documents to which it is a party.
b.
authorise the Finance Director to execute the Finance Documents on behalf of
the Board of Directors.
c.
authorise the Finance Director to sign and/or dispatch all documents and
notices including any Utilisation Requests to be signed and/or dispatched in
connection to the Finance Documents.
d.
confirm as borrowers to comply with the Additional Terms and Conditions.
e.
a certificate of the authorised signature of the Finance Director will be provided
prior to the issue of the Interim Revolving Working Capital Support Facility.
f.
updated financial statements will be provided, as required.
g.
agreement for the Interim Revolving Working Capital Support Facility to be
completed as the Lender shall require and any other Finance Documents not
list above.
h.
a copy of any other documents, opinions or assurance which the lender
considers necessary or desirable in connection with the transaction will be
provided, as requested.
i.
evidence that fees, costs and expenses due from the borrower to the lender
relating to enforcement costs will be provided of having been paid or will be
paid by the first Utilisation Date.
This resolution is approved on behalf of the board by:
__________________________________
Paul Connellan
Chairman
1
18th March 2015
Agenda Item
9b
Title
Register of Interests
Sponsor
Tom Neve
Author (s)
Tom Neve
To amend the centrally held register of interests
Purpose
This report has not been considered by any other
committee
Executive Summary :
The Trust Board is aware that in accordance with the rules of corporate governance,
relevant Director interests are entered in the Trust’s Register and made available for public
inspection. Changes to the Register may be notified to the Board Secretary at any time and
should be done so in writing immediately any changes occur. However, as a further routine
check, the Register will also be reviewed collectively, each March and October.
7. To deliver against the required local and
national frameworks in order to meet all the
n/a
This complies with best governance practice
and regulatory requirements of both Monitor
and the CQC.
requirements
undertaken?
No
No direct impact on sustainability
Sustainability?
Board members are required to check their entry on the Register of Interests and confirm
that it is correct or indicate amendments as appropriate to the Company Secretary
1
DECLARATION OF DIRECTORS’ INTERESTS
Mr P Connellan
Chair
Director of Aviat Consulting Ltd which provides consultancy advice to a
number of organisations.
Mr D A Ward
Non-Executive Director
Trustee and Non Executive Director of Cheadle Royal (Industries)
Limited, a charity which provides secure employment and rehabilitation
for persons with mental illness and learning difficulties.
Mrs A Dray
Transition Programme Director for Calderdale CCG
Mrs A Higgins
Director of Anne Higgins Consultancy Ltd
Consultant in Innovation and Transformation in care and support services
Mrs J Soboljew
Director of Meteor Mortgages and Money Ltd.
Mrs T Kalloo
CEO, Wellness International Ltd
Wellness International, (W.I.) delivers health and wellbeing services to
corporates and individuals in both the private and public sector.
Ms K James
Chief Executive
No interests.
Mrs C Yarwood
Director of Finance
No interests.
Mr J Goodenough
Director of Nursing
No interests.
Mrs T Cavanagh
Director of Clinical Services
No interests.
Mr B Ryan
Medical Director
No interests.
Ms A Bromley
Associate Director of HR
No interests
2
Agenda Item
9c
Title
Fit and Proper Persons Requirement (CQC
Fundamental Standards of Care)
Sponsoring Director
Paul Connellan
Author (s)
Tom Neve
Purpose
To confirm that all directors or equivalents of
Tameside Hospital NHS Foundation Trust meet the
Fit and Proper persons Requirement
This report has not been considered by any other
committee
Executive Summary :
As the Board is aware, new regulations setting out fundamental standards of care will come
into force for all care providers on 1 April 2015. However, for NHS bodies, the fit and proper
person requirements for directors came into force on 27 November 2014.
All directors or equivalents of Tameside Hospital NHS Foundation Trust meet the fitness
test. This self-certification process will be an annual requirement however it is incumbent on
all directors or equivalents to inform the Chair and Company Secretary of any circumstances
that may impact on their fit and proper person declaration.
7. To deliver against the required local and
national frameworks in order to meet all the
AF3480
Compliance with The Fit and Proper
requirement of the CQC’s Fundamental
Standards of Care
requirements
undertaken?
No
This does not directly affect sustainability
Sustainability?
To note the requirement that any changes in circumstances that may impact on board
directors or equivalents fit and proper declarations must be communicated to the Chair and
Company Secretary
1
Fit and Proper Persons Requirement (CQC Fundamental Standards of Care)
As the Board is aware, new regulations setting out fundamental standards of care
will come into force for all care providers on 1 April 2015. However, for NHS bodies,
the fit and proper person requirements for directors came into force on 27 November
2014.
This requirement applies to all directors and "equivalents". This will include executive
and non-executive directors of NHS foundation trusts and the decision has been
taken to extend this to members of the Trust’s Executive Team.
It will be the responsibility of the chair, to ensure that all directors meet the fitness
test and do not meet any of the ‘unfit’ criteria.
In addition to the usual requirements of good character, health, qualifications, skills
and experience, the regulation goes further by barring individuals who are prevented
from holding the office (for example, under a directors' disqualification order) and
significantly, excluding from office people who: "have been responsible for, been
privy to, contributed to or facilitated any serious misconduct or mismanagement
(whether unlawful or not) in the course of carrying on a regulated activity, or
discharging any functions relating to any office or employment with a service
provider".
Colleagues will recall that I required all board colleagues to sign a self-certification
form declaring that they meet the fitness test and do not meet any of the “unfit”
criteria. In addition to this I requested the Company Secretary to conduct a check
with Companies House to confirm that none of the trust’s directors or equivalents
appears on the disqualified directors register.
I am pleased to confirm that all directors or equivalents of Tameside Hospital NHS
Foundation Trust meet the fitness test. This self-certification process will be an
annual requirement however it is incumbent on all directors or equivalents to inform
the Chair and Company Secretary of any circumstances that may impact on their fit
and proper person declaration.
The trust’s recruitment process has also been revised accordingly and candidates to
senior roles will have to satisfy the Fit and Proper requirement prior to appointment.
Paul Connellan
Chair
2
Agenda Item
Title
9d
