Board of Directors in Public
MEETING
1 March 2018 10:00
PUBLISHED
27 February 2018
Agenda
Location Date Owner Time
Hexham General Hospital 1/03/18 10:00
1. Opening matters 10:00
1.1. Apologies for absence and declarations of interest - verbal -to note
Chair
1.2. Minutes of the previous meeting dated 19th October 2017 -(Enc 1) - to approve
Chair
1.3. Action log & matters arising - (Enc 2) - to approve Chair
1.4. CEO’s report inc. Well-led review update- verbal - to note CEO
1.5. Chair’s report- verbal - to note Chair
2. Quality
2.1. Patient and staff stories- (Enc 3a & 3b) A Laverty 10:15
2.2. Patient experience update- (Enc 4) to note A Laverty 10:25
2.3. Board walk round- verbal - to note M Knowles/EMonkhouse
10:35
2.4. Learning from deaths report- (Enc 5) - to note J Rushmer 10:45
2.5. Guardian of Safe Working - (Enc 6) to follow J Rushmer 10:55
2.6. Medicines optimisation annual report- (Enc 7) - to note D Campbell 11:05
3. Performance and regulatory items
3.1. Finance report (Enc. 9) - to note P Dunn 11:15
3.2. Regulatory report (Enc. 10) - to note B Bartoli 11:25
3.3. Assurance Framework- (Enc 11) - to note P Dunn 11:35
3.4. Health & Safety - (Enc 12) - to note S Bannister 11:45
3.5. Charitable funds report- (Enc 13) - to note C Riley 11:50
4. Any other business
2
1
Board of Directors
Held in Public
Thursday 19th
October 2017
Cobalt Conference Centre
Present:
Alan Richardson Chairman
Allan Hepple Non-Executive Director
Moira Davison Non-Executive Director
Malcolm Page Non-Executive Director
Alison Marshall Non-Executive Director
David Chesser Non-Executive Director
Martin Knowles Non-Executive Director
Peter Sanderson Non-Executive Director
Birju Bartoli Executive Director of Performance & Governance
Ann Stringer Executive Director of Human Resources
Debbie Reape Interim Executive Director of Nursing
Daljit Lally Executive Director of Community Services
Jeremy Rushmer Medical Director
In Attendance:
Sophie Stephenson Company Secretary
Claire Riley Director of Communications and Corporate Affairs
Annie Laverty Director of Patient Experience (agenda item 2.1 and 2.2 only)
Chris Platton Director of Nursing – Delivery (agenda item 3.2 only)
Nikhil Premchand Consultant – Infectious Diseases /Acute Medicine (agenda item 3.6
only)
1.1/10/17 Apologies for absence
Apologies were received from David Evans, Chief Executive.
1.2/10/17 Declarations of interest
The Chairman noted that the register of interests was on the agenda for consideration. No interests
were declared in relation to specific items on the agenda. Board members were reminded to
ensure interests are actively declared and to ensure the register is kept up-to-date.
1.3/10/17 Minutes of the previous meeting
The minutes of the Board of Directors meeting held in public on 19th
July 2017 were reviewed and
noted.
3
2
1.4/10/17 Matters arising
No matters arising were noted.
2. Quality
2.1/10/17 Patient story
A ie La e t p ese ted the patie t sto a d e phasised the positi e e pe ie e fo the patie t s
family despite a tragic outcome. The Board noted that the story exemplifies excellence in critical
care in particular. Discussion followed regarding the support provided to staff who care for patients
in similarly challenging situations. It was noted that resilience training is offered, health and
ell ei g of tea s is o ito ed, a d that the T ust s o upatio al health department has a number
of services (including psychological services) which are accessed by staff across the Trust, including
staff in similar services to those outlined in the patient story. The Chair informed the Board that
staff stories would be introduced to Board meetings in the near future.
The Board noted the patient story.
2.2/10/17 Patient Experience quarterly report
Annie Laverty summarised the report and highlighted the following:
All domains in the Patient Perspectives data have statistically increased since the Trust first
started measuring the data. The Trust is performing in the top 20% of Trusts across in-
patient and out-patient areas, however, one area in which the Trust is not in the top 20%
elates to the uestio efo e the t eatment, did a member of staff explain what would
happe ? 2017 could be the first year in which the Trust has not recorded a statistical year-on-year
improvement in its real-time data. The Board discussed the possibility that the Trust has
ea hed a eili g i te s of its pe fo a e, ho e e , assurance was provided that the
data, including free text comments, would be thoroughly analysed in order to ensure any
further areas of possible improvement were identified.
There has been a 10% adverse movement i patie ts defi itel gi e e ough suppo t f o health a d so ial se i es du i g t eat e t i the Natio al Ca e Patie t E pe ie e survey which is a key area of focus for clinical teams.
The Trust has established a Patient Experience Collaborative which involves supporting the
patient experience services in 11 organisations. This forms part of the Acute Care
Collaboration Vanguard.
The Board discussed the observations made by Dan Wellings f o the Ki g s Fu d o a e e t isit to the Trust and its patient experience department, and noted in particular his comments regarding
digitising aspects of the patient experience service.
Dis ussio follo ed ega di g the ef esh of the T ust s st ateg a d, i pa ti ula , the eed to e mindful of patient experience data in any proposed changes to clinical pathways.
The Board noted the patient story.
4
3
2.3/10/17 Corporate Safety & Quality Report
Birju Bartoli presented the report and drew the attention of the Board to the following:
The Trust has met the four hour A&E target for quarter 2 and confirmation has been
received from NHS Improvement that the Trust will receive STF monies associated with the
target.
The Trust has met its target for referral to treatment times (RTT) for incomplete pathways,
however, it was noted that the number of patients waiting between 42 and 52 weeks for
treatment has increased which is a key area of focus for the Delivery team.
The Trust has missed the target for 62-day cancer waiting times GP referral to treatment.
The actio pla as e ie ed the Boa d s Fi a e, I est e t & Pe fo a e Co ittee on 16
th October 2017.
The e has ee a sig ifi a t i p o e e t i the T ust s o plai ts espo se ate.
The Board noted the Corporate Quality & Safety Report.
2.4/10/17 Register of interests, gifts and hospitality
The Board noted the Register of Interests.
3. Strategy
3.1/10/17 Strategic refresh
Birju Bartoli briefed the Board on activities planned during October and November 2017 to refresh
the T ust s st ateg , including a Board away day on 8th
November 2017 which will focus on
undertaking a SWOT analysis and reviewing feedback gathered to date from senior leaders including
clinicians throughout the Trust. It was also noted that following a positive discussion at Clinical
Policy Group on 13th
October 2017, clinical leaders are working with business units to provide
feedback to the Executive team on the strategic refresh.
The Board noted the update.
3.2/10/17 Supportive/additional roles – 3 month review of the pilot
Chris Platton summarised the report by emphasising the success of the ward medicines assistant
posts and the need for further work to be undertaken regarding the source of funding for additional
roles. It was also noted that CQC is supportive of the T ust s pla s ega di g suppo ti e oles.
Discussion ensued regarding the need to align the on-going work about supportive and additional
roles with the use of beds throughout the Trust.
The Board noted the report.
5
4
3.3/10/17 Workforce report
Ann Stringer introduced the report and highlighted the following matters to the attention of Board
members:
Staff sickness levels continue to improve, however, this is expected to plateau as a minimum
given that the Trust is entering the most challenging time of year from a sickness
perspective.
Appraisal rates and statutory and mandatory training rates have deteriorated and are being
closely monitored by the Workforce Committee and Executive Director of Human Resources.
8b and above appraisal workbooks now include a section on succession planning, following
findings outlined in the 2016 Well-led review.
Following investment in a staff physiotherapy service, there has been a significant reduction
in staff sickness related to muscoskeletal issues.
The recruitment tool used by the Trust is due to change from Stepchange to Trac – this
should streamline the recruitment process by automating steps such as reference requests.
The Board was otified of a sig ifi a t isk asso iated ith the T ust s E“‘ s ste , the license for
which is due to expire in December 2017, and discussion ensued regarding the risks and possible
impact of this risk.
Board members discussed the need to recognise the positive shift in sickness absence and it was
agreed:
Action 1: A letter to be drafted and sent out to congratulate staff for the significant reduction in
staff sickness levels.
Action for: Claire Riley/Ann Stringer
Action by: November 2017
The Board noted the report.
3.4/10/17 Corporate Financial Compliance Report
Paul Du p ese ted the fi a e epo t a d highlighted the T ust s ash positio fo dis ussio the Board. It was noted that, following the Finance, Investment & Performance Committee on 16
th
October 2017, approximately £6m of NHS cash payments had been received.
The Board noted the report.
3.5/10/17 Key Issues Reports
The Board noted the reports for Finance, Investment & Performance Committee and Safety &
Quality Committee.
6
5
3.6/10/17 Guardian of Safe Working report
Nikhil Premchand provided a brief presentation which highlighted the key themes within the report.
The Board discussed the number of exception reports from December 2016 to October 2017 and
also the impact on locum spend. Discussion followed regarding different ways to communicate with
junior doctors and the need to ensure IT infrastructure, including inbox sizes, is appropriate.
The Board noted the report.
Questions from the public
No questions were posed to the Board from members of the public.
Any other business
The Chairman e p essed his deep g atitude o ehalf of the Boa d of Di e to s fo Da id E a s leadership over the past two years in his role as Interim Chief Executive. He noted that David Evans
would be stepping down from this role at the start of November 2017, following the end of Jim
Ma ke s se o d e t to NH“ I p o e e t.
The Chai a also e plai ed that it as De ie ‘eape s last Boa d of Di e to s eeti g efo e she retires. He thanked her for 38 years of service to the NHS as well as praising her exemplary
leadership in the role of Executive Director of Nursing and collaborative working style.
MEETING CLOSED
7
Key:
Not achieved and overdue
Action delayed
On track for timely completion
Completed
Action Log Board of Directors Committee (Public) October 2017
There are no live actions outstanding
Ref. Action Owner Date
raised
Deadline Status
Completed actions [include actions completed at the previous meeting]
Ref. Action Owner Date
raised
Deadline Status
TB1/10/17 A letter to be drafted and
sent out to congratulate
staff for the significant
reduction in staff sickness
levels.
Claire Riley/Ann
Stringer
19/10/17 Nov 17
Enc.
2
8
Patient Story WGH Ward 10 January 05 2018 Female age 80
Patient gave consent for story to be used but did not consent to name being used
I ha e ’t ee i hospital si e y hildre ere or o er 50 years ago. I have had 2 knee
replacements in the last 3 years. My right knee was performed by Mr Emmerson in 2014, my second
(this time) by Mr Asaad.
Both of my surgeries were planned. I received a letter to attend the pre-op assessment unit. I had
bloods taken, an ECG and a list of questions to answer by Meg the pre op nurse. I saw her the 1st
time and she was lovely and kind so I was delighted to see her the second time. The letter stated it
ould take up to 3 hours for the pre op he ks to e do e. It did ’t take that at all – I was in and out
within 90 minutes.
There have been some changes over the years. My first operation went smoothly. I had the spinal
i je tio a d I did ’t k o a ythi g else u til I oke up in recovery. This time I could hear banging
a d rashi g. I ould ’t feel a ythi g ut the usi did ’t dro out the oise ery ell. The anaesthetist comforted me. She said everything was under control and it was. I needed to stay a bit
longer in theatre because my heart rate dipped. I heard the nurse talking to the anaesthetist and
they ere ’t too concerned, just kept a closer eye on me. The nurses in recovery were smashing. We
had a lovely chat and I realised I live a few doors from her mother!
After the 1st
operation I was put into a wonderful chair. It was a recliner and a lovely warm blanket
placed on top of me – it was a very soothing experience. This time it was all very quick. Not
uncomfortable but I was back on the ward quicker than expected.
When I came to the ward I was offered something to eat straight away – that did ’t happe last time. I as ’t as drowsy or confused either. I had trouble getting comfortable in bed. The new beds
have a locking mechanism on to keep the bed in the same position. The nurses positioned me just
right and I never moved. It is the small difference between being in pain all night and being
comfortable. The medication alongside the ice pack on my knee has worked well.
I was up and walking the very next day. Not too far but it was a good start. The physios have been
marvellous. I walked slowly but they soon had me walking at a quicker pace. I have also had a stair
assessment and I am ready for home.
My son said I was looking well and I actually feel good. I wish I had done this years ago. I think a
mixture of professionalism and good quality care has made me feel as well as I do. I am going for a
bit of rehabilitation, just for a bit of extra support but I can’t fault my experience as a whole. The
food is exceptionally good and the company is great! The ward was bustling with life yesterday, with
patients coming and going. Today it is a lot calmer. The ladies that bring the tea round could make
anyone smile. I have had a laugh and a bit of banter. The nurses have approached me with a happy
and caring attitude.
I a pleased I do ’t eed to ha e a y other operatio s; however I would have no problems
recommending the ward or both surgeons to a friend or family member.
9
Staff story collected 04/01/2017 Ward 1 NSECH Band 3 Assistant
Consent given
I spend a lot of time individually with patients who make my work meaningful and purposeful. A lot
of patients I care for need a lot of assistance with eating and drinking. I enjoy encouraging people to
eat and drink, it puts them on the road to home.
Mostly the ward staff on this ward do get their breaks but sometimes it is literally a quick slurp of
tea. No o e e er tells e I a ’t take a reak or ot to take reak. It is my choice if I do miss a
break; I prefer to get all of my work done.
I thi k a lot of tea eeti gs e ha e are e hausti g as e do ’t e er see to ake a progress or decide one way or another. It is really hard to stick to an agenda as people go off on tangents and
in different directions. Sometimes it does feel chaotic. Lately nutritional meetings have changed and
do follow a more structured format with a strict agenda, a chairperson and another keeping a check
on time. This way has a much better outcome.
I do enjoy my job; I love my job. The getting out of bed would still be hard for me even if I had the
easiest job in the world. I am not a morning person but I do love this job.
I tend to structure my day, I have a routine and structure to make sure everything is completed and
recorded. This is often the case as opposed to a very often feeling in relation to you asking me
whether I have unachievable deadlines. As some days the patient workload can be more demanding.
