Board of Directors - Royal Berkshire Hospital us...1 Board of Directors Monday 30 June 2014 9.15am...

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Board of Directors Monday 30 June 2014 9.15am – 11.55am Boardroom, Level 4, Royal Berkshire Hospital We are here to provide a comprehensive service, based on clinical need, not an individual’s ability to pay. We aspire to the highest standards of excellence and professionalism and to put patients at the heart of everything we do. We are committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources. We are accountable to the public, communities and patients that we serve.

Open Board Meeting – Part 1 Item Lead Time The meeting will commence with a patient story

Alistair Flowerdew

9.15 – 9.25

1. Apologies for Absence

Stephen Billingham -

2. Minutes: 29 May 2014 (Attached to approve)

Stephen Billingham 9.25 – 9.30

3. Matters Arising and Outstanding Actions Schedule (Attached to note)

Keith Eales 9.30 – 9.40

4. Declarations of Interest (Verbal to note)


Minutes of Meetings

5. To note and agree recommendations a) Clinical Governance Committee - 22 May 2014 b) Council of Governors – 29 May 2014 c) Board Strategy Group – 5 June 2014 d) Board Strategy Group - 17 June 2014 e) Board Patient Experience Group – 5 June 2014 f) Resources Committee - 17 June 2014

Janet Rutherford Stephen Billingham Janet Rutherford Janet Rutherford Jane May Jane May

9.40 – 9.55

Performance Reports

6. a) Chief Executive’s Report (Attached to note) b) Quality Performance Report (Attached to note) c) Care Group Performance (Attached to note) d) Finance Report (Attached to note)

Alistair Flowerdew/ Executive Team

9.55 – 10.55

Agenda

2

Major Issues

7. A&E Update Report (Attached to note)

Sue Edees 10.55 – 11.05

8. CQC Inspection Update (Attached to note)

Alistair Flowerdew 11.05 – 11.15

9. Nursing and Midwifery Staffing (Attached to note)

Caroline Ainslie

11.15 – 11.25

Governance Items

10. Risk Appetite Statement (Attached to approve)

Keith Eales 11.25 – 11.35

11. Monitor Self-Certification (Attached to approve)

Craig Anderson/ Keith Eales

11.35 – 11.45

12. Standing Financial Instructions (Attached to approve)

Craig Anderson 11.45 – 11.55

Information Items

13. Staff Survey Results (Attached to note)

Paul Jones -

14. Board Work Plan (Attached to note)

Keith Eales -

15. Directors’ Duties and Financial Sustainability (Attached to note)


16. Date of Next Meeting Thursday 31 July 2014 (Verbal to note)


17. Exclusion of the Press and Public (Verbal to approve)


Closed Board Meeting - Part 2 The following section of the meeting will be closed to the press and public as the material to be discussed discloses exempt information as defined by the Freedom of Information Act.

Agenda Item 2

Minutes of the Board – 29 May 2014 1

Board Thursday 29 May 2014 9.15am – 1.30pm Boardroom, Royal Berkshire Hospital, Reading Members Present Mr. Stephen Billingham (Chairman and Non-Executive Director) Mr. Alistair Flowerdew (Acting Chief Executive) Mr. Craig Anderson (Director of Finance and Interim Deputy Chief Executive) Mr. John Barrett (Non-Executive Director) Mr. Brian Hendon (Non-Executive Director) Dr. Alison Hill (Non-Executive Director) Mr. Peter Malone (Care Group Director, Planned Care) Ms. Jane May (Non-Executive Director) Mrs. Janet Rutherford (Non-Executive Director) In attendance Mrs. Heather Allen (Director of IM&T) Dr. Lindsey Barker (Care Group Director, Networked Care) Mrs. Mandy Claridge (Director of Operations, Urgent Care) (for minutes 95/14 and 97/14) Mr. Keith Eales (Director of Corporate Affairs & Secretary) Mr. Paul Jones (Interim Director of Workforce & Organisational Development) Mr. John Taylor (Interim Commercial Director) (for minutes 98/114 and 109/14) Mr. Jeremy Tozer (Interim Chief Operating Officer) Apologies Ms. Caroline Ainslie (Director of Nursing) Dr. Sue Edees (Care Group Director, Urgent Care) Dr. Brian Reid (Interim Medical Director) There were three members of the press, three Governors and one member of staff present. The meeting commenced with a You Tube film produced by the Trust for children on the experience of being prepared for an operation. Funding for the film had been provided by the League of Friends. 91/14 Minutes: 30 April 2014

The minutes of the meeting held on 30 April 2014 were approved as a correct record and signed by the Chairman subject to In Attendance The addition of Mr. Jeremy Tozer to those in attendance at the meeting

Minutes


Minutes of the Board – 29 May 2014 May 2014

Minute 68/14: Finance Report The replacement of ‘pay’ with ‘cash’ in the first line of the second paragraph on page 5.

92/14 Schedule of Matters Arising and Outstanding Decisions The Director of Corporate Affairs & Secretary submitted the schedule of matters arising

from the last meeting and outstanding issues from previous meetings. Progress against each decision was noted.

Minute 175/13: Executive Report (Late reporting and income) The Director of Finance advised that work on mapping income processes would begin in

the next two to three weeks.

Minute 74/14: Decontamination Business Case It was agreed that an update would be distributed to Board members confirming that the

contract placed no liabilities on the Trust in respect of staff at the end of the five year period.

Resolved: that the report be noted.

93/14 Declarations of Interests

There were no declarations of interest.

94/14 Chief Executive Report

The Acting Chief Executive submitted a report summarising key strategic and other issues since the April Board meeting. The Acting Chief Executive drew attention to a report published by the Foundation Trust Network highlighting the costs incurred by trusts in implementing the recommendations of the Francis, Keogh and Berwick reviews. These costs had been incurred without additional funds being provided to trusts. The Acting Chief Executive also drew attention to a Kings Fund report on the challenges faced by the NHS in meeting the increasing demand for health care with reducing funds. The Acting Chief Executive reported that the proposed acquisition of Heatherwood & Wexham Park Hospitals NHS Foundation Trust by Frimley Park Hospital NHS Foundation Trust had been cleared by the Competition and Markets Authority and endorsed by Monitor. The Acting Chief Executive reported on his attendance at a public meeting in Reading and gave an overview of the issues discussed. The cancellation of appointments had been a particular topic of debate Resolved: that



(a) the report be noted (b) the Care Group Director, Networked Care prepare a briefing for Board

members on Hospital at Home.

95/14 Quality Performance Report

The Acting Chief Executive introduced, on behalf of the Director of Nursing, the quality performance report.

The report drew attention to performance against the Monitor Risk Assessment Framework, national and local performance indicators and assurance against CQC standards. The Acting Chief Executive drew attention to areas of exception reporting, including the ‘red’ performance rating in respect of serious incidents reported, cancer waiting time targets, the number of formal complaints received and the number of complaints relating to attitude and behaviour. The Chair of the Clinical Governance Committee advised that the report had been reviewed by the Committee. Areas discussed in detail included trends in serious incidents, which would be the subject of a report to the next meeting, complaints in respect of attitude and behaviour, the review of the maternity service, cancelled appointments and medical records. Clarification was sought with regard to the preparation of an action plan to address the issues identified in respect of data testing on cancelled operations. The Acting Chief Executive advised that this was not yet available. The document would be distributed to Board members. Further information was sought with regard to the location of unapproved incidents in corporate areas. The Acting Chief Executive advised that most related to the Estates & Facilities Directorate. The Board noted that the in house inpatient survey overall recommendation rate had reached its highest ever score of 99%. The Board noted the success of the project to address aspiration pneumonia in stroke patients being internally fed. The work was to be implemented in nine other hospitals. The Board asked for its congratulations to be passed to the team. Clarification was sought with regard to the reasons for the increase in agency expenditure. The interim Director of Workforce & Organisational Development advised that agency expenditure was increasing despite the fact that permanent positions were being recruited to. This was partly as a consequence of delays in recruitment. The Executive was considering additional controls that could be implemented to control costs. The interim Director of Workforce & Organisational Development advised that it was anticipated that these would be in place in June. Resolved: that (a) the report be noted



(b) the action plan regarding data quality issues in respect of cancelled

operations be distributed to Board members (c) the Director of Estates & Facilities distribute to Board members a note on the

action being taken to remove the backlog of unapproved incidents in the Directorate

(d) the Director of Nursing include in future reports a monthly forecast for the

level of unapproved incidents (e) the interim Medical Director pass on the congratulations of the Board to the

staff involved in the project to address aspiration pneumonia in stroke patients being internally fed and arrange for this to be the subject of a patient story at a future meeting

96/14 Care Group Performance Reports The Board received the monthly Care Group reports.

Networked Care

The Care Group Director, Networked Care gave an overview of the Group dashboard, issues in respect of patient outcomes, experience, use of resources and key risks. A revised dashboard was distributed. The Care Group Director, Networked Care drew particular attention to the opening of the Bracknell Urgent Care Centre, the Bracknell soft facilities management contract that was due to end in September and progress in developing QIPP projects. Urgent Care The Director of Operations, Urgent Care gave an overview of the Group dashboard, issues in respect of patient outcomes, experience, use of resources and key risks. The Director of Operations, Urgent Care advised that complaints performance had improved to 75%. Clarification was sought as to why there were areas of overspend in the first month of the year. The Director of Operations, Urgent Care advised that in some areas budgets had not been aligned following staff transfers between areas. In addition, the Director of Finance advised that Care Groups had decided to profile cost QIPP savings evenly across the year. The overall Trust profile had, however, been adjusted to reflect the anticipated delivery of savings. The Board considered that Care Group budgets should be profiled against expected delivery. The Director of Finance undertook to take this forward with Care Groups. The Board noted that QIPP project proposals amounting to £1.2m were still to be identified. Clarification was sought as to when plans would be in place for this amount. The Director of Operations, Urgent Care advised that these would be in place next month.



The Board congratulated the Emergency Department for the achievement of the A&E. target.

Planned Care The Care Group Director, Planned Care gave an overview of the Group dashboard, issues in respect of patient outcomes, experience, use of resources and key risks. Information was sought with regard to progress with the implementation of the new theatres agreed by the Board. The Director of Finance advised that he was not yet satisfied with the terms of the contract proposed and was in discussions with the provider. It was recognised that the delay made the planned October start date challenging. The interim Chief Operating Officer advised that contingencies were being investigated. It was noted that the Care Group was undertaking a mortality review. Any issues of significance would be reported to the Quality Performance and Learning Committee.

Resolved: that (a) the report be noted

(b) the Urgent Care report to the June Board meeting include details of the

projects identified to meet the current £1.2m QIPP target shortfall (c) the Director of Finance distribute to Board members, within the next fortnight,

a progress report on the implementation of the new theatres. 97/14 Finance Report

The Director of Finance submitted a report on the financial performance of the Trust for April 2014. The Director of finance advised that the Trust had reported a deficit of £2.08m in the month. which was £0.02m better than budget. The position had been supported by the release of budgeted contingencies. The Director of Finance advised that the key issues were in respect of the delivery of income and control of pay. Income was £0.03m worse than budget. Whilst pay costs were in line with budget, they were not sustainable at the current run rate. The Director of Finance advised that the Continuity of Service Risk Rating (CoSRR) was 2, which was in line with the forecast. The Board noted that cash was worse than forecast, at £17.32m. However, it was considered that the position would be as forecast in June. Clarification was sought in respect of the position on QIPPs. The Director of Finance advised that the target was £19.7m. To date, projects amounting to £15.5m had been identified. The Programme Management Office risk rating for these projects was £7.15m. The Executive was taking action in three key areas to strengthen the position-a weekly review with each directorate to review progress, workstreams seeking to increase the value



of projects identified and the review of actions that could be taken immediately to reduce costs. Clarification was sought as to when it was anticipated that projects and savings equivalent to the overall QIPPs target would be identified. The Director of Finance advised that it was anticipated that this would be completed by the end of June. Clarification was sought as to the extent to organisational awareness about the financial challenge facing the Trust. It was considered that, whilst there was awareness down to clinical lead level, understanding amongst front-line staff could be improved. Resolved: that (a) the report be noted

(b) a progress report on the implementation of immediate cost savings be made

to the Resources Committee in May (c) a communications plan for broadening awareness amongst staff of the

financial challenges facing the Trust be developed. 98/14 A&E Update Report

The Director of Operations, Urgent Care submitted a report on action being taken to improve the performance of the Emergency Department in respect of achieving the A&E target and progress in respect of the Berkshire wide system recovery plan. The Director of Operations, Urgent Care advised that performance against the target in April was 95.7%. The position was improving as a result of many of the planned initiatives now delivering. A revised trajectory had been submitted to NHS England and Monitor. This demonstrated achievement of the four hour target at the end of quarter one. Confirmation was sought that the planned building works in the Emergency Department would not impact on the continuing achievement of the target. The Director of Operations, Urgent Care advised that this was unlikely to be the case. Resolved: that the report be noted

99/14 CQC Intelligent Monitoring Assurance

The interim Commercial Director submitted a report on the approach being developed to provide assurance to the Board in respect of the indicators incorporated in the CQC’s Intelligent Monitoring Report. The interim Commercial Director explained that the internal reporting processes for all the 93 indicators in the Intelligent Monitoring Report were being mapped. This would include identifying those indicators that which not currently being monitored or reported on. Proposals would be developed for the monitoring of these indicators. The intention was to



provide information on current performance in respect of all 93 indicators from the July 2014 Board. Resolved: that the report be noted.

100/14 Monitor Self-Certification

The Director of Finance and the Director of Corporate Affairs & Secretary submitted a report in respect of self-certification statements to support the Annual Plan process. The Director of Corporate Affairs & Secretary explained that the Board was required to self- certify in respect of three statements by 30 May. Further statements were required for submission by 30 June. The statements for submission by 30 May related to systems for compliance with licence conditions and the availability of resources. The Director of Finance and the Director of Corporate Affairs & Secretary explained the information that supported the Board marking each of the three statements as confirmed. Resolved: that the three Board statements be marked as confirmed and submitted to Monitor.

101/14 Standing Financial Instructions (SFI’s)

The Director of Finance submitted revised for consideration by the Board. The Director of Finance advised that the changes proposed in the document reflected a general approach of tightening controls on expenditure. However, a number of post titles required amendment. The Board endorsed the general approach of tightening controls and asked that that a revised document be submitted to the next meeting. Resolved: that revised SFI’s be submitted to the next meeting of the Board for approval.

102/14 Minutes of Meetings

The Board received the draft minutes of the following meetings Board Strategy Group 12 May 2014 Resources Committee 12 May 2014 Audit & Risk Committee 15 May 2014 Clinical Governance Committee 22 May 2014 The Chairs drew attention to significant issues discussed and matters that had been agreed should be highlighted to the Board by the Resources Committee and the Clinical Governance Committee. Resolved: that the minutes of the meetings be received and the recommendations therein endorsed.



103/14 Board Work Plan The Board received the updated work plan for review.


104/14 Date of Next Meeting

Resolved: that the next meeting of the Board be held at 9.15am on Monday, 30 June 2014.

105/14 Exclusion the Press and Public Resolved: that the press and public be excluded from the remainder of the meeting

given the exempt nature of the business to be conducted, as defined by the Freedom of Information Act.

Chairman

Date 30 June 2014

Board Schedule of Matters Arising and Outstanding Actions Agenda Item 3

June 2014 Board 1

Board Date Board Minute Subject Decision Owner Update November 2011 167/11 Real Estate Strategy

(RES) Final strategy to be submitted. Also January Board Minute 05/13.

Philip Holmes Real Estate Strategy will be progressed following the IBP’s approval in June and will be submitted to the Resources Committee in September ahead of submission to the October Board meeting.

October 2013 157/13 Executive Report The interim Commercial Director review the structure and content of the Trust and Corporate Group dashboards to ensure the accuracy of the content and their consistency with the position reported in Care Group reports

John Taylor

Trust dashboard reviewed for accuracy and reported to Care Groups and Quality Performance and Learning Committee prior to finalising. Care Group template to be revised by COO for July 2014.

November 2013 175/13 Executive Report The Chair of Audit & Risk Committee discuss with the Director of Finance a possible audit of activity to provide assurance that potential income was not being lost due to late reporting.

Craig Anderson

Agreed that we will be using Deloittes to perform a short piece of work over the next four weeks to progress this assurance. Update to be provided to July Board.

November 2013 178/13 QGF/IBP timetables The Executive review the proposed timetable in respect of the QGF and IBP to bring forward completion dates for individual actions where possible

Alistair Flowerdew/ Caroline Ainslie

Quality Governance Framework will be submitted to the July Board.

January 2014 04/14 Executive Report The Care Group Director Planned Care arrange a post-Board briefing session with the clinical lead for Ophthalmology to discuss the performance of the service.

Peter Malone Scheduled to take place after the June Board meeting.

January 2014 10/14 Patient Engagement and Experience Strategy

A progress report on the implementation of the strategy be submitted to the July 2014 Board meeting.

Caroline Ainslie Scheduled for the June Board PEG meeting.

February 2014 18/14 Schedule of Matters Arising and Outstanding Decisions

The integrated business plan be submitted to the June Board meeting

John Taylor

Item on the agenda

February 2014 21/14 Performance Report Ophthalmology be included in the areas covered by the target for reducing rescheduled appointments in 2014/15

Caroline Ainslie/ John Taylor

Included in Quality Account (May 2014) and Exception


June 2014 Board 2

Good and poorly performing departments would be highlighted in the analysis of performance against waiting times.

Caroline Ainslie/ John Taylor

Report included in Board Agenda (June 2014) Waiting times exception report included in Board Agenda June 2014

March 2014 39/14 (35/14) Matters Arising: Budget Planning 2014/15

The Director of Finance advised that he would be discussing the rephasing of the Trust loans with the Foundation Trust Financing Facility within the next three months.

Craig Anderson Initial meeting held with FTFF. Proposal to develop options to be completed by September.

March 2014 46/14 Care Quality Commission (CQC) Intelligent Monitoring Report

The Executive give consideration to the opportunity for tracking, and giving advance warning of issues in respect of Trust performance against the indicators used by the CQC to produce the quarterly reports.

Alistair Flowerdew/ Caroline Ainslie

CQC Assurance Paper presented to May Board. Comprehensive assurance system will be in place by July to highlight risks of potential future IM risks and provides assurance that current IM risks are being effectively managed.

March 2014 74/14 Decontamination Business Case

An analysis be undertaken of the potential for the disposal of the remaining part of the Battle site Confirmation be provided that the contract placed no liabilities on the Trust in respect of staff at the end of the five year period

Philip Holmes Craig Anderson

Options appraisals being progressed to now include Valencia Close. No change from prior month. Awaiting final contract review.

March 2014 58/14 Monitor Operational Plan The Executive review as a priority the plans to achieve the 108 reduction in headcount

Alistair Flowerdew

Specific plans are not yet completed and verbal update to be given at Board.

April 2014 63/14 (43/14) Matters Arising: Medical Records

The report in respect of Medical Records to be submitted to the May Board meeting.

Brian Reid The Health Records Steering Group continues to achieve improvements in the availability, quality and content of records through actions with ward admin staff, clinical staff and the medical records team. The


June 2014 Board 3

success of actions taken following the audit in Nov 2013 will be monitored, re-audited and outcomes collated in a report for the Board and for the next Clinical Governance Committee (following discussion at the meeting of 22 May).

April 2014 67/14 Care Group Performance Reports

A report be submitted to the May meeting of the Resources Committee setting out the financial and operational impact of the Newton Europe work with the Trust

Craig Anderson Deferred to July Resources Committee

April 2014 85/14 Incidents and Safeguarding Report

The trend in the number of serious incidents over the previous 18 months be submitted to the Clinical Governance Committee.

Caroline Ainslie Report to be submitted to the Clinical Governance Committee in July 2014

May 2014 92/14 (72/14) Matters Arising: Decontamination Business Case

It was agreed that an update would be distributed to Board members confirming that the contract placed no liabilities on the Trust in respect of staff at the end of the five year period.

Craig Anderson To be confirmed as part of final contract review but the Trust is not expecting to accept any liabilities for staff at the end of the contract. Staff are expected to transfer under TUPE rules as normal.

May 2014 94/14 Chief Executive Report The Care Group Director, Networked Care to prepare a briefing for Board members on Hospital at Home.

Lindsey Barker Completed

May 2014 95/14 Quality Performance Report

The action plan regarding data quality issues in respect of cancelled operations be distributed to Board members The Director of Estates & Facilities distribute to Board members a note on the action being taken to remove the backlog of unapproved incidents in the Directorate The Director of Nursing include in future reports a monthly forecast for the level of unapproved incidents

Peter Malone Philip Holmes Caroline Ainslie

Action plan to be circulated to Board members week beginning 30 June. Completed. Update to be provided


June 2014 Board 4

The interim Medical Director pass on the congratulations of the Board to the staff involved in the project to address aspiration pneumonia in stroke patients being internally fed and arrange for this to be the subject of a patient story at a future meeting

Brian Reid

Update to be provided.

May 2014 96/14 Care Group Performance Reports

The Urgent Care report to the June Board meeting include details of the projects identified to meet the current £1.2m QIPP target shortfall The Director of Finance to distribute to Board members, within the next fortnight, a progress report on the implementation of the new theatres.

Sue Edees Craig Anderson

Completed. Completed.

May 2014 97/14 Finance Report A progress report on the implementation of immediate cost savings be made to the Resources Committee in May A communications plan for broadening awareness amongst staff of the financial challenges facing the Trust be developed.

Craig Anderson Completed. Completed.

May 2014 100/14 Monitor Self-Certification The three Board statements to be marked as confirmed and submitted to Monitor.

Keith Eales/ Craig Anderson

Completed

May 2014 101/14 Standing Financial Instructions (SFIs)

Revised SFI’s to be submitted to the next meeting of the Board for approval.

Craig Anderson Item on the agenda

May 2014 107/14 CQC Inspection and Improvement Plan

The Trust response to the draft report be distributed to Board members in advance of submission The draft presentation for the quality summit be distributed to Board members for comment.

Alistair Flowerdew Alistair Flowerdew

Completed. Completed.

May 2014 109/14 Incidents and Safeguarding Report

The Director of Nursing distribute to Board members further information, including the action taken, in respect of the adult safeguarding alert referred to in the report.

Caroline Ainslie Update to be provided

Agenda Item 5a

1

Clinical Governance Committee Thursday 22 May 2014 9.00am – 11.00am Boardroom, Level 4, Royal Berkshire Hospital Members Ms Janet Rutherford (Non-Executive Director) (Chair) Ms. Caroline Ainslie (Director of Nursing) Dr. Lindsey Barker (Care Group Director, Networked Care) Mr. John Barrett (Non-Executive Director) Dr. Sue Edees (Care Group Director, Urgent Care) Dr. Alison Hill (Non-Executive Director) Mr. Peter Malone (Care Group Director, Planned Care) Mr. Brian Reid (Interim Medical Director) In Attendance Mr. Keith Eales (Director of Corporate Affairs & Secretary) Ms. Kate Jury (Deloittes) Mrs. Caroline Lynch (Deputy Company Secretary) Mr. John Taylor (Interim Commercial Director) Apologies 18/14 Minutes: 18 February 2014

The minutes of the meeting held on 18 February 2014 were approved as a correct record and signed by the Chair.

1914 Declarations of Interest

There were no declarations of interest. 20/14 Matters Arising Schedule The Committee received the matters arising schedule. Minute 02/14 (106/13): Matters Arising: Quality Report: The Planned Care Group Director

confirmed that he attended Sepsis Group meetings periodically in order to provide support Minute 09/14: Quality Report: The Director of Nursing confirmed that narrative in respect of

the mortality figures was included in the Quality Performance report.

Resolved: that the matters arising schedule be noted.

Minutes

Minutes of Clinical Governance Committee 2

Clinical Governance Committee 22 May 2014

21/14 Items Referred from the Board The Chair advised that the Board had asked the Committee to review trends in the number of

serious incidents over the last 18 months. The Director of Nursing confirmed this would be included in future Quality Performance reports. Action: C Ainslie

22/14 Revised Terms of Reference for Committee

The Chair drew attention to the list of key tasks for the Committee which had been circulated for discussion. It was proposed that the Committee would meet on a bi-monthly basis. The Committee agreed that its role was to provide assurance to the Board that effective systems and processes for clinical governance were in place and to alert the Board to any key issues. It was agreed that issues should always be reviewed at Executive operational level in the first instance prior to being escalated to the Committee. The Committee agreed that it was important to ensure staff were made aware of changes to the Committee arrangements and to ensure that feedback mechanisms were in place to advise staff of decisions made when any issues were escalated. It was considered that a regular article in the staff Round Up could be used for this purpose together with Senior Managers’ Briefing sessions. Action: A Flowerdew A work programme for the Committee would be developed and specific issues would be reviewed in detail such as those referred from the Board. The Committee would also undertake in depth reviews of the individual Quality Account priorities and monitor progress and actions against the Quality Strategy. It was reiterated that this was not an operational group. Its purpose is to assure the Board that key risks to quality and safety were being identified and to gain assurance that the action plans being put in place by the Executive would address these risks. The Committee discussed the suggested timing for future meetings. It was agreed that the Executive would confirm availability of data from quality performance meetings in order to develop the cycle into which future Committee dates would fit. Following this a meeting cycle for the Governors’ Clinical Assurance committee would be developed.

Action: A Flowerdew

It was agreed that the terms of reference for the Quality Performance and Learning Committee and the Clinical Governance Committee would be circulated for any further comments. Action: C Ainslie

23/14 Arrangements for Annual Reports The Chair queried arrangements for the large number of sub-groups reporting to the

Committee and asked whether the Committee should receive annual reports at a seminar. It was agreed that the Director of Nursing would review the sub-groups and confirm whether there was a legal requirement for any of the groups to report directly to the Committee. Action: C Ainslie



24/14 Quality Performance Exception Report The Director of Nursing circulated an updated report and drew attention to the Infection

Prevention and Control Annual Plan for 2014/15. Progress against the plan would be reported monthly to the Infection Control Committee.

The Director of Nursing confirmed that trends in the number of serious incidents over the last

18 months would be provided to the next meeting. Action: C Ainslie The Committee noted the backlog of incidents which had not been reviewed or approved.

The Director of Nursing advised that this related to capacity issues within the incidents team. However, the Associate Director of Infection Prevention and Control was currently reviewing this.

The Director of Nursing reported that the number of complaints had increased significantly in

April and complaints relating to behaviour and attitude had risen to ten during April, five of which related to medical staff. It was noted that reduction of the number of complaints relating to staff behaviour and attitude had been included as a Quality Accounts priority for 2014/15. This priority had been included in previous years but had not been achieved. The Committee sought assurance that the target would be achieved for 2014/15. The Acting Chief Executive advised that work was ongoing with the interim Medical Director to identify an Executive lead for each Quality Account priority. This would be reported to the next meeting. Action: A Flowerdew/B Reid

The Committee noted that cancer access targets were not achieved during April 2014. The

Planned Care Group Director advised that this was due to rising demand in addition to capacity issues with CT services. It was noted that the 62 day target had not been achieved due to one patient. Issues with the CT backlog were being addressed however it was noted that there was an issue related to availability of validated data to assist in review of waiting lists. The Committee sought assurance that issues affecting potential achievement of cancer access targets were being anticipated. The Planned Care Group Director advised that liaison with the multi-disciplinary teams was ongoing and an update would be provided to the next meeting. Action: P Malone

The Committee recommended that the Executive should review the issues relating to

availability of validated data with particular emphasis on cancer access targets. Action: A Flowerdew It was noted that an external review of maternity services had been commissioned by the

Trust and support for funding from the Clinical Commissioning Group (CCG) in respect of a business case for additional midwifery staff was being sought. The terms of reference for the external review were currently being developed and would be submitted to the next meeting. The Committee would monitor progress on actions following the external review.