Quality and Governance Committee, 5th March
2015
Aggregated learning summary report –
attached
Ms T Kalloo
Author (s)
John Fletcher, Head of Assurance and Governance
Purpose
To note/receive
Quality and Governance Committees
5th March 2015
Executive Summary
Notes of the Quality and Governance meeting March 2015.
Relates to all Corporate objectives
Relates to all areas of risk
requirements
None identified
None
undertaken?
Not applicable
Sustainability?
Not applicable
The Board is asked to receive and note the discussions and Summary Aggregated Learning
Report.
Quality and Governance Committee
5th March 2015
The Committee received and accepted the minutes of the last meeting and reviewed
the actions arising from them. All action required for the February meeting were
completed or included on the agenda.
The meeting commenced with a discussion with the Outpatient Improvement Lead
and Head of Service Improvement. They outlined the significant change that had
been implemented across the Outpatient clinical areas and administration areas that
form the service. This included strengthened nurse leadership, additional nursing
and Health Care Assistant’s in addition to implementation of reception staff in the
clinic areas to provide a responsive service which enabled the clinic to flow and also
ensure issues that arise can be dealt with in real time. This had positively impacted
on the number of concerns and complaints received for this area. The restructuring
of the Outpatient Scheduling and Booking process was described and the revised
work practices put into place in the “White house” administration area described.
These have transformed the area, work environment and staff engagement. They
have enabled achievement of turnaround times for clinical correspondence, with staff
identifying that the benefits are real and that they have been empowered to work
differently and implement change. Assurance s were provided and accepted in
relation to the RICAP action plan relating to Outpatients which had been subject to
scrutiny and challenge.
The HealthWatch Enter and View report was received which included in full the trust
response within the documentation. The report provided positive assurance of the
progress we have made but highlighted issues and inconsistency in application that
we are already working on and will continue to be addressed.
The Committee received and discussed the Patient Experience update, which
provided a progress report. The current ongoing National Patient Surveys were
identified; with CQC published in patient survey results are expected in March 2015
from Patient’s discharged in July 2014. Work is still ongoing in relation to the
Maternity survey and Children’s Young people’s survey. In relation to the A&E
survey results sample results from the local survey were reviewed and more
focussed work is progressing to address further and continue to monitor the
elements of the work included in the action plan.
The report also contained the first annual review of the Dementia strategy which
along with the MIAA Safeguarding Audit report providing significant assurance
against our implementation of the Trust policies and process for safeguarding
demonstrate the significant work that has been progressed and the achievements
made since the Keogh review and subsequent CQC inspections.
The Committee received further updates and detail on the results of the Ward
Accreditation programme which was scrutinised and reviewed.
The Serious Incident Report was discussed and challenged with details of new
investigations and progress on investigations that had previously been discussed.
The updated Significant Risk paper was also presented. Due to the sequencing of
the meetings this was as presented to the Trust Board. The systematic scrutiny in
the Risk Management Committee of Divisional Risk registers was noted within the
discussion.
An updated summary Learning from Experience and the Aggregated Learning report
was provided. The number of incidents, complaints and concerns related to specific
work areas and core services were noted especially those linked to the RICAP action
plan and issues where Duty of Candour was required to be implemented.
The Committee received an update on the progress with the RICAP action plan,
these were also triangulated where appropriate with unannounced walk round
feedback presented was reviewed and discussed and assurance provided that these
were occurring. The Committee specifically reviewed evidence relating to the actions
from the Cardiology review. Good progress had been made with respect to all
actions. Four of the six recommendations were recommended to turn blue on the
action plan and be reported to Trust Board.
An updated Quality Improvement Strategy was presented for consideration and
comment as the current strategy will need to be refreshed in April 2015 along with
the publication of the Trust Quality Account.
The Committee were made aware of the gap analysis that was being undertaken in
respect of the Freedom to Speak out and learning from Francis 2015, and noted the
assertive work progressed by the Director of HR/OD in relation to this. Once
completed this will be reports back to the committee.
Minutes of the reporting committees were received, scrutinised and reviewed for
assurance and awareness.
The committee received an update in respect to the production of the Trust Annual
Quality Account, a draft copy would be provided to the next meeting.
A review of the Trust Committee structure was ongoing due to the proposed changes
in the risk management terms of reference, and this would be brought back to the
next meeting for review.
Ms T Kalloo
March 2015
Summary Aggregated Learning information –
Initial Data for February 2015 **still being validated
Incidents reported
New incidents (reported in month- includes delayed
reports)
Reported with Moderate harm
Reported with Major harm
Reported with Catastrophic harm
Never Event
RIDDOR reported incidents
Complaints and PALS issues
New Complaints
New MP enquiry
New External complaint
New Enquiry
New PALS issues
Total issues received
Re opened Complaints
Issues /cases responded to
Complaints %age closed in agreed timescale
Average time to close issues/cases (working days)
Number issues on-going @ time of monthly report
Ombudsman Cases upheld
Other Indicators
Mortality reviews required
Mortality initial review undertaken within 14 days
Inquests with TGH involvement closed /heard
Coroner-Prevention of Future Death report (Rule 43 )
Internal issue
StEIS reports
External issue
Never events
Safeguarding Allegation on hospital care
Adult cases
Allegation on other care
reported
DOLS
Cases reported to Supervisory
Body
PREVENT
Cases reported
February
2015**
731
13
1
1
0
0
33
0
0
1
188
225
0
240
91%
26
172
0
76
100%
12
1
0
13
0
4
24
17
0
Aggregated Dashboard – November 14 –January 2015 dashboard
November
14
766
3
0
0
0
0
Incidents reported
New incidents (reported in month- includes delayed reports)
Reported with Moderate harm
Reported with Major harm
Reported with Catastrophic harm
Never Event
RIDDOR reported incidents
December
14
771
5
0
3
0
2
January
15
742
5
0
0
0
2
4 month
avg trend
12 month
avg trend