I do really enjoy caring for other people. We had a gentleman a couple of months ago, who was in
alcohol withdrawal, and he as i a poor state. He had ’t ee eati g or dri ki g ell. Alo g ith the team we persevered with him, encouraging and caring for him. I built a good rapport with him
and built up hi eating and drinking. One month later he left us. He was in remission from his
alcoholism; he was no longer confused but now able to look after himself and had gained a stone in
weight. I am filling up now thinking of him. Recalling stories like this puts my faith back into
humanity.
There are times when relationships at work do get strained; we are all just human after all.
So eti es people do ’t al a s see e e to e e ut ge erall e are a good working team who all
support each other.
I do have say over how I work but I do have some challenges. I have a barrier with the catering staff
yet to overcome but we are getting there.
The team here do acknowledge and tap into ea h other’s skills a d e pertise ut e role as ’t fully understood when I first started. I found it hard that when I was on leave I would come back to a
lot of missed things. However now everyone has a greater understanding of the role and we have
seen better results around nutrition.
10
Time flies when I am at work because I stick to my structure and I have to meet my deadlines. Plus I
do enjoy what I do so time never drags.
Sometimes I can get myself into a bit of a flap when I have so much to do, but if I follow my structure
I can always achieve my goals.
I do ’t a t to sound cocky but I have a lot of care in me, I support patients and their families. There
has been a lot of bad press, nationally, about patients being malnourished in hospital. That makes
e feel ad e ause here i Northu ria that just is ’t true.
I have a good relationship with my manager, even if I just go in and have a rant. It gets everything off
my chest, and then I can go and get on with my day.
Most staff on this ward are able to tune into and understand each other sensing how we are feeling.
I personally have worked in other role so I do understand their work pressures. I can help them too; I
juggle things around to help out. Yesterday for example I was taking patients to theatre. Everyone is
like that here just willing to help on another.
Some days are of course more difficult than others. Before Christmas we had a tough time. We were
short staffed with five level 4 patients. The ward was full. It was just manic!! Well I had a tea party
planned; I asked if it was okay to go ahead thinking it would also help boost staff morale too. I was
given the go ahead and brought our patients together so we could watch them all at once. It
boosted staff, staff were smiling everyone took turns to join us for a cuppa. Junior doctors and
pharmacy staff too. It was really nice. The most important thing for me that day was that the
patie ts did ’t k o ho e ere all feeli g a d that the ard is struggli g. We a aged that. O e relative, a husband visiting his wife, said that the tea party was the first date they had had in 25
years.
Da s he e are ot struggli g are reall i e. I do ’t just sit ith patie ts ho eed at hi g. I ha e the ti e to sit ith our patie ts ho do ’t ha e a isitors. It is just a drea .
11
Title of Report Improving Patient Experience – 1st March 2018
Author Annie Laverty / Paul Drummond
Executive Lead Annie Laverty
Executive Summary Patient perspective results: Feedback from 2202 patients : Excellent
performance – 96% of inpatients, 98% of outpatients and 98% of patients
receiving day case care rating their experience as good, very good or
excellent. The Trust performs very well with all benchmarked national
data for performance overall. Waiting times to seeing a doctor or nurse,
pain control and Information on the purpose of medicines in emergency
care are recognised areas for improvement. There is considerable
variation across sites for emergency care – a difference of 10% comparing
the Hexham urgent care experience with urgent care service users at
North Tyneside and Wansbeck. Whilst this variation exists, all emergency
care sites sit within the top 20% nationally.
Real Time 2017: Feedback from 7726 patients: The Norovirus and flu
outbreak meant that the real time programme was suspended in January.
Analysis of whole year data shows high quality care has been consistently
being maintained across the Trust when compared with 2016 results. This
attainment is in keeping with national results and the highly positive
externally validated Patient Perspective feedback for inpatient care.
National Maternity Survey 2017: The National Maternity Survey results
highlight an area of care where the Trust has the greatest opportunity to
improve. Performance is very consistent with previous results in 2015
suggesting that overall the maternity experience has not improved since
the opening of The Northumbria. Whilst the Birth and Labour experience
was rated within the top 20% of Trusts, Antenatal and Postnatal care was
placed within the Middle 60% of Trusts. Full survey performance and
subsequent action planning to be taken through safety and quality
committee. The Patient experience team are currently supporting
improvement work to establish an innovative Birth Reflection Pathway as
part of the national Maternity Challenge fund.
Friends and Family Test: Feedback from 8057 patients: No meaningful
change this quarter. Response rates remain low and fell further in
December due to competing pressures within the system. Friends and
family scores for emergency care are below the national average, this
finding is not in keeping with national survey data nor monthly
benchmarked data provided by patient perspective and reflects the mode
of data collection. The ED response rate has remained at 8% in line with
the target set by commissioners of 6%
Patient experience network awards March 1st 2018 – Named Trust of the
Year for the last two years, the excellent work of Northumbria teams has
once again been recognised this year with the Trust shortlisted as finalists
in 8 categories.
12
Recommended
actions required by
Board/committee
Trust Board members are asked to note the contents of this report and
that the Trust is demonstrating a strong overall performance towards
achieving our strategic aims.
1 2 3 4 5 6Link to strategic
objectives
(please tick)
Strategic objective
reference
3.1 Patient Experience
Caring Responsive Well-led Effective SafeLink to CQC KLOE
(please tick) Compliance/
regulatory
requirements (if
applicable)
CQUIN and CQC requirements for safe, caring and responsive care.
Financial impact?
13
Board of Directors Meeting 1st March 2018
Patient Experience Update
14
Patient Perspective data.
Inpatient / Day Case & Outpatients.
15
Patient Perspective Data – IP / DC / OP
Overall satisfaction, (rating the inpatient service as Excellent, Very good or Good)
Patient Perspective Data: Inpatients (n=893)
Patient Perspective Data: Outpatients (n=998)
Q3 Oct-17 Nov-17 Dec-17
N % N % N %
Inpatient 224 95.7% 112 98.3% 148 94.9%
Day Case 109 98.2% 134 97.8% 139 98.6%
Q3 Oct-17 Nov-17 Dec-17
N % N % N %
Outpatients 332 98.4% 655 97.9% 446 99.3%
16
Patient Perspective Data – Inpatients Q3
In this quarter, the inpatient results continue to be very good.
• The average score for the Trust is 88.3%, well within the top 20% of
Trusts in England (threshold 84%).
• The Trust is in the top 20% of all trusts for all 19 of the most
important questions for patients.
• 96% of inpatients rate the Trust as excellent, very good or good.
Hospital Score Respondents
Hexham General Hospital 94% 58
Wansbeck General Hospital 89% 86
NSECH 87% 257
North Tyneside General Hospital 85% 86 17
Overall, for the Trust, results remain good in all areas, but particularly:
• Overall ratings, respect and dignity, staff working well together
• All aspects of communication with doctors and nurses
• Cleanliness and hand-washing
• Pain management
• Information on medicines
• Discharge planning
Patient Perspective Data – Inpatients Q3
18
Patient Perspective Data – Outpatients Q3
In this quarter, the inpatient results continue to be extremely good.
• The average score for the Trust is 90.2%, and within the top 20% of
Trusts in England (threshold 85%).
• The Trust is in the top 20% of all trusts for 19 of the 20 most
important questions for patients. All specialties except
Gastroenterology are in the Top 20%
• 98% of inpatients rate the Trust as excellent, very good or good.
Hospital Score Respondents
Morpeth NHS Centre 94% 25
Alnwick Infirmary 93% 25
NSECH 92% 28
Hexham General Hospital 91% 232
Wansbeck General Hospital 91% 353
North Tyneside General Hospital 89% 330
Berwick Infirmary 88% 21 19
Patient Perspective Data – Outpatients Q3
Overall results are particularly good in these areas:
• All aspects of communication between doctors and patients, and
information given
• Involvement in decisions
• Discharge planning
• Letters copied to patients
• Overall ratings and respect and dignity
The one question not in the top 20% of Trusts is:
• Before the treatment, did a member of staff explain what would
happen?
20
Patient Perspective data.
Emergency Care.
21
Patient Perspective Data – Emergency Care Q3
In this quarter, the Emergency Department results continue to be
very good.
• The average score for the Trust is 83.2%, and within the top 20%
of Trusts in England (threshold 78%).
• The Trust is in the top 20% of all trusts for 22 of the 27 most
important questions for patients.
• Results vary across the site, average score are;
o Hexham 90%
o The Northumbria Hospital 81%
o North Tyneside 80%
o Wansbeck 80% 22
Patient Perspective Data – Emergency Care Q3
Overall results are particularly good in these areas:
• Privacy whilst in the department
• Information on waiting times
• Overall time in A&E
• Communication with doctors and nurses
• Cleanliness of the department and toilets
• Planning for leaving hospital
• Overall ratings and respect and dignity
There is room for improvement in these areas:
• Waiting times until triage and to seeing a doctor or nurse
• Pain control
• Information on the purpose of medicines
23
Emergency Care overall scores
24
Real time data.
25
Real Time Domain Averages 2017 9
.61
9.9
0
9.7
2
9.8
5
9.8
9
9.7
7
9.8
8
8.2
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9.6
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9.7
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9.6
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7.8
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.87
9.5
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9.6
9
9.5
9
9.8
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9.6
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9.7
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4
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9.8
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8.4
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9.6
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9.7
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9.9
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8.1
4
9.4
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9.6
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9.7
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9.6
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9.8
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9.5
8
9.7
8
9.8
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9.8
8
9.8
5
8.3
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9.4
7 9
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9.6
1
9.6
5
9.5
2 9.8
5
9.6
4
9.8
8
9.8
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7
9.8
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8.0
6
9.4
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9.5
9
9.6
6
9.6
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9.8
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9.7
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4
9.8
9
9.9
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9.3
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9.6
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9.6
9
9.5
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9.9
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9.6
5
9.8
3
9.8
4
9.8
7
9.8
9
7.8
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9.2
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9.8
9
9.5
5
9.7
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9.4
6 9.8
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9.6
7
9.8
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6
9.8
6
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9.5
8
9.7
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9.4
8 9.8
7
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9.5
6
9.6
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9.5
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9.7
7
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.96
9.6
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9
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8
9.8
8
9.8
9
8.3
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9.9
4
9.5
9
9.7
2
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
Consistency
&
Coordination
Respect &
dignity
Involvement Doctors Nurses Cleanliness Pain Control Medicines Noise at
Night
Kindness &
Compassion
Domain
Average
Key
Promoter
Score
Baseline 2017 January 2017 February 2017 March 2017 April 2017 May 2017 June 2017
July 2017 August 2017 September 2017 October 2017 November 2017 December 2017
Domain Averages to date (n=7726)
26
Real Time Data 2016/2017
Year
No of
Patients
Surveyed
% of
Patients
Surveyed
Coor-
dination*
Respect
& dignity
Involve
-ment* Doctors Nurses
Clean-
liness*
Pain
Control Medicines
Noise at
Night
Kindness &
Compassion
Domain
Average
2016 6848 53 9.61 9.90 9.72 9.85 9.89 9.77 9.88 8.23 9.44 9.92 9.62
2017 7726 53 9.53 9.89 9.65 9.83 9.87 9.84 9.88 8.16 9.37 9.90 9.59
Difference -0.08 -0.01 -0.07 -0.02 -0.03 0.07 0.00 -0.07 -0.07 -0.01 -0.03
• The overall domain score has dropped slightly from 9.62 to 9.59 making a
difference of 0.3%
• The Coordination domain and Involvement domain has the biggest variations and
is significant worse.
• The only domain that shows a significant improvement is Cleanliness, rising to
9.84 from 9.77.
• The other domains have stayed the same. 27
Real Time Comments 2016/2017
Overall Comments
When comparing the Real time overall comments between 2016 and 2017 there has been
an improvement of the Positive comments of 4%, rising from 84% in 2016 to 88% in 2017,
this difference is significantly better. There has been a 2% drop for both Negative and
Neutral comments.
84%
7% 9%
88%
5% 7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Positive Negative Neutral
Real Time Overall Comments 2016 - 2017
2016 (6678) 2017 (7549)
28
National Maternity Survey
2017
29
When comparing with other Trusts, Northumbria is about the same in 49 (96%)
questions and better than other Trust in 2 questions (4%). There were no questions
where the Trust was worse than other Trusts.
4%
96%
0%
Comparison with other Trusts
Better than other Trusts (2) Same as other Trusts (49) Worse that other trusts (0)
30
When comparing with 2017 against the 2015 survey results, Northumbria showed no
significant change in 45 (92%) questions, significantly better in 2 questions (4%) and
Significantly worse in 2 questions (4%).
4%
92%
4%
Comparison between 2017 and 2015
Significantly Better (2) No Significant Change (45) Significantly Worse (2)
31
Antenatal
• The question about Thinking about your antenatal care, were you spoken to in a way you
could understand? Is rated as "Better" than other Trusts. While all other questions were
rated about the same.
• There is no statistical change in any questions when compared to 2015.
Birth and Labour
• The question about Thinking about your stay in hospital, how clean was the hospital room
or ward you were in? Is rated as "Better" than other Trusts. While all other questions were
rated about the same.
• The questions regarding Thinking about your stay in hospital, if your partner or someone
else close to you was involved in your care, were they able to stay with you as much as you
wanted? and Thinking about your stay in hospital, how clean was the hospital room or
ward you were in? are significantly better when compared against the 2015 results.
• The question If you needed attention while you were in hospital after the birth, were you
able to get a member of staff to help you within a reasonable time? is significantly worse
when comparing against 2015.
Postnatal
• All questions were rated with other Trust as about the same.
• The question Were you given information or offered advice from a health professional
about contraception? is significantly worse when comparing against 2015.