Action: A Flowerdew/C Ainslie 25/14 CQC Improvement Plan Update The Acting Chief Executive circulated a report which set out progress of delivery of actions

identified following the March inspection. The Committee noted that the formal CQC report would be publicly available on 14 June. It was agreed that CQC would be a standing item on future agendas and the action plan would be linked with the Quality Governance Framework action plan. Action: A Flowerdew/C Ainslie



The Committee discussed the issue in respect of cancelled appointments. The Acting Chief Executive advised that the issue had also been raised at one of the Senior Managers’ briefing sessions. The Committee noted that the key action was to book clinicians leave in good time in order limit last minute rescheduling of clinics. It was agreed that cancelled appointments would be added to the Committee’s work programme and a further update provided to the next meeting. Action: A Flowerdew

26/14 Quality Governance Framework Update The Director of Nursing advised that a review of the Quality Governance Framework was

ongoing. A feedback session from Deloitte was scheduled to take place later that day. Action: C Ainslie

27/14 Never Event Action Plan The Acting Chief Executive gave an update on never events and advised that a recent never

event had been downgraded following discussion with the CCG. The Committee queried how learning was shared following a never event. The Acting Chief Executive advised that a root cause analysis was carried out following each never event and reflection on never events was incorporated into individuals’ appraisals.

It was agreed that never events would be included as a standing item on future agendas. Action: C Ainslie 28/14 Corporate Risk Register and Board Assurance Framework The Director of Corporate Affairs & Secretary introduced the Corporate Risk Register and

drew attention to the revised risk score relating to failure to meet the A&E target which had been reduced due to mitigating actions in place.

The Committee recommended that the narrative in respect of the risk of regulatory action following the CQC inspection in March should be reviewed following receipt of the formal CQC inspection report. Action: K Eales

The Committee discussed the risk relating to health records and expressed concern in

respect of the lack of progress against the action plan as this posed a significant risk for the Trust. This issue had been raised at the informal feedback session following the recent CQC inspection. The Planned Care Group Director advised that improvement in the availability of notes for clinics had been demonstrated and work was ongoing to repair health records and merge temporary records. The Acting Chief Executive advised that the interim Chief Operating Officer in conjunction with the Programme Management Office were currently reviewing how support could be provided to the health records project. It was agreed that an update should be submitted to the next meeting. Action: B Reid

29/14 Key Messages for Care Groups and the Board

The Committee reviewed the key issues to draw to the attention of the Board many of which would be discussed at the next meeting which included:-

• Serious Incident trends and themes over the last 18 months (to include backlog, and escalation themes)

• Cancer Waits • Review of Complaints in respect of behaviour and attitude • Maternity Review Terms of Reference and timescales



• Cancelled appointments action plan with trajectory to provide assurance in respect of Quality Account target

• Medical Records Action Plan with trajectory to provide assurance in respect of Quality Account target

• Review of Vascular Services and implications for the Trust • Date of Meeting for Annual Report seminars (to agree which Committee to include)

30/14 Date of Next Meeting It was agreed that the next meeting would be arranged for a July date. Resolved: that the next meeting be held in July.

SIGNED

DATE

Agenda Item 5b

1

Council of Governors 6.05pm – 8.10pm Seminar Room, Trust Education Centre Thursday 29 May 2014 Present Mr. Stephen Billingham (Chairman) Mrs. Vera Doe (Public Governor, Wokingham) (Lead Governor) Dr. Muhammad Abid (Public Governor, Reading) Mrs. Aileen Blackley (Public Governor, West Berkshire) Mr. Tom Bune (Public Governor, Southern Oxfordshire) Mrs. Carol Bolderson (Public Governor, West Berkshire) Ms. Wendy Bower (Partner Governor, West Berkshire Federation CCG’s) Mr. Jeremy Butler (Public Governor, East Berkshire) Mr. Ross Carroll (Public Governor, East Berkshire) Mr. Ian Clay (Volunteer Governor) Mr. David Cooper (Public Governor, Reading) Mr. Martyn Cooper (Public Governor, Reading) Ms. Margie Cutts (Public Governor, Reading) Ms Jennie Ford (Partner Governor, East Berkshire Federation CCG’s) Cllr. Alan Law (Partner Governor, West Berkshire Council) Mr. Colin Lee MBE (Public Governor, West Berkshire) Mr. John McKenzie (Public Governor, Wokingham) Mr. David Mihell (Public Governor, East Berkshire) Ms. Anne-Marie Probert (Staff Governor, Nursing/Midwifery) Ms. Deborah Sander (Public Governor, Reading) Mr. Tony Skuse (Public Governor, Wokingham) Cllr. Bet Tickner (Partner Governor, Reading Borough Council) In attendance Mrs. Heather Allen (Director of IM&T) Mr. Craig Anderson (Director of Finance) Dr. Lindsey Barker (Care Group Director, Networked Care) Mr. John Barrett (Non Executive Director) Mr. Keith Eales (Director of Corporate Affairs & Secretary) Mr. Alistair Flowerdew (Acting Chief Executive) Mr. Brian Hendon (Non Executive Director) Dr. Alison Hill (Non Executive Director) Mrs Caroline Lynch (Deputy Company Secretary) Mr. Peter Malone (Care Group Director, Planned Care) Ms. Jane May (Non Executive Director) Mrs. Janet Rutherford (Non Executive Director) Apologies Mr. Peter Dooley (Partner Governor, Berkshire Carers Service) Dr. Sue Edees (Care Group Director, Urgent Care) Dr. Warren Fisher (Staff Governor, Medical & Dental)

Minutes

Council of Governors 2

Council of Governors 29 May 2014

Mr. Sanusi Koroma (Partner Governor, Reading CRE) Mr. Jonathan Mason (Staff Governor, Allied Health Professionals/Scientific) Cllr. Bob Pitts (Partner Governor, Wokingham Borough Council) Ms. Pamela Simmons (Staff Governor: HCA/Ancillary) Ms. Maria Walker (Staff Governor, Admin/ Management) 18/14 Minutes: 29 January and 8 May 2014

The minutes of the meetings held on 29 January and 8 May 2014 were agreed as a correct record and signed by the Chair subject to the amendment of the date of the next meeting.

19/14 Matters Arising Schedule Minute 05/14: Trust Executive Report: The Director of Finance advised that future reports

would include figures relating to headcount. Action: C Anderson

Minute 06/14: New Ways of Working: The Director of Corporate Affairs & Secretary confirmed that implementation of the new ways of working would be overseen by the Council Strategy Committee and this had been reflected in the Committee’s revised terms of reference. Resolved: that the matters arising schedule be noted

20/14 Changes to Council Membership The Council noted the changes to Council membership which included the election of

Anne-Marie Probert and Ian Clay. Resolved: that the changes to Council membership be noted. 21/14 Trust Executive Report The Acting Chief Executive introduced the Executive report and drew attention to the

publication of a public consultation document in respect of the proposed development of a private acute hospital in Maidenhead. The Trust would monitor developments in order to consider the potential impact posed by this proposal.

The Acting Chief Executive advised that a meeting had been hosted by Reading West MP

Alok Sharma to discuss the future of healthcare in South Reading where the public were invited to discuss issues of concern. Senior Executives from the Trust had attended the meeting where the issue of cancelled appointments had been raised. Work to address cancellations was being undertaken by the interim Chief Operating Officer.

The Acting Chief Executive advised that the CQC Summit was scheduled for Friday 13

June at which the Trust would receive the final CQC inspection report. The Acting Chief Executive advised that projects to address issues with medical records and ophthalmology were ongoing and would be reported at the CQC Summit. The CQC inspection report would be made publicly available the following week.

The Director of Finance introduced the finance update and advised that a deficit of £2.08m

was declared in April which was £170K less than the same month in 2013. The Trust had



a Continuity of Service Rating (COSRR) of 2 at present but a key challenge for the Trust was to reduce costs.

In response to a query regarding issues raised at the meeting hosted by Reading West MP

it was noted that the CCGs Hospital at Home project was discussed. The Care Group Director, Networked Care, confirmed that the Trust was actively involved in the project. It was agreed that a detailed briefing on the Hospital at Home project would be arranged for governors. Action: A Flowerdew/L Barker

Resolved: that the report be noted

22/14 Annual Report and Accounts 2013/14

The Director of Finance gave a presentation on the annual report and accounts for 2013/14 and advised that the charity accounts were now consolidated with the Trust accounts. The Director of Finance advised that 2012/13 accounts had been restated as requested by Monitor and external audit to move £26.7m impairment to operating expenses. The effect of this was that the Trust recorded a deficit of £25/8m in 2012/13. The accounts would be provided to Monitor and then laid before Parliament in June ahead of formal presentation to members at the Annual Members Meeting in July. The Director of Finance advised the budget for 2014/15 had been set to ensure a cash level of £22m was retained. Key assumptions in the budget related to delivery of CCG QIPPs, Trust QIPPs and Planned Care income growth. Resolved: that the update be noted

23/14 Statutory Power in Respect of Private Patient Income

The Director of Corporate Affairs & Secretary drew attention to the statutory power of the Council in respect of private patient income. The Council must approve any proposed increases in private patient income of 5% or more in any financial year.

24/14 Extra Ward Business Case

The Care Group Director, Planned Care gave a presentation. The Council noted that the Board had recently approved a business case for the development of a new surgical ward and private patients’ suite. The ward would create nine en suite rooms and four day case pods for private patients and an additional 11 beds for General Surgery choose and book NHS work. From a funding perspective, the costs of the unit would be met by the planned increase in private patient income. Capital requirements would be funded through a ten year lease purchase. Clarification was sought as to whether planning permission had been granted. Governors concluded that the reduction in the number of car parking spaces in the south wing could be a concern to the Planning Authority. It was noted that planning permission had not yet been granted however discussions with the local authority were ongoing in respect of car parking. In addition, a site wide review of car parking capacity was ongoing which would support any planning applications. Action: P Holmes Clarification was sought in respect of the Trust’s liability for private patients and staff treating these patients. The Acting Chief Executive advised that private patients were



already treated by the Trust and indemnity for staff would be covered by the Trust’s current indemnity provided to staff in respect of treatment of NHS patients. In response to a query regarding assumptions made on predicted income the Care Group Director, Planned Care, advised that income growth had been based on the level of private patient income achieved by other trusts.

The Council unanimously approved the planned increase in private patient income of £5m

to fund the provision of a new surgical ward and private patients’ suite.

Resolved: that the planned increase in private patient income of £5m to fund the provision of a new surgical ward and private patients’ suite be approved.

25/14 Minutes of Meetings

The Chairs of Council Committees introduced the minutes of the following sub-groups held and highlighted particular issues and recommendations:

• Nominations Committee 21 January 2014 • Nominations Committee 8 April 2014 • Remuneration Committee 26 March 2014 • Strategy Committee 15 April 2014 • Business Assurance Committee 28 April 2014 • Patient Experience Group 18 February 2014 • Patient Experience Group 1 May 2014 • Membership Committee 6 March 2014 • Membership Committee 14 May 2014 • Clinical Assurance Committee 12 February 2014 • Clinical Assurance Committee 14 May 2014

Nominations Committee The Chair advised that the Committee had recommended the merger of the Nominations and Remuneration Committees. Remuneration Committee The Chair advised that the Committee had reviewed the appropriateness of the introduction of a performance payment scheme for Non Executive Directors. It was recommended that this should not be introduced. The Committee had also recommended the merger of the Nominations and Remuneration Committees. Strategy Committee The Chair advised that its reviewed terms of reference were recommended for approval. Business Assurance Committee The Chair advised that the input and support from Non Executive Directors in the work of the Committee had been welcomed.



Patient Experience Group The Chair advised that at the meeting held on 1 May 2014 the Group had recommended that it be disbanded and any outstanding actions concluded by the Clinical Assurance Committee. This Committee would absorb the patient experience remit. Membership Committee The Chair of the Committee advised that a discount of £30,000 per annum had been negotiated by Tom Bune with the Royal Mail on the Trust’s postage contract. The Committee had recommended that the Council be asked to endorse a recommendation to the Board that funds released by this discount be used to funding the printing and distribution of Pulse. It was agreed that the Executive should be asked to consider whether this saving could be allocated to re-introduce the printing and distribution of Pulse. Action: A Flowerdew Business Assurance Committee The Chair of the Committee advised that following the meeting a working group consisting of members of the Committee, the Director of Finance and the Director of Corporate Affairs & Secretary had been set up in order to streamline reporting to meetings. Clinical Assurance Committee The Chair of the Committee advised that the Committee had received updates on work to confirm the immunisation status of staff. The Committee had also received a presentation on Never Events, CQC inspection and endorsed the Council’s statement on the Quality Accounts. Resolved: that the minutes of the above meetings be received and the recommendations therein endorsed.

26/14 Election of Lead Governor

The Chairman reported on the outcome of the election for the Lead Governor of the Council. Resolved: that David Cooper be elected as Lead Governor of the Council for the term of his office.

27/14 Changes to the Constitution The Director of Corporate Affairs & Secretary introduced the report which set out the

required changes to the Constitution following the Council’s decision to continue to combine the roles of Vice Chair and Lead Governor, retaining the title of Lead Governor. The report set out the changes needed to delete references to Vice Chair and to insert Lead Governor in its place.

Resolved: that the changes to the Constitution be approved



28/14 Proposed Merger of Nominations and Remuneration Committee

The Director of Corporate Affairs & Secretary introduced the combined terms of reference of the Nominations and Remuneration Committee. The terms of reference were recommended for approval by the Remuneration Committee and Nomination Committee. It was noted that the terms of reference followed the Foundation Trust model for merged committees. Resolved: that (a) the Nominations Committee and Remuneration Committee be disbanded (b) a Nominations and Remuneration Committee be established (c) the terms of reference for the committee, as submitted to the meeting, be approved.

29/14 Questions from the Public

There were no questions from the public. 30/14 Date of Next Meeting

The next meeting would be held on Thursday 31 July 2014 at 6.00pm. 31/14 Exclusion of the Press and Public

Resolved: that the press and public be excluded from the remainder of the meeting given the exempt nature of the business to be conducted, as defined by the Freedom of Information Act. SIGNED DATE

Agenda Item 5c

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Board Strategy Group Thursday 5 June 2014 3.00pm – 4.30pm Boardroom, Level 4, Royal Berkshire Hospital Present Mrs. Janet Rutherford (Non-Executive Director) (Chair) Mr. Craig Anderson (Director of Finance) Mr. Alistair Flowerdew (Acting Chief Executive) Mr. Philip Holmes (Director of Estates & Facilities) Dr. Brian Reid (Interim Medical Director) Mr. John Taylor (Interim Commercial Director) In attendance Mr. Graham Butler (Deputy Director of Finance) Dr. Sue Edees (Care Group Director, Urgent Care) Mr. Paul Jones (Interim Director of Workforce & Organisational Development) Mrs. Caroline Lynch (Deputy Company Secretary) Ms. Hannah Oatley (Business Development Manager) Apologies Dr. Lindsey Barker (Care Group Director, Networked Care) Mr. Brian Hendon (Non-Executive Director) Dr. Alison Hill (Non-Executive Director) Mr. Peter Malone (Care Group Director, Planned Care) 12/14 Minutes: 12 May 2014

The minutes from the meeting held on 12 May 2014 were approved as a correct record and signed by the Chair.

13/14 Matters Arising

Minute 10/14: Integrated Business Plan: The interim Commercial Director gave an update on the joint meeting with the Clinical Commissioning Group (CCG). The Group noted that a further meeting was scheduled for 12 June when the findings from the Ernst & Young review would be available. An update would be provided to the next meeting on 17 June. Action: J Taylor

The Chair advised that following the Board workshop on 29 May it had been agreed that

the five year strategic plan would be based on a number of scenarios which reflected the CCGs’ success or otherwise in achieving their QIPPs.

Minutes

2

4 June 2014

13/14 Update on Financial Five Year Strategy The Director of Finance introduced the report and advised that the financial plan for 2015

and 2016 had been previously submitted to Monitor on 31 March but Monitor had asked Trusts to review assumptions for 2015/16 as it considered sector assumptions were optimistic. Reworked figures for these financial years had therefore been developed and included in the five year plan.

Capital expenditure in the first two years of the plan had been included at £12m and spend in the last three years was in line with depreciation. The Director of Finance drew attention to the year end cash balance which had been based on various scenarios in respect of delivery of CCG QIPPs.

The Director of Finance drew attention to the inflation and growth assumptions which had been agreed with Berkshire West CCG. The tariff deflator had been based on actual figures for the first year of the plan and on latest guidance for the following four years. Pay inflation had been has been increased for 2016/17 and 2017/18 to take account of increased pension costs. Assumptions for CCG QIPPs were based on Berkshire West CCG actual figures but had been uplifted on a pro rata basis to take account of other CCGs QIPPs. The Group noted the revised figures 2015/16 which would be resubmitted to Monitor. Key changes included the tariff deflator which reflected latest guidance, activity growth to match CCG assumptions, pay inflation to reflect upcoming changes in pension costs and QIPPs delivery.

The Director of Finance advised that the year end cash balance assumed a base level of growth, delivery of Trust QIPPs and reduction of non-pay costs. Three further scenarios would be developed including achievement of growth in market share in the last three years, moderate growth in the first two years and delivery of Trust QIPPs.

14/14 Update on Five Year Strategic Plan The interim Commercial Director introduced the report and reported that CCG intentions

had been reflected in the plan. It was agreed that, in the short term, it made sense to make limited addition to elective activity to ensure financial viability. In the medium term, there would be integration of services where it would improve quality or financial viability. Ultimately there would be transformation of services based upon the national Monitor / NHS England models.

Further narrative in respect of estates, quality, data quality, IT and workforce were yet to be added to the plan. It was suggested that a cross reference to the Monitor operational plan could also be included. Action: J Taylor

The Group considered that due to the significant number of uncertainties within the local

health economy it was important to model various scenarios and the Trust’s likely response. It was agreed that the Trust’s ambition to be an Emergency Care Centre, its input into the Strategic Clinical Networks and plans to deliver integrated pathways should also be included in the document Action: J Taylor


Resolved: that the next meeting would be on Tuesday 17 June at 9am. SIGNED

DATE

Agenda Item 5d

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Board Strategy Group Tuesday 17 June 2014 9.00am – 10.20am Boardroom, Level 4, Royal Berkshire Hospital Present Mrs. Janet Rutherford (Non-Executive Director) (Chair) Mr. Craig Anderson (Director of Finance) Dr. Lindsey Barker (Care Group Director, Networked Care) Mr. Alistair Flowerdew (Acting Chief Executive) Mr. Peter Malone (Care Group Director, Planned Care) In attendance Mr. John Barrett (Non-Executive Director) Mr. Stephen Billingham (Chairman) Mr. Keith Eales (Director of Corporate Affairs & Secretary) Mr. Philip Holmes (Director of Estates & Facilities) Mrs. Caroline Lynch (Deputy Company Secretary) Mrs. Jane May (Non-Executive Director) Mr. John Taylor (Interim Commercial Director) Apologies Ms. Caroline Ainslie (Director of Nursing) Dr. Sue Edees (Care Group Director, Urgent Care) Mr. Brian Hendon (Non-Executive Director) Dr. Alison Hill (Non-Executive Director) Mr. Paul Jones (Interim Director of Workforce & Organisational Development) Dr. Brian Reid (Interim Medical Director) 16/14 Minutes: 4 June 2014

The minutes from the meeting held on 4 June 2014 were approved as a correct record and signed by the Chair.

17/14 Matters Arising It was agreed that all matters arising were covered by the agenda items. 18/14 Update on Financial Five Year Strategy

The Director of Finance introduced the report and advised that the plan included a base level of growth of 2.5% per annum. Figures for 2014/15 were as per the agreed budget, figures for 2015/16 had been reduced as per presentation on the 4th June with our returning to a 1% surplus in 2016/17. Planning assumptions reflected the latest tariff guidance and growth assumptions were consistent with the CCG assumptions for base level activity growth.

Minutes

2

4 June 2014

The Director of Finance drew attention to the scenarios which had been developed in

respect of CCG QIPP delivery and the subsequent impact on cash. It was noted that should the CCG successfully deliver 75% or more of their QIPPs this would result in negative impact on year end cash.

The Director of Finance drew attention to the inflation and growth assumptions which had

been agreed with Berkshire West CCG. Pay inflation had been increased for 2016/17 and 2017/18 to take account of increased pension costs and the tariff deflator had been amended accordingly.

The Director of Finance advised that the year end cash balance assumed a base level of growth, delivery of Trust QIPPs and reduction of non-pay costs. Three further scenarios would be developed including achievement of growth in market share in the last three years, moderate growth in the first two years, and delivery of Trust QIPPs.

19/14 Update on Five Year Strategic Plan The interim Commercial Director circulated the report. The Group discussed the timetable

for the final plan to be submitted to Monitor on the 30 June.

The report would be circulated to all Board members and the Executive team for comments to the interim Commercial Director by Friday 20 June. The Director of Finance would provide a final financial report to the interim Commercial Director on 20 June following the meeting with Monitor. A further draft plan would then be circulated on 23 June to the Board and the CCG. NEDs would discuss the revised plan on 23 June.

Action: C Anderson/J Taylor The Group discussed the timetable for the strategic plan to be shared with governors and

other stakeholders. A meeting of the Council Strategy Committee had been scheduled for 25 June to which all governors had been invited. It was agreed that the draft documents should be circulated to governors as soon as possible with a covering note outlining the difficulties encountered and the subsequent delay in the draft plan being available to them. Action: K Eales

The Acting Chief Executive confirmed that the Strategic Plan would be shared with staff at a senior managers briefing scheduled for 24 June. Action: A Flowerdew


Resolved: that the next meeting would be on Tuesday 22 July at 3pm. SIGNED

DATE

Agenda Item 5e

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Patient Experience Group Thursday 5 June 2014 1.05pm – 2.50pm Boardroom, Level 4, Royal Berkshire Hospital Members Ms. Jane May (Non-Executive Director) (Chair) Ms. Caroline Ainslie (Director of Nursing) Mr. John Barrett (Non-Executive Director) Mr. Paul Jones (Interim Director of Workforce Development & Human Resources) Mr. Brian Reid (Interim Medical Director) In Attendance Mrs. Caroline Lynch (Deputy Company Secretary) Apologies Mr. Alistair Flowerdew (Acting Chief Executive) Mrs. Sharon Herring (Networked Care Group Director of Nursing) 01/14 Minutes for Approval: 23 October 2013

The minutes of the meetings held on 23 October 2013 were approved as a correct record.

02/14 Matters Arising Schedule The Group received the matters arising schedule. Minute 34/13 (26/13, 18/13): Matters Arising: Patient Experience Walkabout Annual

Report: The Director of Nursing advised that the patient experience walkabout programme had been circulated. However, the out of hours walkabout visits would be arranged once the Chief Executive’s new PA had been recruited. Action: A Flowerdew

Minute 36/13: Planned Care Group Patient Experience Initiatives: The Planned Care

Group Director would be asked to circulate the information in respect of rescheduled appointment rates. Action: C Lynch

Minute 38/13: Analysis of Friends & Family Test: The Director of Nursing advised that

analysis of feedback received from the Friends & Family test was ongoing. Further information was provided in the report on the agenda.

Patient Experience Group

Patient Experience Group 2

Patient Experience Group 5 June 2014

03/14 Patient Experience and Strategy Update The Director of Nursing introduced the report which set out progress against the Patient

Experience Work Programme for 2014/15. The Group noted that the Trust’s NHS choices rating remained at 4 stars and the target response rate for Friends and Family test had been achieved and the Net Promoter Score for inpatient care had exceeded the Trust target with a score of 79 in May. The Director of Nursing confirmed that all comments received were fed back to ward areas and published on ward patient experience boards. The Friends and Family test had also been successfully implemented for maternity and outpatients. The interim Director of Workforce Development & Human Resources advised that the staff Friends and Family test would be implemented during June and quarterly updates would be included in the workforce reports to the Board and Resources Committee. Action: P Jones

The Group queried the national average figure for the Net Promoter scores. It was agreed

that the Director of Nursing would ascertain what this figure was and advise the Group. Action: C Ainslie The Director of Nursing advised that the complaints policy had been reviewed and updated

and had been circulated as part of the consultation process. The Director of Nursing had met with directorate managers to review the complaints process and it was anticipated that the new policy would be launched in July. An external company had also been engaged to provide training which would be offered to investigating officers.

The Group noted that the first cohort of the patient leadership course was nearing

completion and to date positive feedback on the course had been received. The Group discussed the number of complaints which related to staff attitude and

behaviour. The Director of Nursing advised that this had been a quality account priority for the Trust for a number of years however the number of complaints received related to staff attitude and behaviour were increasing. It was noted that nursing staff undertook psychometric and values based testing as part of the recruitment process however there was no such tests for medical staff. The interim Medical Director advised that any complaints received in respect of medical staff should be reviewed at the individual’s appraisal and revalidation process. The interim Medical Director and interim Director of Workforce Development & Human Resources undertook to give consideration to the use of a template for doctors’ appraisals to ensure complaints were discussed. Action: P Jones/B Reid

The Group noted that six complaints had been referred to the Parliamentary and Health

Service Ombudsman compared to twelve in the previous year. One of these complaints had been upheld by the Ombudsman.

Resolved: that the report be noted. 04/14 Patient Relations Annual Report 2013/14 The Director of Nursing advised that the second stage review process would be removed

from the complaints process. It was noted that 54% of complaints received for Estates & Facilities related to car parking. The Chair requested that the Director of Estates & Facilities be asked to provide a report to the Resources Committee setting out how complaints in respect of car parking were being addressed. Action: P Holmes



The Group queried the complaints received in respect of diversity issues. The Director of Nursing agreed to clarify the nature of these complaints. Action: C Ainslie

The interim Medical Director advised that the General Medical Council (GMC) had recently

advised that complaints received in respect of medical staff would be passed back for the complaint to be investigated by the trust itself. The interim Medical Director advised that previously the GMC notified the Trust in writing in respect of investigations into complaints received against medical staff and four such letters had been received in the last four months. The Group recommended that the Director of Nursing should be provided with this information in order to review against complaints received direct by the Trust. Action: B Reid

The Group recommended that further information should be included in the summary

relating to key trends and hotspots. Resolved: that the report be noted. 05/14 Picker Inpatient Survey Results The Director of Nursing introduced the report and advised that the Trust had achieved a

higher than average response rate of 48% compared to 46% in other trusts. The Trust had performed better than average on nine questions and worse on four questions.

The Group noted that five themes had been identified as priority actions which included

patient flow, involvement in decisions about care and treatment, hospital and ward, medication leaving hospital and leaving hospital. Working groups were being set up to address these work programmes. Action: C Ainslie

Resolved: that the report be noted 06/14 Executive Walkarounds Update The Director of Nursing introduced the report and advised that walkarounds had been re-

launched for 2014. The new format incorporated the NHS Institute for Innovation and Improvements 15 step challenge and the 6 C’s Compassion in Practice. The Director of Nursing advised that all actions arising from walkarounds were monitored by the patient experience team. Any actions unresolved after one month were escalated to Matrons and any actions unresolved after two months were escalated to the Director of Nursing.

The Group queried whether estates issues were still being highlighted in walkarounds. The

Director of Nursing advised that there had been some improvement noted. However, it had been identified on occasions that the estate issue highlighted had not been registered with the estates team.

The Group recommended that consideration should be given to including junior doctors on

walkarounds. The interim Medical Director undertook to raise this with the Medical Education lead. Action: B Reid




07/14 Patient Experience Committee minutes The Group received the minutes of the meetings held on 12 November 2013 and 18 March

2014. 08/14 Governors Patient Experience Group The Group received the minutes of the meetings held on 11 November 2013, 18 February

2014 and 1 May 2014. It was noted that the Group had been disbanded and any outstanding actions would be monitored by the Clinical Assurance Committee.

09/14 Messages for the Board

• Reviewed the generally good progress of the Patient Experience Programme reflecting the Strategy agreed earlier this year. Noted the Staff Friends and Family test would be implemented during June. Supported the further review of the complaints process and it was anticipated that the new policy would be launched in July. HR and Medical Director agreed actions to ensure complaints about doctors are followed through.

• Reviewed the Patient Relations Annual Report 2013/14 prior to submission to Board, noting the overall reduction in complaints but the increase in car parking issues and attitude and the slow response speed.

• Reviewed the Picker Inpatient Survey Results, very similar to last year and slightly above average, and welcomed the actions being taken to address the key findings

10/14 Date of Next Meeting Resolved: that the next meeting be held on Tuesday 18 November at 3.30pm.