n/a





n/a

Top Incident Causes reported with
Moderate harm and above (December 2014)
Incidents with reported moderate or greater harm
November 2014 - January 2015
Failure To Follow Procedures
Emergency & Critical Care
Elective Services
Diagnostic & Therapeutic
Womens & Childrens
Corporate/Planning &…
Clinical Management and Diagnosis
Delayed Treatment
Slips/Trips/Falls
0
5
Moderate Harm
10
Severe Harm
15
20
25
Catastrophic harm
Complaints and Concerns
November
14
December
14
January
15
52
2
2
1
171
230
6
265
82%
23
0
43
0
0
0
190
236
8
267
84%
23
0
42
2
0
0
191
237
9
252
92%
26
0
New Complaints
New MP enquiry
New External complaint
New Enquiry
New Concerns (PALS) issues
Total issues received
Re opened Complaints
Issues /cases responded to
Complaints %age closed in agreed timescale
Average time to close issues/cases (days)
Ombudsman Cases upheld
4 month
avg trend










12 month
avg trend










Complaints by Month by Division
Complaints by Divison
Top issues reported in December 14 related to
Aspects Of Clinical Care
Planning & Service Improvement
Womens & Childrens
Elective Services
Communication/ Pt Info
Attitude of Staff
Appointments Delay/cancelled OP
0
Emergency &
Critical Care
Nov-14
Dec-14
Jan-15
10
20
30
40
50
Elective Services
Womens &
Childrens
Diagnostic &
Therapeutic
21
17
7
2
22
13
6
24
9
7
60
70
80
Admissions, discharge And Transfers
Planning &
Service
Improvement
1
2
Top issues reported in December 14 related to
Appointments Delay/cancelled OP
Concerns by Divison
Aspects Of Clinical Care
Womens & Childrens
Planning & Service Impr.
Elective Services
Communication/ Pt Info
Appointments, Delay/cancelled IP
0
50
100
150
200
250
Nov-14
65
Emergency &
Critical Care
45
Dec-14
90
44
8
14
12
Jan-15
66
46
26
13
20
Elective Services
Planning &
Service Impr.
12
Diagnostic &
Therapeutic
14
Womens &
Childrens
11
Admissions, discharge And Transfer
Attitude of Staff
November
14
Indicators
71
Mortality reviews required
Mortality initial reviews undertaken (@time of
100%
reporting)
Inquests with TGH involvement closed /heard
7
Coroner-Prevention of Future Death report (Rule
0
43 )
Themes reported

Morality – themed feedback to Division for learning from reviews
o
Consistent use of NEWS
o
Record keeping standards
o
DNAR
o
Re-assessment and of patients

December14
January
15
4 month
avg trend
12 month
avg trend
103
121

n/a
100%
100%

n/a
12
10

n/a
0
1
n/a
n/a
Inquest and Coroner
o
n/a
Indicators
StEIS reports
Safeguarding Adult cases
reported
DOLS
Internal issue
External issue
Never events
Allegation on hospital care
Allegation on other care
Cases reported to Supervisory
Body
November
14
0
5
1
5
4 month
avg trend
12 month
avg trend
0
6
0
5
January
15
1
11
0
7


n/a

n/a
n/a
n/a
n/a
15
28
18

n/a
3
5
7

n/a
December14
Themes reported
StEIS

Related to Infection control and patients admitted with Pressure ulcers

Care related issues as above
Adult Safeguarding allegations/issues relate to

Pressure Ulcers (grade 3-4)