Outlying Questions and Results
32
Ranked Trust Antenatal Labour & Birth Postnatal Maternity Average
1 Wirral University Teaching Hospital NHS Foundation Trust 8.1 8.7 8.7 8.5
T2 East Cheshire NHS Trust 7.8 8.9 8.6 8.4
T2 Torbay and South Devon NHS Foundation Trust 8.1 8.6 8.6 8.4
T2 The Newcastle upon Tyne Hospitals NHS Foundation Trust 7.9 8.6 8.6 8.4
T5 Wye Valley NHS Trust 7.9 8.7 8.5 8.3
T5 Northampton General Hospital NHS Trust 8.0 8.7 8.4 8.3
T5 Shrewsbury and Telford Hospital NHS Trust 7.7 8.7 8.5 8.3
T5 North Cumbria University Hospitals NHS Trust 7.8 8.8 8.3 8.3
T5 Maidstone and Tunbridge Wells NHS Trust 7.8 8.8 8.3 8.3
T5 Burton Hospitals NHS Foundation Trust 7.9 8.6 8.3 8.3
T5 University Hospitals of Morecambe Bay NHS Trust 7.8 8.5 8.5 8.3
T5 Gloucestershire Hospitals NHS Foundation Trust 7.9 8.7 8.3 8.3
T5 Mid Cheshire Hospitals NHS Foundation Trust 7.7 8.6 8.5 8.3
T5 Western Sussex Hospitals NHS Foundation Trust 7.7 8.6 8.5 8.3
T15 Sherwood Forest Hospitals NHS Foundation Trust 7.8 8.6 8.3 8.2
T15 Salisbury NHS Foundation Trust 7.7 8.6 8.4 8.2
T15 York Teaching Hospital NHS Foundation Trust 7.8 8.7 8.2 8.2
T15 Gateshead Health NHS Foundation Trust 7.7 8.5 8.5 8.2
T15 Royal Surrey County Hospital NHS Foundation Trust 7.8 8.6 8.2 8.2
T15 Royal Cornwall Hospitals NHS Trust 7.8 8.6 8.3 8.2
T15 Countess of Chester Hospital NHS Foundation Trust 7.8 8.4 8.4 8.2
T15 Airedale NHS Foundation Trust 7.7 8.7 8.2 8.2
T15 The Whittington Hospital NHS Trust 7.9 8.5 8.2 8.2
T15 Medway NHS Foundation Trust 7.6 8.7 8.2 8.2
T15 Chesterfield Royal Hospital NHS Foundation Trust 7.7 8.6 8.3 8.2
T15 Royal United Hospitals Bath NHS Foundation Trust 7.7 8.7 8.1 8.2
T15 Northumbria Healthcare NHS Foundation Trust 7.6 8.7 8.2 8.2
T15 Colchester Hospital University NHS Foundation Trust 7.6 8.7 8.2 8.2
T15 Bolton NHS Foundation Trust 7.7 8.3 8.5 8.2
T15 City Hospitals Sunderland NHS Foundation Trust 7.5 8.7 8.4 8.2
T15 Hampshire Hospitals NHS Foundation Trust 7.7 8.6 8.3 8.2
T15 Wrightington, Wigan and Leigh NHS Foundation Trust 7.5 8.5 8.5 8.2
T15 South Tees Hospitals NHS Foundation Trust 7.9 8.4 8.2 8.2
T15 George Eliot Hospital NHS Trust 7.4 8.6 8.5 8.2 33
Ranked Trust Antenatal
Average
Labour and
Birth Average
Postnatal
Average
Maternity
Average
T2 Newcastle 7.9 8.6 8.6 8.4
T5 North Cumbria 7.8 8.8 8.3 8.3
T15 Gateshead 7.7 8.5 8.5 8.2
T15 Northumbria 7.6 8.7 8.2 8.2
T15 Sunderland 7.5 8.7 8.4 8.2
T15 South Tees 7.9 8.4 8.2 8.2
T47 Durham and Darlington 7.3 8.4 8.3 8.0
T111 North Tees & Hartlepool 7.1 7.9 7.8 7.6
Area Northumbria
Score
Highest
Scoring Trust
Lowest Scoring
Trust Rank
Antenatal 7.6 8.1 6.8 T44th Middle 60% of Trusts
Birth & Labour 8.7 8.9 7.5 T5th Top 20% of Trusts
Postnatal 8.2 8.7 7.5 T35th Middle 60% of Trusts
Average 8.2 8.5 7.5 T15th Top 20% of Trusts
Regional Table
Trust Performance by area
34
35
Friends and Family.
36
Friends and Family Test – IP/DC
National Average FFT Score – 78
National Average % Recommend – 95%
National Average% Response rate – 21.4%
IP FFT
DH
Extremely
likely Likely
Neither
likely nor
unlikely
Unlikely Extremely
unlikely
Don't
know Total Score
Response
Rate Eligible
% of
Extremely
Likely &
Likely
Oct-17 1487 152 26 7 9 10 1691 86 18.2% 9314 97%
Nov-17 1499 173 27 12 12 29 1752 84 18.4% 9539 95%
Dec-17 968 82 11 3 4 11 1079 89 12.2% 8839 97%
Q3 2017 3954 407 64 22 25 50 4522 86 16.3% 27692 96%
37
Friends and Family Test – A&E
National Average FFT Score – 54
National Average % Recommend – 85%
National Average% Response rate – 11.6%
FFT AE Extremely
likely Likely
Neither
likely nor
unlikely
Unlikely Extremely
unlikely
Don't
know Total Score
Response
Rate Eligible
% of
Extremely
Likely &
Likely
Oct-17 663 158 44 43 35 70 1013 57 8.4% 12056 81%
Nov-17 526 132 30 31 29 54 802 58 7.1% 11250 82%
Dec-17 618 189 47 21 39 44 958 56 8.2% 11619 84%
Q3 2017 1807 479 121 95 103 168 2773 57 7.9% 34925 82%
38
Friends and Family Test – Maternity
National Average FFT Score – 75
National Average % Recommend – 96%
National Average% Response rate – 19.2%
FFT
Maternity
Extremely
likely Likely
Neither
likely nor
unlikely
Unlikely Extremely
unlikely
Don't
know Total Score
Response
Rate Eligible
% of
Extremely
Likely &
Likely
Oct-17 224 32 1 3 4 0 264 82 17.8% 1485 97%
Nov-17 253 26 4 0 0 1 284 88 20.3% 1402 98%
Dec-17 184 24 2 2 2 0 214 83 15.3% 1400 97%
Q3 2017 661 82 7 5 6 1 762 84 17.8% 4287 98%
39
PENNA Awards The Trust been shortlisted for eight awards in the annual Patient Experience Network
National Awards (PENNA). The awards are being held today in Birmingham.
Entry name Category
Palliative Care Northumbria Partnership Working to Improve the Experience
Continuity of Care
Using Patient Experience Data for Service Improvement
(Ward 23, North Tyneside General Hospital) Measuring Reporting and Acting
Introducing a Birth Reflection Pathway in Maternity
Services
Laying the Foundations
Patient Insight for Improvement – Outstanding
Contribution
Pilot use of an assistive hearing device with patients
who have a hearing impairment (Ward 9, The
Northumbria)
Communicating effectively with patients and families
Patient Insight for Improvement – Outstanding
Contribution
Patient Experience Team Team of the Year
40
Thank You
41
Title of Report Learning From Deaths – Q3 Review Data
Author Dr Jeremy Rushmer
Executive Lead Dr Jeremy Rushmer
Executive Summary
Q3 Review data: No Hogan 4 deaths have been identified within the 97 cases reviewed in the quarter. In 70 case the reviewers recorded good care and practice and in the remainder the learning has been cascaded to teams and summarised in the newsletter. Review rate: The numbers of notes reviewed has improved. Additional review sessions at NSECH are being piloted from February and requests for attendance have been enhanced. In the 93 cases reviewed so far from Q3 there has been insufficient numbers for the December 2017 month. 30 randomly selected of case notes from December will be added as ‘Mandatory’ reviews to ensure there is a sufficient sample. An increase in deaths within ED was noted at last mortality group, which
one of our nurse directors is reviewing. This is not unexpected given the
increase in LOS in ED associated with winter escalation, but is being
checked.
LfD Improvement: There has been senior attendance at the Royal College Physicians SJR training and a proposal will be made to S&Q and CPG in March, with an aim to improve engagement with a ‘revitalised’ review process. A meeting has occurred with coroners’ and registrars’ teams, the principle improvements planned are: bereavement information review, with joint branding, a joined up process for coroner referral and potential to develop a Registrars’ office at NSECH. Early assessment of the RCP recommendations are improve the quality, rather than quality of the review, with a significant recommendation being to spend sufficient time on each review, to enhance the potential for learning. Meetings have occurred with the Comms team to discuss proposals for an intranet repository for learning and an internal communication tool.
42
Recommended actions required by Board/ Committee
Trust Board to approve this report, following approval of S & Q Committee
Link to strategic objectives (please tick)
1 2 3 4 5 6
Strategic objective reference
2.3
Link to CQC KLOE (please tick)
Caring Responsive Well-led Effective Safe
Compliance/ regulatory requirements (if applicable)
CQC – learning from deaths
Financial impact?
No
43
44
Medicines Optimisation Strategy
Annual Report March 2018
45
• Trust Board approved strategy in 2013
• “a transformational approach; to maximise outco es for i dividual patie ts”
• 6 strategic challenges 1. Build on the what we already do well
2. Deploy technological solutions to reduce risk
3. Work more closely with patients and the public
4. Provide effective financial management and controls
5. Support a shift in focus from secondary to primary care
6. Develop and deploy workforce
Background/context
46
Strategic challenge 1
Build on what we already do well
47
Model Hospital Headline Metrics Pharmacy Staff &
Medicines Costs per
WAU
£222 2016/17
Data Quality of NHS
England Monthly Data
Set Submissions From
Providers
27 Sep 2017
Top 10 Medicines –
Savings Delivered to
Current Month
£1.67m To Dec 2017
% Pharmacists
Actively Prescribing
50.9% 2015/16
Top 10 Medicines - %
Delivery of Savings
Target Achieved to
Current Month
£144% To Dec 2017
Sunday ON WARD
Clinical Pharmacy
Hours of Service
(MAU/Equivalent)
8.5 2015/6
Clinical Pharmacy
Activity (Pharmacist
Time Spent on Clinical
Activities)
82% 2015/16
Number of Days
Stockholding
15.1 2015/16
e-Commerce –
Ordering (AAH)
86% 2015/16
e-Commerce -
Ordering (Alliance)
97% 2015/16
48
Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17Q1 17-
18
Q2 17-
18
Q3 17-
18
Trustwide 96% 99% 97% 96% 98% 97% 95% 96% 94% 97% 96% 95.2%
Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95.0%
50%
60%
70%
80%
90%
100%
1. % of patients with medicines reconciliation started within
24 hours of admission by Business Unit
0
1
2
3
4
5
6
7
8
9
10
Jan 17Feb
17
Mar
17Apr 17
May
17Jun 17 Jul 17
Aug
17
Sep
17Oct 17
Nov
17
Dec
17
Trust 8.10 7.87 8.41 8.14 8.32 8.06 8.16 7.80 8.01 8.05 8.19 8.30
Baseline 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00
3. Patient Experience Real Time
Jul-16 Aug-16 Sep-16 Oct-16Nov-
16Dec-16 Jan-17 Feb-17
Mar-
17
Q1 17-
18
Q2 17-
18
Q3 17-
18
Trust 0.9% 1.0% 1.7% 1.0% 2.5% 0.9% 1.8% 0.9% 0.7% 0.8% 0.2% 0.5%
Target 0.9% 0.9% 0.9% 0.75% 0.75% 0.75% 0.5% 0.5% 0.5% 0.5% 0.5% 0.5%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
6. % of patients who have had an omitted dose of a critical
medicine
49
• Keep doing the good things we’ve been doing (core clinical)
• Adoption of digital technology as a major enabler
• Revisit commercial partnerships/outsourcing
• Explore supply chain collaboration at regional level
• Exploit opportunities within a new ACO framework
• Facilitate fast adoption of best value medicines, specifically biosimilar medicines
HoPMOp update
Carter/Model Hospital
50
Governance/Risks
NICE
Controlled
Drugs:
Fully compliant
risk very low
I can’t think of anything
else green or
red to report
here
Patients’ regular medication not
prescribed in a timely
manner at NSECH National &
global
shortages
NICE
Medicines
Optimisation
Partially
compliant;
risk low
Trust
training
records
target
achieved
eMeds roll
out
progressing
Data
warehouse
not yet
implemented:
eMeds benefits
not fully
realised
Errors/omissions
on discharge
51
• Ward automation (Omnicell)
• EPMA (MedChart)
• Chemotherapy EPMA (Chemocare)
• Stores/dispensing robot
• Nervecentre
Strategic challenge 2
Deploy technology to reduce risk
52
Strategic challenge 5
Support a shift in focus from secondary
care to primary care
53
Northumbria Integrated Model
• Caring for our patients wherever they
are in the system
• Doing the right thing for patients • Detailed clinical reviews
• Shared decision making
• Working as one pharmacy team
• Working with the wider health and social care team
www.health.org.uk/pills
54
New behaviours in hospital
55
Benefits of whole system approach
• Great for patients; satisfaction, experience,
outcomes e.g. reduction in admissions, safer transfer
• Efficiency; flow, net prescribing savings
– For every £1 spent, there is a saving of £3.06
– A Northumberland-wide service would save £3.98m per
annum, including c650 admissions avoided – equivalent to
7,750 COTE bed days (or 10 months of WGH Ward 4)
• Saves medical and nursing staff time
• Flexibility in workforce development and deployment
• Model system for medicines optimisation
• Staff love it 56
Examples and opportunities include:
• Nurse associates
• Physicians associates
• Ward medicines assistants
• Chemotherapy assistants
• Advanced clinical pharmacist practitioners
• Pharmacists in ED (via IUC)
Challenge 6
Develop and deploy workforce
57
SUMMARY
• Successful performance, innovation and improvement
• Gaps/risks
• 2018/19
- Continue to build on what we are doing well
- Progress with other opportunities to integrate care e.g.
developing joined-up services with NT CCG
- Mitigate/deal with the risks
- Refresh Medicines Optimisation Strategy
- Respond to WHO global patient safety challenge
- Exploit opportunities in workforce development strategy
58
COMMERCIAL IN CONFIDENCE 1
Northumbria Healthcare NHS
Foundation TrustFinancial Performance Period Ended:
January 2017
59
COMMERCIAL IN CONFIDENCE 2
Preface• The report that follows details the financial
performance for the Trust
• The plan is based upon the NHS Improvement APR re-submission made in March 2017
• The plan was based upon the draft year-end accounts
• The actual performance reflects the monthly return to monitor
• The profile of income and expenditure is driven by the number of working days (per month) and the CIP programme
60
COMMERCIAL IN CONFIDENCE 3
Summary At the end of the reporting period covered
by this report the Trust delivered:
• An I&E surplus of £21.35m– Including: £0.4m prior year STF, £0.9m Winter
Funding
• Plan = £21.20m £0.15m above YTD Control Total excluding: 1617 STF; Winter Funding
• Use of Resources risk rating of 1 (best)
• A cash balance of £ 10.0m61
COMMERCIAL IN CONFIDENCE 4
Key TargetsTarget Perio
dYea
rComments
Income & Expenditure
Performance to date is in line with plan (£145k above plan). (This excludes the impact of £0.4m additional STF relating to 1617 and £0.9m Tranche 1 Winter Pressures Funding, which do not contribute to performance against the Control Total for 1718).