SIGNED

DATE

Agenda Item 5f

1

Resources Committee Monday, 17 June 2014 10.30 – 12.30pm Boardroom, Level 4, Royal Berkshire Hospital Members Mrs. Jane May (Non-Executive Director) (Chair) Mr. Craig Anderson (Director of Finance) Mr. Stephen Billingham (Chairman of the Trust) Mr. Alistair Flowerdew (Acting Chief Executive) Mr. Peter Malone (Care Group Director, Planned Care) In Attendance Dr. Lindsey Barker (Care Group Director, Networked Care) Mr. John Barrett (Non-Executive Director) Mr. Keith Eales (Director of Corporate Affairs & Secretary) Dr. Sue Edees (Care Group Director, Urgent Care) (for minute 68/14) Mr. Steve Green (Director of Operations, planned Care) (for minute 68/14) Mrs. Vanessa Harding (Head of Programme Management Office) (for minute 68/14) Mr. Philip Holmes (Director of Estates & Facilities) Ms. Angela Hughes (Director of Finance, Networked Care) (for minute 68/14) Mr. Mark Robson (Director of Operations, Networked Care) (for minute 68/14) Mrs. Janet Rutherford (Non-Executive Director) Mr. Tim Seymour (Director of Finance, Planned Care) (for minute 68/14) Apologies Ms. Caroline Ainslie (Director of Nursing) Mr. Brian Hendon (Non-Executive Director) Dr. Alison Hill (Non-Executive Director) Mr. John Taylor (Interim Commercial Director) 63/14 Minutes: 12 May 2014

The minutes of the meeting held on 12 May 2014 were approved as a correct record and signed by the Chair.

64/14 Matters Arising Schedule The Committee noted the matters arising schedule.

Resources Committee

2

Resources Committee June 2014

Minute 40/14: Pathology Update The Director of Estates & Facilities advised that the short-term maintenance programme in

Pathology had been completed. The medium term programme would be completed within three months.

Minute 42/14: Estates & Facilities Data The Director of Estates & Facilities advised that the Executive discussion on the issues

raised in the report would take place in June. Minute 53/14: Quarterly Workforce Report (Staff Survey Results) It was noted that the report on the staff survey results would be submitted to the Board in

June. Resolved: that

(a) The report be noted

(b) A column setting out the date for each action to be completed be added to the matters arising schedule.

65/14 Finance Update The Chair reminded the Committee that the monthly update on financial performance would

be given at the Non-Executive Director briefing each month, prior to discussion at the Board.

The Director of Finance submitted a report on immediate cost actions that had been agreed

for implementation by the Executive. The intention was to tighten further the controls on pay costs and discretionary spend. Additional initiatives would be considered over the next two months.

Clarification was sought as to whether the initiatives in the report were in addition to

existing QIPPs. The Director of Finance advised that whilst this was the case, QIPPs currently identified amounted to £14.5m-15m against the target of £18.5m. The immediate actions would assist in addressing the shortfall.

Resolved: that the report be noted. 66/14 Trust Business Rates The Director of Estates & Facilities submitted a report setting out details of the business

rates payable for the Trust main site. The Director of Estates & Facilities advised that the total cost of business rates for 2015/15

were £1,142,340. Approval was sought for payment of 10 monthly instalments of £114,234.

3


Clarification was sought with regard to the opportunity for seeking a reduction in the rates for the main site. The Director of Estates & Facilities advised that rates were reviewed by the local authority on a cyclical basis. The opportunity for appeal arose after the rateable value had been reviewed and set. The next review was in 2015.

Clarification would be provided on the restrictions on establishing the Trust as a Charity. Resolved: that

(a) Approval be given to the payment of 10 monthly instalments of £114,234 in respect of the Trust (main site) business rates for 2014/15 (b) The Director of Estates & Facilities undertake a comparison of the Trust main site

business rates with similar hospital sites. 67/14 Pathology Business Case The Care Group Director, Networked Care submitted a report on the strategic options

considered for the pathology service and the full business case for the joint pathology service across Berkshire and Surrey.

The Care Group Director, Networked Care advised that three broad options had been

considered for the pathology service-the current service configuration, outsourcing to the private sector or the NHS and the NHS joint venture. The outcome of the assessment of each option was explained.

The Committee commented that

• The range of possible savings that could be made from the strategic options be set out

• There could be greater clarity in the comparison of the financial analysis between the options

• The financial impact of the notes to each of the models should be set out

• The level of contingency built into the cases should be confirmed

• There would be merit in assessing the joint venture model against an established operation

Clarification was sought with regard to the assessment of IT costs to support the joint venture approach. The Care Group Director, Networked Care advised that a sub-group had been assessing the IT implications and costs over the course of the last year. The sub-group was confident that the IT implications and costs had been fully assessed. Clarification was sought with regard to the premises costs for the joint venture option. The Care Group Director, Networked Care advised that the business case was not based on a specific location.

4


The Committee discussed the key risks associated with the joint venture model. It was noted that the impact on staff of the location of the hub was a key area of concern. Resolved: that (a) The report on the comparison of strategic options be noted

(b) A further meeting be held, before the next meeting of the Committee, between the

Chairman of the Board, the Director of Finance and the Care Group Director, Networked Care, to which all other Committee members will be invited, to discuss the financial comparison of the strategic options assessed in the draft and final versions

(c) The joint venture model be assessed, from an operational and financial

perspective, against an established and successful joint venture pathology service

(d) Progress with the development of the full business case be noted and the final

version be submitted to the July meeting of the Committee

68/14 QIPPs The Committee reviewed progress by Care Groups and corporate directorates in

developing projects to meet QIPP targets. (a) Corporate

The Director of Finance submitted a report on behalf of the corporate departments setting out progress. To date ideas totalling £2.47m, with a Programme Management Office risk assessment of £1.18m, against a target of £3.29m had been identified.

The Director of Finance advised that there were two key issues to bring to the attention

of the Committee. Firstly, it would be challenging for the Estates & Facilities Directorate, given its comparatively low level of expenditure, to meet the QIPP target with costs savings alone. Income opportunities were being identified to offset any shortfall in cost QIPPs.

Secondly, the key issue for the corporate directorates was the action to be taken to

achieve the 25% reduction in costs. The Director of Finance would be submitting a progress report on this in July or September. It was recognised that this discussion was most appropriately taken forward through the Strategy Group.

The Director of Finance confirmed that all cost QIPPs identified in corporate

directorates and Care Groups had been mapped by project, area and month. The Chair sought confirmation that the corporate directorates would, collectively, meet

the QIPP target of £3.29m. The Director of Finance advised that it would be challenging for the Estates & Facilities Directorate to meet its element of the target but with income support it was anticipated the gap would be closed.

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The Director of Finance advised that the QIPP delivery profile was now reflected consistently in corporate and Care Group budgets and that the June forecast would reflect the expected timings of savings.


(b) Networked Care

The Care Group Director, Networked Care, submitted a report on the QIPP programme within the Care Group.

The Care Group Director, Networked Care advised that, as at 11 June, the risk adjusted

value of the programme was £3.080m against a target of £4.2m. It was confirmed that this included income QIPPs. The Director of Finance advised that care was needed in proposing income QIPPs to ensure that the project had not already been included in the Trust budget.

The Committee discussed a number of projects. In response to a question, the Care Group Director, Networked Care advised that she

was more optimistic now about meeting the overall QIPP target for the Care Group. Resolved: that the report be noted and that the level of cost and income QIPPS be

agreed between the Care Group and Corporate Finance.

(c) Planned Care

The Care Group Director, Planned Care advised that the Care Group had a QIPP target of £6.3m.

The Care Group Director, Planned Care advised that to date, the risk adjusted value of

the QIPP programme was £3.1m against the target. With regard to income QIPPs, the risk adjusted value of savings to date was £3.82m against a target of £6.9m

The Care Group Director, Planned Care advised that he was confident in meeting the

target. This confidence was based on, in part, the comparison with savings achieved at this stage of the year, and the final year end position, in 2013/14.

The Committee discussed a number of projects. Resolved: that the report be noted and that the level of cost and income QIPPS be

agreed between the Care Group and Corporate Finance. (d) Urgent Care

The Care Group Director, Urgent Care advised that the QIPP target was £4.8m. Projects identified to date amounted to £4.01m of cost and £1m of income QIPPs. The key risks were outlined.

In response to a question, the Care Group Director, Urgent Care advised that she was

more optimistic now about meeting the overall QIPP target for the Care Group.

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Resolved: that the report be noted and that the level of cost and income QIPPS be agreed between the Care Group and Corporate Finance.

The Head of the Programme Management Office distributed a schedule of QIPP projects and further opportunities identified following discussions with PwC. The schedule set out the proposed projects that PwC would assist with. Resolved: that discussions be held with PwC regarding a success based contract for work of Trust QIPP projects.

69/14 Messages for the Trust Board The Committee considered that the following matters should be brought to the attention of

the Board

• the development and implementation of a range of immediate costs savings actions by the Executive in respect of pay and discretionary expenditure

• the analysis of strategic options for the pathology service and the progress with the

Berkshire and Surrey joint venture

• approval of business rates for the main Trust site

• progress with QIPP projects in corporate directorates and Care Groups and the level of confidence in achieving the overall target

70/14 Work Plan Review The Committee received the revised work plan. Resolved: that the work plan be noted. 71/14 Date of Next Meeting Resolved: that the next meeting be held at 2pm on Wednesday, 16 July 2014. SIGNED DATE:

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Royal Berkshire NHS Foundation Trust Agenda Item 6a

Board of Directors

Title: Chief Executive Report

Date: June 2014

Lead: Alistair Flowerdew, Acting Chief Executive

Purpose: The purpose of this paper is to update the Board with a summary of key strategic and environment issues since the previous Board meeting: This includes items that may impact on policy changes, quality and financial risks in the health economy.

Key Points:

Key Items of note include:

• Report published by Kings Fund which introduces and conceptualises the health and economic benefits of patients who are engaged in the management of their care.

• The NHS Confederation has issued a challenge to all political parties to accept and propose how they will deal with seven “burning issues” affecting health and social care.

• Monitor’s finding from its study of the impact of the size of smaller hospitals on their financial and operational performance.

• The establishment of System Resilience Groups by NHS England to enhance the capability of the health and social care system to deal with system capacity pressures.

• Monitor’s “Well-led framework for Governance” has been published, aligned with the NHS TDA and CQC regimes, to support trusts in improving assurance surrounding governance processes.

Decision required:

The Board is asked to note the Chief Executive Report.

FOI Status:

This report will be made available on request.

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1 Patient Activation

1.1 “Patient Activation Measure” is a patient reported outcome that measures an individual’s knowledge, skill and confidence for self management. A report published by the King’s Fund “Supporting People to manage their health” introduces the concept as a means of measuring an individual’s engagement with their own care, known as “patient activation”.

1.2 Based on the evidence that about 60-70% of premature deaths are caused by lifestyle choices and behaviours that are detrimental to health, the report proposes that it is essential for people to engage more with managing their own health in order to reduce the incidence of premature death.

1.3 The socio-economic benefits attributed to the increased involvement of people in managing their own health include; reduced health inequalities, improved health outcomes, better quality and lower costs of care. The paper also highlights some of the key findings of research into the benefits of patient facilitation. These include:

• Patient activation is a better predictor of health outcomes than known socio-demographic factors such as ethnicity and age.

• People who are more activated are significantly more likely to attend screenings, check-ups and immunisations, to adopt positive behaviours (e.g., diet and exercise), and have clinical indicators in the normal range (body mass index, blood sugar levels, blood pressure and cholesterol). Highly activated patients are also more likely to adopt healthy behaviour, to have better clinical outcomes and lower rates of hospitalisation, and to report higher levels of satisfaction with services

• People who have low levels of activation are less likely to play an active role in staying healthy and are more likely to attend accident and emergency departments, to be hospitalised or to be re-admitted to hospital after being discharged.

• The healthcare costs for less activated patients are about 21% higher a year than activated patients.

• Studies of interventions to improve activation show that patients who start with the lowest activation scores tend to increase their scores the most, suggesting that effective interventions can help engage even the most disengaged.

1.4 The report provides a simple, evidence-based mechanism for establishing the capacity of individuals to manage their health and then using that information to optimise the delivery of care. This concept provides an opportunity for hospitals to curb avoidable admissions, inappropriate attendance and readmissions. It also provides an avenue for engaging with patients through social media platform to educate, inform and support care in patients’ homes. The Trust will continue to explore this for potential adoption in relevant clinical settings.

2 NHS Confederation 2015 challenge declaration

2.1 In a report called “2015 Challenge Declaration”, the NHS Confederation has issued a challenge to all political parties to accept seven “burning issues” facing the health and care system, and to produce election manifestos that allow the NHS and social care the space to be able to address them.

2.2 The document refers to a number of “burning issues” facing the health and social care system:

• The need challenge: meeting the rising demand for care, particularly from people with complex needs or long-term conditions and preventing ill health.

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• The culture challenge: creating a more open and transparent NHS, which enables patients, citizens and communities to be partners in decisions, and staff to improve care.

• The design challenge: redesigning the health and care system to reflect the needs of people now and remains sustainable in the future. Shifting more care closer to people’s homes, while maintaining great hospital care. A focus on joining up all parts of the health and care system so care revolves around the needs and capacities of individuals, families and communities.

• The finance challenge: debating honestly and openly the future levels and sources of funding for health and social care.

• The leadership challenge: creating value-based, system leaders across the NHS and empowering them to improve health and wellbeing for local people.

• The workforce challenge: planning for a workforce to better match changing demand. Developing staff roles and skills to provide complex, multidisciplinary, coordinated care, in partnership with individuals and communities and more often in community settings.

• The technology challenge: using technology to help transform care and enabling people to access information and treatment in a way that meets their needs. Spreading innovation to improve the quality of care while responding to the financial challenge facing the NHS and care system.

2.3 This debate is particularly relevant to the Trust as it works with commissioners and partners to develop a longer-term strategy and future configuration for the Berkshire health economy. NHS Confederation is asking individuals and organisations to support the challenge by sending their comments to: [email protected].

3 Sustainability of smaller hospitals

3.1 Monitor has published findings from a review looking at the impact of the size of smaller hospitals on their financial and operational performance. It undertook a comprehensive analysis of range of clinical and financial indicators to test whether any special factors affected the performance of hospitals with fewer than 700 beds (typically in trusts with an income of less than £300 million).

3.2 The study found no clear evidence that smaller acute hospitals performed any worse clinically than larger counterparts. However, it revealed evidence that smaller providers may be starting to face greater financial challenges, with performance worsening more than the sector as a whole in the last two years.

3.3 The report concludes that size is likely to become more of an issue as hospitals face greater pressures to recruit staff to further improve the quality of care.

3.4 Monitor recommends that the healthcare sector should:

• identify new models of care for patients, for example re-designing services to improve the integration of care and move care closer to home;

• come up with creative ways to address the capacity challenges, such as sharing staff with nearby trusts, using new technology, or building networks between smaller hospitals and major centres;

• make sure that the right balance is struck in local communities between redesigning services and making sure patients are treated near to where they live;

mailto:[email protected]�

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• “bigger isn’t always better” and just merging or taking a ‘one size fits all’ approach to local health services is not the answer to improving access to care; and

• consider other constraints such as the impact of clinical specialisation to make sure patients continue to benefit from the local hospitals that they value so much

3.5 We will consider the implications of the full report in relationship to our continued sustainability.

4 System Resilience Groups

4.1 In order to deal with the seasonal pressures on capacity, the Urgent Care Working Group was formed in the winter of 2012/13. This brought together NHS and local authority providers from primary, community and secondary care services. The primary objective was to manage the capacity within the urgent care system to cope with the upsurge in demand during the winter period.

4.2 Following the success of this group, NHS England, in collaboration with NHS Trusts Development Authority, Monitor and Directors of Adult Social Services (DASS) has published guidelines for expanding this group to include elective care services. The expanded group will be called the “System Resilience Group” (SRG).

4.3 The group will become the forum for coordinating capacity planning and operational delivery across the health and social care system. This is considered necessary in order to bring both elective and urgent care into one planning process and ensure that both parts are addressed simultaneously in order for local health and care systems to operate as effectively as possible in delivering year-round services for patients. It will also enable the NHS, working with its partners in local authorities, to be in a position to move away from a reactive approach to managing operational problems, and towards a proactive system of year round operational resilience. The report also cites the Better Care Fund as a positive lever in fostering this integrated health and social care resilience planning

4.4 Membership of the group will consist of representatives of all local providers, commissioners, social care organisations and independent or voluntary sector representatives. The guidelines emphasises the need for a broad range of clinical representation from elective and urgent care groups as well as ambulance, mental health and primary and community care providers.

4.5 The SRG will have responsibility for identifying drivers of system pressures and ensuring that a collaborative approach is developed to deal with the pressures. It will also hold members to account for any actions that are required of them, share intelligence and pool resources where this is needed to improve performance.

4.6 The guidelines prescribe the framework and time line for SRGs to develop operational resilience capacity plans (involving all organisations) which will include the following as mandatory elements:

• a vision of “what good looks like” in each major component part of the elective and urgent care system

• aim to provide safe, effective and prompt care to the local populations while minimising emergency department attendances

• “care flow models” for emergency and elective care that outlines objectives for system partners, shows broad patient flows and delivery standards

• Specific plans to address emergency department exit blocks, including “ Full Capacity Protocols” and “Boarding Protocols”

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4.7 SRGs need to submit their plans to the relevant local area teams of NHS England by 30 July 2014. Assurance processes will be concluded in September and published on the SRG websites and refreshed in October ready for the winter.

4.8 The Trust, as part of the local System Resilience Group, will have to comply with the planning and governance requirements as well as play its part in the implementation. Membership of the group offers the Trust a platform to influence whole system demand management and stave off the perennial intractable pressure imposed on its urgent care resources.

5 Monitor’s “Improving Clinical Engagement” survey

5.1 The Monitor has run a survey to get an overview of how different providers structure their management and identify what has been particularly effective and why. The survey includes questions on how far Service Line Management (SLM) has been implemented.

5.2 The study is intended to enable Monitor to improve their understanding of how the FT sector is organising itself and supporting clinical engagement with decision-making. The results will be used to devise learning and support programmes (in partnership with others as appropriate) where these would be helpful.

5.3 The results will be published in a report so that providers can compare their position with those of others, including how common challenges have been addressed and the benefits realised from chosen approaches.

6 Well-led framework

6.1 Monitor’s ‘Risk assessment framework’ set out the expectation that NHS foundation trusts carry out an external review of their governance every three years and to support trusts in this Monitor has published its new ‘Well-led framework for governance reviews’, following consultation. The purpose of this document is to support NHS foundation trusts in gaining assurance that they are well led i.e. leadership, management and governance. This will help them continue to meet patients’ needs and expectations in a sustainable manner under challenging circumstances. The framework represents a ‘core’ reference for NHS foundation trusts to structure reviews of their governance.

6.2 This framework is built along the lines of the existing ‘Quality Governance Framework’, with 4 domains, 10 high level questions and a body of ‘good practice’ outcomes and evidence base that organisations and reviewers can use to assess governance. The framework is intended to support the system response to Francis and align with the ‘ward to board’ inspection regime of the CQC, which asks NHS foundation trusts how they have assured their governance arrangements.

6.3 The Trust contributed to the consultation process and is please to see that many of its comments have been reflected in the final guidance. The Trust will be developing its response to the new framework as assessments are phased in from October 2014.

7 “Pride of Reading” award

7.1 A cardiology team and a consultant from the Trust elderly care team have been nominated for the “Pride of Reading” award for their respective outstanding work towards patient care.

7.2 Dr Hannah Johnson, elderly care consultant, has been nominated for the “Health Worker of the year” award in recognition of her role in leading the process for securing funding and developing the now renowned dementia friendly ward in the Trust. The Cardiology team is nominated for their work in ensuring that heart attack patients brought to the Royal Berkshire received the speediest treatment anywhere in the UK.

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8 Patient participation groups

8.1 As part of a nationwide campaign to increase public awareness and engagement in health care planning and provision, representatives of Healthwatch Reading and the Patient Participation Groups from GPs surgeries in Reading organised a series of public events early this month. Events were aimed at explaining the purpose and benefits of joining Patient Participation Groups. Further public awareness events are planned throughout Berkshire West in the coming months.

9 Care Quality Commission Inspection

9.1 Following the findings of the CQC inspection in March 2014, a Trust Improvement Programme has been developed which brings together the QIPPs (financial improvement), operational improvement projects, the CQC Improvement Plan and the action plans following both the Deloitte Board Evaluation review and the Quality Governance Framework (QGF) review.

9.2 The CQC Improvement Plan, the Board Evaluation Plan and the actions required following the findings of the QGF review will be amalgamated into one overall plan (with the ability to track and report on the individual plans if so required). The Improvement Programme and individual projects will in future be included as standing agenda items within the monthly Trust Board reports with a report on progress against each project.

9.3 Oversight of the Improvement Programme will be undertaken by the Head of PMO, and additional project management resource has been agreed to support teams in delivering the key actions. Updates on all of the individual projects will be included from next month. Updates on the Board Evaluation and CQC inspection are covered elsewhere within this month's agenda.

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Royal Berkshire NHS Foundation Trust Agenda Item 6b

Title: Quality Performance Report

Date: 30 June 2014

Lead: Caroline Ainslie, Director of Nursing

Purpose: The purpose of this paper is to provide the Board of Directors with an analysis of quality performance to the end of May 2014. The report covers performance against the Monitor Risk Assessment Framework as well as national and local key performance indicators

Key Points: The Quality Performance Report is designed to provide high level analysis and identify and escalate key performance issues and this month additional reports have been included for key performance exceptions (included in Part 2 of the Board papers).

The Quality Performance report consists of the following components:

• Quality Report narrative: additional analysis and data of exception items requiring commentary. Includes performance issues.

• Quality Dashboard: highlighting quarterly, current month performance and forecast against the most significant indicators. Additional operational indicators have been included for Cancer and Waiting Times.

• Quality KPI Scorecard: additional metrics with granularity by theme, month and previous year’s outturn.

• Performance exception reports (Part 2): Present status, action plan and date when recovery of target/standard is expected.

Items of note from this month’s report include:

• ‘Red’ performance was recorded against 17 targets (out of 34) on the Trust dashboard in May. Additional targets have been introduced. However, performance worsened in only 8 of the targets with performance trend improving for 15 targets. Notable areas of worsening performance are:

o Serious Incidents reported

o 1 Never Event

o Patient Falls resulting in Harm

o PALS concerns received have increased

o Cancer waiting time targets: 2 week wait breast symptoms, 62 day from GP referral, Cancer 31 day Surgery, 62 day screening

o 18 weeks RTT (admitted care)

o Diagnostic 6 week waits

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• Monitor: We are achieving the A&E target in May. However, given the challenges in this area we are closely monitoring performance. This and the potential failure of 62 day cancer target present the risk of failure to comply with the Risk Assessment Framework

• Patient safety: Reporting of incidents remains challenging. Serious Incidents have exceeded target year to date, with 4 reported in May.

• Clinical effectiveness: The Trust mortality data for May is not reported this month as data is not available from Dr Foster at the time of reporting.

• Patient experience: Performance against the Net Promoter Score was 77 which is better than target. The number of formal complaints and complaints related to behaviour and attitude reduced in May.

• Staff: Appraisals and completion of mandatory and statutory training continue to increase slowly but remain below target. Sickness absence is still higher than target.

.

Decision required:

The Committee is asked to note the Quality Performance Report and the actions being taken.

FOI Status: This report will be made available on request.

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1 Introduction

1.1 The purpose of this report is to provide assurance to the Clinical Governance Committee and Board of Directors on compliance against the Monitor Risk Assessment Framework, national and local key performance indicators. It acknowledges significant and notable achievements, and highlights and discusses areas of concern or where performance has a less than favourable forecast.

2 Monitor compliance

2.1 The majority of targets continue to be met, but there is risk of on-going compliance on key targets around A&E and Cancer.

2.2 A&E

2.3 Performance was 96.1% of patients treated in 4 hours in May 2014.

2.4 The Trust continues to keep Monitor informed of progress against the Berkshire West system recovery plan and ECIST recommendations are being implemented.

2.5 Cancer Waiting Times

2.6 The following cancer access targets are showing as unachieved in May 2014 (this data is subject to ongoing validation):

• Two week wait breast symptoms (actual: 89.2% target 93%)

• Cancer 62 day from GP referral (actual: 73.0% target 85%)

• Cancer 31 day surgery (actual: 90.5% target 94%)

• Cancer 62 day wait screening (actual: 89.5% target 90%)

The 62 day performance remains a concern a separate exception report for details current performance issues and actions to improve.

2.7 18 weeks RTT Admitted Patients

2.8 In May 89.18% admitted patients were treated within 18 weeks of time of referral compared to the target of 90%. A separate exception report in Part 2 outlines details of current performance issues and actions to improve.

2.9 Waiting Time for Diagnostic Investigation

2.10 In May 72.8% patients had a diagnostic investigation in 6 weeks compared to the target of 99%. A recovery plan has been agreed with the CCG; both CT and MRI are within trajectory. A separate exception report (Part 2) details current performance issues within ultrasound and actions to improve.

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3 Care Quality Commission Compliance

3.1 The next (third) quarterly draft CQC Intelligent Monitoring report will be sent to the Trust on 23 June 14 for factual accuracy checking, to be undertaken by 4 July 2014. The final version will be issued to the Trust on 21 July 2014 and published on 24 July 2014. The Trust will not be placed in a scored band as in previous reports, but will be placed in a ‘Trusts which have been previously inspected’ band. Risks will continue to be identified within the report. Board assurance processes on CQC indicators are being updated, as highlighted in Appendix !.

3.2 Within the March 2014 CQC Intelligent Monitoring Report, the Trust had four risks. The action relating to the risks is being monitored by the Quality Performance Committee – the latest position on the risks is outlined below:

3.3 Dr Foster: Hospital Standardised Mortality Ratio (weekend) – Elevated Risk.

3.4

This indicator is not expected to be identified as a risk within the next CQC Intelligent Monitoring Report and the internal actions to reduce the rate continue to be implemented. Dr Foster data has not been refreshed for the month of April/May nationally – an update on the Trust’s HSMR performance will be available for the July Board meeting following the release of Dr Foster data for this period on 30 June 2014.

Never Events – Risk

3.5 The Trust is undertaking a Trust-wide review of learning from Never Events focussing on theatres, the location of 6 of the 7 Never Events. This review is led by Planned Care supported by the Director of Quality Improvement. A draft Never Event Strategy Plan is being consulted upon, with proposed deliverable dates by the end of August 2014. Key proposed deliverables include:

. The Trust has had seven never events since 1 April 2013 all of which have individual action plans to address the issues identified which are being monitored through the Trust Clinical Outcomes & Effectiveness Committee, chaired by the Acting CEO. It is expected that Never Events will be identified as an elevated risk within the June 2014 Intelligent Monitoring Report.

(i) Appoint Executive Lead for Theatre Patient Safety by June 2014

(ii) Undertake baseline assessment of theatre culture by June 2014

(iii) Develop a Theatre Safety Quality Improvement Programme by July 2014

3.6 Monitor Governance Risk Rating – Risk.

3.7

The Monitor Governance Risk rating since 7 March 2014 is green. This indicator is not expected to be identified as a risk within the next CQC Intelligent Monitoring Report.

Composite risk rating of ESR items relating to staff turnover – Risk

3.8 In respect of Medical & Dental staff, turnover has reduced marginally from Q3 (9.60 %) to Q4 (9.17%). Discernible reductions in turnover have also been noticed for other occupational staff groups over the same period. However, turnover for Allied Health Professionals remains high and has increased from Q3 (18.28%) to Q4 (19.02%). Q1 data will be available for the July Board.

. Employee turnover continues to remain higher than desirable. During May 2014 employee turnover fell in all areas of the Trust, except for corporate support functions. It is expected that this indicator will continue to be a risk in the next Intelligent Monitoring report.

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3.9 A Recruitment & Retention Strategy will be sent for approval at the July Board. Two international recruitment programmes are planned for July/August. The Director of Nursing has introduced a Safe Staffing Review which will report to the Board from June 2014. One deliverable is to display nursing staffing levels daily in clinical departments.

4 Quality Report: Exceptions

4.1 Patient safety

4.2 Incidents.

4.3 There was one Never Event reported in May (also reported as a Duty of Candour breach). Further details are included in a separate report in Part 2.