Neglect

Physical

Emotional/ Psychological

Financial
PREVENT – no new cases reported
Report to Public Trust Board meeting of the 26th March 2015
Agenda Item
9e
Title
Minutes of the Finance & Performance Committee
held on the 24th February 2015
Author (s)
Purpose
To inform the Board of the discussions held by the
Finance & Performance Committee at its meeting in
February.
Finance and Performance Committee on 24/03/15
Executive Summary :
The attached reflect the minutes of the Finance and Performance Committee which met in
February to review the January financial position.
5 – Develop a strategic plan to secure
clinical and financial sustainability for the
Trust in conjunction with the Trust’s strategic
partners and key stakeholders
7 – to deliver against local and national
frameworks in order to meet all the
requirements
undertaken?
Sustainability?
723 – Failure to meet, deliver Trust’s
financial plan
None
No
N/A
The Board is asked to note the minutes from the Finance & Performance Committee.
FINANCE AND PERFORMANCE COMMITTEE
Agenda item 2
Date of Meeting: 24th February 2015 Time: 10.00 am Location: Meeting Room, Silver Springs
Present
Position
Mrs A Dray
Mr T Ward
Mrs G Parker
Mr P O’Neill
Mr P Nuttall
Ms C Yarwood
Mrs P Cavanagh
Non-Executive Director (Chair)
Director of Estate and Facilities
Turnaround Director
Director of Performance and Informatics
Director of Finance
In attendance
Mr J Cook
JC
Interim Operational Director of Finance
Item
No
28/2015
Initial
Description
Action
Apologies
Ms S Holroyd (SH)
29/2015
Minutes of the previous meeting 27th January 2015
The minutes were accepted as an accurate record of the meeting.
30/2015
AD
TW
GP
PON
PN
CY
TC
Action log
05/2015
Action complete
21/2015
Amend operating framework to read ‘Financial Plan’.
25/2015
GM to resend dates for 2015 meetings
24/2014
Completed to be removed from action log.
1
97/2014
Amend the responsibility to Jackie McShane to report at the April meeting.
97/108/109/2014
Actions completed to be removed from the action log.
03/2015
Action completed
05/2015
Action regarding LoS to be reported in April.
05/2015
TC to provide an update at the March meeting.
06/2015
Action completed to be removed from the action log
16/2015
Report as part of the plan and remove from the action log
31/2015
CIP Delivery & QIA Quarterly
PON provided an update for month 10.
£650k was reported against a target of £687k which is a slight reduction. This gives
a cumulative position £5.158m against the target which is ahead of profile. There are
no concerns with the in-year position.
The Committee agree that future CIP reports will be included within the Finance
report. PON to check the February profiled plan of £687k as this varied from the
profile in the finance report of £617k.
Full year effect has increased to £3.96m which is an improvement, but is still below
target. There are a number of schemes that have been confirmed which will take
the figure to £5.25m. £138k has been identified in Radiology and conformation is
required for a further £31k. If this is realised this will result in a full year effect of
around £5.4m.
There have been some minor amendments to the plan. Meetings with John
Goodenough and Brendan Ryan are to be arranged to discuss the PIDs and QIAs
which have been drafted and are out for editing with the divisions. Divisions have
been asked for outline project plans to be included within the sign off process to
2
PON
provide additional assurance.
PON confirmed he had checked with the PWC benchmarking report and concluded
that there were no other CIP opportunities which have not already been identified.
32/2015
Finance and Activity Performance:
JC provided an update for Month 10.
The activity and income position has continued to improve, at the end of month 10
the deficit stood at £14.4m which is £1.7m adverse to the £17.5m plan and £2.4m
favourable to the £21m deficit re-forecast. Of the £2.4m favourable variance against
the revised plan £2.4m was attributable to clinical income. £636k was additional
winter reliance monies. RTT activity was ahead of the revised plan by £174k and the
balance of £1,566k is underlying activity performance.
Monitor has been informed that the revised forecast is now £19m rather than the
£21m that was reported last month.
An agreement has been made with the CCG to fix an income positon for 2014/15 and
further discussions are being held to agree the penalties to be applied for 2014/15.
The forecast is the penalties will be circa £1.2m to £1.3m and this will reflect the
benefit that in Q4 there will be no penalties for RTT other than for the 52 week
waiters. This has been confirmed by the CCG.
In month position includes activity relating to prior months and in month 10, the