YTD performance has been impacted significantly by a sustained reduction in activity levels, with elective activity below 1617 levels (in addition to not achieving planned growth in 1718) and non-elective income impacted by a higher use of ambulatory care. This has been further affected by winter pressures and infection control measures since Month 9. Commercial income also remains below plan, with growth impacted by the effect of the living wage. This has been mitigated through a change in accounting policy for deferred commercial income, and expected VAT recovery.
The pay bill was higher than budgeted. Agency spend continues to increase, although it remains broadly in line with planned levels (2.0% of pay-bill). YTD agency spend is £0.7m below the Agency Ceiling set by NHSI. Non-pay expenditure is also higher than budget.
CIP performance was below the YTD plan by £1.2m at Month 10. The CIP targets increase progressively over the remainder of the year and so close monitoring and adherence to plans is critical.
The 1617 Arbitration has been concluded with all issues found in favour of the Trust, except £0.3m (relating to 50% share of close out deal dispute). The CCG continue to challenge the 1718 impact of A&E and T&O coding, and have issued Contract Performance Notices (CPNs) to this effect. Additional CPNs have also been raised by the CCG in relation to Ambulatory Care and Community Hospitals. A formal joint process is currently underway to resolve these matters under the terms of the NHS Standard Contract, including audits of patient activity. These challenges could have a significant (c£5m) adverse impact on the financial position. However, the Trust believes it has a strong case and the CCG challenges are unfounded.
Liquidity Cash is significantly down due to ongoing reduced payments by Northumberland CCG and NHS Fleet debtors. The cash balance is £10.0m, which is £31.7m below plan. The liquidity day metric is 19.3 for January (plan = 17.3), which gives a Liquidity risk rating of 1.
Capital Investment
Capital investment is currently running £7.7m below planned levels.
Use of Resources Rating
At the end of the period the Use of Resources rating was 1 (the highest rating), consistent with plan.
62
Summary Performance to date is in line with plan. However, expenditure (in particular pay) is not sustainable given
the reliance on CCG income. The key actions/issues emerging from the performance to date are:
(1) Cost reduction Plans need to be delivered. There are fortnightly meetings (now led jointly by the Director of Finance and the Director of Delivery) in place to track progress and to ensure accountability across the organisation. A quarterly report will be presented to FIP so that the Committee are fully appraised of progress and where necessary corrective action agreed. As part of the escalation process individual business units maybe required to attend.
(2) Cyber attack the impact of the cyber attack impacted on activity in May with an assessed (uninsured) loss of £0.9m related to lost activity (elective and outpatients).
(3) Clinical income continues to be below plan with elective activity below 1617 levels and non-elective income impacted by a higher utilisation rate for ambulatory care, which is chargeable at a lower locally agreed tariff. Winter pressures and infection control measures have further impacted.
(4) Agency Spend is at reduced levels compared to 1617, but has recently seen a sustained increase. Pressure needs to continue to reduce agency (and other premium pay spend) to ensure compliance with Agency Ceiling set by NHSI.
(5) Northumberland CCG Contract . The Trust have made a final offer to the CCG to settle the contract position, which included a £1.2m reduction to the MIU block. There remain other issues (Safeguarding) and low acuity NEL activity. Both issues may need to go to arbitration but the latter issue requires consent by the Trust to vary PbR which it will not consent to.
(6) Cashflow is well below plan due to delayed payments, particularly from Northumberland CCG and Lease Car debtors. The CCG continue to short pay invoices and discussions are ongoing regarding their aged debt balance (which now stands at £8.8m).
The forecast for the year is delivery of the key financial targets. There are however significant risks and these are identified in the financial forecast.
COMMERCIAL IN CONFIDENCE 563
Report to Finance, Investment & Performance Committee
Title of Report NHSI Regulatory Performance Report
Author Birju Bartoli, Executive Director
Executive Lead Birju Bartoli, Executive Director
Date of meeting 22nd February, 2018Executive Summary From October 2016, under the new oversight framework, Trusts are now
monitored and expected to deliver most key performance metrics on a monthly basis, as opposed to quarterly, with an opportunity to recover financial penalties at the end of each quarter based on an aggregated quarterly performance. On 19th October NHS Improvement published the latest provider segmentation (which is based on the level of support trusts need). This confirmed that the trust remains in Segment 1. This is the best possible segment.
Performance in January for the A&E target was 91%, i.e. the Trust failed to meet the 95% target. There were 608 ‘excess’ breaches; that is, if 608 more of the January attenders had been admitted/discharged from A&E within 4 hours we would have met the 95% target. Year to date is at 93.8% (as at 8th February).
Referral to treatment times (RTT) for incomplete pathways: the standard is to have at least 92% of patients waiting less than 18 weeks at month end. This standard was met for January, with a performance of 92%.
January performance data for the 62 day cancer waiting times GP referral to treatment target (85%) is still to be confirmed, but the provisional performance figure is 80%.
Performance for the 62 day bowel screening target (90%) – the provisional performance figure for January is 100%.
Diagnostics: percentage of patients waiting six weeks or less for a diagnostic test. We achieved the 99% standard for January.
IAPT: the proportion of people completing treatment who moved to recovery is provisionally 52.5% for January. The standard to meet for the quarter is 50%.
This report is written in accordance with NHS Improvement’s Single Oversight Framework, which became operational from 1st October, 2016 and was updated in November 2017.
Assurance Frwk ref. 2.1 - 2.51 inclusive
Alignment to Trust’s Annual/ Strategic Plans or business unit annual plans
Yes – aligned
Risk rating (very high, high, moderate, low risk)/ any recommended changes
Moderate
Compliance/ reg’tory requirements (if applicable)
Yes – compliant
Actions required by the Board
The Committee is asked to approve this report.
64
Regulatory Performance Report
Finance, Investment & Performance Committee22nd February, 2018
Strategic Objective: Excellence in safety, quality and complianceAt the same time as delivering the best quality healthcare and excellent customer services we have to ensure patients are safe and that we meet national regulatory safety and quality standards. This will provide independently verified assurance to our stakeholders and will give us the necessary freedom to focus on our priorities.
Key Strategic QuestionTo what extent are we providing high quality, caring, safe, health and care services in accordance with the national regulatory standards?
Key Findings and Performance LevelsThe purpose of this executive summary is to provide the Board of Directors with the evidence of achievement against the national regulatory systems, emerging risks and the assurance that an improvement plan is in place and is effective.
The Board has delegated full authority to the following Committees to ensure these standards are met: FIP, Safety & Quality and Assurance. The evidence to support the governance of these standards is provided to these Committees.
65
NHS Improvement (NHSI) – Single Oversight Framework (SOF)
NHSI’s Single Oversight Framework became operational from 1st October, 2016
Q1 Q2 Q3 Q4
Trust overall assessment Actual Actual Actual Forecast
Performance
Operational performance metrics(8 acute; 4 mental health) (see note 1)
9 of 10 standards
met***
8 of 10 standards
met***
10 of 12 standards
met ***
10 of 12 standards
met ***
Quality of care (safe, effective, caring, responsive) monitoring metrics
See quarterly Excellence in Safety & Quality report
Care Quality Commission
Quarter
1 2 3 4
Overall Trust Rating Outstanding Outstanding Outstanding
CQC ‘insight’ performance monitoring to be included upon publication
Score = 1* Score = 1* Score = 1*
Annual Quality Governance Fully met Fully met Fully met
Material risks No No No
Segment 1**
Segment1**
Segment 1**
* Score = 1 is the best score possible
** Segment = 1 means the provider has maximum autonomy
*** Amber means there is a risk to the trust remaining in Segment 1 (because of performance on the
A&E 4-hour wait standard and the cancer 62 day GP referrals standard)
Notes 1. Five acute standards with monthly frequency: A&E four hour wait; 18 weeks RTT incomplete pathways; Cancer 62
day waits (2 standards); and 6 week wait for diagnostic procedures.
Three acute standards with quarterly frequency: three measures about dementia assessment and referral, relating to
case finding, assessment and referral.
Two mental health standards with quarterly frequency: the Data Quality Maturity Index (DQMI) for the Mental Health
Services Data Set (MHSDS); and one relating to the Improving Access to Psychological Therapies service - the
proportion of people completing treatment who move to recovery.
Two mental health standards with 3-month rolling frequency: per cent waiting 6 weeks or less from referral to entering
a course of treatment under IAPT, and per cent waiting 18 weeks or less.
Performance and quality metrics
Care Quality Commission
Single Oversight Framework (SOF) Segment
Other factors
Finance and use of resources
Board statement
66
Safety & Quality Regulatory Risk AssessmentThis section provides a risk assessment of the regulatory standards.
Strategic, Operational & Financial Risks: High Risks SOF Risk
A&E 4 hour wait (95% target) Performance in January for the A&E target was 91%, i.e. the Trust failed to meet the 95% target.
A&E attendances remain at around 15,500-17,000 per month, but 1.1% higher overall than during the same period (Apr-Jan) last year.Length of stay has decreased compared to last year: 31% of patients stayed 3+ days compared to 30% for the same period (Apr-Dec) last year.
Yes
Referral to treatment times (RTT) for incomplete pathways: % patients waiting less than 18 weeks at month end
Referral to treatment times (RTT) for incomplete pathways: 92% patients waiting less than 18 weeks at month end. This standard was met for January, with a performance of 92%.
No
62 day referral to treatment Cancer standards: urgent GP referrals and referrals from the national screening service
January performance data for the 62 day cancer waiting times GP referral to treatment target (85%) is still to be confirmed, but the provisional performance figure is 80%.
Summary level performance is adversely affected by performance at cancer-site level where there is a combination of low percentage achievement and relatively high volume of treatments. Urology continues to be of particular focus.
Performance for the 62 day bowel screening target (90%) – the provisional performance figure for January is 100%.
Yes
Diagnostics – percentage of patients waiting six weeks or less for a diagnostic test.
We achieved the 99% target for patients waiting at the end of January.
No
Improving access to psychological therapies: proportion of people completing treatment who move to recovery
IAPT: the proportion of people completing treatment who moved to recovery is provisionally 52.5% for January. The standard to meet for the quarter is 50%.
No
MRSA While no longer a Monitor target, the expectation is that trusts will have zero cases of MRSA. There have been two cases identified so far during 2017/18. One case was identified in September, but this has been apportioned to the CCG. A second case was identified in January, and this has been apportioned to a third party.
Not appl
Clostridium difficile
During January there were five cases of C diff. The target for 2017/18 remains at no more than 30 cases. There was one case between 1st and 12th February, so there have been 31 in total which exceeds the maximum allowed target of 30.
By default, each case is deemed to be ‘due to a lapse in care’ unless it has been through a formal appeals process.
Not appl
Surgical site (deep) infection rates in Orthopaedics (in arrears; the position up to and including December 2017 is reported)
During December there were four deep joint infections: one for hip replacement, one for knee replacement and two for fractured neck of femur. During 2017/18 to date there have been 24 – twelve for hip replacement, five for knee replacement and seven for repair of fractured neck of femur.
Not appl
Complaints Complaints responses within the period agreed with the complainant 74% (out of complaints closed within the agreed timescale) for January. Monthly monitoring of Trust and Business Unit performance is undertaken at the Safety and Quality Committee.
Not appl
67
RecommendationsThis report is provided for information to Board members.Birju BartoliExecutive Director, February 2018.
Assurance Framework References 2.1 – 2.51 inclusiveKey controls – Yes, key controls are in placePositive assurance – this report provides positive assuranceGaps in controls or assurance – There is no gap in our controls.
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Title of Report Board Assurance Framework 2017/18 (v4.3)
Author Neil Gibson, Head of Quality and Assurance
Executive Lead Birju Bartoli, Executive Director of Systems, Strategy and Transformation
Executive Summary The Trusts Board Assurance Framework (BAF) identifies the strategic
objectives, priorities and key risks to achieving those priorities. For each
identified risk, the controls and assurances are identified together with
the responsible lead Director and responsible committee.
Following review by the Executive Director of Human Resources/OD a
number of amendments have been made to risks within Strategic
Objective 5: Attract, retain, support and train the best staff.
The BAF was reviewed in conjunction with the Trusts combined risk
register at Assurance Committee on the 16th January, this review did not
identify any emerging high risks for escalation to the Board.
Recommended
actions required by
Board/committee
The Board is asked to note and approve the content of the report.
1 2 3 4 5 6Link to strategic
objectives
(please tick)
Strategic objective
reference
n/a
Caring Responsive Well-led Effective SafeLink to CQC KLOE
(please tick) Compliance/
regulatory
requirements (if
applicable)
n/a
Financial impact? n/a
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Assurance Framework for the Key Strategic Objectives 2017/18
Report to Board of Directors1. Introduction
The system for assurance of the delivery of the Trust’s strategic objectives is by the Board Assurance Framework (BAF). In line with best practice recommended by “The Intelligent Board” the Audit Committee and the Board of Directors considers the progress of its strategic objectives at quarterly intervals to support the self-certification to NHS Improvement.
This report needs to be considered in conjunction with the monthly Board of Directors NHSI Regulatory Performance Report.
NHS Improvement (NHSI) – Single Oversight Framework (SOF)
NHSI’s Single Oversight Framework became operational from 1st October, 2016
Q1 Q2 Q3 Q4
Trust overall assessment Actual Actual Forecast
Performance
Operational performance metrics(5 acute; 5 mental health) (see note 1)
9 of 10 standards
met***
8 of 10 standards
met***
8 of 12 standards
met***
Quality of care (safe, effective, caring, responsive) monitoring metrics
See quarterly Excellence in Safety & Quality report
Care Quality Commission
Quarter
1 2 3 4
Overall Trust Rating Outstanding Outstanding Outstanding
CQC ‘insight’ performance monitoring to be included upon publication
Score = 1* Score = 1* Score = 1*
Annual Quality Governance Fully met Fully met Fully met
Material risks No No No
Segment 1**
Segment 1**
Segment 1**
* Score = 1 is the best score possible
** Segment = 1 means the provider has maximum autonomy
*** Amber means there is a risk to the trust remaining in Segment 1 (Amber means there is a risk to the trust remaining in Segment 1 (because of performance on A&E four hour waits, and the two
Cancer 62 day standards and the IAPT standard)
Notes
1. Five acute standards with monthly frequency: A&E four hour wait; 18 weeks RTT incomplete pathways; Cancer 62 day waits (2 standards); and 6 week wait for diagnostic procedures.