In May there were 4 serious incidents reported on STEIS, three of which were patient falls and one was a grade 4 pressure ulcer. An external review of Maternity services has been commissioned from the Royal College of Obstetricians and Gynaecologists and we are awaiting confirmation of the timing of this review.

4.4 The backlog of unapproved incidents on Datix has reduced to 251 incidents. Of the total not reviewed by the responsible manager or validated, 171 unapproved incidents were attributed to Care Groups and 80 were attributed to the corporate departments who delivered a 53% reduction during the month of May. The challenge is now to sustain this level of performance improvement.

Figure 1: Backlog of unapproved incidents

4.5 Infection Control:

0

100

200

300

400

500

600

Estates, Facilities and other

Urgent Care

Planned Care

Network Care

Unapproved incidents

There were 3 cases of Clostridium Difficile reported by the Trust in May compared to one case the previous month. During May there was also an increase in reportable community C.diff with a total of 14 cases reported in this category (see Figures 2 & 3 belwo). This is the highest incidence of community C diff since August 12 when there were 17 cases and higher than the peak of 12 cases that was experienced in July and August 13. We believe that last summer a community outbreak spilled over into the hospital and so the current increase may be an early indicator of a similar pattern this year.

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Figure 2: Hospital acquired C Difficile 12 month trend

Figure 3: Community attributed C Difficile trend

4.6 Maternity Care

4.7 Clinical effectiveness

: the normal birth rate has reduced to 58.5% against a target of 63%. Less than 60% normal birth rate prompts a red flag. This has been impacted by the 50% closure of Rushey Unit. The caesarean section rate continues to be higher than target (actual 27.1%, target 23%).

4.8 Mortality Indicators:

4.9 Patient experience

The Trust mortality data for May is not reported this month as data is not available from Dr Foster at the time of reporting.

4.10 Performance against the Friends and Family Test (Inpatient Survey) has exceeded target for May (77 against target of 70) and the response rate was 38.7% against a target of 30%.

4.11 Complaints & PALS:

0123456789

10

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2013/14 Actual 2014/15 Actual

2013/14 target 2014/15 target

The number of complaints reduced in May to 34 which is 10 less than the previous month. Performance against responding to complaints in 25 days and the average number of days taken to close a complaint was 29 in May. However there has been a recent increase in PALS concerns and, although not a concern in itself, this will be monitored.

0

2

4

6

8

10

12

14

16

18

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2012/13 2013/14 2014/15

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4.12 Improving staff attitudes and communication

Figure 4: Complaints relating to behaviour and attitude 12 month trend

Complaints relating to behaviour and attitude reduced in May to a total of five compared to ten the previous month. Thisis still above target for 2014/15.

5 Workforce

5.1 Appraisals:

5.2

In May, appraisal rates improved by 2% to 87% but are still short of the 95% target. Significant improvements have occurred across all areas towards achievement of the target. Planned Care performance improved by 6% to 83% during May.

Mandatory Training:

5.3

The snapshot position at the end of May was 73% of staff had received Mandatory Training compared with the target of 85%. This is a slight improvement on the previous month.

Sickness absence:

5.4

The absence rate has increased slightly in May to 3% and remains above the Trust target. Estates and Facilities remains highest due to the physical nature of the role, but as management continue to make reasonable adjustments to accommodate staff returning to work, we expect to see a reduction in this figure. Occupational Health and Human Resources are working with those departments that are seeing increased levels of absence in month 2.

Agency spend:

6 Contact

This remains higher than target at 6% (target 5.3%). The most notable concern is in Corporate Areas. Although there has been a reduction in 3%, spends still sits at 16.4% of total staff spend. This includes 17 members of staff on interim contracts, 13 of whom are covering substantive contracts.

Contact: Caroline Ainslie, Nursing Director

John Taylor, Acting Commercial Director

0

2

4

6

8

10

12

14

16

behaviour and attitude complaints 2014/15 target = 39

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Quality Performance Report: Appendix 1 CQC Intelligent Monitoring Board Assurance

Following the paper to the May 2014 Trust Board outlining the process for providing the Board with assurance as to the performance of the indicators within the Intelligent Monitoring Report, a review of the existing governance and monitoring arrangements for each of the indicators included within the IM report has been undertaken. The table below highlights the indicators which are either not currently formally monitored within the Trust, or have governance arrangements in place which would benefit from review to deliver board assurance in the future on their performance. Transparent/structured monitoring arrangements will be in place by the September 2014 Board to deliver assurance on any performance risk that may result in one of the indicators being a risk or elevated risk within future Intelligent Monitoring Reports.

Between the June and September Boards, this work-stream will identify current committee and Executive Lead accountabilities for indicators for which clear performance monitoring arrangements exist and will propose committee and Executive accountabilities where this is currently absent. Monitoring arrangements will be established throughout this period, the rate of delivery being determined by management capacity at a time when resource is required to follow-up CQC inspection requirements.

Indicators not currently formally monitored within the Trust: • In-hospital mortality at specialty level • Maternity outlier alert – puerperal sepsis and other puerperal infections • Maternity outlier alert – maternal readmissions • Composite risk rating of ESR items relating to staff sickness rates • Composite risk rating of ESR items relating to staff registration • Composite risk rating of ESR items relating to staff turnover • Composite risk rating of ESR items relating to staff stability • Composite risk rating of ESR items relating to staff support/ supervision • Composite risk rating of ESR items relating to ratio: Staff vs bed occupancy

Indicators for which governance/reporting arrangements require review to deliver Board assurance on performance from September 2014:

• PROMs EQ-5D score: Groin Hernia Surgery • PROMs EQ-5D score: Hip Replacement (PRIMARY) • PROMs EQ-5D score: Knee Replacement (PRIMARY) • The proportion of cases assessed as achieving compliance with all nine standards of care

measured within the National Hip Fracture Database • Percentage of Secondary Uses Service (SUS) records for Accident and Emergency care with valid

entries in mandatory fields • Percentage of Secondary Uses Service (SUS) records for inpatient care with correct entries in

mandatory fields. • Percentage of Secondary Uses Service (SUS) records for outpatient care with valid entries in

mandatory fields • GMC National Training Survey – trainee's overall satisfaction • Whistleblowing alerts • Safeguarding concerns • Healthcare Worker Flu vaccination uptake • Percentage of Secondary Uses Service (SUS) records for Accident and Emergency care with valid

entries in mandatory fields. • Percentage of Secondary Uses Service (SUS) records for inpatient care with correct entries in

mandatory fields. • Percentage of Secondary Uses Service (SUS) records for outpatient care with valid entries in

mandatory fields. • Proportion of patients who received all the secondary prevention medications for which they were

eligible (MINAP) • The proportion of cases assessed as achieving compliance with all nine standards of care

measured within the National Hip Fracture Database • Proportion of patients scanned within 1 hour of clock start (SSNAP Pilot Report 2 - trust level)

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Q1 Q2 Q3 Q4 April May Q1 Q2 Q3 Q4 Apr May

2013/14 2013/14 2013/14 2013/14 2014 2014 2013/14 2013/14 2013/14 2013/14 2014 2014

Indicative Monitor Governance Risk Rating

Patient Experience

CQC Identified Risks (IMR) n/a n/a 9 4 1+ n/a Number of complaints 121 94 106 91 44 34 78 400 reducing

Patient Safety Number of PALS concerns 691 734 722 832 233 278 511 3000 increasing

Meeting the C.Diff objective 10 15 9 6 1 3 4 40 reducingComplaints relating to Behaviour & Attitude

12 20 28 18 10 5 15 39 reducing

Never events 0 1 1 3 0 1 1 0 no changeComplaints average response time

no data 35 29 32<= 25 days

reducing

Rate of patient safety incident reporting

5.96 5.20 5.57 7.0 reducingFriends and Family Test Inpatients response rate

No data No data No data No data 31.3% 38.7% 35.0% 40% increasing

All serious incidents (SI) 19 16 17 23 6 4 10 50 no changeFriends and Family Test NPS inpatient NPS

58 63 65 71 79 77 78 70 increasing

Patient falls resulting in Harm (SI)

2 7 2 3 5 20 increasing Operational: Waiting Times

Grade 3 or 4 avoidable pressure ulcers (SI)

7 6 5 2 0 1 1 14 reducing A&E: seen in 4 hours 94.5% 95.1% 92.4% 89.7% 96.6% 96.1% 95.9% 95% increasing

Harm Free Care - all harms reported on PST

92.6% 93.9% 92.9% 93.1% 93.8% 94.3% 94.0% 95% no change Cancer 2 week wait 93.0% 93.6% 94.7% 93.0% 88.1% 93.5% 90.6% 93% increasing

Clinical EffectivenessCancer 2 week wait: breast patients

93.2% 94.4% 95.0% 93.3% 87.4% 89.2% 88.3% 93% increasing

HSMR 12 month rolling -all days see detailed report 89.21 100 reducingCancer 31 day wait: to first treatment

97.5% 99.1% 98.8% 97.1% 97.1% 99.4% 98.3% 96% increasing

HSMR 12 month rolling - weekend

see detailed report 96.63 100 reducing Cancer 31 day wait: surgery 96.8% 96.5% 97.5% 95.5% 95.5% 90.5% 93.0% 94% reducing

Emergency re-admissions in 30 days

7.9% 7.2% 7.1% 6.7% 6.8% 6.8% 6.8% 7.3% reducingCancer 31 day wait: drug treatments

99.5% 99.0% 100% 99.5% 100.0% 100% 100.0% 98% no change

StaffCancer 31 day wait: radiotherapy

97.8% 98.6% 98.6% 96.2% 100.0% 96.4% 98.3% 94% no change

Appraisals 84% 79% 81% 85% 85% 87% 86.0% 95% no change Cancer 62 day wait: GP Referral 85.9% 89.2% 85.8% 85.1% 85.6% 73.0% 79.3% 85% reducing

Mandatory Training Data Data Data 65% 71.6% 73.0% 72.0% 75% increasingCancer 62 day wait: screening referral

92.6% 95.2% 91.1% 88.4% 90.0% 89.5% 89.7% 90% reducing

Sickness/absence 3.0% 2.8% 3.0% 3.2% 2.9% 3.0% 3.0% 2.8% no change 18 Weeks: admitted patients 94.2% 93.6% 93.7% 93.0% 91.8% 89.18% 92.6% 90% reducing

18 Weeks: non-admitted patients

99.9% 99.9% 99.9% 99.9% 99.9% 99.72% 99.8% 95% no change

Footnote : Cancer waiting time figures for May 14 are provisional

18 Weeks: incomplete pathways

95.0% 93.6% 94.2% 94.2% 94.1% 95.36% 94.8% 93% no change

Diagnostics in 6 weeks % 98.6% 97.6% 98.7% 71.7% 70.1% 72.8% 71.4% 99% reducing

5.70

12 month trendCum YTD 2014/15

Not updated by Dr Foster this month

Cum YTD 2014/15

Threshold 2014/15

12 month trendThreshold 2014/15

Trust Quality Dashboard

10

Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Target 2014/15

Patient Safety Infection Control Meeting the C.Diff objective 5 9 5 1 4 4 1 3 1 2 1 3 40

Patient Safety Thermometer Harm Free Care - All Harms (PST) 93.2% 94.6% 95.0% 92.1% 94.0% 93.6% 91.2% 91.5% 93.3% 94.5% 93.78% 94.28% 95%

Patient Safety Thermometer

Harm Free Care - New Harms (PST) 96.4% 97.6% 98.1% 96.1% 97.8% 98.0% 96.7% 97.2% 97.3% 97.6% 98.27% 99.07% 97.2%

Patient Safety Thermometer Pressure Ulcers New (PST) 0.81% 1.06% 0.31% 0.63% 0.65% 0.49% 0.79% 0.15% 0.29% 0.78% 0.17% 0.46% 0.8%

Incidents Reporting Pressure Ulcer Incidence per 1,000 bed days 1.26 0.95 1.22 0.70 0.89 1.28 1.63 0.95 0.76 1.21 0.37 1.44 1.42

Incidents Reporting Grade 3 or 4 avoidable pressure ulcers (SI) 3 4 1 1 2 2 1 0 0 2 0 1 14

Patient Safety Thermometer New catheters with a UTI (PST) 1.30% 0.91% 0.16% 1.42% 0.81% 0.65% 1.10% 1.38% 1.47% 0.47% 0.52% 0.00% 0.9%

Incidents Reporting Patient Falls per 1,000 bed days 5.1 5.1 5.4 4.3 3.9 4.6 4.4 4.7 4.4 4.1 3.6 4.2 <5

Incidents Reporting Patient falls resulting in Harm (SI) 2 1 2 0 0 3 2 3 2 3 20

Incidents Reporting Rate of Reportable Patient Safety Incidents/100 admissions 5.96 5.20 7.0

Incidents Reporting Unapproved Incidents no data no data no data no data 557 446 336 313 504 558 325 251

Incidents Reporting All serious incidents (SI) 7 7 3 6 11 2 4 6 10 7 6 4 50

Incidents Reporting Medication Errors 277 299 72 76 108 111 83

Incidents Reporting Duty of Candour breaches (SI) 0 0 0 0 0 0 0 0 0 0 0 1 0

Incidents Reporting Never Events 0 1 1 3 0 1 0

Incidents Reporting Number of patient safety incidents reported Average 422 per month during 2013/14 343 301 8798

Clinical EffectivenessMortality Indicators HSMR 12 months rolling

weekdays 101.88 101.52 99.59 99.51 98.29 94.57 92.89 89.23 87.15 HSMR data last refreshed by Dr Foster April 14 100

Mortality Indicators HSMR 12 months rolling weekend 117.19 117.88 116.16 114.49 112.61 113.06 111.77 105.08 96.63 HSMR data last refreshed by Dr Foster April 15 100

Mortality Indicators HSMR 12 months rolling all days 105.49 105.37 103.55 102.89 101.61 99.02 97.47 93.01 89.21 HSMR data last refreshed by Dr Foster April 16 100

Mortality Indicators HSMR weekdays 104.58 93.80 77.01 97.80 89.03 64.56 78.28 73.77 83.52 HSMR data last refreshed by Dr Foster April 17 100

Mortality Indicators HSMR weekend 92.29 114.04 106.82 111.12 97.53 106.48 92.70 57.91 64.80 HSMR data last refreshed by Dr Foster April 18 100

Mortality Indicators HSMR all days 100.06 98.55 83.80 100.88 91.07 75.74 82.36 70.34 78.50 HSMR data last refreshed by Dr Foster April 19 100

Stroke Care Pts spend 90% time on an acute stroke unit 94.0% 92.0% 90.0% 91.0% 91.4% 91.0% 96.3% 93.3% 86.0% 91.4% 92.50% 84.20% 80%

Stroke Care Admission to Acute Stroke Unit within 4 hours 75.0% 76.0% 61.0% 65.0% 75.4% 65.5% 69.2% 72.7% 62.8% 72.7% 62.5% 88.7% 90.0%

Stroke Care Stroke patients scanned within 24 hours 92.0% 96.0% 94.0% 96.0% 93.0% 90.0% 94.0% 98.0% 98.0% 93.0% 98.10% 95.00% 100.0%

Stroke Care Stroke: Discharged to their normal place of residence 89.0% 89.0% 86.0% 100.0% 98.0% 92.0% 86.0% 94.0% 94.0% 90.0% 90.0% 90.0%

Trust KPI Scorecard

11


Maternity Care Breastfeeding initiation 82.0% 79.1% 77.7% 77.0% 77.9% 79.8% 83.1% 81.6% 80.9% 80.4% 79.7% 76.0% 80%

Maternity Care Percentage of ALL caesarean sections 29.0% 26.6% 23.0% 26.6% 28.4% 26.3% 25.4% 29.6% 33.1% 26.4% 27.9% 27.1% 23%

Maternity Care Percentage of normal births 55.0% 61.4% 62.9% 57.5% 56.5% 58.8% 60.8% 54.8% 53.4% 54.8% 59.0% 58.5% 63%

Maternity Care Rubella non-immune women vaccinated 94% 95% 87% 93% 96% 89% 100% 100% 90% 100% 92% 89% 90%

Maternity Care At risk babies who receive BCG vaccination 90% 91% 91% 85% 89% 92% 100% 88% 91% 89% 86% 82% 90%

Maternity Care Women giving birth have 1:1 delivery of care 100% 99% 99% 100% 98% 98% 99% 100% 99% 99% 99% data 85%

Maternity Care Unexpected admission >37 weeks to neonatal care 30 22 18 24 25 20 20 31 24 26 data data <=20

Re-admissions Emergency re-admissions within 30 days 7.7% 7.2% 7.3% 7.2% 7.1% 6.7% 7.5% 6.8% 7.1% 6.3% 6.8% 6.8%

Re-admissions Elective re-admissions within 30 days 6.7% 4.7% 4.6% 3.8% 4.5% 4.4% 5.7% 3.5% 4.6% 4.1% 4.5% 4.9%

Other Clinical Indicators

Patients in ED/CDU with a diagnosis of sepsis receive no data 93% 53% 58% 90% 75% 71% 42% 100% 100% 75% 100% 90%


Nutrition risk assessment in 24 hours 85% 81% 77% 80% 82% 83% 80% 79% 76% 77% 81% 79% 90%


Nutrition risk assessment in 48 hours 93% 93% 93% 92% 92% 94% 93% 91% 89% 91% 93% 89% 90%


Fractured Neck of Femur: Surgery in 36 hours 80.0% 51.3% 77.4% 63.1% 70.5% 81.0% 68.0% 83.7% 84.8% 77.5% 80.5% 78.3%

Other Clinical Indicators VTE Risk Assessment 95.8% 96.2% 95.3% 95.0% 95.5% 95.8% 95.3% 95.2% 95.1% 96.1% 96.4% 96.7% 95%


Adult IP who receive appropriate VTE prophylaxis 96.4% 93.4% 91.4% 89.6% 85.4% 94.7% 94.9% 85.5% 95.2% 89.2% 91.2% 100% 85%

Patient ExperienceSurveys and Feedback

Trust Patient Survey - overall rating 96% 97% 96% 96% 98% 97% 96% 97% 96% 96% 99% 98% 97%

Surveys and Feedback

Inpatient survey question: “Involved as much as desired in 87 90 87 87 83 82 78 84 84 80 86 84 86


Inpatient survey question: “Informed about medication side 89 90 81 87 79 64 83 86 82 85 85 84 85

Surveys and Feedback FFT Response Inpatients 41.0% 32.3% 29.3% 32.7% 33.4% 27.7% 27.0% 38.2% 36.3% 30.6% 31.3% 38.7% 27.66%

Surveys and Feedback FFT Response A&E 15.3% 8.9% 13.0% 15.0% 9.9% 32.6% 24.1% 22.7% 27.5% 25.55% 19.1% 30.3% 27.66%

Surveys and Feedback FFT Net Promoter Score A&E 51 55 48 54 56 46 52 57 59 56 63 64 70

Surveys and Feedback FFT Response Maternity 7.3% 9.7% 13.6% 16.7% 13.4% 11.5% 18.5% 29.4% 27.66%

Surveys and Feedback FFT Net Promoter Score Maternity 71 74 72 70


Single sex accommodation - breaches 0 0 0 0 0 0 0 0 0 0 0 0 0

Complaints Complaints about behaviour and attitude 6 10 7 3 8 5 15 8 2 8 10 5 39

Complaints Number of Complaints 33 32 31 31 36 34 36 36 26 29 44 34 400

Complaints Complaints average response time 35 29 25 days

Complaints Number of PALS concerns 734 722 832 233 278 3000

12


Complaints Number of PALS concerns 734 722 832 233 278 3000

Cancer waiting times

Cancer 2 week wait: cancer suspected 94.8% 94.2% 94.4% 93.2% 94.8% 94.3% 95.0% 91.2% 94.6% 93.2% 88.1% 93.5% 93%


Cancer 2 week wait: breast patients 94.7% 94.2% 94.4% 94.4% 96.5% 94.4% 93.2% 95.1% 94.9% 89.4% 87.4% 89.2% 93%


Cancer 31 day wait: to first treatment 97.4% 99.0% 98.3% 99.0% 99.5% 98.5% 99.3% 97.1% 97.0% 96.9% 97.1% 99.4% 96%


Cancer 31 day wait: drug treatments 100.0% 100% 98.4% 100% 96.4% 96.9% 100.0% 96.3% 94.1% 96.0% 100.0% 100.0% 98%

Cancer waiting times Cancer 31 day wait: surgery 100.0% 94.4% 100% 94.4% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 95.5% 90.5% 94%

Cancer waiting times Cancer 31 day wait: radiotherapy 97.1% 98.0% 97.6% 100.0% 96.6% 100% 98.9% 91.2% 97.6% 97.8% 100.0% 96.4% 94%

Cancer waiting times Cancer 62 day wait: GP Referral 83.1% 91.0% 85.2% 90.8% 81.0% 86.0% 90.2% 87.3% 75.9% 82.8% 85.6% 73.0% 85%


Cancer 62 day wait: screening referral 94.4% 95.2% 100% 88.9% 91.9% 85.0% 100.0% 88.2% 81.3% 90.0% 90.0% 89.5% 90%


62 day consultant upgrade: all cancers 100.0% 100.0% N/A 100.0% 80.0% 100.0% 66.7% 100.0% N/A 100.0% 50.0% 100.0% -

Waiting Times: 18 weeks RTT Diagnostics in 6 weeks % 99.2% 94.2% 99.9% 100% 100% 100% 96.7% 75.6% 68.9% 71.1% 70.1% 72.8% 99%

Waiting Times: 18 weeks RTT 18 Weeks: admitted patients 94.1% 92.5% 93.9% 94.3% 92.3% 95.0% 93.9% 92.0% 93.3% 93.8% 91.8% 89.18% 90%

Waiting Times: 18 weeks RTT 18 Weeks: non-admitted patients 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.72% 95%

Waiting Times: 18 weeks RTT 18 Weeks: incomplete pathways 94.1% 93.9% 93.7% 93.3% 93.9% 94.1% 94.6% 94.5% 93.7% 94.4% 94.1% 95.36% 93%

Waiting Times: 18 weeks RTT 18 weeks - Admitted backlog 98 136 101 103 151 91 93 152 111 115 121 182

Waiting Times: A&E A&E: 4hr Limit (type 1 &2) 97.11% 94.83% 97.34% 92.59% 93.83% 92.6% 90.2% 89.4% 88.7% 91.1% 95.61% 96.11% 95%

Waiting Times: A&E

Seen within 4 hours - RBH site Type 1 only 96.81% 94.28% 97.37% 92.13% 92.09% 92.47% 88.56% 88.41% 87.25% 90.56% 95.55% 95.61% 95%

OP Waiting Times Outpatient cancellation rate 28.0% 28.5% 29.5% 28.3% 28.0% 26.5% 29.5% 27.6% 27.5% 28.9% 28.6% 28.3% 25.8%

OP Waiting Times % Appointments cancelled by RBFT 15.51% 16.06% 17.18% 15.42% 15.19% 14.43% 16.51% 15.78% 15.40% 16.80% 16.29% 15.78%

OP Waiting Times % Appointments cancelled by patient 12.49% 12.42% 12.35% 12.86% 12.80% 12.05% 13.00% 11.78% 12.15% 12.10% 12.27% 12.51%

OP Waiting Times Appointments cancelled by hospital and rescheduled (4 7.7% 9.8% 10.5% 8.6% 7.6% 8.7% 10.1% 8.7% 7.2% 10.1% 10.5% 10.1%

Staff Appraisals Appraisal rate 80% 79% 80% 78% 81% 84% 85% 87% 85% 87% 95%

Training Completed Mandatory Training Data 61% 65% 69% 72% 73%

Absence Sickness/absence 2.9% 2.9% 2.7% 2.7% 3.0% 3.1% 2.9% 3.1% 3.2% 3.2% 2.9% 3.0% 2.8%

Vacancies Vacancy rate 3.9% 4.2% 3.4% 2.5% 2.6% 2.6% 2.4% 1.9% 1.4% 1.6% 8.1% 8.3% 5%

Agency spend Agency spend % of total staff cost 5.9% 5.4% 5.8% 5.0% 4.1% 4.5% 4.7% 6.6% 4.4% 5.5% 6.4% 6.0% 5.3%

Turnover Workforce turnover 1.1% 1.1% 0.8% 1.8% 0.9% 0.9% 1.1% 0.9% 0.8% 1.3% 1.1% 0.8%

13


Operating EfficiencyInpatients Delayed transfers of care 5.20% 5.22% 3.60% 4.20% 4.10% 4.70% 4.10% 5.32% 4.41% 4.67% 4.67% 4.65% 3.5%

Inpatients Operations cancelled by the hospital on the day of surgery for 0.83% 0.39% 0.43% 0.50% 0.32% 0.45% 1.29% 0.42% 0.76% 0.49% 0.62% 0.82% 0.8%

Inpatients Cancelled operations re-scheduled in 28 days 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 15.0% 0.0% 0.0% 5.8% 23.8% 0.0% 5%

Inpatients Theatre Utilisation 87.2% 88.3% 84.8% 91.0% 91.0% 93.0% 84.0% 89.0% 85.0% 86.0% 87.0% 86.0% 91%

Inpatients Average elective length of stay 2.9 2.5 2.7 2.8 2.4 2.4 2.7 2.8 2.7 2.5 2.7 2.6

Inpatients Average non-elective length of stay 5.3 4.7 4.6 4.6 4.8 4.3 4.4 4.7 5.3 4.7 4.6 4.3

Data Quality NHS number coding (IP) 99.2% 99.4% 99.1% 99.3% 99.0% 99.4% 98.9% 99.1% 99.2% 99.3% 99.1% 99.2% 99%

Presentation title here

Agenda Item 6c

Care Group Performance

June 2014

1


Contents Page Lead

1. Networked Care Group Report 3 Lindsey Barker

2. Urgent Care Group Report 8 Sue Edees

3. Planned Care Group Report 12 Peter Malone

2


1. Networked Care Group Dashboard 3

Patient Experience

Clinical Outcomes

Finance

Patient Surveys (NPS) *

Access & Activity ***

Pay against ..

Non Pay against ..

Income against ..

72 £(0.2)m

£0.06m

£0.1m

Falls / 1000 bed days

Dr Foster mortality alerts

SI

Cdiff

Pressure ulcers / 1000 bed days

>70

>85%

2014/15 YTD Av pcm

2014/15 Target pcm

14/15 May bud

2014/15 Target pcm

73

100%

2014/15 May

£(0.28)m

(£0.25)m

£0.30m

14/15 YTD bud

100%

5.0

3

<5.0

<2

0

<1

<1.5

3.5

0.3

1 1

0.4

Patient experience and outcomes remain green with the exception of SIs, 2 falls and one pressure ulcer. Financially the Care Group requires additional delivery of QIPPs to return to budget, focus is now on implementation. Appraisals have dipped following the new financial year , with plans to improve. Mandatory training is continuing its upward trajectory.

4.96

Complaints – 25 day response >85%

<5.0

<1.5

<2

>70

Yr End Forecast

(PCM)

14/15 Yr End

Forecast

People

<1 Sickness rate

Appraisal rate

Vacancies

89.6%

2.6%

95%

5.0%

2.8%

91.2%

2.7%

95.0%

2.8%

6.6% 6.1% 5.0%

Mandatory Training 85% 75.1% 74.6% 85.0%


4 4

Networked Care Group Summary 4

Best patient outcomes:

• Funding bids achieved for Enhanced Recovery Post and Neuro Navigator role.

• National research being undertaken by pain department.

• End of life – “National Care of the Dying Audit” – positive report

Best patient experience:

• Activities undertaken on Mortimer ward to increases functional independence. – social dining, hand massage, quizzes, art group

• Dementia awareness week successfully achieved over 100 attendees to watch ‘Barbara's story’

• Shadowing exercise by new ‘Patient Leaders’ undertaken .

Best place to work, train & learn

• Sickness absence remains better than target

• Improvements continue to be made in mandatory training completion rates

• Appraisal completion rate sit just below 90%

• Vacancies in specialist medicine (therapies / elderly care) have risen to 9.4%

Best Value

• Surplus of £1.12M for May versus £1.16M target

• Achieved savings of £252K in May, £381K ytd, which is 69% of phased savings target

Key risks

• Achieving QIPP target and staying within budget. Identifying remaining £700k projects.