number that relates to previous months was it is highest ever at £965k. The work
being undertaken with the backlog of coding should mean that this variation will be
much lower at year end. Acuity seems to be becoming more complex and therefore
will affect the averages used to-date. JC agreed to provide a draft of the profiling for
the income budget for next year to the March meeting.
PN outlined the planned review of the Clinical Coding processes and confirmed that
this will be an 18 months to two year project. PN to liaise with Mark Gerrard, JC and
Andrea Osbourne to review the data sets which provide the RTT activity information.
A discussion took place regarding patients being treated in the independent sector
and at Wrightington Wigan and Leigh.
Expenditure and pay budgets were discussed. JC to review the accruals process to
determine if this causes the pay costs to fluctuate.
It has been identified that there are non-pay accruals which can be released; this
however has been offset by additional provisions being required for VAT on the PFI
electricity and fuel which has been contaminated.
Capital plans
Capital is behind plan by £662k year to date. This is a further deterioration from the
positon at month 9. The current plan shows a forecast of £38k below plan; the
planned spend for months 11 and 12 is for PACs and Ascribe.
3
JC
PN
JC
Cash
Cash is on target at £500k in month 10 – PDC was drawn down at £474k which
brings the cumulative PDC draw down to £8,346k. The planned draw down for
February and March is £661k and £6,593k in March, which gives a revised PDC
requirement of £15.6m.
33/2015
TC provided an update on the position in Trauma and Orthopaedics. A new theatre
schedule is due to commence in March, which will enable the baseline orthopaedic
activity to be delivered. A meeting is taking place with Stockport to discuss joint
appointments.
TC
JC agreed to investigate why there was an adverse variance on PDC dividend in the
month of £89k.
JC
Contract and Performance Update
JC provided an update on the contract position. The CCG are proposing a significant
investment into primary care next year. A contract offer of £118m is expected which
means that the net investment is equivalent to the tariff deflater of £0.8m.
Discussions are taking place regarding the impact of RTT for the plan for next year.
There is uncertainty as to whether the CCG will be passing on the first tranche of the
winter resilience monies; confirmation from Monitor is awaited regarding the second
tranche of funding.
A letter has been received which outlines two tariff options. There is an enhanced
tariff and a default tariff. It has been agreed the Trust will sign up for the enhanced
tariff option.
CY advised that given the issue with coding the risk is the income will be higher than
the present contract value.
34/2015
Draft Revenue Financial Plans and Budget
7.1 Budget setting principles and process
Options for budget holder training are being explored.
JC provided an overview of the paper and advised that the paper has been signed off
at the Executive Team meeting. The new process provides greater transparency and
openness. The budgets this year will be signed off by Directors before being
presented to Board in March. Next year discussions will take place earlier with
divisional Directors, as they will then be in post, and budget holders.
It is proposed that schemes up to £50k require a mini business case which will be
presented to the Exec Team for approval and schemes above £50k will require a full
business case.
The draft plan is to be submitted to Monitor for comments, the revised version will be
presented to the March Board for final sign off.
4
35/2015
Draft Capital Plans and Budget
GP provided a verbal update as the Capital Planning and Estates committee met on
23rd February and the minutes will be provided for the March meeting. The Terms of
Reference for the group are being reviewed.
GP expressed concern regarding the funding being very close to the 15% tolerance
for the end of the year. The total budget is £3.18m therefore spend will need to be
within £476k to be within the 15% tolerance. There are still risks around £463k
worth of schemes.
A five year forecast was submitted to Monitor in January, there is also a five year
replacement programme for medical equipment. The capital for 15/16 is £2.727m.
£1,111k been allocated for estates schemes, £425k for condition and states, £548k
for IM&T and £643k for equipment.
36/2015
Minutes of reporting Committees:
9.1 Executive Delivery Group
PON provided an update on discussion at the meeting.
9.2 Charitable Funds
CY advised there were no issues to report.
37/2015
Reportable issues log
No issues to report.
38/2015
Work plan