Three acute standards with quarterly frequency: three measures about dementia assessment/referral;
Two mental health standards with quarterly frequency: Data quality maturity index and IAPT: proportion of people completing treatment who move to recovery;
Two mental health standards with 3 month rolling frequency: % waiting 6 weeks or less from referral to entering a course of treatment under IAPT, and % waiting 18 weeks or less
Performance and quality metrics
Care Quality Commission
Single Oversight Framework (SOF) Segment
Other factors
Finance and use of resources
Board statement
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A copy of the BAF for 17/18, based on the strategic objectives is enclosed with this report. Following a recommendation from Internal Audit, nominated lead officers for each of the risks within the assurance framework were asked to confirm they remained accountable for the risk and also the accuracy of the information contained within the assurance framework.
2. Key Strategic Risks
Following a review of the BAF by the Executive Director of Human Resources/OD, a number of amendments have been made which are summarised below:
Risks updated to better reflect the People and OD Strategy (5.3, 5.4, 5.8, 5.10 to 5.14)
Risks associated with code of behaviour, model employer status and working in partnership with staff have been merged under risk 5.3 ‘staff engagement.
New risks relating to change ability, improvement/innovation and leadership/management have been added (5.5 to 5.7)
Removal of the risk linked to national pay negotiations
The graph below provides a quarterly summary of both the overall number and grade of risks contained within the Assurance Framework.
37
37
37
38
8
9
9
6
3
3
3
4
0 10 20 30 40 50 60
Apr 18
Jan 18
Oct 17
July 17
June 17
Very Low
Low
Moderate
High
Very High
Number of Risks
A summary of the current very high/high risks is shown below.
Very High Risks
Ref 2.1 NHSI Single Oversight Framework
A&E 4 hour target – Quarter 3 performance was 93.5% with the target not being met for each month of the quarter. The December position was 91.4%. The Trust was able to achieve the STF trajectory for Q3.
Hospital acquired Clostridium difficile - the cumulative position is no more than 30 cases for the year 17/18, quarter 3 cumulative actual outturn was 25 against a trajectory of 23.
Cancer: GP referral to treatment – the 85% target for 62 day GP referrals was not met October. A recovery trajectory of 83% for November and 85% for December was agreed through FIP. This was met in November and provisional performance for December is 85%. Weekly tracking meetings continue to try and ensure that all patients are seen within timeframe. This remains a very high risk due to the measure only being met for the first time in December. NHSI continue to track recovery of this metric.
National screening service referral (Bowel cancer screening), this target was not met in October and November, but December has a provisional performance of 100%.
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Ref 4.1 – 4.3: Overall Healthcare Funding (4.3 is a high risk)The national and local financial position is extremely challenging with the two main commissioners being required to take action across the local health economy to reduce costs and bring system expenditure into line with current and forecast allocations. This position is particularly acute within the Northumberland system with the CCG requiring in excess of £50m cost reduction or cost avoidance in dealing with existing or forecast activity projections.
In the current year this will result in a requirement for the Northumberland CCG and Trust to jointly deliver a saving of £10m in comparison to the jointly agreed acute “demand plan” of £193.3m. The consequence of this joint action will be the requirement to manage demand more effectively thus reducing projected activity growth and additionally reduce the cost of non-tariff contracts and thereby passing that saving to the CCG.
High Risks
Ref 1.1 Accountable Care OrganisationThe Trust has previously been involved in the development of an accountable care organisation (ACO) in Northumberland (as part of the PACS Vanguard bid). A key component of this was moving away from PBR and more towards a capitated budget and developing a system wide clinical model. The movement of the payment model is recognition that the current system is not sustainable longer term and that there is a need to develop a different model to traditional commissioning arrangements.
In September the board was updated on the probability of moving to an ACO in the foreseeable future and concluded that this was not likely to occur. However, the reasons for moving to an ACO were all still valid and the board were in support of the continued development of the clinical strategy and a system wide approach to ensuring a sustainable local health economy.
This work has continued with the development of the clinical strategy and a number of engagement events with GPs and wider system leaders. It has previously been agreed that where possible elements of the ACO governance structure should be put in place e.g. a collaborative of senior leaders to help to drive the change. A refreshed transformation board in Northumberland has been established to support this work. There is an understanding that currently, any changes in the clinical strategy will be supported by contractual discussions with commissioners to ensure that there is no unforeseen movement in financial risk that cannot be mitigated by a corresponding removal of cost.
An expression of interest (EOI) to be part of the 2nd wave of accountable care systems has been submitted – with all partners (NHCT, NLand GP federation, NUTH, NTW, CCG and Nland county council) signing the application. A decision on the EOI and further details on what this would mean for partners is expected from the national bodies before the end of the financial year.
Ref 2.3 Save Lives and Reduce Harm
Falls been identified from incident reporting and safety thermometer as a key area for improvement. Improvement plans, led by the Executive Director of Nursing are in place and will continue to be monitored by the Safety and Quality Committee.
Surgical Site Infections - In the year to November 2017, 19 deep infections have been reported (4 knee and 10 hip and 5 fractured neck of femur). RCAs for all cases continue to be undertaken with actions being monitored via the SSI working group and Trauma and Orthopaedic board.
MRSA - The target for the number of MRSA positive cases, post 48 hrs admission is 0 for the period 17/18. In 2017/18 to date there have been 0 positive cases allocated to the Trust. Whilst this is no longer a direct target in accordance with the NHSI Single Oversight Framework, NHSI do reserve the right to escalate a Trust in view of MRSA positive cases.
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Ref 2.5 CQC Regulation 9: Person Centred Care Limitations of breast radiological provision – due to the reduction of Breast Radiologists and as the inability to successfully recruit to vacant posts, a two stop clinical pathway has been implemented in the interim period to reduce pressure on the service and meet two week wait standards. Following discussions at EMT, the Trust is now looking to pursue overseas recruitment through already well established contacts.
Ref 2.11 Regulation 15: Premises and Equipment There are two issues which contribute to this being rated a high risk, they relate to:
The CSSD function and capacity at both NTGH and WGH is struggling to meet demand with aging equipment. At present a combination of maintenance contracts and in house maintenance is currently ensuring service provision, however due to the aging hardware and issues with services there is a risk to on-going service provision. A project group has been established to consider all available options.
In June 17 the Board approved the inclusion of fire safety measures across the Trust as a high risk, in summary there are issues with fire compartmentation at a number of Trust sites including NSECH, HGH, Halthwhistle, Blyth and Berwick. There are also issues with fire stopping at NTGH and WGH. Actions to address these issues are in progress and these will be monitored by Estates and Facilities/NHFML.
Ref 2.14 CQC Regulation 18: StaffingThere are a number of staffing issues which are contributing to this risk, these relate to:
Insufficient Breast and General Radiologists – a robust reporting radiographer timetable has been implemented and Locums employed to undertake the reporting to alleviate any risks.. In addition, although additional Haematology biomedical science staff have been recruited, the new staff require a period of training before being able to provide an adequate out of hours service. The risk is currently being mitigated by the Business unit, but inadequate service provision, especially out of hours continues to be a concern. Histopathology consultant staffing is also an emerging concern following the departure of two substantive consultants. This is being mitigated by the appointment of a speciality doctor and the use of locum agency medical staff but long term sustainability is of concern.
Recruitment of theatre nurses continues to be problematic due to national shortages of these staff. To address this shortage a further targeted recruitment campaign is planned.
Maternity Staffing – due to the increase in births at NSECH, there are currently shortfalls in the level of midwifery staffing within the Trust. Additional funding was approved for further recruitment of additional midwives and the situation is now regarded as stable.
Four obstetrics and gynecology consultants are leaving/retiring from the Trust, although two replacements have been recruited (joining May 18).
We have a high turnover of Operating Department Practitioners at present as they are in short supply
We have an increasing turnover of Nurse practitioners as again they are in short supply with a number of them taking up posts outside the organisation – a continued process of appointing to training posts is underway
Monitor Agency Fee Cap – the Trust is currently unable to wholly comply with the current Monitor cap on agency fees. Each potential breach of the cap is assessed on an individual basis, with the maintenance of patient safety being the overriding concern, with approval obtained from the Executive Director of Operations/Deputy Chief Executive. There is the potential for an increased number of breaches when the agency cap is tightened further from April 2016. A separate paper on this issue was presented to the Trust Board in January 2016.
Ref 5.2 Cyber SecurityCyber security remains a high risk for the Trust although this is mitigated against by the contracts and security that the Trust has in place. To provide Board with assurance, GE-Finnamore have been engaged to review our current and future options to reduce the impact of any future virus or malware network ingression. Cyber Security will continue to be monitored, and adoption of ISO27001 will greatly assist in providing on-going assurance. The recent WannaCry virus highlights
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the necessity of continual vigilance and ensuring that systems and applications remain up-to-date and supported.
Ref 5:14 Our Teaching Clinical EducationThis emerging risk was previously highlighted to the Board in April as there was a potential risk that the latest GMC National Training Survey, specifically F2 training, would identify the Trust as an outlier with regards to clinical workload in the emergency department for the 6th consecutive year. The survey has now been received and confirms this position, this will likely lead to the GMC undertaking more frequent monitoring of the actions the Trust is taking to address this issue. HENE has now tasked the Trust with improving this position over the next three years, otherwise there is a risk that trainees may be withdrawn from the emergency department.
In addition to this issue, there are emerging issues with regards to junior doctor staffing (especially GP VTS and ACCS) within the Medicine Business Unit leading to potential gaps in our clinical rota’s.
Moderate RisksRef 5.1 Information and Technology (was High risk)Maternity E3 system - E3 Euroking is the maternity data capture system, the Deputy Director for Emergency Surgery and Elective Care has now confirmed that the E3 system was now working as intended and capable of producing the necessary management information, as a consequence the overall risk rating could be reduced to moderate.
Emerging RisksThe Trustwide risk register was reviewed at the Assurance Committee meeting on the 16th January 2018, with no emerging risks identified for escalation to the Trust Board.
4. Actions to close gaps in controls/assurancesActions to close gaps in controls/assurances are described within the assurance framework, which is attached. This should be considered as a source of accurate, timely and meaningful assurance to the board of directors and should be subject to internal audit reviews similar to other important sources of assurance during 2017/18 and beyond.
5. RecommendationIn line with best practice from the AC Handbook, the Committee is asked to:
Approve the Board Assurance Framework
Note that the high risks have appropriate actions in place to respond to these actions.
Birju Bartoli, Executive Director of Systems, Strategy and TransformationFebruary 2018
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Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
1.0 STRATEGIC OBJECTIVE: To ensure that quality underpins every decision
1.1 Accountable Care OrganisationDelivery of an ACO as part of Northumberland PACS vanguard 5 year forward view process.
Development of ACO concept and approval of business case.
The ACO does not deliver the intended quality, health and financial improvements.
3 5
High risk
Programme Board established
Beachcrofts support
Internal
TB reports from programme board
External
Programme Board report to TB – monthly
ACO Update – June 17
- no n/a
B B
art
oli
Str
ate
gy C
om
mitte
e
1.2 Acute Care Collaboration/Commercial Development5 year forward view to develop ‘chain’ model of working (including provision of some services for NCUH).
Sharing best practice across the wider NHS.
Benefits realisationThe ACC/subsidiary companies do not deliver intended clinical and financial benefits. These include:
NHFML
NPC
NDS
3 4
Moderate risk
Subsidiary companies established with individual boards
Internal
Subsidiary reporting to TB
External
Key issues reports from Trust subsidiary companies – NPC and NHFML
NPC 5 year strategy – TB Dec 17
IA 16/17 NPC – limited assurance
no n/a
B B
art
oli
Str
ate
gy C
om
mitte
e
1.3 New specialist emergency care centre/hospital site and community service reconfiguration That the new model of care introduced with the opening of NSECH.
Reconfiguration of non-NSECH sites/community services to support moving from hospital to community based services.
Model of CarePotential risks involve activity, income and workforce issues.
3 4
Moderate risk
Financial/budgetary control
Monitoring of activity levels
Workforce monitoring including staff feedback
Internal
Trust Board Finance, Performance and Investment Committee
External
Finance/activity reporting to FiP
Corporate finance report – TB monthly
NHSi Performance Report– TB Monthly
FiP key highlights report to TB – monthly from October 15
IA 17/18 – E-referrals – reasonable assurance
IA 17-18 - Staff Retention and Workforce Management – substantial assurance
no n/a
B B
art
oli/
D. Lally
Str
ate
gy C
om
mitte
e
2.0 CORPORATE OBJECTIVE: To provide the safest health and care services to patients and service users
2.1 QualityComplying with NHSi Single Oversight Framework
NHSi Single Oversight Framework Demonstrating non-compliance without adequate explanation leading to adverse regulatory intervention.
5 4
Very High Risk
Annual self-assessment by the Board and Board committees
Performance Mgt system
Internal
Annual Governance Framework
External
Head of IA opinion
External Audit
Well led review 2016
Annual accounts
Excellence in Safety and Quality Report – TB Quarterly
Quality Account
NHSi Performance Report– TB Monthly
SQC – key issues report
KPMG Quality Account/Annual report review 2017
IA 16/17 – Data Quality Cancer Targets 31 days – limited assurance
Deloittes 2016 Well led Review
no n/a
B B
art
oli/
D. Lally
Fin
ance
, In
vestm
en
t an
d
Perf
orm
ance
Com
mitte
e
2.2 QualitySerious incidents, complaints and clinical audit outcomes are used to learn and improve healthcare.
Systemic FailureSerious failures from incidents, complains, claims and clinical audit result from weaknesses in our systems of care and culture
2 4
Moderate risk
Incident management system
Complaints and claims monitoring processes
Safety and Quality Committee
Safety Panels
Quality Panels
Internal
Monthly TB reports
External
Monitor assessment at quarterly intervals
Internal Audit
Report on serious incidents, complaints and claims monthly
Excellence in Safety and Quality Report – TB Quarterly
Ward Assurance Report – TB Monthly
IA 16/17 – Medical Gases – good assurance
IA 16/17 – Policy Management – substantial assurance
IA 16/17 Clinical Audit – substantial assurance
no n/a
E M
onkhou
se/
J R
ushm
er
Safe
ty a
nd Q
ualit
y
Com
mitte
e
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Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
2.3 QualityEnsuring that our safety and quality priorities focus on our key risks and are effective
Use improvement methodology to work smarter.