• W4 building requiring demolition, require relocation of wheelchair service, options being explored

• Staff vacancies, therapies (new intake coming) and elderly care to enhance establishment to new levels set


5 5

Spoke Hospitals – Bracknell

5

Outpatients

- Attendance figures have increased slightly; agreed that Bracknell Clinic Development Manager will revisit all specialties to assist in increasing utilisation where needed

- To provide room availability of summer months to all specialties to try to maintain attendance levels

- Spinal clinic due to start in July; Diabetes/Endo clinic due to start in September

External Leases

- Working with Healthshare Ltd to mobilise the MSK CAT service, due to start 21 July

- Working with Berks East OOH service to enable the service to go live from 8 July


Networked Care Group – 14/15 QIPP Summary

6

Key Projects / actions •Target £4.2M (5.8%). In year plans for £3.5M. Risk adjusted £3.1M

•Agency reduced in nursing - £55K under spent year to date

•Pharmacy – home delivered drugs. Business case to be agreed with CCGs

•£350K, RA £88K

•Pharmacy – Aseptic drugs behind schedule due to staff recruitment – recovery plan on place

•£437K, RA £426K , low mth 1

•Audiology: staff restructure proposal to NCG Board June 2014

•£83K, RA £41K

•Pain management business cases – •£118K

•Contractual negotiations: EMGs, OT - CCG Long Term Conditions Board this week. (start payments – income , not required – cost reduction)

•Each week the NCG Board is receiving 2 specialty plans to review options to make efficiency savings – 4% pay challenge.

•QIA / PIDs are being written in line with Board decisions.

QIPP Projects Last Board Report

(Report from 21.05.14) Update as at

04.06.14 Weekly

Variance Update as at

11.06.14 Weekly

Variance

RAG (Risk adjusted) Value of Projects £

1,799 £

2,596 £

797 £ 3,080 £ 484

Value of In Year Opportunities £

3,683 £

3,493 -£

190 £ 3,499 £ 6

Number of Green Projects 16 29 13 39 10

Number of Amber projects 12 11 -1 6 -5

Number of Red Projects 30 22 -8 18 -4

QIPP source Full year In year RAG % RAG Cost £ 2,518 £ 2,064 £ 1,722 83% Income £ 1,467 £ 1,435 £ 1,357 95% Total £ 3,985 £ 3,499 £ 3,079 88% % cost QIPP 63% 59% 56%

£4,200

£2,731

£3,522

£ 3,101

£-

£500

£1,000

£1,500

£2,000

£2,500

£3,000

£3,500

£4,000

£4,500

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

£'00

0s

NCG QIPP 2013/14 actual vs, 2014/15 Risk Adjusted plus targets

Target 2014

2013/14 actual

In year project plans 2014/15 Cum 19th june


Delayed Transfers of Care

7

0 10 20 30 40 50 60 70 80

No.

Pat

ient

s

Average No. Patients medically fit but delayed

Ave MFFD

Target

0 5

10 15 20 25 30 35

May

Ju

ne

July

A

ugus

t S

epte

mbe

r O

ctob

er

Nov

embe

r D

ecem

ber

Jan-

04

Febr

uary

M

arch

A

pril

May

No.

Pat

ient

s

Average use of Discharge Lounge

Daily Average

before 12 midday,

Target < 20 patients for < 5 days

0 10 20 30 40 50 60

War

ds

NE

TWO

RK

ED C

AR

E

Hur

ley

Vic

toria

Lo

ddon

W

oodl

ey

Bur

ghfie

ld

Mor

timer

E

/Gre

en

Cav

ersh

am

UR

GE

NT

CA

RE

R

edla

nds

CC

U/J

SU

E

CU

W

hitle

y A

/E

Cas

tle

AM

U

Sid

mou

th

AS

U

Ann

exe

ICU

P

LAN

NE

D C

AR

E

Hop

kins

Li

ster

Tr

ueta

D

orre

ll H

unte

r K

enne

t S

onni

ng

Ade

laid

e H

eygr

oves

M

isc Pa

tient

s at

tend

ing

Use of Discharge Lounge May 2014

•Use of Discharge Lounge picked up in May. •New software to confirm patient suitable for DL instigated and DL protocol agreed by Executive Team

Target < 20)


URGENT CARE GROUP DASHBOARD

Patient Experience Finance

2014/15 Target pcm

2014/15 YTD Av pcm

2014/15 May

Yr End Forecast

2014/15 Target 2014/15 YTD 2014/15 May

Yr End Forecast

Patient Surveys 70 77 77 70 Pay against budget £0 £(0.19)m £(0.13)m

Complaints - 25 day response 85% 58% 76% 85% Non Pay against Budget £0 £0.24m £0.25m

Access & Activity Income against budget £0 £(0.05)m £(0.20)m

Clinical Outcomes People

Falls Prevalence <5 4.7 5.4 <5 Appraisal Rate 95% 86.4% 87.6% 95%

Pressure Ulcers 1.6 1.8 2.4 1.6 Sickness rate 2.80% 3.10% 3.20% 2.80%

Cdiff <1 0 0 <1 Vacancies 5% 3.80% 3.80% 3.00%

SI 2 1.5 1 2 MAST

85% 72.8% 72.0% 85%

Dr Foster Mortality Alerts No new alerts

8


9

URGENT CARE GROUP SUMMARY

Best patient outcomes: Performance is amber for the month of May, A&E achieved 96.11% for the reporting month of May. Paediatrics achieved 100% for cancer target in month however Respiratory had 4 breaches of the 2 week cancer wait due to access to CIN protocol x3, this is under investigation by the team to prevent future breaches. The radiology recovery plan is ahead of trajectory for CT and MRI, however there has been slippage in the ultra sound recovery due to staffing pressure, a revised recovery plan is being negotiated with the CCG. Direct access muscular skeletal work has caused a pressure point in the service The radiology manager is providing a detailed update to the commissioners to be submitted with the DMO1 return. Stroke achieved targets in month, cardiology continue to excel in door to needle times. The number of deliveries through Rushey Ward have decreased since March following the bed closures, these were to maintain safe levels to recommended safe levels. Best patient experience: 100% of patients with a TIA consistently being seen within 24 hours Sending women home following Propess for induction of labour has commenced. This improves the patient experience of induction of labour and will be audited within the next 3 months Hot floor portering pilot has improved the waiting times for patients requiring movement around and from the ED department. Best place to work, train &learn: The Lead Nurse for Acute Medicine has been appointed following a successful trial period, whereby complaints have reduced, appraisal and MAST training rates has increased. A Mental Health Coordinator has been appointed to support the increasing demand on Trust services and following the recommendations from the CQC Mental Health review. Best value Income behind plan due to underperformance of NEL paediatrics, despite activity appearing to be on plan . Now the budget is finalised, pay QIPPs are being finalised and will be profiled into the budget by month 3, as a result pay is showing an overspend currently. Non pay is overspent due to the rental MRI and CT scanners being used as part of the recovery plan. Bracknell Radiology for Urgent Care is over performing with a new income stream. 50 laptops have been rolled out to community midwives enabling capture of accurate PbR activity. Key Risks Lack of residential CAMHS places resulting in inappropriate care environment requiring specialised nursing staff. CQC risk rating of Maternity services. The unknown income position and reliability of data Estate issues in Maternity Ventilation/ air cooling in ICU Continued increased demand in radiology outstripping capacity CCG achieving QIPPS putting NEL income at risk Planned closure of Redlands 22 beds to accommodate development of theatres Continued closure of 2 birthing rooms on Rushey Midwifery led unit.

9


A&E Quality Indicators

Adults • Median wait arrival to treatment =62 minutes • 95th percentile from arrival to admission was 5hrs 27 min ↓ • 95th percentile from arrival to discharge was 3hrs 50min ↓ • 0.6% re attendance ↓ • 2.1% left without being seen

A&E Performance (Calendar Months)

A&E attendances in May are their highest level and 4.5% above last year. This total exceeds all but one of the winter months, which demonstrates how exceptionally busy A&E has been.

Type 1 – 8964 attendances – 382 breaches - 95.74%

April – 84.98% compliance to <15min handover 2444 handovers – 2*> 60mins

30-60mins – 16 – improvement on last month

Target Std Jul-

13 Aug-

13 Sep-

13 Oct-

13 Nov-

13 Dec-

13 Jan-

14 Feb-

14 Mar-

14 Apr-

14 A median wait

to assessment

above 15 minutes for ambulance

cases

15 mins 15 14 14 13 18 19 20 20 21 19

10


QIPP Delivery

11

-

1,000

2,000

3,000

4,000

5,000

6,000

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

£000

's

FY13/14

Cumulative phasing of Cost QIPP Delivery v Cost Target FY13/14

Cumulative FYE savings achieved to dateQIPP Cost Target

Forecast FY14/15 (Risk Adjusted)Actuals

Actions in place to deliver QIPP programme: New rota established in ED (commenced June) Service reviews complete (awaiting risk assessments) QIAs to be completed in June for Agency Medics Bed configuration project fully documented and ahead of savings plan

Cost Schemes

RAG RatingNo of Projects

In Year Value

Risk Adj Value

Projects with no Values

Red 11 1,354 339 2 Amber 9 1,768 1,029 - Green 13 872 843 -

33 3,993 2,211 2

Income Schemes

RAG RatingNo of Projects

In Year Value

Risk Adj Value

Projects with no Values

Red 3 - - 3Amber 8 1,053 543 0Green 2 242 242 0

13 1,295 785 3

Actions required to close the gap: Interim COO working with PwC on behalf of Care Group to identify further opportunities. Early indication that a review of Radiology is required. Review of drug usage to identify savings opportunities Further service reviews to be completed

11


3. Planned Care Group Dashboard

12

Patient Experience Finance

2014/15 Target pcm

2014/15 YTD Av pcm

2014/ 15 May

Yr End Forecast

2014/15 Target

2014/15 YTD

2014/ 15 May

Yr End Forecast

Patient Surveys >70 81.6 84 >70 Pay against budget £0 £(0.41m) £(0.51m)

£0

Complaints - 25 day response

>85% 50% 55% 85% Non Pay against Budget

£0

£0.01m £0.11m

£0

Access & Activity Income against budget

£0

£(0.11m) £0.35m £0

Clinical Outcomes People

Falls prevalence per 1000 <5.0 2.13 2.0 <5.0 Appraisal Rate 95% 83% 83% 95%

Pressure Ulcers per 1000 0.53 1.4 1.7 0.53 Sickness rate 2.8% 3.1% 3.0% 2.8%

Cdiff per case 0.5 0 0 0.5 Vacancies 5% 12.5% 12.8% 5%

SI 0 0.5 1 0.08 MAST

85% 70.2% 71.4% 85%

Dr Foster Mortality Alerts 0 0 0 0


Care Group Exceptions

13

13

Access targets Cancer The validations are still to be completed . The 2ww target has been achieved for the month but the quarter remains at risk. There are 2 main issues that have been identified:- capacity in endoscopy clinics. There has been a reduction in locum cover, which will be recovered from 1st August, In the meantime this has been replaced for only 1 day a week. Breast is also an issue with patient choice having had the most significant impact. Clinic capacity has also caused a number of breaches. Breast adhoc additional clinics will continue to be provided at Spire Dunedin. The 62 day target is also under threat this month and the major concern on the 62 day pathway is the diagnostic element. The waiting times for scans is in excess of 2 weeks. The team continues to work hard to achieve compliance. Business case for an onco-plastic breast surgeon is being developed to improve performance. We have also had a number of complex patients this month in gastroenterology which have had an adverse impact on performance – see exception report in appendices. 31 day subsequent surgery has 2 failures and these are unvalidated but expected to pass. 18 weeks The 18 week targets for non admitted and incomplete pathways have been achieved. Admitted target has not been achieved for ophthalmology as it continues to reduce the backlog in line with the agreed action plan with CCG’s. General surgery has also failed to meet the admitted pathway target due to the number of long waiting upper GI cases. People The appraisal rate has remained constant at 83%. This rate remains below the Trust target however and continues to be a priority area for the management team. Mandatory training continues to slowly improve and now stands at 71.4%. Sickness absence has dropped slightly to 3% and agency spend has remained steady this month at 5.6%. Outcomes The trend in improvement for care group mortality continues with natural variation. Radiotherapy is showing 1 reportable incident however this is due to a change in reporting standards and all re-imaging to be reported. No patients were harmed.


Care Group Summary 14

Patient Experience The number of complaints received has decreased from 24 in April and 20 in May 2013 to 13 for May 2014. The main themes are communication and treatment by doctors followed by clinical treatment of doctors and administration issues. The PALS continue to be centered around the administration and access to appointments. The number of complaints responded to in 25 days has improved to 55%. There was 1 serious incident recorded. There were no reportable cases of c-diff. The net promoter score for May is 82 with a rolling average of 83. Finance The Care Group made a surplus of £1.94m in May compared to a budget of £1.99m. Income was ahead of budget by £0.35m, however, pay costs were overspent by £0.51m. Work is ongoing to reduce headcount and agency spend to bring pay costs back into line. Activity Activity is running at 3% below plan YTD. The main areas for variance are non elective activity for gastro which is below plan for month (97 cases) due to changes in pod rota. T+O is below plan 38 cases for electives and 60 day cases.


15

Cancer Targets 15

Target

England Q4

RBFT Q4 RBFT 13/14

Apr-14 May-14

Final Final Final Final Predicted

Two Week Wait 93% 95.0% 93.0% 93.6% 88.1% 93.5%

2 week wait breast symptom

93% 93.9% 93.3% 94.0% 87.4% 89.2%

31 day 1st treated

96% 98.0% 97.1% 98.2% 97.1% 99.4%

31 day Chemo. 98% 99.6% 99.5% 99.5% 100% 100%

31 day Surgery 94% 96.8% 95.5% 96.6% 95.5% 90.5%

31 day Radiotherapy

94% 97.1% 96.2% 97.8% 100% 96.4%

Other 94% 100% 100% 100% 100% 100%

62 day (2ww) 85% 84.4% 85.1% 86.7% 85.6% 73.0%

62 day screening 90% 94.2% 88.4% 92.2% 90.0% 89.5%

62 day upgrade Not pub

92.0% 100% 90.6% 50.0% 100%

UNVALIDATED POSITION Performance 2ww performance has achieved target for May however the quarter is under threat due to high rates of patient choice re holidays and ongoing capacity issues in Gastroenterology. 62 day performance also remains a concern and we’re reliant on very fast treatment once diagnosed and staged Abdominal Surgery - Capital bids have been submitted for the US machine licence, colposcopy couch, colposcopy stacks and additional hysteroscopy kit. - One stop hysteroscopy will start at WBCH at 1 clinic per month in July - Business case for an extra colposcopy list has been approved - Gastroenterology locum recruited whilst 2 substantive recruitments work their notice - Urology are now 0.5 consultant and 1 reg down compared to last year - Business case for another onco-plastic breast surgeon being developed Lung - EBUS is now provided locally Radiology - Meetings with WLO take place twice a week -Extra lists being run at Dunedin Other -PET provision continues to be a concern, Patients should be scanned in 5 days, reported in 2 as per national guidelines but is currently 3-4 weeks total. 2nd PET scanner is now due in September. Oxford have expanded their working day and operate it 6 days a week. - Prostate pathway being redesigned to offer joint Uro-oncology clinics and reduce FUs. Planned implementation is Sept. Informatics help to show how the change affects FU patterns is vital.


Planned Care Group – 14/15 QIPP Summary 16

0.0

1,000.0

2,000.0

3,000.0

4,000.0

5,000.0

6,000.0

7,000.0

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

£000

's

FY14/15

Cumulative phasing of Cost QIPP Delivery v Cost Target FY14/15

Cumulative FYE savings achieved to date

QIPP Cost Target

Forecast FY14/15 (Risk Adjusted)

Actuals

Please note that M03-M12 are shown as forecast

Cost Income

Risk adjusted value £3.311m £6.266m

YTD £211k £804k

No of schemes 43 35

Planned Care CIP Target is currently £6.3m (to be verified) = £2.7m risk adjusted shortfall

Presentation title here • Planned Care achieved £753k of CIPS and Income in M02.

• CIP highlights in M02 included: Reduction in Furniture and Fittings Expenses achieved £22.2k in Month 02; the grouping of procurement projects worth under £10k contributed £18.6k; Change of Spinal Kit saved £8.3k; and Prosthesis carry forward achieved £51.3k. • Income highlights in M02 included: Orthopaedics Coding contributed £306k (M01 and M02 combined); Virtual Fracture Clinics in Bracknell achieved £15.7k; Ophthalmology Outpatients raised £26.9k from the Outpatient Clinic Utilisation work; Fibroscans achieved £19.8k; and PCEU Theatres contributed £21.1k as part of the Theatre Programme, over double the forecast for the month.

• Actions (governance paperwork and validation of figures) have been taken to raise the risk rating for projects in 'development'. The risk adjusted figure has gone down since last month as more projects have been placed into 'implementation', so the actuals have taken over and where they are lower than forecast, the risk rating has gone down.

• Please note that not all schemes have figures against them (Cost projects currently have the potential to achieve £4.889m In Year).

• The PMO are currently working with Project Leads to raise the risk adjusted figures - Large project work streams are being set up; project teams and actions are being initiated; governance paperwork is being finalised; and financials and phasing are being calculated

Planned Care Group – 14/15 schemes 17

1

Board of Directors

Title: Director of Finance Report

Date: 30 June 2014

Lead: Craig Anderson

Purpose: To update the Trust Executive and Board on the financial results of the Trust for May 2014

Decision Required:

To NOTE the contents of this report

Agenda Item 6d

2

Executive Summary Financial Targets The financial aim for 2014/15 is to maintain an CSRR of 3 through:

- Delivering a £1.0m deficit; Driving Planned Care recapture of market share and growth of private patients; Delivering cost QIPPs of £18.5m; Maintaining cash above £8m; Managing capital spend

Area of Review

Key Highlights Month Rating

COSRR COSRR of two with a £0.84m gap to three. Driven by EBITDA and cash.

EBITDA EBITDA : £1.12m, 3.85% in M02, £0.14m behind Budget. Activity / Income : Income ahead of budget £0.10m driven by Specific drug funding £0.14m higher than budget. £o.5m accrual made to cover “missing” activity. Pay Costs : £17.30m, £(0.12)m adverse to budget in month, driven Admin & Management,Ancillary & Maintenance and other pay. Essentially non-delivery of pay cost QiPPS Drugs : Income better than budget (up £0.10m). Cost higher than budget (£(0.21)m) Non Pay exc Drugs : £0.09m better than budget driven by all lines with the exception of Clinical supplies & services, Establishment expenses and Miscellaneous Services. Note contingency of £0.2m in budget. QIPPs : Full year cost QIPPs in budget of £18.5m. Full year savings achieved to date of £1.37m.

Liquidity / Cash

Cash of £17.64m, £1.4, better than budget £16.20m. Delay in receipts from CCG’s offset by delay in Cerner payment and lower than expected creditor payments.

Capital YTD expenditure of £1.11m with a further £1.94m committed, totalling £3.05m., out of full year budget of £12.5m.

3

1. Financial Position

Overall Financial Performance - close to budget, but we need to make large savings if we are to stay there.

A detailed statement of comprehensive Income is attached at Appendix (Vii)

Key messages:

• Income on budget, but significant concerns as to whether all activity is being captured and coded correctly. £0.5m accrued to reflect these concerns

• Pay flat v last month. The key issue remains that if we continue at this rate full year will be £5m more than budget

• Good progress on RAG rated QIPP estimate, next week’s update expected to be over £10m. But still another £9m to go

• Risk to PCG income because of delay in being able to place order for theatres

• No evidence of delivery of CCG Qipps • COSRR 2 • Cash above budget and position expected to improve in June.

Care Group/Corporate Results vs Budget in month • UCG behind Budget with income £0.20m, pay £(0.40)m and

non-pay £(0.40)m • PCG ahead of budget on income £0.35m, pay £0.12m and

non-pay £0.00m. • NCG ahead of Budget with income £0.10m, pay £(0.20)m

and non-pay £(0.12)m • Corporate Services less than Budget

Results for Month 2£m

Actual Vs Budget Actual Vs BudgetIncome 29.18 0.10 57.02 0.07

Pay (17.30) (0.42) (34.60) (0.44)

Drugs (3.16) (0.21) (6.16) (0.38)

Non Pay ex Drugs (9.02) 0.39 (18.12) 0.64

Other (0.52) (0.01) (1.04) (0.02)

Exceptional Items (0.00) (0.00) (0.01) (0.00)

Surplus/(Deficit) (0.83) (0.15) (2.91) (0.13)

COSRR 2.0

Actual Budget Actual Budget

Cashflow from Operations 0.32 (1.80)

Cash 17.64 16.20 17.64 16.20

EBITDA 1.12 1.27 1.00 1.12

EBDITDA margin 3.8% 4.4% 1.7% 2.0%

Net Surplus/(Deficit)

Actual £mVs Budget

£m Actual £mVs Budget

£mUrgent Care 1.32 (0.58) 3.44 (0.47)

Planned Care 1.94 (0.05) 3.64 (0.51)

Networked Care 1.12 (0.05) 2.03 (0.23)

E&F (1.69) 0.14 (3.47) 0.27

Corporate Services (3.53) 0.39 (8.56) 0.81

Total Trust (0.83) (0.15) (2.9) (0.13)

MONTH YTD

MONTH YTD

MONTH YTD

4

Income on budget overall, although income from activities £0.21m behind.

Key Messages • Income from activities £0.21m below budget, with UCG

below by £0.20m and PCG (excl effect of prior period budget adjustment ) below by £0.15m , offset by NCG £0.10m above budget.

• PCG budget for new theatres amended so theatres now phased to commence at start of Q3.

• Concerns voiced by care groups that activity not being counted / coded. £0.5m accrued centrally to reflect this whilst issues investigated.

• CQUINs included at 90% • Provisions for diagnostic imaging and first to follow ups

eliminated. • Provision made for risk on NEL marginal rate for

providers other than BWCCG’s • Risk that income for Physician of the Day (“POD”) is not

being split correctly between the three care groups • Freeze date for M1 income/activity imminent, risk of loss

of income if all changes to counting and coding not made in time

• No evidence of delivery of CCG Qipps • Order for new theatres to be placed once final response

from Monitor received Actions • POD income: derive change in budget targets resulting

from change in POD rotas HA/CA • Ensure informatics resource is adequately targeted to

ensure that issues that will affect contract invoices are addressed before flex and freeze dates. HA

• Drive delivery of theatres and of planned care income growth PM

• Drive income from activities SE/LB • Track activity for evidence of delivery of CCG Qipps

PM/SE/LB

Income

Actual £mVs Budget


£mIncome from Activities 24.58 (0.21) 47.95 (0.67)

Drug Income 2.48 0.14 4.89 0.50

Other Patient Care Income 0.33 (0.07) 0.67 (0.13)

Other Operating Income 1.79 0.24 3.50 0.37

Total Income 29.18 0.10 57.02 0.07

MONTH YTD

23.00

25.00

27.00

29.00

31.00

33.00

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

Monthly Income £m

2013/14 Actual

2014/15 Actual

2014/15 Budget

2014/15 Q1F

0.95

1.00

1.05

1.10

1.15

1.20

1.25

1.30


Average Daily income £m

2013/14 Actual

2014/15 Actual

5

Pay costs close to budget, but not sustainable at the current run rate

Key Messages • Pay flat v last month. Up 3% YTD

compared to same period last year. Medical staff up 5%. Admin & Management up 12% due to IT contractor costs now going to Pay rather than Non Pay.

• If Pay continues at this rate full year cost will be £5m more than budget.

• All pay categories showing better than budget other than Other Pay, which is where QIPP targets are held. This gives risk that active cost centres could recruit up to budget and drive overall Trust pay over budget.

• Variability in extent of development in Pay QIPP plans, with PCG the most advanced.

Actions

• All new requests for recruitment being validated by Finance that they are within cost centre budget.

• All pay QIPPs to be driven down to active cost centres

• All vacancies that pre date Finance check on budget to be cancelled and re-requested, so that we can be sure that recruitment will not drive cost centres over budget.

15.00

15.50

16.00

16.50

17.00

17.50

18.00


Monthly Total Pay £m

2013/14 Actual

2014/15 Actual

2014/15 Budget

2014/15 Q1F

Pay Costs £m

Group Description M12 2014 M01 2015 M02 2015 MoM var Month vs Budget

YTD vs Budget

Medical Staff (4.58) (4.85) (4.98) (0.13) 0.13 0.38

Nursing (6.98) (6.77) (6.98) (0.22) 0.34 0.88

PAMs (0.92) (0.95) (0.94) 0.01 0.05 0.07

Scientist and PTBs (1.05) (1.08) (1.06) 0.02 0.08 0.13

Pharmacists (0.19) (0.19) (0.20) (0.01) 0.00 0.01

Admin & Management (2.50) (2.54) (2.43) 0.11 0.03 0.08

Ancil lary & Maintenance (0.78) (0.76) (0.78) (0.02) (0.03) 0.02

Other Pay (0.03) (0.18) 0.14 0.31 (0.64) (1.63)Pay (17.03) (17.30) (17.23) 0.07 (0.04) (0.06)

Of Which: Agency (1.00) (1.02) (1.04)

Agency as a % of Total Pay 5.8% 5.9% 6.0%

Bank as a % of Total Agency 27% 15% 28%

Pay Costs £m

By Care Group/Directorate M12 2014 M01 2015 M02 2015 MoM var Month vs Budget

YTD vs Budget

UCG (5.67) (5.42) (5.74) (0.32) (0.40) (0.46)

PCG (5.53) (5.62) (5.61) 0.01 0.12 0.22

NCG (3.67) (3.63) (3.75) (0.12) (0.20) (0.27)

Total Care Group (14.87) (14.68) (15.11) (0.43) (0.48) (0.52)

Estates & Facil ities (0.82) (0.82) (0.83) (0.00) (0.03) 0.02

Chief Nursing Officer (0.29) (0.25) (0.26) (0.00) 0.01 0.03

Chief Medical Officer (0.22) (0.26) (0.25) 0.00 (0.01) (0.03)

Corporate Affairs (0.07) (0.06) (0.06) 0.00 0.01 0.01

Commercial Directorate (0.03) (0.03) (0.03) (0.00) (0.01) (0.02)

Finance (0.08) (0.27) (0.30) (0.03) (0.00) 0.02

Chief Exec & Non-Execs (0.02) (0.02) (0.01) 0.00 0.00 0.00

Human Resources (0.19) (0.18) (0.18) 0.01 (0.01) (0.03)

Corporate - Other (0.04) (0.28) 0.12 0.40 0.50 0.59

Capital Charges & PDC Dividend 0.00 0.00 0.00 0.00 0.00 0.00

IT (0.40) (0.45) (0.32) 0.13 (0.02) (0.16)

TOTAL Other (2.16) (2.62) (2.12) (0.46) 0.44 0.45 Pay (17.03) (17.30) (17.23) 0.07 (0.04) (0.06)

VS BUDGET

VS BUDGET

6

Non Pay Costs – Drugs – Over budget but partially offset by Drugs Income

Key Messages • £0.21m over budget, but £0.14m offset by Drugs Income

better than budget

Drugs £(0.21)m adverse to Budget • YTD Drugs income as a percentage of cost at 72.6% is

better than budget, 70.5%

Drugs £(0.21)m higher vs Budget • PCG £(0.12)m adverse including Gastroenterology drug

issues, the majority will be PbR excluded. • NCG £(0.09)m adverse. • UCG £(0.03)m adverse

Actions • QIPP projects on Waste management , aseptic unit.LB

1.80

2.00

2.20

2.40

2.60

2.80

3.00

3.20


Monthly Drugs spend £m

2013/14

2014/15 Actual

2014/15 Budget

2014/15 Q1F

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%


Monthly Drugs Income %

2013/14

2014/15 Actual

2014/15 Budget

2014/15 Q1F

Non Pay - Drugs

Actual £mVs Budget


£mUrgent Care (0.28) (0.03) (0.53) (0.03)

Planned Care (1.43) (0.12) (2.91) (0.29)

Networked Care (1.44) (0.09) (2.71) (0.14)

Other (0.02) 0.03 (0.02) 0.08

Total Drugs (3.16) (0.21) (6.16) (0.38)

MONTH YTD

7

Non Pay Costs – Excluding Drugs better than budget at Trust level, but £0.5m worse than budget in care groups

Key messages

• Better than budget in month on most cost lines, but not surprising given most non pay QIPPs still held within Miscellaneous Services

• Phasing hedge on QIPPs previously held in Corporate now held out in Care Groups, so Care Group budgets look easier now, but will look correspondingly more challenging in second half of the year.