39/2015
GP to provide conformation of the 15/16 Capital Plan to the April meeting,
and a year -end paper for 14/15 to the May meeting
Draft Revenue Financial Plans and Budget for March meeting
Any other Business
39.1 Board Paper NICE Guideline for Ward Nurse Staffing.
JC provided an overview of the paper and advised that the NICE recommendation is
for one registered nurse for every eight patients during the day and one for every
ten patients during the night. A review of compliance has taken place which identifies
which wards and shifts were not compliant. The proposed staffing within the paper
reflects compliance with the guidance. A discussion took place regarding the
financial risks, cost pressures, skill mix and the benefits for patients.
5
39.2 Transitional Care Unit Business Case
GP tabled a revised spread sheet from the Business case and outlined the
amendments in the report. Final negotiations are taking place and the earliest
patients can be transferred is the 16th March.
40/2015
Date of Next Meeting 24th March @ 10.00am Silver Springs Board Room
6

March 2015 Papers - Tameside Hospital

Transcription

Similar documents

4. COMMUNITY DEVELOPMENT MARK PATCHETT MPCS

Party Invite - Captain`s Cove Online

Name: Sarah Jo Ward

NCR_resources_SGLG

COUNCILLOR SCOTT MOFFATT Thank you to our

CHSCP - Principles - Social Work Scotland

Course description

Medici family, usury and Rocky Balboa

CaseStudy-Direct Energy 2016_8

Set the Record Straight June 2015