Save lives and reduce harmSafety culture is not open and transparent
Increase in mortality/harm
Failure to achieve the targets set, resulting in financial underperformance and possibly reputational damage:
Safety and Quality priorities
CQUIN
National Priorities
Best practice tariff
4 4
High Risk
Quality Laboratory
Quality Panels
Monthly monitoring through safety and quality report
Internal
Quality and Safety report
Annual Plan
Quality Account
Performance Report
External
CHKS
CQC
National staff survey
Independent Assessment of Quality Account
Internal Audit
Excellence in Safety and Quality Report – TB Quarterly
NHSi Performance Report– TB Monthly Quality Account
Governors Body
Exec walkabout report to TB monthly
Corporate Financial compliance and financial strategy report – TB quarterly
Report on serious incidents, complaints and claims monthly
Learning from deaths report – TB 1/4
Annual national staff survey
KPMG Quality Account review 2016
IA 16/17 – Lone Working – limited assurance
IA 16/17 – Medical Gases – good assurance
IA 16/17 – CQUIN targets – good assurance
no n/a
B B
art
oli/
D R
ea
pe/J
Rushm
er
Safe
ty a
nd Q
ualit
y C
om
mitte
e
2.4 CQC ComplianceEnsuring on-going compliance with Health and Social Care Act 2008 Regulations 2014.
Regulation 5: Fit and Proper Persons: Directors: The risk concerns those people with director level responsibility for the quality of care and treatment not meeting the fit and proper persons requirements. 2 5
Moderate risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
¼ PCA update/report to assurance ctte
External
CQC inspections
NHSi Performance Report– TB Monthly
HR/OD Development Report – TB Quarterly
WFC key issues report
IA 16/17 – CQC – substantial assurance
no n/a
A. S
trin
ger
Assura
nce
Com
mitte
e
2.5 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 9: Person-centred care: The risk concerns ensuring that people who use the service have care/treatment which is personalised specifically for them.
3 5
High risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
External
Care Quality Commission
NHSi Performance Report– TB Monthly
15 steps monthly report to SQC
Chief Matrons nursing ward assurance report to TB
IA 16/17 – CQC – substantial assurance
no n/a
E M
onkhou
se/D
Lally
Assura
nce
Com
mitte
e
2.6 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 10: Dignity and respect: The risk concerns ensuring that people who use the service are treated with respect and dignity at all times whilst they are receiving treatment.
2 5
Moderate risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
External
Care Quality Commission
NHSi Performance Report– TB Monthly
15 steps monthly report to SQC
Estates and Facilities Strategic Report – TB Qtrly
IA 16/17 – CQC – substantial assurance
no n/a
E M
onkhou
se/D
Lally
Assura
nce
Com
mitte
e
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Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
2.7 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 11: Consent to care and treatment: The risk concerns ensuring that consent is given by all those people using the service before any treatment or care is provided by the Trust. 2 5
Moderate risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
External
Care Quality Commission
Internal Audit
NHSi Performance Report– TB Monthly
Excellence in Safety and Quality report – TB qtrly
15 steps monthly report to SQC
IA report NAM 1418 – significant assurance
IA 16/17 – CQC – substantial assurance
IA 17/18 – Patient Consent – reasonable assurance
no n/a
D L
ally
Assura
nce
Com
mitte
e
2.8 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 12: Safe Care and Treatment: The risk concerns ensuring that people who use the service are prevented from unsafe care and treatment and avoidable harm/risk of harm.
Note: this regulation is wide ranging and covers Medicines Management, Premises, Equipment, Emergency Preparedness and Infection Control
2 5
Moderate risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Premises Assurance Model – self assessment and evidence files
Internal
Quality and Safety report – monthly
External
Care Quality Commission
Internal Audit
NHSi Performance Report– TB Monthly
15 steps monthly report to SQC
Infection control annual report – Sept 17
Estates and Facilities Strategic Report – TB quarterly
Estates & Facilities Performance Report – EFC quarterly
Emergency preparedness, resilience and response annual plan
IA 16/17 – CQC – substantial assurance
IA – 16/17 – lone working – limited assurance
IA 16/17 – Community Estates – good assurance
IA 16/17 – Transport – reasonable assurance
IA 17/18 – Maternity Framework – reasonable assurance
no n/a
E M
onkhou
se/J
Rushm
er/
D L
ally
/B
Bart
oli
(S. B
annis
ter)
Assura
nce
Com
mitte
e
2.9 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 13: Safeguarding service users from abuse and improper treatment: The risk concerns ensuring that people who use the service are safeguarded from any form of abuse or improper treatment which receiving care and treatment.
2 5
Moderate risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Annual self assessment section 11 audits reviewed by both LSCB’s
Internal
Quality and Safety report – monthly
External
Care Quality Commission
NHSi Performance Report– TB Monthly
15 steps monthly report to SQC
Safeguarding quarterly reports
Report on serious incidents, complaints and claims monthly
Safeguarding Annual report
IA 16/17 – CQC – substantial assurance
IA 16/17 – Safeguarding Children and Vulnerable Adults – good assurance
IA 16/17 – MCA and DoLS – reasonable assurance
no n/a
E M
onkhou
se
Assura
nce
Com
mitte
e
2.10 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 14: Meeting nutritional and hydration needs: The risk concerns ensuring that people who use the service have adequate nutrition and hydration to reduce the risks of malnutrition and dehydration whilst they receive care and treatment.
2 5
Moderate risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
External
Care Quality Commission
NHSi Performance Report– TB Monthly
15 steps monthly report to SQC
Estates and Facilities Strategic Report – TB Qtrly
IA 16/17 – CQC – substantial assurance
IA 16/17 – Food and Nutrition, spilt opinion Governance: reasonable assurance, Operational: Good assurance
no n/a
E M
onkhou
se
Assura
nce
Com
mitte
e
77
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Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
2.11 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 15: Premises and Equipment: The risk concerns ensuring that premises where care and treatment is provided is clean, suitable for the intended purpose, maintained and where required appropriately located. In addition, equipment used to deliver care and treatment needs to be clean, suitable for the intended purpose, maintained, securely stored and used properly.
Note: this regulation covers Premises, Equipment and Infection Control
3 5
High risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Premises Assurance Model – self assessment and evidence files
Internal
Quality and Safety report – monthly
External
Care Quality Commission
Internal Audit
NHSi Performance Report– TB Monthly
15 steps monthly report to SQC
Infection control annual report – Sept 17
Estates and Facilities Strategic Report – TB quarterly
Estates & Facilities Performance Report – EFC quarterly
Estates Annual Report – TB June 16
Fire Safety Management – Sept 17
Health and Safety Annual report – TB Dec 17
IA 16/17 – CQC – substantial assurance
IA 16/17 – Community Estates – good assurance
IA 16/17 – Transport – reasonable assurance
The CSSD function and capacity at both NTGH and WGH is struggling to meet demand with aging equipment. A business case is being developed to address the issues with initial option estimates ranging from circa £1 million to £10 million.
December 2019
E M
onkhou
se/J
Rushm
er/
D L
ally
/B
Bart
oli(
S.B
an
nis
ter)
Assura
nce
Com
mitte
e
2.12 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 16: Receiving and acting on complaints: The risk concerns ensuring that there is an effective and accessible system for identifying, receiving, handling and responding to complaints with the necessary actions taken where failures are identified.
2 5
Moderate risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
External
Care Quality Commission
NHSi Performance Report– TB Monthly
Excellence in Safety and Quality report – TB qtrly
IA 16/17 – CQC – substantial assurance
IA 17/18 – Maternity Framework – reasonable assurance
no n/a
E M
onkhou
se
Assura
nce
Com
mitte
e
2.13 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 17: Good Governance: The risk concerns ensuring that the Trust has effective governance processes (including auditing and assurance systems) which drive quality improvements, including patient experience, and also the health and safety of people who use the service and others.
Note: this regulation covers Records Management, Patient Experience, Clinical Audit and Health and Safety
2 5
Moderate risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
External
Care Quality Commission
Internal Audit
NHSi Performance Report– TB Monthly
Excellence in Safety and Quality report – TB qtrly
HR/OD Development Report – TB Quarterly
Nurse staffing update – June 17
IA 16/17 – CQC – substantial assurance
IA 16/17 Clinical Audit – substantial assurance
IA 16/17 – patient confidentiality – good assurance
IA 17/18 – Maternity Framework – reasonable assurance
no n/a
B B
art
oli/
J R
ushm
er
/A S
trin
ger/
C R
iley
Assura
nce
Com
mitte
e
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Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
2.14 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 18: Staffing: The risk concerns ensuring that the Trust deploys enough suitably qualified, competent and experienced staff to meet the needs of the people using the service at all times. Staff should also receive the support, training, appraisal, professional development and supervision in order for them to carry out their role.
3 5
High Risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
Worked Nos report on nursing written by Deputy Director of Nursing
External
Care Quality Commission
Internal Audit
NHSi Performance Report– TB Monthly
15 steps monthly report to SQC
Ward Assurance report – SQC and TB monthly
HR/OD Development Report – TB Quarterly
Six monthly EDON reviews
Responsible officer annual report – Sept 17
Maternity staffing establishment review – TB Nov 17
IA 16/17 – CQC – substantial assurance
Hard truths monitoring
Care hours per patient day
IA 16/17 SM Training – Substantial assurance
IA 16/17 – Audit of Safe Staffing: substantial assurance
IA 17-18 - Staff Retention and Workforce Management – substantial assurance
no n/a
E M
onkhou
se/D
Lally
/A
Str
inger
Assura
nce
Com
mitte
e
2.15 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 19: Fit and proper persons employed: The risk concerns ensuring that the Trust only employs fit and proper staff.
1 5
Moderate risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
External
Care Quality Commission
Internal Audit
NHSi Performance Report– TB Monthly
HR/OD Development Report – TB Quarterly
IA 16/17 – CQC – substantial assurance
no n/a
A S
trin
ger
Assura
nce
Com
mitte
e
2.16 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Regulation 20: Duty of Candour: The risk concerns ensuring that the Trust is open and transparent with people who use services.
2 5
Moderate risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
External
Care Quality Commission
NHSi Performance Report– TB Monthly
Report on serious incidents, complaints and claims monthly
IA 16/17 – CQC – substantial assurance
IA 16/17 – Duty of Candour – good assurance
no n/a
E M
onkhou
se//D
Lally
Assura
nce
Com
mitte
e
2.17 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.
Social Care CQC registrationFailure to monitor compliance with the Health and Social Care Act in respect of all applicable outcomes in accordance with the terms specified under the partnership agreement with Northumberland County Council.
2 4
Moderate Risk
Designated Trust leads for this standard
Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.
Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.
Internal
Quality and Safety report – monthly
External
Care Quality Commission
Internal Audit
NHSi Performance Report– TB Monthly
9/9 services inspected and rated as ‘Good’,
no n/a
D L
ally
Assura
nce
Com
mitte
e
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/tmp/transcoder/9380f407-4124-4425-9d44-1e72db1c7451.docx Page 12 of 18
Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
2.18 Service PerformanceThe Trust meets Information Governance standard level 2 as a minimum.
Information GovernanceThat the trust may not meet the new enhanced standards for information governance.
3 4
ModerateRisk
IM&T Strategy
IM&T Committee
Information Governance sub-committee, key performance indicators.
Information governance policy and procedures.
IG Governance sub-committee ¼ report to IM&T Committee
Internal
IM&T minutes/reports to TB
Information governance sub-committee report and minutes to IM&T Comm
External
Internal Audit
IM&T Strategy - TB quarterly
IA 16/17 - Web Filtering – reasonable assurance
IA 16/17 IT Asset Management – good assurance
IA 16/17 Q2 Server Testing – reasonable assurance
IA 16/17 Ascribe IT Security – reasonable assurance
IA 16/17 – Information Governance toolkit – substantial assurance
IA 16/17 PAS – reasonable assurance
IA 16/17 – ePMA project – good assurance
IA 16/17- ICE IT security controls – reasonable assurance
IA 16/17 – Endosoft - reasonable assurance
IA 17/18 – Mobile Device Management – limited assurance
no n/a
B B
art
oli
(M. T
hom
as)
Fin
ance
, In
vestm
en
t an
d P
erf
orm
ance C
om
mitte
e
2.19 Service PerformanceInformation and technology helps the business by delivering accurate, complete, meaningful and timely information
Data Quality Clinical coding may not be adequate to ensure comorbidities are recorded.
Sign and symptom code as a primary diagnosis with potential adverse impact on income and risk adjusted measures produced.
Analysis adversely affected by use of non-specific diagnosis/procedure codes.
Loss of income if coding not completed within 20th day after month end.
Incorrect or missing NHS numbers.
3 4
Moderate Risk
IM&T Strategy
IM&T Committee
Safety and Quality committee, key performance indicators.
Data quality policy and procedures.
Internal
IM&T minutes/reports to TB
Safety and Quality report to TB
External
KMPG Quality Account review
IM&T Strategy - TB quarterly
Excellence in Safety and Quality Report – TB Quarterly
KMPG Quality Account review – May 17
IA 16/17 Healthcare agreements – substantial assurance
IA 16/17 – Audit of performance: cancer targets 62 days – substantial assurance
no n/a
B B
art
oli
Fin
ance
, In
vestm
en
t an
d P
erf
orm
ance C
om
mitte
e
3.0 STRATEGIC OBJECTIVE: To be recognised as a caring organisation locally, regionally and nationally
3.1 Patient Experience Aim to apply consistent excellent customer care across the organisation at all times to the same level expected from commercial organisations. Aim is to continue to operate in top 20% of hospitals.
Patient experienceFailure to maintain and improve on our customer service standards.
3 4
Moderate risk
Data collection processes and analysis.
Feedback to wards and monthly monitoring of patient feedback.
Internal
Patient experience quarterly report to the TB
External
CQC
Internal Audit
Patient satisfaction report TB – quarterly
Annual patient survey no n/a
B B
art
oli
Safe
ty a
nd Q
ualit
y
Com
mitte
e
3.2 Patient ExperienceEmbed ’15 steps’ ward assessment programme throughout the trust
Patient experienceFailure to maintain and improve on our customer service standards.