• Year to date worse than budget in Misc Services, driven by unbudgeted Newtons cost in CMO and VAT expense (which will even up against budget later in the year). Offset by centrally held contingency.

• Year to date better than budget in Other Corporate driven by centrally held contingency and budget QIPP adjustment between pay and non pay.

Actions

• Drive delivery of cost QIPPs All exec directors

7.00

7.50

8.00

8.50

9.00

9.50


2013/14

2014/15 Reported

2014/15 Budget

2014/15 Q2F

Non Pay ex Drugs

Actual £mVs Budget


£mClinical Service & Supplies (3.53) (0.06) (6.88) 0.10

General Supplies & Services (0.53) 0.07 (1.03) 0.22

Establishment Expenses (0.43) (0.10) (0.72) (0.05)

Other Establishment Expenses (0.78) 0.05 (1.61) 0.03

Prem, Trans & Fixed Plant (1.23) 0.16 (2.72) 0.20

Depreciation (1.43) 0.01 (2.86) 0.02

Leases (0.05) 0.14 (0.16) 0.22

Miscellaneous Services (1.03) (0.17) (2.16) (0.39)

Total Non Pay ex Drugs (9.02) 0.09 (18.12) 0.34

MONTH YTD

Non Pay ex Drugs

Actual £mVs Budget


£mUrgent Care (1.22) (0.40) (2.04) (0.38)

Planned Care (2.19) 0.00 (4.30) 0.07

Networked Care (1.19) (0.12) (2.55) (0.38)

Estates & Facilities (1.07) 0.08 (2.22) 0.14

HFMS 0.08 0.03 0.16 0.06

Other Corporate (3.44) 0.50 (7.16) 0.83

Total Non Pay ex Drugs (9.02) 0.09 (18.12) 0.34

MONTH YTD

–

8

FY Cost QIPPs budgeted at £18.5m for FY 14-15

Following recent adjustments to Care Group and Corporate budgets, individual QIPP targets have been amended. The overall target now totals £18.94m.

The Trust has identified £14.2m of ideas / plans to date towards the year end target. This is less than last month following PMO validation of the ideas (some of which were either not feasible, or the values were reduced once further work was undertaken). The latest PMO risk assessment of the £14.2m of cost plans is £9.3m, and therefore there remains a gap of £9.6m between the current risk assessed position and the year end target.

PwC have now completed their initial high level review of QIPP opportunities and are satisfied that the Trust is already developing plans in all the areas they would expect. However their review suggests that a further £4m (conservative view) of additional opportunity is possible from the projects already underway, where the work could be accelerated or the scope widened. The Executive have commissioned PwC to support 5 different work streams over the next 2 months which will commence 23rd June. Support will be given in developing detailed plans and improving processes that will provide a means for realising benefits.

In the meantime, work continues in all 9 of the trust wide / transformational projects. Bi weekly performance meetings are continuing to take place with all Care Groups with close scrutiny of all the projects being delivered on a line by line basis.

Care Group budgets have been amended to reflect realistic phasing of cost QIPP delivery. From next month this report will include a graph to show actual delivery by month against the trajectory for the year.

The current PMO risk rating of the QIPP Programme is £9.3m against a cost target of £18.94m. Additional support has been commissioned from PwC over the next 2 months.

Downside Cash Position: delivery of Trust Qipps essential if we are to avoid running out of cash

Assumptions • No trust QIPPs included. QIPPs will be

recognised when delivered • Tariff Deflator 1.2% • Theatres live in M9 14/15 • Pay 1% • General inflation 2.5% • Drug cost/income 4% • CCG Qipps FY15 £8.2m, FY16 £7.7m

Key Messages • If CCGs do not deliver their QIPP

cash runs out in Q2 FY16 • If CCG’s deliver their QIPP cash runs

out in Q1 FY16

Cash Balance Downside Forecast balances by quarter (£'m)

Scenario 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3Annual Plan 11.97 8.40 13.17 22.03 17.30 15.78 18.55

Flat Cash 17.52 6.52 7.10 7.03 0.77 (10.71) (14.97)

CCG QIPPS 17.61 5.96 4.99 3.47 (4.82) (18.22) (24.32)

CCG Act Growth 17.61 6.87 7.72 8.94 3.56 (6.91) (10.10)

10

Appendices

The following reports are included in the supplementary pack: Appendix (i) Statement of Comprehensive Income Appendix (ii) Statement of Comprehensive Income (SOCI): Month vs Budget – By Area Appendix (iii) Care Group Financials Appendix (iv) Income by Point of Delivery Appendix (v) Statement of Financial Position (SOFP) Appendix (vi) Cash Flow Statement Appendix (viii) Capital Expenditure Summary Appendix (ix) Continuity of Service Risk Rating Appendix (x) Service Line Reporting - Update

1

Appendix (i) Statement of Comprehensive Income Appendix (ii) Statement of Comprehensive Income (SOCI): Month vs Budget – By Area Appendix (iii) Care Group Financials Appendix (iv) Income by Point of Delivery Appendix (v) Statement of Financial Position (SOFP) Appendix (vi) Cash Flow Statement Appendix (viii) Capital Expenditure Summary Appendix (ix) Continuity of Service Risk Rating Appendix (x) Service Line Reporting - Update

Director of Finance Report May 2014 Appendices

DOF Report Craig Anderson

2

Appendix (i) Statement of Comprehensive Income for Month 02

£'m Act Budget PY vs Budget vs PY Act Budget PY vs Budget vs PYIncome from Activities 27.06 27.13 27.12 (0.08) (0.06) 52.84 53.01 51.78 (0.17) 1.06 Primary Care Trusts Income 24.58 24.79 25.20 (0.21) (0.62) 47.95 48.62 47.92 (0.67) 0.04 Specific Drug Funding 2.48 2.34 1.91 0.14 0.56 4.89 4.39 3.87 0.50 1.02 Drugs Income 2.24 2.15 1.71 0.10 0.54 4.47 4.02 3.51 0.46 0.96 Drugs Income - Infliximab 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Drugs Income - Herceptin 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Devices Income 0.24 0.19 0.21 0.04 0.03 0.41 0.38 0.35 0.04 0.06 Department Of Health Income 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Other Patient Care Income 0.33 0.40 0.37 (0.07) (0.04) 0.67 0.81 0.75 (0.13) (0.07)Other Operating Income 1.79 1.54 1.59 0.24 0.19 3.50 3.13 3.11 0.37 0.39

Total Income 29.18 29.08 29.08 0.10 0.10 57.02 56.95 55.64 0.07 1.38 Medical Staff (4.98) (5.11) (4.74) 0.13 (0.24) (9.82) (10.20) (9.34) 0.38 (0.49)Nursing (6.99) (7.32) (6.88) 0.33 (0.12) (13.76) (14.63) (13.84) 0.87 0.08 PAMs (0.94) (0.99) (0.90) 0.05 (0.03) (1.89) (1.96) (1.79) 0.07 (0.10)Scientist and PTBs (1.06) (1.14) (1.03) 0.08 (0.03) (2.14) (2.26) (2.09) 0.13 (0.04)Pharmacists (0.20) (0.20) (0.19) 0.00 (0.01) (0.38) (0.40) (0.38) 0.01 (0.00)Admin & Management (2.50) (2.45) (2.23) (0.04) (0.26) (5.04) (5.04) (4.44) 0.01 (0.59)Ancillary & Maintenance (0.78) (0.75) (0.72) (0.03) (0.06) (1.53) (1.55) (1.51) 0.02 (0.03)Other Pay 0.14 1.08 (0.04) (0.94) 0.17 (0.04) 1.89 (0.08) (1.93) 0.04

Total Pay (17.30) (16.88) (16.72) (0.42) (0.58) (34.60) (34.16) (33.46) (0.44) (1.14)Drugs (3.16) (2.96) (2.65) (0.21) (0.51) (6.16) (5.78) (5.09) (0.38) (1.07)Clinical Service & Supplies (3.53) (3.47) (3.11) (0.06) (0.42) (6.88) (6.97) (6.56) 0.10 (0.31)General Supplies & Services (0.53) (0.60) (0.60) 0.07 0.06 (1.03) (1.24) (1.25) 0.22 0.23 Establishment Expenses (0.43) (0.33) (0.37) (0.10) (0.06) (0.72) (0.67) (0.64) (0.05) (0.08)Other Establishment Expenses (0.78) (0.83) (0.93) 0.05 0.14 (1.61) (1.64) (1.63) 0.03 0.02 Prem, Trans & Fixed Plant (1.23) (1.39) (1.47) 0.16 0.23 (2.72) (2.92) (3.24) 0.20 0.53 Depreciation (1.43) (1.44) (1.37) 0.01 (0.06) (2.86) (2.88) (2.71) 0.02 (0.16)Leases (0.05) (0.19) (0.09) 0.14 0.03 (0.16) (0.38) (0.17) 0.22 0.01 Miscellaneous Services (1.03) (1.16) (0.80) 0.13 (0.23) (2.16) (2.07) (1.65) (0.09) (0.51)

Total Non Pay (12.18) (12.37) (11.38) 0.18 (0.80) (24.28) (24.54) (22.94) 0.26 (1.34)PDC Dividend (0.42) (0.42) (0.42) 0.00 (0.00) (0.84) (0.84) (0.83) 0.00 (0.01)Interest Receiveable (0.10) (0.09) (0.10) (0.01) (0.00) (0.20) (0.18) (0.20) (0.02) (0.00)

Total Other (0.52) (0.51) (0.52) (0.01) (0.01) (1.04) (1.03) (1.03) (0.02) (0.01)Exceptional (0.00) (0.00) (0.00) (0.00) 0.00 (0.01) (0.00) (0.01) (0.00) 0.00

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Net Surplus/(Deficit) (0.83) (0.68) 0.45 (0.15) (1.28) (2.91) (2.78) (1.80) (0.13) (1.11)

Month YTD

Appendix (ii): Statement of Comprehensive Income - By Area

3

M02

Month £m Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs BudIncome 8.56 (0.20) 11.19 0.35 7.50 0.10 27.24 0.24 0.22 0.01 1.72 (0.14) (0.01) (0.01) 29.18 0.10 Pay (5.74) (0.40) (5.62) 0.11 (3.76) (0.20) (15.12) (0.49) (0.83) (0.03) (1.36) 0.40 0.00 0.00 (17.30) (0.12)Non-Pay (1.49) (0.43) (3.62) (0.11) (2.63) (0.22) (7.74) (0.76) (1.09) 0.08 (3.44) 0.53 0.08 0.03 (12.18) (0.12)Other 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 (0.46) (0.02) (0.07) 0.01 (0.52) (0.01)Exceptional 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) 0.00 0.00 (0.00) (0.00)

Net Surplus/(Deficit) 1.32 (1.03) 1.94 0.34 1.12 (0.32) 4.38 (1.01) (1.70) 0.06 (3.53) 0.77 0.01 0.04 (0.83) (0.15)

M02

YTD £m Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs BudIncome 17.17 (0.05) 22.09 (0.11) 14.68 0.30 53.94 0.14 0.45 0.03 2.63 (0.09) (0.00) (0.00) 57.02 0.07Pay (11.16) (0.46) (11.25) 0.21 (7.39) (0.28) (29.80) (0.53) (1.65) 0.02 (3.15) 0.37 0.00 0.00 (34.60) (0.14)Non-Pay (2.56) (0.41) (7.21) (0.22) (5.26) (0.52) (15.03) (1.15) (2.24) 0.14 (7.17) 0.90 0.16 0.06 (24.28) (0.04)Other 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 (0.86) 0.02 (0.19) (0.04) (1.04) (0.02)Exceptional 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 (0.01) (0.01) 0.00 0.00 (0.01) (0.00)

Net Surplus/(Deficit) 3.44 (0.92) 3.64 (0.12) 2.03 (0.50) 9.11 (1.54) (3.44) 0.20 (8.56) 1.19 (0.03) 0.02 (2.91) (0.13)

Total Care Groups

Corporate Services HFMS RBFT

Urgent Care Planned Care NetworkCare Estates & Facilities Corporate Services HFMS RBFT

Urgent Care Planned Care NetworkCare Estates & FacilitiesTotal Care Groups

Appendix (iii) : Care Group Financials - NCG


4

FINANCIAL YEAR 2014/15 - COMPARISON OF NETWORKED CARE ACTUAL RESULTS TO BUDGET

Actual BudgetVariance to

Budget Actual BudgetVariance to

Budget

Income from activities (excl drugs) 6.08 6.08 0.00 11.96 11.96 -0.01

Drugs Income 1.17 1.10 0.08 2.18 1.97 0.21

Other Patient Care Income 0.06 0.07 -0.01 0.13 0.15 -0.02

Other Operating Income 0.19 0.15 0.03 0.42 0.31 0.11

Total Income 7.50 7.40 0.10 14.68 14.39 0.30

Medical Staff -1.01 -1.01 0.00 -2.01 -2.01 0.00

Nursing -1.17 -1.23 0.05 -2.33 -2.45 0.12

PAMs -0.32 -0.34 0.02 -0.64 -0.69 0.05

Scientist and PTBs -0.78 -0.71 -0.07 -1.50 -1.41 -0.09

Pharmacists -0.18 -0.19 0.01 -0.35 -0.39 0.03

Admin & Management -0.28 -0.29 0.01 -0.56 -0.58 0.02

Ancillary & Maintenance -0.01 -0.01 0.00 -0.03 -0.02 -0.01

Other Pay (Excl Pay Savings) 0.01 0.02 -0.01 0.02 0.03 -0.01

Pay Savings 0.00 0.22 -0.22 0.00 0.40 -0.40

Total Pay -3.76 -3.56 -0.20 -7.39 -7.11 -0.28Pay as % of income 50% 48% 50% 49%

Drugs -1.44 -1.35 -0.09 -2.71 -2.57 -0.14

Clinical Services and Supplies -0.92 -0.98 0.07 -2.03 -1.99 -0.04

General Services and Supplies -0.04 -0.04 0.00 -0.06 -0.08 0.01

Establishment Expenses -0.04 -0.04 0.01 -0.08 -0.09 0.00

Other Establishment Expenses 0.00 0.00 0.00 -0.01 0.00 -0.01

Prem, Trans & Fixed Plant -0.05 -0.05 0.00 -0.09 -0.11 0.03

Leases 0.00 0.00 0.00 0.00 0.00 0.00

Miscellaneous Services (Excl Savings & Internal Recharges) -0.14 -0.26 0.13 -0.26 -0.40 0.14

Non Pay Savings 0.00 0.05 -0.05 0.00 0.25 -0.25

Internal Recharges -0.01 -0.01 0.00 -0.01 -0.01 0.00

Total Non Pay (excl depn) -2.63 -2.69 0.06 -5.26 -5.01 -0.25

Operating Surplus (Loss) 1.12 1.16 -0.05 2.03 2.26 -0.23

Margin (Surplus/ Loss as a % income) 15% 16% 14% 16%

MONTH 02 MONTH 02 YTD

Appendix (iii) : Care Group Financials - NCG


5

Financial position Commentary: Key risks to financial performance

During May, there is a pay deficit due to budgeted savings which have not been achieved. It is imperative that outstanding savings plans are defined and that holds on implementation of plans are addressed as a matter of urgency.

In May, Networked Care achieved a surplus of £1.116m.

•The Care Group Board is discussing, approving and supporting the directorates as they draft their options to save 4% of pay. QIA and PIDs are being written with the PMO where required, early implementation of projects is critical to Networked Care achieving savings of £4.2m during 14/15.

Income: Overall as a Care Group, CCG activity income was in line with budget. However, there are still two main areas of concern regarding income reporting, both have been highlighted to the informatics team.

•There are as yet no firm actions to reduce non-pay. Concentration is required to control the clinical supplies costs in microbiology, biochemistry, renal and audiology, within their budget.

- Elderly Care (£206k Adverse) - NEL and NEL excess bed day activity are below budget (26% & 55% respectively). This is being investigated by the informatics team.

• Ensuring the recording of all activity remains as high priority for the Care Group - we continue to focus on the audiology pathway and general uncoded activity and patients 'not checked out' on EPR to be assured that all activity is being captured and invoiced to the CCG.

- Renal Other income (£146k Adverse) - Renal PD activity (£59k Adv Ytd) and post transplant (£29k Adv Ytd). It is understood that PD activity started to reduce latter half of last year, the budgets were established using the first 6 months of the year. Key Opportunities/ActionsRehab/ Neurology income is below the planned level. In part, this is driven by reduced clinics in month. Investigation by the informatics team is to be undertaken to explain the remaining deficit to plan.

• Rationalise, organise and monetise the home delivery of medicines to patients. Business Case is being prepared for approval week commencing 23rd June.

Rheumatology, Endocrinology and General Medicine NEL outperformed the budget in month by £355k, £127k and £236k respectively. • Re-present the service developments not agreed by the CCG for funding e.g. surgical liaison officer

Pay: • Review of the productivity and the skill mix of the Audiology team and establishment of new and expanding services in Bracknell

Medics: As a Care Group, Medics pay has come in on budget this month. Elderly care medics costs have come in £2k above budget - the position includes Acute Stroke costs.

• Signing of the Partnership agreement with Surrey Pathology services to provide consolidated gynae cytology services.

Neuro Rehab medics costs are £7k adverse to variance due to Stroke trainee's being paid in this cost centre. Transfer of costs and budget are yet to go to UCG as there are issues with stroke income apportionment between the Care Groups which are yet to be resolved. • Implementation of the agreed pay reduction options. • Review the stock control systems in microbiology, biochemistry and audiologyDermatology medics budget uplifted in month to reflect 2 x GPs on RBFT payroll this year who were part of bought in TVIC contract last year. • Integrated procurement with the Trusts hoping to create Berkshire Surrey pathology partnership. • Controlled approval of Non Clinical agency Nursing: Nursing pay is £51k favourable against budget this month.

Elderly Care are costs are operating below budget in month, the new nursing skill mix is fully reflected in the budget. Agency costs are down on last month, however bank is up by 46% (£23k) coming through against Elderly Care wards/ Rehab/ MIU and Renal Victoria.Scientists: Scientists pay spend is £67k above budget in month, £55k of this is redundancy payments. Non Pay:Pathology Consumables are adverse to budget again this month.

Initial reviews of the stock ordering, receipting and holding processes indicate that there are some timing differences where goods are ordered in qtrly and that stock holding is limited. The next step is to look at the procurement of these goods and to quantify the financial impact of some of the larger changes to practice or activity that have occurred over the last year, for example increases in Chlamydia screening activity and the introduction of more comprehensive test kits for screening. Audiology digital hearing aid spend is significantly down on last month when we saw costs over and above the average spend level. The purchases are receipted through the stores service, causing timing issues.Rheumatology Drugs expenditure was over budget in month, this is offset by corresponding drugs income.

Appendix (iii) : Care Group Financials - PCG


6

FINANCIAL YEAR 2014/15 - COMPARISON OF PLANNED CARE ACTUAL RESULTS TO BUDGET

6 6 6 YTD_M06 YTD_M06 YTD_M06

2014 2014 2014 2014 2014 2014

Actual Budget Variance Actual Budget Variance

Income from activities (excl drugs) 9.76 9.45 0.32 19.15 19.48 (0.33)

Drugs Income 1.14 1.08 0.06 2.40 2.11 0.29

Other Patient Care Income 0.15 0.22 (0.07) 0.31 0.45 (0.14)


Total Income 11.19 10.84 0.35 22.09 22.20 (0.11)

Medical Staff (2.29) (2.39) 0.10 (4.57) (4.79) 0.21

Nursing (2.17) (2.38) 0.21 (4.31) (4.76) 0.45

PAMs (0.25) (0.28) 0.03 (0.52) (0.56) 0.03

Scientist and PTBs (0.21) (0.25) 0.04 (0.44) (0.51) 0.07

Admin & Management (0.72) (0.72) 0.00 (1.44) (1.44) 0.00

Ancillary & Maintenance (0.01) (0.01) 0.00 (0.01) (0.02) 0.00

Other Pay 0.03 0.92 (0.90) 0.05 1.23 (1.18)

Total Pay (5.62) (5.11) (0.51) (11.25) (10.84) (0.41)Pay as % of income 50% 47% 3% 51% 49% 2%

Contracted wte -1445.91 -1644.22 198

Drugs (1.43) (1.31) (0.12) (2.91) (2.62) (0.29)

Clinical Services and Supplies (1.59) (1.64) 0.05 (3.11) (3.28) 0.17

General Services and Supplies (0.23) (0.25) 0.02 (0.43) (0.48) 0.05

Establishment Expenses (0.06) (0.06) 0.00 (0.11) (0.13) 0.01

Other Establishment Expenses (0.00) (0.00) 0.00 (0.00) (0.00) 0.00

Prem, Trans & Fixed Plant (0.06) (0.05) (0.02) (0.14) (0.09) (0.05)

Leases (0.03) (0.03) 0.00 (0.06) (0.06) 0.00

Miscellaneous Services (Excl Internal Recharges) (0.21) (0.39) 0.18 (0.45) (0.55) 0.10

Total Non Pay (excl depn) (3.62) (3.73) 0.11 (7.21) (7.22) 0.01

Operating Surplus (Loss) 1.94 1.99 (0.05) 3.64 4.15 (0.51)

Contribution % 17% 18% 16% 19%

MONTH 2 MONTH 2 YTD

Appendix (iii) : Care Group Financials - PCG


7

Financial positionCommentary

Income:

The Care Group income was £11.19m for May. Overall income was £0.35m favourable to budget.

Key issues are:- CCG underlying activity was £320k favourable to budget. The specialties signif icantly up are:Orthopaedics £600k and Ophthalmology £50k. The specialties down on budget are Gastroenterology (£300k) and Urology (£60k).

- Gastro is primarily caused by changes in the POD rota, which are not budgeted. The Gastro consultants have reduced their POD rota f rom 30% to 15%. This has impacted monthly non-elective activity which is down on budget by £300k per month. In addition, we are awaiting the arrival of two additonal consultants which will improve elective activity.

- Orthopaedic activity is not vastly dif ferent to expected, however, income is up on budget through the improved coding project.

The pay position of PCG is £510k adverse to budget this month driven by increased QIPP target..Work is ongoing to reduce the costs to budgeted levels.

Nursing continues to be extremely well controlled and is £210k favourable to budget this month, although agency costs are too high in Hunter / Lister and Hopkins - recruiting to vacancies will resolve this but it will take time.

Admin and management is on budget now. The holding of two Planned Care Board vacancies and elmination of all interim costs in the Care Group has facilitated this

The adverse variance on Other pay is the gap between the agreed budget control total and Planned Care staf f ing costs budgeted to include vacancies, QIPPS, pay uplif t and increments.

Non-pay:

Overall, non pay spend is £110k favourable, no major issues with most lines favourable. The one exception to this is oncology drugs costs which are recovered through income.

Key Risks to Financial performance

Key risk is income - we need to improve theatre utilisation at the spokes and ensure more ef fective backf illing of lists.

The estate is always a concern as the Care Group consistly loses theatres due to breakdowns or water ingress. There is no contingency in the plan to cover such eventualties

Cancellations on the day of surgery, although reduced f rom the position a year ago, are still too high and there is a project plan in process to reduce.

Ophthalmology - cost risk through outsourcing, income risk through loss of market share as 18 week backlog still exists

Key Opportunities

Improved coding / f ibroscan / private patients / reduced outsourcing / improved theatre utilisation esp at spokes / Bracknell growth especially through MSK and Urgent Care Centre/ contined growth of private patients / cash up clinics / check green forms / increased outpatient activity through Newtons initiatives / reduce theatre cancellations on the day

BUPA private patient income is expected to improve as a result of Bracknell being approved and the range of work RBH is approved for being expanded.

Headcount reductions

Agency reduction esp Hunter / Lister and Hopkins wards

Job plan changes - elimination of 18 SPAs targetted - value £220k of cost / >£2m of income

ActionsDriving the activity in 14/15 more ef fectively and approval and delivery on key projects:Newton outpatientsImproved codingDecontaminationBracknell MSK Tier 2Pre-OpGeneral Surgery & Private WardLaminar f low theatres & Orthopaedic centre

Appendix (iii) : Care Group Financials - UCG


8

£m

Actual BudgetVariance to

Budget Actual BudgetVariance to

Budget

Income from activities (excl drugs) 8.23 8.47 -0.24 16.45 16.65 -0.20

Drugs Income 0.17 0.16 0.01 0.31 0.31 -0.01

Other Patient Care Income 0.04 0.04 -0.01 0.13 0.09 0.04


Total Income 8.56 8.76 -0.20 17.17 17.22 -0.05

Medical Staff -1.58 -1.58 0.00 -3.05 -3.15 0.10

Nursing -3.37 -3.45 0.08 -6.58 -6.89 0.31

PAMs -0.35 -0.35 0.00 -0.69 -0.70 0.01

Scientist and PTBs -0.07 -0.07 0.00 -0.14 -0.15 0.01

Pharmacists 0.00 0.00 0.00 0.00 0.00 0.00

Admin & Management -0.35 -0.37 0.01 -0.71 -0.73 0.02

Ancillary & Maintenance -0.02 0.00 -0.02 -0.02 0.00 -0.02

Other Pay 0.00 0.20 -0.20 0.02 0.64 -0.62

Total Pay -5.74 -5.61 -0.13 -11.16 -10.98 -0.19Pay as % of income 0.67 0.64 0.65 0.64

Contracted wte 0.00 0.00 0.00 0.00 0.00 0.00

Drugs -0.28 -0.25 -0.03 -0.53 -0.50 -0.03

Clinical Services and Supplies -0.99 -0.82 -0.17 -1.62 -1.65 0.03

General Services and Supplies -0.07 -0.08 0.00 -0.13 -0.16 0.03

Establishment Expenses -0.04 -0.03 -0.01 -0.07 -0.08 0.01

Other Establishment Expenses 0.00 0.00 0.00 -0.01 -0.01 0.00

Prem, Trans & Fixed Plant -0.04 -0.03 0.00 -0.08 -0.07 -0.01

Leases 0.00 0.00 0.00 0.00 0.00 0.00

Miscellaneous Services (Excl Internal Recharges) -0.06 -0.01 -0.05 -0.10 0.16 -0.26

Internal Recharges -0.01 -0.01 0.00 -0.02 -0.02 0.00

Total Non Pay (excl depn) -1.49 -1.24 -0.25 -2.56 -2.33 -0.24

Operating Surplus (Loss) 1.32 1.91 -0.58 3.44 3.91 -0.47

Margin (Surplus/ Loss as a % income) 16% 22% 20% 23%

Month 2 Month 2 YTD

FINANCIAL YEAR 2014/15 - COMPARISON OF URGENT CARE ACTUAL RESULTS TO BUDGET

Appendix (iii) : Care Group Financials - UCG


9

Financial Position Commentary on the Urgent Care Group Month 2 Financial position

Care Group contribution at £1.32m is £(0.58)m behind budget

Income is £(0.20)m lower than budget

A&E/AMU combined income is £(0.06)m lower than budget and £(0.20)m down on April due to adjustment of M01 Point of Delivery calculations £(0.11), partially offset by uplift in A&E £0.05mICU income is £(0.02)m lower than budget due to £(0.03)m credit note issued in month. Activity income is £0.01m favourable to budget and £0.13m up on AprilRadiology Income is in line with budget and £0.06m higher than April. Activity is outperforming plan but income is capped for Q1 to 13/14 outturn, £(0.27)m impact in M02Cardiology income from activities is £0.05m ahead of budget, driven by elective, daycases and outpatients.