3 4
Moderate risk
Assessment toolkit developed
Assessment plan/standard reporting established
SharePoint site for sharing lessons learnt
Internal
15 steps audit reports to SQC
External
Internal Audit
NHSi Performance Report– TB Monthly
Monthly 15 steps report to SQC
Excellence in Safety and Quality Report – TB Quarterly
- no n/a
B B
art
oli/
E M
onkhou
se
Safe
ty a
nd
Q
ualit
y
Com
mitte
e
80
Northumbria Healthcare NHS Foundation Trust 2017-18 Assurance Framework: 4.3 – January 2018
/tmp/transcoder/9380f407-4124-4425-9d44-1e72db1c7451.docx Page 13 of 18
Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
4.0 STRATEGIC OBJECTIVE: Maintain long term financial strength despite the challenging environment
4.1 Overall healthcare funding (including underachievement of cost reduction targets)
Maintain a Financial Risk rating of 4.Failure to deliver 10 year investment strategy.
Failure to achieve cost reduction programme.
Incorrect assumptions over inflationary and cost increases
Inability to manage capital investments
Better Care Funds: Plans by CCG's and Health and Wellbeing Board to reduce Trust Contracts to form pooled budget with L.A.
5 4
Very High Risk
Budgetary control system
10 year investment strategy, updated annually.
Cost Improvement Plans in place and agreed with Business Units
Budgetary control systems
Capital management programme
Financial strategy in place
Monthly reporting to EMT, FIP Cttee and regular Contract discussions with CCG's
Internal
Corporate Compliance Report – TB monthly
External
Internal Audit
Corporate Compliance Report – TB monthly
AC report to TB – Qrtly
Trust Annual Plan
IA 16/17 – Finance 3rd party – good assurance
IA 16/17: Financial Reporting and budgetary Control – substantial assurance
IA 16/17 NHS Improvement Submissions – substantial assurance
IA 16/17 – TaER – reasonable assurance
IA 16/17 – Asset Management – substantial assurance (land and buildings), reasonable assurance (equipment)
IA 16/17 – audit of management of projects/business cases – reasonable assurance
IA 16/17 – RTA income – substantial assurance
IA 16/17 – CIP – good assurance
IA 17/18 – Ordering and Receipt of Goods (JELS) – substantial assurance
no n/a
P D
unn
Fin
ance
, In
vestm
en
t an
d P
erf
orm
ance C
om
mitte
e
4.2 As above National Tariff changes and ReadmissionsInability to operate within the national tariff, that funding is not indexed in line with the assumptions in the plan.
5 4
VeryHigh Risk
Plan to reduce avoidable emergency admissions agreed with commissioners.
Treasury Management policy.
Budget control system.
Financial Strategy
Internal
Corporate Compliance Report – TB monthly
External
External Audit
Internal Audit
Corporate Compliance Report – TB monthly
AC report to TB - Qrtly
IA 16/17: Financial Reporting and budgetary Control – substantial assurance
IA 16/17 Healthcare agreements – substantial assurance
no n/a
P D
unn
Fin
ance
, In
vestm
ent and
P
erf
orm
ance
C
om
mitte
e
4.3 as above Commissioning IntentionsDemand management by the commissioners leads to activity switch from Trust materially affecting market share and income.
Provider impact on demographic changes – longer life expectancy and complexity of health issues.
4 4
High Risk
Budget control system.
Financial Strategy
Internal
Corporate Compliance Report – TB monthly
External
Internal Audit
Corporate Compliance Report – TB monthly
AC report to TB - Qrtly
IA 16/17 Healthcare /non-healthcare agreements – substantial assurance
no n/a
P D
unn
Fin
ance
, In
vestm
en
t and P
erf
orm
ance
Com
mitte
e
81
Northumbria Healthcare NHS Foundation Trust 2017-18 Assurance Framework: 4.3 – January 2018
/tmp/transcoder/9380f407-4124-4425-9d44-1e72db1c7451.docx Page 14 of 18
Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
4.4 Stakeholders Deliver the level of Surplus contained in the Annual PlanInability to achieve planned surplus.
Financial Position of CCGs. The CCGs are forecasting deficit position which could impact on ability to pay for contract activity. 2 4
Moderate risk
Financial Strategy/3 year plan in place
Treasury Management Policy
Budget Control System
Internal
Corporate Compliance Report – TB monthly
External
External Audit
Internal Audit
Corporate Compliance Report – TB monthly
AC report to TB – Qrtly
IA 16/17 – Financial Ledger – substantial assurance
IA 16/17: Financial Reporting and budgetary Control – substantial assurance
IA 16/17 – Assurance Audit of education training income – substantial assurance
IA 16/17 Healthcare /non-healthcare agreements – substantial assurance
IA 16/17 – TaER – reasonable assurance
IA 16/17 – RTA income – substantial assurance
IA 16/17 – CIP – good assurance
no n/a
P D
unn
Fin
ance
, In
vestm
en
t an
d P
erf
orm
ance C
om
mitte
e
4.5 as above Achieve significant assurance with no issues of note in our key financial internal audit plansFailure to address and maintain issues raised in previous audits.
2 4
Moderate risk
Audit Committee actively monitoring progress
Internal
Audit Committee Annual report
Audit Committee minutes to TB
External
External Audit
Internal Audit
AC report to TB - Qrtly IA 16/17 Healthcare /non-healthcare agreements – substantial assurance
IA 16/17 Accounts Receivable – substantial assurance
IA 16/17 – Financial Ledger – substantial assurance
IA 16/17 – Ordering and Receipt of Goods – substantial assurance
no n/a
P D
unn
Fin
ance
, In
vestm
en
t an
d
Perf
orm
ance
Com
mitte
e
4.6 as above Maintain service line reporting in accordance with Monitor's guidance for clinical specialitiesLack of resource to identify income and costs to Business Units.
2 4
Moderate risk
Service Line Reporting embedded in Bus and reported to BU Boards and FiP
Internal
Corporate Compliance Report – TB monthly
External
External Audit
Internal Audit
Corporate Compliance Report – TB monthly
Audit Committee report to TB – Qrtly
IA 16/17: Financial Reporting and budgetary Control – substantial assurance
IA 16/17 – Financial Ledger – substantial assurance
IA 16/17 – CIP – good assurance
no n/a
P D
unn
Fin
ance
, In
vestm
ent and
P
erf
orm
ance
C
om
mitte
e
4.7 as above To operate a strong working capital performance:Non payment of debt by commissioners. Poor budgetary control. 2 4
Moderate risk
Treasury Management policy. Budget control system.
Financial Strategy
Internal
Corporate Compliance Report – TB monthly
External
External Audit
Internal Audit
Corporate Compliance Report – TB monthly
AC report to TB – Qrtly
IA 16/17 Accounts Receivable – substantial assurance
IA 16/17 – Bank and treasury management – substantial assurance
IA 16/17 – Accounts Payable – substantial assurance
no n/a
P D
unn
Fin
ance
, In
vestm
en
t an
d
Perf
orm
ance
Com
mitte
e
5.0 STRATEGIC OBJECTIVE: Attract, retain, support and train the best staff
82
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Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
5.1 Information and technologyClinical and Business needs are at the centre of our IM&T service delivery – Electronic Integrated Health Record
Completion of ward clinical management system roll out; e-enablement of remaining case note documentation; achieve best in class CHKS data quality award; pilot of e-health record between GP and Trust IT projects do not address the clinical/business needs of the Trust
3 4
Moderate risk
Project management plans approved by IM&T committee
IM&T Committee meets monthly and cycles each meeting through strategic programme, finance and performance, projects and governance
Internal
IM&T Cttee
External
IG Level 2
Internal Audit
IM&T Strategy - TB quarterly
IA 16/17 – ePMA project – good assurance
IA 16/17 – audit of management of projects/business cases – reasonable assurance
no n/a
B B
art
oli
(M.T
hom
as)
Fin
ance
, In
vestm
en
t an
d
Perf
orm
ance
Com
mitte
e
5.2 Information and technologyClinical and Business needs are at the centre of our IM&T service delivery
Cyber SecurityLoss of data through encryption or theft could impact on direct patient care, of financial position of the Trust. Malicious attacks could disable key equipment impacting direct care.
3 5
High risk
Contracts with Anti-virus vendors
CareCert monitor nationally and provide early sight of alerts.
ExternalISO 27001 accreditation
IGSoC annual submission GE-F review underway, to report to Board in September and monthly updates to TB
Not yet identified Not yet identified
B B
art
oli
(M.T
hom
as)
Fin
ance
, In
vestm
ent and
P
erf
orm
ance
C
om
mitte
e
5.3 Staff Engagement Listen to and act on Staff Feedback
Staff experienceAn inability to attract, recruit and retain talented staff, high levels of absence and reduced quality of care provision to patients and service users. A reduction in Top 20% rating/lack of progress will affect our CQC rating.
3 4
Moderate risk
Partnership Agreement
Employee relations - engagement from first contact to point of leaving
Analysing and reflecting on our Staff Survey, Leavers Survey and Friends and Family Survey Results and developing meaningful actions plans
Developing a culture of Diversity & Inclusion
Staff survey report presented to WFC,
Partnership and Board of Directors including an appropriate action plan.
Internal
Quarterly HR report
Annual Leavers Report
Partnership meeting
External
CQC validation
National staff survey
Staff Friends and Family Test
Stonewall Index
Staff Survey results – TB
HR/OD Report – TB Quarterly
Patient experience report – TB quarterly (incl. staff experience from Sept 11)
2016 annual staff survey
IA 17-18 - Staff Retention and Workforce Management – substantial assurance
no n/a
A S
trin
ger
Work
forc
e C
om
mitte
e
5.4 Health & Wellbeing Developing and sustaining fit, healthy and supported staff
Reduced staff health and motivation has detrimental effect on overall patient care.
3 4
Moderate risk
Healthy Workforce Strategic Action Plan
HR policies and procedures
Weekly workforce report to line managers
Health Roster & HR Dashboard - monitored by BU’s and Workforce Committee
Flu reporting
Internal
Workforce Committee
Healthy Workforce Steering Group
Risk register
External
CQUIN
Internal Audit
Better Health at Work Assessments
NHS England Healthy workforce minimum offer
SEQOHS
HR/OD Report – TB Quarterly
Staff Survey
IA 16/17 Absence Monitoring – good assurance
SEQOHS Accreditation
no n/a
A S
trin
ger
Work
forc
e C
om
mitte
e
5.5 Change Agility A change adept and ready workforce supported by agile leaders
Failure to respond to unprecedented and unpredictable pace of change.Poor employee relations.Failure to consult
3 4
Moderate risk
Partnership working
Change Programmes
Robust Policy and Procedures
Internal
Workforce Committee
Partnership meeting
External
HR/OD Report – TB Quarterly
- no n/a
A S
trin
ger
Work
forc
e
Com
mitte
e
83
Northumbria Healthcare NHS Foundation Trust 2017-18 Assurance Framework: 4.3 – January 2018
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Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
5.6 Improvement & Innovation Doing things differently (and better) in the best interest of patients and staff alike
Failure to learn and continuously improve services affects quality of care to our patients
3 4
Moderate risk
Internal
Workforce Committee
Risk register
External
CQC Annual Healthcheck
HR/OD Report – TB Quarterly
- no n/a
A S
trin
ger
Work
forc
e
Com
mitte
e
5.7 Leadership & Management Recruiting and developing compassionate and enabling leaders and managers at all levels
Leaders and managers not having the right skills, knowledge and experience to deliver the strategic plan.
3 4
Moderate risk
Development of a comprehensive and inclusive leadership and management development portfolio based on national standards.
Internal
Workforce Committee
Risk register
External
NHS Improvement
The Kings Fund
HR/OD Report – TB Quarterly
- no n/a
A S
trin
ger
Work
forc
e C
om
mitte
e
5.8 Compliance with European Working Time Directive (including implementation of Junior Doctor 2008 Terms and Conditions)
Junior Doctors Hours:
100% compliance in terms of protocols and actual hours worked 3 4
Moderate risk
Doctors are aligned to correct rota/week on the staff rota electronic system.
Health Roster & HR Dashboard - monitored by BU’s and Workforce Committee
Internal
Workforce Committee.
Risk Register
External
Internal Audit
HR/OD Report – TB Quarterly
Guardian of Safe Working Educational and Trust Board update reports
- no n/a
A S
trin
ger
Work
forc
e
Com
mitte
e
5.9 Management of Equal Pay Claims:Ensure appropriate defence to equal pay work of equal value claims
Inappropriate defence to equal pay claims.
3 4
Moderate risk
Regular case review and strategy meetings with Beachcroft
Effective local control of the process
Workforce Management system
Internal
Workforce CtteeRisk register
External
Case review and strategy meetings with Beachcroft
TB Equal Pay update – Commercial in confidence updates to TB
HR/OD Report – TB Quarterly
- no n/a
A S
trin
ger
Work
forc
e
Com
mitte
e
5.10 Workforce Planning:Trust workforce plan to be updated in line with Clinical/Trust strategy
Responding to the impact of an ageing workforce
profile and difficulty recruiting into specialist
roles. 3 4
Moderate risk
People & OD Strategy Workforce Management system
Trust workforce plan
Localised service plans
Internal
Workforce Cttee
Risk register
External
Workforce Committee report to TB – quarterly
Assurance from Health Education North East around robustness of workforce plan
no n/a
A S
trin
ger
Work
forc
e
Com
mitte
e
5.11 Recruitment – continue to recruit high quality candidates
Inability to recruit high quality candidates
2 4
Moderate risk
Recruitment policies and procedures
Nursing Recruitment and Retention strategy
Workforce system reports
Internal
Workforce Cttee
Risk register
External
Internal Audit
HR/OD Report – TB Quarterly
- no n/a
A S
trin
ger
Work
forc
e
Com
mitte
e
5.12 Performance and DevelopmentHigh performing staff who are enabled to be the best they can be.
Inability to implement may limit our success in the future
3 4
Moderate risk
Probationary & PDR
Compliance monitoring
Workforce system reporting
Internal
Workforce committee report
External
Internal Audit
Staff Survey
HR/OD Report – TB Quarterly
- no n/a
A S
trin
ger
Work
forc
e
Com
mitte
e
84
Northumbria Healthcare NHS Foundation Trust 2017-18 Assurance Framework: 4.3 – January 2018
/tmp/transcoder/9380f407-4124-4425-9d44-1e72db1c7451.docx Page 17 of 18
Grade(including change in
risk)
Assurances ReceivedRef Principal Objective Principal Risks:
LH
Cons
Rating
Existing Key Controls Possible Sources of Assurance
Internal External
Gaps in control/assuran
ce and description of
mitigating actions
Completion Date for Actions
Lead
E
xecu
tive
D
irecto
r (s
)
Lead
C
om
mit
tee
5.13 Talent ManagementSpotting, developing and making best use of our talented staff.
Staff do not have the right skills, knowledge and/or experience to deliver the strategic plan.
2 4
Moderate risk
People and OD Strategic updates via Workforce Committee
Workforce Management system
Internal
Workforce Cttee
Risk register
External
HR/OD Report – TB Quarterly
People & OD Strategy annual review
- no n/a
A S
trin
ger
Work
forc
e
Com
mitte
e
5.14 Our TeachingClinical Education – Trust aims to be a leader in the field of delivering quality education.
Inadequate clinical education standards
Reduced reputation and recruitment ‘attractiveness’ to trainee medical staff who choose us less, exacerbating recruitment gap
4 4
High risk
Trust-wide Education Strategy
Medical Education Board
Undergraduate Education Board
Internal
Education Board
Medical Board
Undergraduate Board
External
Deanery Reports
HR/OD Report – TB Quarterly
Post grad medical and dental education - self assessment report – Nov 17 TB
Deanery Reports
IA 16/17 – Assurance Audit of education training income – substantial assurance
IA 17-18 - Staff Retention and Workforce Management – substantial assurance
no n/a
A S
trin
ger
Work
forc
e C
om
mitte
e
6.0 STRATEGIC OBJECTIVE: Develop an internationally recognised brand and build strong local and national relationships
6.1 Brand & ReputationBuild a brand which is well respected within the North East, nationally and wherever possible internationally
Manage the reputation of the OrganisationTo ensure the organisation is positioned at the heart of the local community alongside being nationally and internationally renowned for quality of care and innovation within the NHS.
3 4
Moderate risk
Objectives approved by the Trust Board and monitored with EDG
Media performance measured monthly and reported to EDG quarterly.
Reputation risk register managed closely to manage risks.
Internal
External
Media Monitoring report.
Public perception research.
Internal Audit
¼ updates to TB
IA 17/18 - Modern
Slavery Act – reasonable assurance
no n/a
C R
iley
Tru
st B
oard
6.2 Market Led StrategyTo grow market share
Market share of core business declinesOpportunities to grow market are not maximised.
3 4
Moderate risk
Monthly market share analysis acts as an early warning system and reported to EMT
Market analysis tool commissioned and analysis informs Trust activity.
Market share position used to frame communication and engagement activity with GP’s and the public
Internal
EDG
FiP
Externaln/a
¼ Marketshare to FiP - no n/a
C R
iley
Fin
ance
, In
vestm
ent and
P
erf
orm
ance
6.3 MembershipContinue to grow our membership and comply with terms of authorisation.
Growth of MembershipMembership of our Foundation Trust does not meet best practice standards
3 4
Moderate risk
Membership strategy agreed by the Governors Body and Board of Directors.
Implemented by the Membership Committee.
Internal
Membership committee
External
Monitor assessment at quarterly intervals
Quarterly reports to the Governors Body and findings included in the quarterly declaration to NHSi
- no n/a
C R
iley
Mem
bers
hip
com
mitte
e
Key:
Risk Rating Key/Source (RMP03 - Policy for the Reporting and Management of Incidents)
Key to Risk Assessment Consequence
Likelihood Insignificant
1
Minor
2
Moderate
3
Major
4
Catastrophic/
Tragic
85
Northumbria Healthcare NHS Foundation Trust 2017-18 Assurance Framework: 4.3 – January 2018
/tmp/transcoder/9380f407-4124-4425-9d44-1e72db1c7451.docx Page 18 of 18
Changes to Risk Ratings:
No change in risk rating from previous version of assurance framework
Risk rating has been downgraded from previous version of assurance framework
Risk rating has been increased from previous version of assurance framework
Lead officers have been asked to confirm the accuracy of each of the risks identified within the Assurance Framework, any changes to the content of the assurance framework have been identified in red.
5
1 Rare Very low risk
(green)
Very low risk
(green)
Low risk
(yellow)
Moderate risk
(orange)
Moderate risk
(orange)
2 Unlikely Very low risk
(green)
Very low risk
(green)
Low risk
(yellow)
Moderate risk
(orange)
Moderate risk
(orange)
3 Possible Very low risk
(green)
Low risk
(yellow)
Low risk
(yellow)
Moderate risk
(orange)
High risk
(brown)
4 Likely Very low risk
(green)
Low risk
(yellow)
Moderate risk
(orange)
High risk
(brown)
Very high risk
(red)
5 Certain/Almost
certain
Very low risk
(green)
Low risk
(yellow)
Moderate risk
(orange)
Very high risk
(red)
Very risk
(red)
86
Title of Report Health and Safety Annual Report 2016-2017
Author Steven Bannister, Director of Estates & Facilities
Executive Lead Steven Bannister. Director responsible, delegated from CEO.
Executive Summary This is a short paper to update the board on the steps taken to clarify
elements of the 16/17 annual health and safety report. Members will
recall the report was shared at the November and December trust boards.
It has subsequently been shared at the assurance committee of the 16th
January 2018. A further update on progress against the plan and actions
was delivered at the audit committee on the 22nd February 2018.
The appended update indicates good progress against the plan.
Recommended
actions required by
Board/committee
The board is asked to:
Note the content of the report which demonstrates the trusts
continued commitment to Health and Safety
Note that the Health and Safety manager will take the lead on
implementing the recommendations.
The Health and Safety group will be chaired by the director
responsible to give leadership.
The Health and Safety Group has been reconfigured after
recommendations for the assurance committee.
1 2 3 4 5 6Link to NHCT
strategic objectives
(please tick)
Strategic objective
reference
2.18 – H & SCA Regulates I5 – premises and equipment low risk.
Caring Responsive Well-led Effective SafeLink to CQC KLOE
(please tick) Compliance/
regulatory
requirements (if
applicable)
Compliance with Health and Safety regulations and CQC Standards.
Financial impact? None Identified
87
Health and Safety Interim Follow Up Review
Report to the Trust Board- 1st march 2018
Introduction
A Health and Safety audit was scheduled for quarter 3 of 2017/18 but as the Health and
Safety Manager had just taken up his position on 25 September 2017 AuditOne decided to
request a further deferral to 2018/19, and issued an interim report to highlight progress to
date.
Progress to date
The action plan for 2017/18 was heavily based on the recommendations contained in the
Capita review. A Health and Safety Manager has been appointed and took up post on 25
September 2017. Since this appointment the following progress has been made:
Action Ref. No.
Health and Safety Manager appointed 1.1
The H&S Manager has started to rewrite the existing H&S Policy. 1.4
A COSHH training package has been produced. 1.5
A draft audit template has been agreed. 1.6
The H&S Manager has audited NSECH, Hexham, Alnwick, Berwick and JELS. 1.6
Weekly visits to NSECH are being conducted to check safe systems of work are
being followed by fire stopping contractors.
1.6
Risk assessment training has commenced. 1.7
The Health and Safety Steering Group has been reorganised and TOR
reviewed. The agenda has been revised to give more focus to H&S issues in
Business Units.
1.8
A meeting has been held with Alison Marshall who has been supportive and
has given us some pointers given her professional background
1.8
A new H&S training workbook has been produced and is in use. 1.9
A new template has been drawn up for Business Units to report on H&S issues
to the Health and Safety Steering Group.
1.10
The H&S steering group will report to the assurance committee which will feed up to
the Trust Board.
1.10
The new Health and Safety manager is is a member of the Institute of Occupational
Safety and Health (IOSH) and has qualified with the national Examination Board in
Occupational Safety and Health.
1.11
Training is to be arranged for the Executive Board members to receive Corporate
Manslaughter training.
1.12
The annual plan and report will be reviewed by the HSSG and progress against plan is
now a regular agenda item,
2.2
The Health and Safety Risk register is reviewed for completeness and progress as a
regular agenda item at the HSSG.
2.3
88
Remaining Risks and Associated Mitigations
The following actions are still outstanding and are being taken forward by the Health and
Safety Manager.
Action Ref. No.
The Health and Safety Manager will has access to all new risk assessments
submitted from 1 March 2018. Any that are not suitable and sufficient will not
be signed off.
1.2 &
2.1
From 1 March 2018 the Health and Safety Manager will provide assistance and
training to any person submitting a risk assessment deemed to be not suitable
and sufficient to improve it.
1.2 &
2.1
The IT department do not currently have the capacity to support the
department in completing risk assessment software as planned, therefore a
suitable package of electronic risk assessments forms is to be developed. The
H&S Manager has drafted a new risk assessment form to be completed online.
COSHH assessments are to be held in a centralised database. An on-line
system for completion of DSE risk assessments is being sourced.
1.3
The new workplace risk assessment template will be implemented from 1
March 2018.
1.3
The revised Health & Safety Policy will be in place by May 2018. 1.4
A database of COSHH risk assessments is to be developed in conjunction with
Theatres.
1.5
COSHH training is to be implemented when the database of COSHH risk
assessments is in place from May 2018.
1.5
Audits of NTGH, WGH and Blyth will be completed by March 2018. 1.6
Recommendations
The board are asked to note the progress made against the Capita review recommendations
and to support the actions proposed.
89
Title of Report Northumbria Healthcare Charity (Bright Northumbria)
Quarterly update September-December 2017
Author Brenda Longstaff, Head of Charity ,Volunteering, Arts & International
Executive Lead Claire Riley, Director of Communications and Corporate Affairs
Executive Summary Key pieces of activity during this period have included:
Pears Foundation–funding for youth volunteering
Trust gains Investors in Volunteering award
NHS70 arts programme under development
CEO of Kilimanjaro Christian Medical Centre visits trust
International team shortlisted for HSJ award
Fundraising policy updated
Minutes of the meeting held on 11th December 2017 are provided in Appendix 1
Recommended
actions required by
Board/committee
The corporate trustees are asked to note the content of the report and approve
the recommendations contained within the report
1 2 3 4 5 6Link to strategic
objectives
(please tick)
Strategic objective
reference
Charity strategic plan
Caring Responsive Well-led Effective SafeLink to CQC KLOE
(please tick)
Compliance/
regulatory
requirements (if
applicable)
Financial impact?
90
Enc
Charitable Funds Committee: Report to Charity Trustees on 1st February 2018
1 Date of meeting: 11th December 2017
2 The minutes of the meeting are available on the website at: www.northumbria.nhs.uk
3 Executive Summary
3.1 FINANCE REPORT
The financial year to date has seen an increase in total funds of 125K to 2,794K
The committee reported that no legacies were outstanding at this stage
The sale of Vodafone and Legal and General shares were completed in November 2017
3.2 HEAD OF CHARITY, VOLUNTEERING, ARTS & INTERNATIONAL REPORT
Staff Lottery – The December 2017 draw of the staff lottery hit the £2,000 milestone for first prize.
Help force – Presentations have been given to a number of schools across the trust areas to begin to
recruit the first batch of volunteers. Claire Riley, the trust’s Director of Communications and
Corporate Affairs, has been appointed to the Helpforce Board.
Pears Foundation – the trust has secured funding from the Pears Foundation for a two year project
to develop youth volunteering / social action across the trust area.
Investors in Volunteering - The trust is the first NHS trust in the north of England to be awarded the
prestigious investors in Volunteering award which was achieved in October 2017.
New areas of development:
Healing Arts - Organ Memorial artwork for the Northumbria Hospital. The Trust Organ Donation
Committee has approached the charity to assist with the commissioning of artwork to thank the
families of those who donated their organs
Artwork for MHSOP – The charity is continuing to work with staff from Mental Health Services for
Older People (MHSOP) to provide accessible dementia friendly artwork for the new wards.
91
Art Workshops for palliative care – Following a pilot programme of art sessions within the palliative
care unit at North Tyneside hospital, funding has been granted from the service to continue the
workshops at both North Tyneside and Wansbeck hospital for a period of 6months.
Music concert - A 95 year old lady performed on the grand piano at Hexham General Hospital during
October 2017. The lady, who is a highly accomplished pianist, made arrangements to play a concert
at the hospital through an occupational therapist at the Fairnington Centre.
Christmas Performances –The charity team organised the annual music programme involving local
schools and choirs for the festive celebrations.
NHS 70th Birthday Celebrations – The charity is planning a series of events to celebrate the 70th
birthday of the NHS in 2018.
Fundraising
Great North Run – The charity has secured 35 places in next year’s Great North Run. It is hoped that
further places will be sought in the summer during clearance.
International Development
Visit of KCMC Chief Executive – Dr Gileard Masenga, Executive Director of KCMC visited the trust
week commencing 20th November 2017 and met with Jim Mackey to discuss continued collaboration
and renewal of the Memorandum of Understanding between institutions.
Health Service Journal Awards 2017 – the trusts international team travelled to London on 22nd
November 2017 to attend the HSJ Awards.
Team visit to KCMC – A team from the Trust visited KCMC in October 2017 to follow up on the burns
project. The team were also joined by a team of 9 from Health Education North East (HENE) who
undertook teaching and training at KCM College and within the community.
3.3 VOLUNTEER REPORT
A recruitment drive was held on Monday 7th August 2017 at North Tyneside and Wansbeck Hospital.
Potential volunteers have now been placed trust-wide to help on the trolley, meet and greet and
shop.
Long Service Awards Wansbeck–on Thursday 21st September 2017 at Wansbeck General Hospital.
Long Service Awards Hexham - held Monday 30th October 2017 at Hexham General Hospital.
Percy Hedley Student - The volunteer service have placed a volunteer within the meet and greet
team at North Tyneside.
Macmillan coffee morning – Hospital Voluntary Services (HVS) shops raised £604.52 to support the
Macmillan service.
#iwill campaign – Northumbria Healthcare Volunteering Service has been chosen as a ‘Beacon Area’
to support the development of youth volunteering
92
4. Any other Business
Update to Fundraising Policy – RMP47
The committee approved updates to the Fundraising Policy.
RECOMMENDATION
That the Trustees accept the report and agree the following:
Amendments to RMP 47 Fundraising Policy
93