Respiratory Income is £0.05m ahead of budget, driven by outpatientsMaternity income is £0.15m ahead of budget. Risk share has been accrued in line with budget.Paediatrics income £(0.29)m behind budget driven by critical care and NEL. NEL Activity shows an increase on M01, yet income has dipped £(0.29)m. Critical Care activity is being investigated by Informatics as reported activity appears lower than actual activityRisks and Opportunities to budget:Income risk in Paediatrics as income has declined against budgeted run rate despite delivery of activity plan. Key risks Recovery plan agreed with commissioners for diagnostic imaging waiting list, ensuring full payment is critical. Capturing NEL activity and ensuring payment. Income mapping to correct department. 4% contracted growth in Paediatrics whilst work is undertaken with commissioners to reduce Paediatric admission ratesPay Increased temporary staffing costs whilst vacancies are filled and trust capacity is stretched increasing expenditure in ECU/AMU. Continuing need to provide 1:1 care (mitigating action in place is to cohort where possible). Closure of Redlands Ward through summer is at risk with current levels of admissionNon pay Radiology costs of £(0.18)m to hire mobile scanners, this will recur into June £(0.09)m. Ongoing use of Familial carersManagement action is identifying and driving full programme of QIPP in line with budgeted £4.8m target.Review all medical agency - QIAs to be completedDoN daily monitoring of ward requirements to mitigate agency usageEmbed budgetary control within individual departmentsEmbed process of agency booking and update to ensure correct values are accrued monthly

Care Group Pay costs are £(0.32)m higher than the previous month and £(0.13)m higher than budget

Medical staffing costs increased by £(0.11)m in Month 2 and were in line with budget:

CDU Drs costs increased by £(0.04)m in Month, this related to an increase of £(0.03)m in the accrual for SPR agency staff when compared with Month 1. £(0.02)m increase in prior month accrual - Action with care group to embed processA&E Increase of £(0.02)m due to cost of SpRs (additional activity and locums)ICU Cost of 5 SpR posts awaiting budget transfer £(0.01)mRadiology £0.01m awaiting consultant start

Cardiology £(0.01)m in additional activity to support increased incomeObstetrics 4 SPR in post without budget £(0.01)m.Paediatric SpR agency costs have outweighed substantive vacancy £(0.03)m

Medical QIPP £0.05m delivered

Nursing/Midwifery costs increased by £(0.16)m in Month 2 (month on month), £0.08m favourable to budget:

Maternity and Children’s £0.04m lower than budget driven by vacancies and sickness management (QIPP delivery), £(0.05)m higher than April.

Acute Med Nursing costs were £(0.02)m higher than budget and £(0.05)m higher than April driven by Cardiology (Whitley 1:1 cohorting), Respiratory (Castle - cover of absence) and Sidmouth (1:1).

Emergency Nursing costs were £(0.09)m higher than budget, £(0.06)m higher than prior month. This variance to budget was driven by A&E/AMU which together are £(0.05)m higher than budget and ICU £(0.05)m which contains 11 WTE (budget correction will follow in M03)

Nursing QIPP £0.03m delivered

Portering costs of £(0.02)m during the 'Hot Floor' pilot in A&E

QIPP targets held in other pay £(0.33)mBudget funding held in other pay for medical/nursing/portering posts identified above £0.13m

Care Group Non Pay costs increased by £(0.42)m in Month 2 and are £(0.25)m higher than budget.Hire of mobile MRI and CT scanners as part of plan to reduce backlog £(0.19)mOutsourced MRI scans £(0.03)m and reporting £(0.01)m as part of plan to reduce backlogDiagnostic Income has been capped in Q1 to contract value. Costs are, therefore, not aligned to income. Action Trust DoF opening discussions with commissioners to ensure full payment of activity in Radiology

Familiar carer costs of £(0.02)m in respiratory. Action CGDoN initiating discussion with commissioners regarding the funding of this service

Cardiology devices £(0.02)m driven by activityPaediatric prior year invoice £(0.03)mEmergency Directorate £(0.04)m activity drivenPrior year clinical audit charge £(0.01)mQIPP Phasing adjustment £0.09m

Appendix (iv) : Point of Delivery - Month


10

May 2014

All CCGs (including NCAs)

POD Group POD Detail

Annual Budget

(Activity)

Annual Budget (£'000)

Mth 02 Budget

(Activity)

Mth 02 Budget (£'000)

Mth 02 Actual

(Activity)

Mth 02 Actual (£'000)

YTD Var (Activity)

YTD Var (£'000)

A&E Accident & Emergency 114,838 13,441 9,753 1,142 9,869 1,168 116 26A&E Total 13,441 1,142 1,168 26

Outpatient Outpatient FA Multi Prof Cons Led 2,689 652 217 53 109 29 (108) (24)Outpatient FA Single Prof Cons Led 150,089 22,962 12,071 1,846 12,866 1,957 795 111Outpatient FA Single Prof Non-Cons Led 2,852 170 215 12 175 10 (40) (2)Outpatient FUP Multi Prof Cons Led 4,771 1,068 385 86 410 71 25 (15)Outpatient FUP Single Prof Cons Led 208,109 21,372 16,724 1,717 16,508 1,694 (215) (23)Outpatient FUP Single Prof Non-Cons Led 4,998 210 289 11 379 16 90 5Non Face to Face 6,456 168 521 14 181 5 (340) (9)Outpatient Procedures 47,251 9,545 3,811 770 4,045 964 234 194

Outpatient Total 56,148 4,507 4,746 238

Inpatient Elective Inpatients 9,502 29,364 766 2,368 588 2,055 (178) (313)Elective Excess Bed Days 2,903 740 234 60 111 31 (123) (29)Day Cases 36,671 32,913 2,957 2,654 2,946 2,839 (11) 185Haematology - Regular Day Atts (Chemo & Other Infusions) 2,483 1,018 200 82 153 71 (47) (11)Emergency Inpatients (Excluding Maternity) 30,006 67,625 2,548 5,744 2,691 5,673 143 (71)Maternity Inpatients 25,023 22,842 2,613 1,894 2,870 2,021 257 127Emergency Same Day 2,354 2,200 200 187 85 75 (115) (112)Emergency Short Stay 2,698 2,090 229 178 241 154 12 (24)Emergency Excess Bed Days 22,328 5,632 1,896 478 2,039 507 143 29Maternity Excess Bed Days 822 347 68 29 121 51 53 22

Inpatient Total 164,772 13,673 13,477 (196)

Critical Care Adult Critical Care 5,516 7,838 469 666 346 466 (123) (200)Neonatal Critical Care 7,701 4,541 642 378 151 91 (491) (287)Surgical HDU 0 0

Critical Care Total 13,218 12,379 1,110 1,044 557 (613) (487)

Renal Renal 78,179 10,881 6,640 924 6,128 796 (512) (128)Renal EPO Drugs 493 42 39 (3)

Renal Total 11,374 966 835 (131)

Drugs PbR Excluded Drugs 25,065 2,147 2,242 95PbR Excluded Devices 2,396 193 236 42

Drugs Total 27,461 2,340 2,478 138

Other Orthotics Direct Access 3,323 799 277 67 138 106 (139) 39Pathology Direct Access 3,129,825 6,969 252,405 562 223,106 496 (29,299) (66)Radiology Direct Access 56,695 2,844 4,572 229 4,879 117 307 (112)Anti Coagulant Reviews 104,770 838 8,731 70 8,445 67 (286) (3)Diagnostic Imaging 44,855 4,543 3,617 366 5,899 844 2,282 478Diagnostic Imaging to Q1 Contract 0 0 0 0 (2,282) (478) (2,282) (478)Post Discharge Rehab 203 122 16 10 78 44 62 34Pre-op Assessments 16,965 685 1,368 55 1,356 55 (12) (0)Rehab Bed Days 5,615 1,729 468 144 352 109 (116) (35)Non PbR Block Items 16,967 0 1,414 0 1,389 (25)Other 34,513 567 2,294 25 2,016 51 (278) 26

Other Total 36,064 2,942 2,800 (142)

Adjustments ESD Discount (150) (12) (12) 0Audiology Hearing Aid Assessment Discount (re Pathway Tariff) (286) (24) (16) 8Daycase : OP Procedure Ratio (462) (38) (38) 0ICU 10% Discount (178) (15) (9) 6SCAS Delays Penalties (65) (5) (6) (1)CQUINs 6,240 520 520 0Best Practice Top Ups (included in individual POD lines above) 0 0 0MRET & 30-day Readmits net of re-investment 0 (33) (33)Reinvestment of NEL Threshold & 30-Day Readmits Penalty 800 67 0 (67)Contract Data Challenges 0 0 0Contract Deductions (3,320) (277) 41 318Contract Income Provision Release re 2013/14 0 0 0Accrual for missing activity 0 208 208Phasing Adjustment 3 20 0 (20)

Adjustments Total 2,582 235 655 420

TVIC Dermatology 1,750 146 164 18Bowel Screening 580 48 49 1Change re Spells in Progress (vs M12 13-14) 6 6Others 1,043 89 122 33

Other Income from Activities Total 3,373 283 341 58

TOTAL (= 'Income from Activities') 327,595 27,133 27,056 (76)

Other Income from Activites

Appendix (iv) : Point of Delivery - YTD April to May 2014

All CCGs (including NCAs)

POD Group POD Detail

Annual Budget

(Activity)

Annual Budget (£'000)

YTD Mth 02 Budget

(Activity)

YTD Mth 02 Budget (£'000)

YTD Mth 02 Actual

(Activity)

YTD Mth 02 Actual (£'000)

YTD Var (Activity)

YTD Var (£'000)

A&E Accident & Emergency 114,838 13,441 19,192 2,246 19,024 2,240 (168) (6)A&E Total 13,441 2,246 2,240 (6)

Outpatient Outpatient FA Multi Prof Cons Led 2,689 652 423 103 211 54 (212) (49)Outpatient FA Single Prof Cons Led 150,089 22,962 23,538 3,599 23,849 3,644 311 45Outpatient FA Single Prof Non-Cons Led 2,852 170 448 27 354 21 (94) (6)Outpatient FUP Multi Prof Cons Led 4,771 1,068 750 168 766 177 16 9Outpatient FUP Single Prof Cons Led 208,109 21,372 32,611 3,349 33,856 3,492 1,244 143Outpatient FUP Single Prof Non-Cons Led 4,998 210 786 33 785 33 (1) (0)Non Face to Face 6,456 168 1,015 26 352 9 (663) (17)Outpatient Procedures 47,251 9,545 7,431 1,501 8,202 1,804 771 303

Outpatient Total 56,148 8,805 9,234 429

Inpatient Elective Inpatients 9,502 29,364 1,494 4,618 1,164 3,856 (330) (762)Elective Excess Bed Days 2,903 740 456 116 230 61 (226) (55)Day Cases 36,671 32,913 5,767 5,176 5,793 5,394 26 218Haematology - Regular Day Atts (Chemo & Other Infusions) 2,483 1,018 390 160 295 148 (95) (12)Emergency Inpatients (Excluding Maternity) 30,006 67,625 5,015 11,302 5,142 11,195 127 (107)Maternity Inpatients 25,023 22,842 4,048 3,695 4,355 3,885 307 190Emergency Same Day 2,354 2,200 393 368 245 225 (148) (143)Emergency Short Stay 2,698 2,090 451 349 426 297 (25) (52)Emergency Excess Bed Days 22,328 5,632 3,732 941 3,277 819 (455) (122)Maternity Excess Bed Days 822 347 133 56 147 62 14 6

Inpatient Total 164,772 26,782 25,942 (840)

Critical Care Adult Critical Care 5,516 7,838 922 1,310 766 1,063 (156) (247)Neonatal Critical Care 7,701 4,541 1,284 757 362 224 (922) (533)Surgical HDU 0 0

Critical Care Total 13,218 12,379 2,205 2,067 1,287 (1,077) (780)

Renal Renal 78,179 10,881 13,065 1,818 12,033 1,618 (1,032) (200)Renal EPO Drugs 493 82 78 (4)

Renal Total 11,374 1,901 1,696 (205)

Drugs PbR Excluded Drugs 25,065 4,016 4,474 458PbR Excluded Devices 2,396 377 414 37

Drugs Total 27,461 4,393 4,888 496

Other Orthotics Direct Access 3,323 799 554 133 471 186 (83) 53Pathology Direct Access 3,129,825 6,969 492,190 1,096 463,106 1,030 (29,084) (66)Radiology Direct Access 56,695 2,844 8,916 447 10,333 391 1,417 (56)Anti Coagulant Reviews 104,770 838 17,461 140 17,044 136 (417) (4)Diagnostic Imaging 44,855 4,543 7,054 714 11,800 1,192 4,746 478Diagnostic Imaging to Q1 Contract 0 0 0 0 (4,746) (478) (4,746) (478)Post Discharge Rehab 203 122 32 19 97 55 65 36Pre-op Assessments 16,965 685 2,668 108 2,663 108 (5) 0Rehab Bed Days 5,615 1,729 936 288 905 279 (31) (9)Non PbR Block Items 16,967 2,828 2,809 (19)Other 34,513 567 4,589 49 4,114 94 (475) 45

Other Total 36,064 5,823 5,802 (21)

Adjustments ESD Discount (150) (25) (25) (0)Audiology Hearing Aid Assessment Discount (re Pathway Tariff) (286) (48) (32) 16Daycase : OP Procedure Ratio (462) (77) (76) 1ICU 10% Discount (178) (30) (19) 11SCAS Delays Penalties (65) (11) (11) (0)CQUINs 6,240 1,040 1,040 0Best Practice Top Ups (included in individual POD lines above) 0MRET & 30-day Readmits net of re-investment (66) (66)Reinvestment of NEL Threshold & 30-Day Readmits Penalty 800 133 (133)Contract Data Challenges 0Contract Deductions (3,320) (553) (117) 436Contract Income Provision Release re 2013/14 0Accrual for missing activity 500 500Phasing Adjustment 3 4 (4)

Adjustments Total 2,582 434 1,194 760

TVIC Dermatology 1,750 292 328 36Bowel Screening 580 97 97 0Change re Spells in Progress (vs M12 13-14) (107) (107)Others 1,043 176 240 64

Other Income from Activities Total 3,373 564 558 (7)

TOTAL (= 'Income from Activities') 327,595 53,014 52,841 (173)

Other Income from Activites

12

Appendix (v): Statement of Financial Position

Analysis : • Cash at £17.63m – behind Budgeted

position of £16.20m.

March 2014 April 2014 May 2014Annual Plan

May 2014

Assets £m £m £m £mAssets, Non-CurrentIntangible Assets, Net 9.30 9.15 9.65 8.94Property, Plant and Equipment, Net 188.18 187.24 186.24 187.55Other Investments, at Cost 4.36 4.28 4.24 3.70Deferred Tax Assets 0.00 0.00 0.00 0.00Other Receivables, Non-Current 0.89 0.88 0.87 0.75Assets, Non-Current, Total 202.73 201.55 201.00 200.94

Assets, CurrentInventories 5.21 5.09 5.94 4.70NHS Trade Receivables, Current 3.34 2.49 10.77 2.40Non-NHS Trade Receivables, Current 1.58 1.55 1.69 1.20Other Receivables, Current 0.90 1.35 1.27 1.80Accrued Income 8.67 9.41 5.16 6.00Prepayments, Current, non-PFI related 1.35 1.38 2.23 2.33Cash and Cash Equivalents, Total 21.27 17.32 17.63 16.21 Assets held for sale 2.25 2.25 2.25 2.25Assets, Current, Total 44.57 40.84 46.94 36.89

ASSETS, TOTAL 247.30 242.39 247.94 237.83

LiabilitiesLoans, non-commercial, Current (DH, FTFF, NLF, etc) (3.67) (3.67) (3.67) (3.67)Deferred Income, Current (2.14) (2.08) (2.17) (0.50)Provisions, Current (3.31) (3.56) (3.72) (4.50)Current Tax Payables (3.95) (3.94) (4.04) (4.00)Trade Creditors, Current (9.09) (5.48) (8.39) (5.00)Other Creditors, Current (2.75) (2.73) (2.80) (2.75)Capital Creditors, Current (2.54) (2.25) (2.72) (1.00)Accruals, Current (17.05) (17.44) (16.93) (16.00)Payments on Account (1.87) (1.57) (4.17) (2.00)PDC dividend creditor, Current 0.00 (0.42) (0.84) (0.84)Interest payable on non-commercial interest bearing borrowings, current (0.36) (0.47) (0.57) (0.57)Other Liabilities, Current 0.00 (0.40) (0.45) (0.10)Liabilities Current, Total (46.74) (44.01) (50.47) (40.93)

NET CURRENT ASSETS (LIABILITIES) (2.17) (3.17) (3.53) (4.04)

Loans, Non-Current non-commercial (DH, FTFF, NLF, etc) (30.57) (30.57) (30.57) (30.58)Provisions, Non-Current (0.30) (0.30) (0.30) (0.30)Deferred Tax liability (0.10) (0.10) (0.10) (0.10)Trade and Other Payables, Non-Current (0.50) (0.47) (0.44) (0.43)Liabilities Non-Current, Total (31.47) (31.44) (31.41) (31.41)

TOTAL ASSETS EMPLOYED 169.09 166.94 166.06 165.49

13

Appendix (vi): Cash Flow Statement

May 14 YTD May 14 YTD May 14Actual Actual Projection

£000 £000 £000

Opening cash Balance 17.32 21.27 21.50

Income 29.18 57.02 56.64Expenditure (excluding depreciation) (28.05) (56.02) (55.52)

Cash generated 1.13 1.00 1.12

Working Capital(Increase)/decrease in inventories (0.85) (0.73) 0.00(Increase)/decrease in receivables (4.94) (5.27) (0.93)(Increase)/decrease in asssets held for s 0.00 0.00 0.00Increase/(decrease) in payables 5.60 2.71 (3.20)

(0.19) (3.29) (4.13)

Capex (Capital expenditure) (0.46) (1.09) (2.05)PDC paid 0.00 0.00 0.00

Financial ActivityInterest income/ (Expense) (0.11) (0.20) (0.18)Other (0.05) (0.05) (0.06)

(0.16) (0.25) (0.24)

Loan Drawdown 0.00 0.00 0.00Loan (Repayment) 0.00 0.00 0.00

Net increase/(decrease) in cash 0.32 (3.63) (5.30)

Closing Cash Balance 17.64 17.64 16.20

14

Appendix (viii): Capital Expenditure Summary

2014/15 Original

Plan

2014/15 Revised Forecast

Spend to Date

Commit-ments

Orders to be raised

Sub Total

£m £m £m £m £m

Medical Equipment 2.00 2.00 (0.19) (0.06) (1.75) (2.00)IT Infrastructure 3.00 3.00 (0.81) (1.05) (1.14) (3.00)Statutory Compliance 2.50 2.56 (0.06) (0.50) (2.00) (2.56)Backlog Maintenance 2.00 2.52 (0.03) (0.24) (2.25) (2.52)

Major Works - A&E 0.70 0.81 (0.00) (0.04) (0.77) (0.81) - Pre Op / New Ward 1.00 0.61 (0.00) (0.03) (0.58) (0.61) - Maternity Ventilation 0.40 0.45 (0.00) (0.00) (0.45) (0.45) - Decontamination 0.55 0.15 (0.00) (0.02) (0.13) (0.15) - WBCH Single Sex Accom 0.12 0.12 (0.00) (0.00) (0.12) (0.12) - Other 0.25 0.30 (0.02) (0.00) (0.28) (0.30)

Total 12.52 12.52 (1.11) (1.94) (9.47) (12.52)

Q1 Q2 Q3 Q4 Total

£m £m £m £m £m

Medical Equipment (0.22) (0.26) (0.76) (0.76) (2.00)IT Infrastructure (0.89) (0.61) (0.75) (0.75) (3.00)Statutory Compliance (0.29) (0.74) (0.77) (0.76) (2.56)Backlog Maintenance (0.20) (0.70) (0.94) (0.68) (2.52)

Major Works - A&E (0.03) (0.33) (0.45) (0.00) (0.81) - Pre Op / New Ward (0.00) (0.01) (0.08) (0.52) (0.61) - Maternity Ventilation (0.00) (0.27) (0.18) (0.00) (0.45) - Decontamination (0.00) (0.01) (0.06) (0.08) (0.15) - WBCH Single Sex Accom (0.00) (0.00) (0.01) (0.11) (0.12) - Other (0.01) (0.10) (0.10) (0.09) (0.30)

Total (1.64) (3.03) (4.10) (3.75) (12.52)

Q1 Estimate (3.13) (3.13) (3.13) (3.13) (12.52)

( Under ) / Over Q1 Estimate (1.49) (0.10) 0.97 0.62 0.00

May 14 Performance against capital budgets is shown

15

Appendix (ix): Continuity of Service Risk Rating

Risk Ratings May 2014£m

Revenue available for Debt Service £m 1.00 0.84

Debt Service £m (1.05)

Debt Service Cover metric 0.95

Debt Service Cover rating 1

Cash for CoS liquidity purposes £m (11.71) 5.18

Operating Expenses within EBITDA £m (56.02)

Liquidity Metric (12.54)

Liquidity rating 2

Continuity of Service Risk Rating 2

Additional reguired for a

rating of 3

16

Appendix (x): Service Line Reporting Key Messages • This is produced on a quarterly

basis, so figures shown are the same as last month for YTD Q3

• Figures carry a significant health warning given the on-going validation work

• Progress on validation work improving:

– Paediatrics and Rheumatology signed off as materially correct

– Orthopaedics,Renal, Geriatric and Cardiology now started

– Still no engagement from Ophthalmology

– Being driven by interim who is here until 30 June

• Deep dive work – In progress with examples

raised in all care groups. – PWC working on Obstetrics

and Respiratory

£'000

Specialty Group

Direct and Indirect

Income [ A ]

Direct and Indirect

Costs [ B ]

Contribution to

Overheads [ A - B ]

Contribution % to Trust Overheads

Overhead Costs [ C ]

Net Surplus/ Deficit

Total 255,972 191,886 64,086 25% 61,484 (3,076)Networked Total 65,755 49,811 15,944 24% 14,206 1,549Networked Audiological Medicine 5,791 2,612 3,179 55% 656 2,521Networked Clinical Haematology 6,338 5,564 774 12% 1,244 (481)Networked Dermatology 4,648 1,841 2,807 60% 425 2,372Networked Endocrinology 1,842 1,540 302 16% 452 (159)Networked General Medicine 453 232 221 49% 78 142Networked Geriatric Medicine 12,043 10,221 1,822 15% 3,544 (1,727)Networked GUM 4,263 2,071 2,192 51% 528 1,664Networked Neurology 2,179 2,203 (24) -1% 575 (652)Networked Orthotics 646 461 185 29% 114 71Networked Pain Management 631 425 206 33% 167 38Networked Palliative Care 304 25 279 92% 4 275Networked Pathology 5,642 5,076 566 10% 1,440 (929)Networked Rehabilitation 2,267 2,001 266 12% 573 (312)Networked Renal 12,604 9,732 2,872 23% 2,920 (67)Networked Rheumatology 5,848 5,566 282 5% 1,403 (1,134)Networked Therapies 256 241 14 6% 81 (73)Others Total 3,933 1,150 2,782 71% 279 2,501Others Other Services 3,285 603 2,683 82% 141 2,542Others Psycology 1 0 1 86% 0 (2)Others Wheelchair Service 646 547 99 15% 138 (39)Planned Total 111,516 85,427 26,089 23% 27,021 (2,886)Planned Anaesthetics 409 163 246 60% 72 61Planned Cancer 190 614 (424) -223% 128 (552)Planned Clinical Oncology 13,158 10,682 2,477 19% 2,553 (152)Planned ENT 5,612 3,711 1,901 34% 1,470 374Planned Gastroenterology 11,318 8,283 3,035 27% 3,019 (52)Planned General Surgery 15,548 13,104 2,444 16% 4,597 (2,545)Planned Gynaecology 6,061 4,512 1,549 26% 1,438 (66)Planned Ophthalmology 18,621 12,694 5,927 32% 3,612 2,123Planned Oral Surgery 2,087 1,518 569 27% 450 110Planned Plastic Surgery 742 556 185 25% 142 43Planned Trauma & Orthopaedics 30,239 23,603 6,637 22% 7,506 (1,668)Planned Urology 7,531 5,988 1,543 20% 2,035 (562)Urgent Total 74,768 55,498 19,271 26% 19,977 (4,240)Urgent Accident & Emergency 11,464 9,619 1,844 16% 2,838 (1,420)Urgent Cardiology 12,644 8,326 4,318 34% 2,781 1,469Urgent Critical Care Medicine 7,439 4,381 3,059 41% 1,794 1,264Urgent Obstetrics 15,295 13,119 2,175 14% 4,602 (5,174)Urgent Paediatric Medicine 13,274 9,940 3,334 25% 3,585 (447)Urgent Radiology 5,997 3,954 2,043 34% 2,301 (337)Urgent Thoracic Medicine 8,656 6,158 2,498 29% 2,077 404

ED Update June 2014 1

Royal Berkshire NHS Foundation Trust Agenda item 7

Board of Directors

Title: Accident and Emergency Recovery Plan

Date: 30th

Lead:

June 2014

Sue Edees Care Group Director Urgent Care

Purpose:

The purpose of this paper is to inform the Board of the A&E performance and progress against the Berkshire West system wide recovery plan

Key Points: The Trust has been successful in achieving the 4 hour trolley wait target for May 2014 achieving 96.11% for the reported month. The improved performance in May has continued, with many of the planned initiatives now delivering and supporting the achievement of the target A revised trajectory has been submitted to NHS England and Monitor showing achievement of quarter one.

Decision required:

Support the work being undertaken

FOI Status This report will be made available on request.


1 Background

1.1 The Trust has been working with the whole system on a recovery plan to meet the 4 hour target.

1.2 A revised trajectory was submitted following the Trusts improved performance showing achievement of quarter 1 in 2014/15

Revised Trajectory

Week Ending

6 Apr 13 Apr 20 Apr 27Apr 4May 11May 18May 25May 1 Jun 8 Jun 15 Jun 22 Jun 29Jun Quarter A&E

Cumulative Year To Date

95.38%

95.79%

96.30%

95.61%

95.86%

96.06%

95.96%

91.79%

92.71%

93.71%

A&E Weekly Actual

Performance 95.38

% 96.24

% 97.35

% 93.54

% 96.87

% 97.02

% 95.41

% 94.75

% 96.69

% 92.68

% 95.24

%

A&E Weekly Performance

Trajectory 95.38

% 96.24

% 97.35

% 93.23

% 94.77

% 93.60

% 94.94

% 96.03

% 94.68

% 96.17

% 95.56

% 94.82

% 96.03

% A&E Monthly Performance

Trajectory

95.54%

95.00

%

95.65%

95.37%

A&E Average daily

attendance 264 267 276 284 255 265 272 270 275 270 270 270 265

Medically fit

actual 47 54 40 38 52 49 59 46 55 52 50

Medically Fit for discharge

trajectory 30 30 30 30 25 25 25 25 20 20 20 20 20

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

0

10

20

30

40

50

60

70

86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

102.00%

06/04/2014 20/04/2014 04/05/2014 18/05/2014 01/06/2014 15/06/2014 29/06/2014

A&E Performance and Trajectory 2013-2014 (Type 1and2 )

A&E Cumulative Year To Date A&E Weekly Actual Performance A&E Weekly Performance Trajectory

Medically Fit for discharge trajectory Medically fit actual


2 Current Position 2.1 May attendances were high at an average of 290 attendances per day with 11 occasions of

over 300 and a run of 7 consecutive days at that level mid month, which caused the performance to fall below trajectory.

2.2 There were three days of over 100 admissions putting pressure on the discharge teams

causing the whole system to fall behind their system wide action plan.

2.3 Early June is seeing the same level with average attendance at 300 each day.

2.4 The Emergency Care Unit (ECU) was escalated for 1 week following the 7 days of pressure

reducing the same day discharges.

2.5 The increasing pressures were escalated to the Urgent Care Programme Board when the

Berkshire West recovery plan was reviewed, aspects below plan were reviewed;

(i) Community beds at Wokingham have been closed to allow essential fire maintenance work causing delays in discharge replacement beds have been allocated but are out of area and not popular with patients.

(ii) Issues surrounding 111 services were reported and are being investigated by the CCG

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Regional A&E Weekly Performance Ryl Berkshire Frimley Buckinghamshire

Heatherwood Oxford Univ 95% Target


3 Trust actions

3.1 The ECIST steering group have reviewed their action plan and working groups and have formed 2 new workstreams:

(i) A Physician’s working group, looking at early assessment and treatment of medically expected patients referred by GP’s to reduce the pressure on the emergency department in the forthcoming winter. They are also reviewing access to short stay medicine and how it may enhance flow moving forward

(ii) An ambulatory care pathway group to build upon the success of the current same day discharge model, creating pathways guided by best practice under the guidance of ECIST

4 Recommendations

4.1 The Trust Board is asked to note the continued developments and actions across the Urgent Care pathway of care and support the work being undertaken within the Trust towards achieving the 4 hour A&E target.

5 Contact Contact: Sue Edees Clinical Director Urgent Care Phone: 0118 322 6772

Version 3 – May 20 2014 1


Board of Directors

Title: CQC Inspection Update

Date: 30 June 2014

Lead: Alistair Flowerdew, Acting Chief Executive

Purpose: This paper informs the Board of the outcome of the CQC inspection and the Trust’s actions for implementing a performance improvement plan in response to the inspection report.

Key Points: • Following the CQC formal inspection 24th – 26th March, the Trust has now received the final report detailing the findings (attached in Appendix 1).

• An overall rating of ‘Requires Improvement’ has been given to the Trust, with separate ratings given for each CQC domain (safe, effective, caring, responsive, and well-led) and ratings for each core service.

• The Trust was able to challenge many of the findings within the report that were felt to be inaccurate or out of context, and the majority of these were successfully upheld by the CQC and reflected in the final report.

• The report findings include a total of 13 actions the Trust must take and a further 14 actions that the CQC suggest the Trust should take. These actions have been amalgamated into 7 ‘Compliance Actions’ (regulatory legal actions that confirm the essential standards the Trust must meet through delivery of the action plan).

• The Trust is now developing a detailed Improvement Plan to address all of the actions within the report and will be submitted to the CQC for sign off by the deadline of 11th July. A copy of the Plan and progress will be submitted to Board each month.

• Governance of the Plan internally will be via the monthly Quality Performance and Learning Committee, and externally with the CCG via the Quality Review and Joint Senior Governance Groups. Updates will be provided to the Trust’s CQC liaison lead.

• An overall Trust Improvement Plan has been developed pulling all of the Improvement projects together, including the Board Evaluation and Quality Governance framework action plans. Oversight of the Improvement Plan will be undertaken by Head of PMO. Additional project management resource has been agreed to support staff in delivering the actions over the next few months.

Version 3 – May 20 2014 2

Decision required:

The Board is asked to note the findings of the inspection report.


Contact Contact: Vanessa Harding, Head of PMO Alex Baker, Healthcare Standards Manager Phone: 0118 322 6827

20140523 Royal Berkshire NHS Foundation Trust Quality report June 2014 1

Royal Berkshire NHS Foundation Trust Quality report Royal Berkshire NHS Foundation Trust Craven Road Reading RG1 5AN Tel: 0118 322 5111 www.royalberkshire.nhs.uk

Date of inspection visit: 24 to 26 March 2014 Date of publication: June 2014

This report describes our judgement of the quality of care at this trust. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations.

Overall rating for this trust Requires improvement

Are services at this trust safe? reccident and emergency

Requires improvement

Are services at this trust effective? Good

Are services at this trust caring? Good

Are services at this trust responsive? Requires improvement

Are services at this trust well-led? Planning

Requires improvement

Royal Berkshire NHS Foundation Trust provides acute services to a population of 600,000 people across Reading, Wokingham and West Berks, and specialist services to a wider population across Berkshire and the surrounding borders. Royal Berkshire Hospital is the main inpatient site, with five other sites including West Berkshire Community Hospital, Windsor Dialysis Unit, Prince Charles Eye Unit, Royal Berkshire Bracknall Clinic and Townlands Hospital Outpatients. During the inspection, we visited the Royal Berkshire Hospital, West Berkshire Community Hospital (Day Surgery Unit and Outpatient services), Windsor Dialysis Satellite Unit and Prince Charles Eye Unit. We carried out this comprehensive inspection because the Royal Berkshire NHS Foundation Trust was initially placed in a high risk band 1 in CQC’s intelligent monitoring system. Immediately prior to the inspection the intelligent monitoring bandings were updated and the trust was placed in a low risk band 5. The inspection took place between 24 and 26 March 2014 and an unannounced inspection visit took place on 29 March and 2 April 2014.

Letter from the Chief Inspector of Hospitals


Overall, this hospital requires improvement. We rated it good for being caring and effective but improvement was required in providing safe care, being responsive to patients’ needs and being well-led. We rated the A&E service, end of life care and services for children and young people as good, but we rated outpatients, medical, surgical, maternity and critical care as requiring improvement. Our key findings were as follows:

Staff were caring and compassionate and treated patients with dignity and respect.

The hospital was clean and well maintained; although there were some examples where cleanliness fell below expected standards.

The workforce were committed and we noted an open culture during the inspection.

Infection control rates in the hospital were similar to those of other trusts except the C.Difficile rates, which were higher than average and the trust was taking steps to improve.

Staffing levels were not always sufficient to meet the needs of patients on all ward areas, with a consequent reliance on bank and agency staff.

Medical records and the electronic patient record system and processes were not robust, which resulted in patient records not being available, reliance on temporary records and inability to access records as required in a timely manner, impacting on the ability to deliver care.

ICU capacity was insufficient and operations were going ahead when no ICU bed was available, resulting in patients being cared for in the recovery area overnight.

The observation ward in A&E was a room with three beds but it was not included in the four-hour decision to discharge, admit or treat A&E target as it was used as a ward, although it did not have any shower facilities. There were concerns about appropriate use and care of patients in this observation area.

The major incident process associated with decontamination was not appropriate because of the distance and journey for patients through the hospital.

Safeguarding processes and knowledge of the Mental Capacity Act was not sufficient.

DNACPR forms were not consistently completed.

The end of life care team worked collaboratively with key stakeholders.

Paediatric care was generally positive. We saw several areas of outstanding practice including:

Caring interventions and support for families in in the Intensive Care Unit.

The Children’s A&E department.

Consultant geriatricians worked in the A&E department 8am to 8pm seven days a week.

The responsiveness of the Palliative Care team. However, there were also areas of poor practice where the trust needs to make improvements. Importantly, the trust must:

Ensure that medical records are kept securely and records can be located and accessed promptly when needed to appropriately inform the care and treatment of patients.

Maintain the privacy and dignity of patients placed in the observation bay in the A&E department.

Ensure that the design and layout of the emergency department protects patients and staff against the risks associated with unsafe or unsuitable premises.


Take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced staff employed to care for patients’ needs, and safeguard their health, safety and welfare.

Accurately complete ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms, and document the discussions about end of life care with patients.

Take proper steps to ensure that each patient is protected against the risks of receiving care or treatment that is inappropriate or unsafe by planning the delivery of care and appropriate treatment to meet patients’ individual needs, and have procedures in place to deal with emergencies which are reasonably expected to arise.

Review the ICU capacity across the trust; employ suitably qualified, skilled and experienced staff; and have necessary equipment available to care for patients who require intensive or high dependency care.

Ensure that planning and delivery of care meets patients’ individual needs, and ensure the safety and welfare of all patients.

Increase staff knowledge of Deprivation of Liberty Safeguards (DOLs) and the Mental Capacity Act (MCA) through necessary training to improve safeguarding.

Improve contemporaneous record keeping by all staff to avoid misplacing records of care and observations.

Ensure the staffing levels and admission criteria in the Rushey Midwife-led unit is maintained to ensure safe care is provided to all women.

Ensure that at all times there is a sufficient number of suitably qualified, skilled and experienced staff employed to provide safe midwifery care in all areas.

Take action to improve the ventilation system on the delivery suite, to protect patients and others who may be at risk from the use of unsafe equipment.

Professor Sir Mike Richards Chief Inspector of Hospitals

Background to Royal Berkshire NHS Foundation Trust

Royal Berkshire NHS Foundation Trust has been a foundation trust since June 2006. It employs around 5,000 staff and has 745 beds and 22 operating theatres (across three surgical sites). The trust’s turnover is £330 million with a £2.68 million deficit in 2012/13. The Royal Berkshire NHS Foundation Trust’s inpatient site is the Royal Berkshire Hospital. The trust also provides services at West Berkshire Community Hospital (Day Surgery Unit and Outpatient services), Windsor Dialysis Satellite Unit and Prince Charles Eye Unit, Bracknall Clinic and Townlands Hospital Outpatients. The former chief executive left the trust in December 2013 and the medical director became interim chief executive until a formal appointment was made. The executive team comprised of six permanent executive positions and five interim executives. The trust had adopted a clinically led model with three of the executives holding positions as Care Group Directors of urgent care, planned care and networked care. At the time of the inspection the trust did not have a chief operating officer (COO) post, but an interim COO was starting immediately post inspection. The significant number of interim appointments presented challenges for consistent leadership.


The Chairman had been in post since July 2012 and four of the five non-executive directors had joined following his appointment, with the most recent being in December 2013. The trust had recently been under enforcement action from Monitor because its A&E consistently failed to meet the four-hour target, its financial stability, its quality governance, and C. difficile rates. At the time of the inspection concerns had been signed off by Monitor and the trust was rated as green, with no evident governance concerns. The trust continued to face financial challenges with a financial stability rating of 2 from Monitor, meaning that there was a material level of financial risk. The trust had also recently faced concerns in the media regarding its radiology waiting times.

Our inspection team Our inspection team was led by: Chair: Professor Kay Riley, Chief Nurse, Barts Health Head of Hospital Inspections: Heidi Smoult, Care Quality Commission The team of 45 included CQC inspectors and analysts, consultants, junior doctors, senior nurses, a student nurse, a senior physiotherapist, patients and public representatives, experts by experience and senior NHS managers. Some team members were present at the inspection for one of the two days on site. The Patients Association was also part of our team to review how the trust handled complaints.

How we carried out this inspection To get to the heart of patients’ experiences of care, we always ask the following five questions of every service and provider:

Is it safe? Is it effective? Is it caring? Is it responsive to people’s needs? Is it well-led?

The inspection team inspected the following eight core services at the Royal Berkshire Hospital:

Accident and emergency Medical care (including older people’s care) Surgery Critical care Maternity and family planning Services for children and young people End of life care Outpatients.

In addition, the inspection team also inspected the following core services at other locations linked to the Royal Berkshire Hospital:

Medical provision at the Windsor Dialysis Satellite Unit Day surgical and outpatient services at West Berkshire Community Hospital Surgical services at Prince Charles Eye Unit.

Prior to the announced inspection, we reviewed a range of information we held and asked other organisations to share what they knew about the hospital. These included the clinical commissioning group (CCG), Monitor, NHS England, Health Education England (HEE), the General Medical Council (GMC), the Nursing and Midwifery Council (NMC), Royal Colleges and the local Healthwatch.


We held a listening event, in Reading on 24 March 2014, when 128 people shared their views and experiences of the Royal Berkshire Hospital. As some people were unable to attend the listening events, they shared their experiences via email or telephone. We carried out the announced inspection visit between 24 and 26 March 2014. We held focus groups and drop-in sessions with a range of staff in the hospital, including nurses, junior doctors, consultants, midwives, student nurses, administrative and clerical staff, physiotherapists, occupational therapists, pharmacists, domestic staff and porters. We also spoke with staff individually as requested.

We talked with patients and staff from all the ward areas and outpatient services. We observed how people were being cared for, talked with carers and/or family members, and reviewed patients’ records of personal care and treatment. We carried out unannounced inspections on 29 March and 02 April 2014. We looked at how the hospital was run out of hours and at night, the levels and type of staff available and the care provided.

What people who use the trust’s services say We held a listening event, which 128 people attended. Some people told us about us that they had

good care at Royal Berkshire Hospital. However, people had concerns about the long waiting times in A&E particularly for care of older people.

The Adult Inpatient Survey in 2012 Royal Berkshire Hospital NHS Foundation Trust scored ‘about the same’ as other trusts for all 10 areas. The trusts performance had reduced in one area and improved in three areas. Of the 60 questions asked the trust performed better than other trust in one question.

The results from the Friends and Family Test (FFT) between September 2013 to December 2013 show the trust has scored below the England average for all four of the months, achieving the lowest in October. Response rates are fairly consistent over the four months. A&E scores compared to the England averages were higher in two months and lower in two months.

The Cancer Patient Experience Survey (CPES), Department of Health, 2012/13, showed that out of 69 questions, for which the trust had a sufficient number of survey respondents on which to base findings, the trust was rated by patients as being in the bottom 20% of all trusts nationally for 14 of the 69 questions and performed better in 9 questions.

CQC’s Survey of Women’s Experiences of Birth 2013 showed that under the ‘Care during labour and birth’ that the trust is performing better than other trust’s for one of the three areas of questioning. Comparison with the 2010 results highlighted an upward trend in one of the eight questions. The other seven questions saw no change in the results.

Between January 2013 and February 2014, Royal Berkshire Hospital had 294 reviews from patients on the NHS Choices website. It scored 4 out of 5 stars overall, with 91 comments with a rating of 5 stars and 34 with a rating of one star. The highest ratings were for cleanliness, staff co-operation, dignity and respect, involvement in decisions and same sex accommodation. The lowest ratings were for staff being rude, breach of confidentiality, patient aftercare, pain management and communication.

Patient-Led Assessment of the Care Environment (PLACE) is self-assessments undertaken by teams focus NHS and independent healthcare staff and also the public and patients. In 2013, Royal Berkshire scored greater than 92% for all four measures, with cleanliness scoring the highest at 99.2%.

The patients association attended the inspection and will publish their report independently.


Facts and data about this trust Context

Foundation trust since June 2006 Approximately 745 beds Population 600,000 Staff approximately 5,000 Annual turnover: 330 million Deficit: £2.68m in 2012/13

Activity (2012/13)

Inpatient admissions 94,755 Outpatient attendances 449,627 A+E attendances 101,497

Intelligent Monitoring – Low risk (March 2014)

Items Risks Elevated Score Safe 8 1 0 1 Effective 31 0 1 2 Caring 18 0 0 0 Responsive 10 0 0 0 Well led 26 2 0 2 Total 93 3 1 5

Safety

4 never events (Dec 2012-Jan 2014) STEIs 93 SI’s (Dec 2012-Jan 2014)

NRLS Deaths 13

Severe 5 Abuse 14 Moderate 680

Caring: CQC inpatient survey (10 areas): Average for all 10 areas Cancer patient experience survey (69 questions): Above for 9 questions Average for 46 questions Below for 14 questions Responsive: Bed occupancy 89.1% A&E: four hour standard Below average Cancelled operations Similar to expected Delayed discharges Similar to expected 18 week Referral to treatment (RTT) Similar to expected Diagnostic target Below average Well-led:


Staff survey (28 questions) Above average for 18 questions Average for 6 questions Below for 4 questions Sickness rate 3.5 % Below national average

Summary of findings

Are services at this trust safe? Requires improvement

Overall we rated the safety of services in the trust as ‘requires improvement’. For specific information please refer to the report for Royal Berkshire Hospital. Nursing staffing levels were insufficient on many wards and consequently there was a significant reliance on agency and bank staff. The agency and bank staff were appropriately checked and had an induction checklist carried out. The trust was taking steps to recruit nurses internationally due to the difficulty in recruiting. Midwifery staffing was a concern in the Rushey unit, however, immediately after our inspection the trust closed two beds until further staff were recruited. Consultant presence in obstetrics was not in line with national standards. Medical staffing out of hours was a concern, particularly in medicine. Due to capacity pressures and workload, medical staffing needed improvement in some areas and in particular the critical care unit as consultants regularly needed to stay in overnight when they were on call. Clinical data was not always easily accessible due to the fragmented structure of the trust’s electronic patient record (EPR) and patient records were not easily accessible or well-maintained with an over-reliance on ‘temporary’ records. This affected patient care as significant information was not available and in some instances patients had more than one test as the initial result was not available. The trust recognised the safety concerns relating to medical records and set up a working group led by the interim medical director to address the issues as a priority. Medical equipment checks were not consistently completed or recorded and staff reported difficulties in being able to get equipment checked or replaced.

Are services at this trust effective? Good

Overall we rated the effectiveness of the services in the trust as ‘good’. For specific information please refer to the report for Royal Berkshire Hospital.

Most patients were treated according to national evidence-based guidelines and clinical audit was used to improve practice. There were good outcomes for patients and mortality rates were within the expected range. Seven-day services were in development and there were good examples of seven-day working. There were good examples of robust ward rounds and multi-disciplinary team working with input from allied health professionals. There were examples of clear documented pathways of care.

Are services at this trust caring? Good

Overall we rated the caring aspects of services in the trust as ‘good’. For specific information please refer to the report for Royal Berkshire Hospital.

Overall, patients received compassionate care and were treated with dignity and respect. The Critical Care service provided some excellent caring interventions both for the patients and their families, with positive feedback about their bereavement service. Patients and relatives we spoke with said they felt involved in their care. There were examples of patients not feeling appropriately cared for in A&E and some ward


areas where staff were busy. Staff acknowledged that, at times, workload pressures could prevent the level of care and support patients needed. Staff were extremely committed and aimed to put the needs welfare of patients as their priority.

Are services at this trust responsive? Requires improvement

Overall we rated the responsiveness of services in the trust as ‘requires improvement’. For specific information please refer to the report for Royal Berkshire Hospital.

The trust faced significant capacity pressures. The A&E department was not consistently meeting the four-hour target for treatment, admission or discharge. The department was designed for 65,000 attendances but had around 100,000 attendances a year at the time of the inspection. This resulted in patients waiting in corridors to be seen and, in some instances, spending longer than 12 hours in A&E.

The flow throughout the trust was not robustly managed, with patients who were clinically fit for discharge not being discharged in a timely manner. There were significant waiting times for radiology diagnostic procedures, which impacted on both inpatients and outpatients. The trust was taking steps to improve the radiology waiting times and looking at other ways of providing diagnostic treatment.

The critical care capacity was not sufficiently meeting the demand and resulted in either patients’ operations being cancelled or patients staying in recovery overnight. The trust did not have clear robust plans to address the capacity and flow issues. However the appointment of the interim chief operating officer was intended to concentrate on addressing them.

Are services at this trust well-led? Requires improvement

The trust’s leadership was rated as ‘requires improvement’. Many of the executive team were interim positions and the former chief executive had left in December 2013. The trust had proactively commissioned a review into its leadership and governance processes and we had confidence that they were beginning to take appropriate steps to address some of the trust wide issues found during the inspection. They were aware of the potential risks associated with interim posts and were in the process of appointing a new chief executive. This recent instability in leadership has resulted in front line staff not feeling fully informed about the recent changes and unclear on the overall vision for the trust. Staff did not feel the executive team were visible enough, although many staff told us that the Director of Nursing was more visible and had ‘made a difference’ in the relatively short time she had been in post since June 2012.

Whilst the trust board was aware of the improvements that were required, they were facing a legacy of some areas of governance not being standardised or robust and systems and process being inconsistently applied, which would take some time to address. During the inspection there was some evidence of improvement starting, but it was too soon to establish the impact. There were some areas that needed stronger leadership from the board to the ward to realise the required changes.

Vision and strategy for this service

The trust had been through significant change at board level and was awaiting recruitment of a permanent chief executive.

The trust was managing the capacity pressure as a priority and the longer term vision was being reviewed awaiting new leadership.

The impact of numerous interim directors being in post resulted in staff not feeling they were clear on the future vision of the trust given the financial pressures.

Governance, risk management and quality measurement

The overall governance structures lack standardisation and clear performance management, which


impacted on the board holding to account in a timely manner.

Whilst the care group structure has some inevitable benefits through the clinical leadership model the trust aimed to achieve, each care group was operating primarily independently of each other in ‘silos’ without robust standardisation of reporting to the board on performance and quality.

The care group directors were accountable to the board for performance and quality of their care group, however they were not consistently held to account on delivery of their targets and key performance indicators. Furthermore, it was not clear how the corporate functions were structured to work with the care groups and where the lines of accountability were in all cases.

The trust had recognised there were significant improvements needed in their quality governance structure and had commissioned work from an external company to commence work within the immediate few weeks following the inspection.

During the inspection it was evident that there were significant data quality issues across the trust, which, at times, resulted in the board taking assurance from data that could not always be relied on. Whilst the majority of the board recognised there was a data quality concern, the care groups were not interrogating the data consistently in the reports they presented to the board.

The levels of incident reporting were a concern as there was a theme that staff members did not always report incidents because they did not always see resultant changes when they had reported in the past.

The care group ‘silo’ working had meant that learning from incidents and complaints was not shared effectively trust wide. Whilst themes and aggregated data was, at times, discussed at the trust board, this communication of learning was not fed back to the clinical staff delivering care to patients in a robust manner.

The care groups had recently recognised the lack of formal information sharing as an issue and consequently set up a new formal meeting where each care group shared learning and discussed performance and quality with the aim to eradicate the ‘silo’ working and encourage ‘trust-wide’ operational working where appropriate. However, it remained unclear how the corporate functions linked into this approach.

Leadership of service

The leadership of the trust had been through some significant changes in the preceding months of the inspection as the chief executive left in December 2013, which left some resultant confusion among staff at all levels.

The board was made up of a significant number of interim positions with more commencing in post following the inspection. At the time of the inspection the executive team comprised of six permanent executive positions and five interim executives. The significant number of interim appointments, presented challenges for consistent leadership.

Under the leadership of the former chief executive, a clinically-led model had been adopted with three of the executives holding positions as Care Group Directors of urgent care, planned care and networked care. The care group directors worked clinically and were ultimately accountable for their care group performance, however the amount of time allocated specifically for the care group director role was not consistent.

Development of board members had not been a priority and it was apparent that the executives were not, at times, joined up in their approach. When the three care group directors were appointed there was limited formal support and development provided in relation to the new roles.

At the time of the inspection the trust did not have a Chief Operating Officer (COO) post but an interim COO was starting immediately post inspection.

Feedback from staff highlighted that many staff members did not know who the members of their executive team were and there was a consistent theme that executives were not visible enough. One main exception was that many staff members knew the director of nursing and felt she was


visible, although they would like visibility to still increase.

The consistent leadership of the trust was an issue raised by staff at all levels, particularly given the financial pressure the trust faced.

Culture within the service

The trust wide culture was one of pride and commitment among staff who were very positive about the trust as a place to work, with many clinical staff having worked at the trust for the majority of career.

The staff focus groups were very well attended and, whilst there were many issues raised regarding staffing and systems and processes, the overriding message received was that that they were proud to work for the trust and they felt well supported by managers in their development.

The recent resignation of the former chief executive had impacted on the culture as a consequence of staff not feeling they were aware of the plans for the trust and what changes might occur with new leadership.

There was an open and transparent culture among staff at all levels.

Public and staff engagement

Staff consistently stated they felt involved in the development of their work and in particular more locally in their clinical areas.

The care group structure meant that staff often felt involved in their ‘care’ group’ rather than the trust overall.

Patient feedback was obtained through the Friends and Family test and the NHS Choices website and inpatient feedback captured by volunteers.

Innovation, improvement and sustainability

Staff were encouraged to improve standards of care through innovation and felt support in developing their own practice locally, however capacity and staffing pressure meant that they did not feel they were able to improve the standards of care proactively in all cases as time constraints prevented them doing so.

The sustainability of the trust was a concern to staff given the instability at the executive level and to compounding financial pressure and staff were awaiting the commencement of the new chief executive and a permanent executive team to secure a sustainable future for the trust.


Our ratings for Royal Berkshire Hospital are: Safe Effective Caring Responsive Well-led Overall

Accident and emergency Good Inspected but

not rated1 Good Requires improvement Good Good

Medical care Requires improvement Good Good Requires

improvement Requires

improvement Requires improvement

Surgery Requires improvement Good Good Requires



Critical care Requires improvement Good Outstanding Requires



Maternity and family planning Inadequate Requires

improvement Good Requires improvement

Requires improvement Requires

improvement

Children and young people Good Good Good Good Good Good

End of life care Good Good Good Outstanding Good Good

Outpatients Requires improvement

Inspected but not rated1 Good Requires



Overall Requires improvement Good Good Requires



Safe Effective Caring Responsive Well-led Overall

Overall trust Requires improvement Good Good Requires



Notes:

1. We are currently not confident that we are collecting sufficient evidence to rate effectiveness for both accident and emergency and outpatients.

Overview of ratings


Outstanding practice

We saw several areas of outstanding practice including:

Caring interventions and support for families within in the Intensive Care Unit.

The Children’s A&E department.

Consultant geriatricians worked in the A&E department 8am to 8pm seven days a week.

The responsiveness of the Palliative Care team.

Areas for improvement However, there were also areas of poor practice where the trust needs to make improvements. Importantly, the trust must: Ensure that medical records are kept securely and records can be located and accessed promptly

when needed to appropriately inform the care and treatment of patients.

Maintain the privacy and dignity of patients placed in the observation bay in the A&E department.

Ensure that the design and layout of the emergency department protects patients and staff against the risks associated with unsafe or unsuitable premises.

Take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced staff employed to care for patients’ needs, and safeguard their health, safety and welfare.

Accurately complete ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms, and document the discussions about end of life care with patients.

Take proper steps to ensure that each patient is protected against the risks of receiving care or treatment that is inappropriate or unsafe by planning the delivery of care and appropriate treatment to meet patients’ individual needs, and have procedures in place to deal with emergencies which are reasonably expected to arise.

Review the ICU capacity across the trust; employ suitably qualified, skilled and experienced staff; and have necessary equipment available to care for patients who require intensive or high dependency care.

Ensure that planning and delivery of care meets patients’ individual needs, and ensure the safety and welfare of all patients.

Increase staff knowledge of Deprivation of Liberty Safeguards (DOLs) and the Mental Capacity Act (MCA) through necessary training to improve safeguarding.

Improve contemporaneous record keeping by all staff to avoid misplacing records of care and observations.

Ensure the staffing levels and admission criteria in the Rushey Midwife-led unit is maintained to ensure safe care is provided to all women.

Ensure that at all times there is a sufficient number of suitably qualified, skilled and experienced staff employed to provide safe midwifery care in all areas.

Take action to improve the ventilation system on the delivery suite, to protect patients and others who may be at risk from the use of unsafe equipment.


This section is primarily information for the provider

Compliance actions Action we have told the provider to take The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.

Regulated activity Regulation Treatment of disease, disorder or injury Surgical procedures

Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010 Care and welfare of people who use services How the regulation was not being met: People who use services and others were not protected against the risks of receiving care or treatment that is inappropriate or unsafe by means of carrying out an assessment of the needs of the services user and the planning and delivery of care and, where appropriate, treatment to meet the needs and ensure the safety and welfare of the service users. Regulation 9 (1) (a) (b) HSCA 2008 (Regulated Activities) Regulations 2010 Care and welfare of people who use services

Regulated activity Regulation Treatment of disease, disorder or injury Diagnostics and screening

Regulation 16 HSCA 2008 (Regulated Activities) Regulations 2010 Safety, availability and suitability of equipment How the regulation was not being met: The registered person had not ensured that equipment was properly maintained and available in sufficient quantities in order to ensure the safety of service users and meet their assessed needs. Regulation 16 (1) (a) (2) Safety, availability and suitability of equipment

Regulated activity Regulation Treatment of disease, disorder or injury

Regulation 17 HSCA 2008 (Regulated Activities) Regulations 2010 Respecting and involving people who use services How the regulation was not being met: The registered person had not, so far as reasonably practicable, made suitable arrangements to ensure the privacy and dignity of service users. Regulation 17 (1) (a) Respecting and involving people who use services


Regulated activity Treatment of disease, disorder or injury Maternity and midwifery services

Regulation 15 HSCA 2008 (Regulated Activities) Regulations 2010 Safety and suitability of premises How the regulation was not being met: The registered provider must ensure service users are protected against the risks associated with unsafe or unsuitable premises by means of- suitable design and layout and adequate maintenance of the premises in connection with the regulated activity. Regulation 15 (1) (a) (ii) (c) (i) Safety and suitability of premises

Regulated activity

Treatment of disease, disorder or injury Surgical procedures Maternity and midwifery services

Regulation 18 HSCA 2008 (Regulated Activities) Regulations 2010 Consent to care and treatment How the regulation was not being met: The provider did not have suitable arrangements in place for obtaining and acting in accordance with, the consent of service users in relation to the care and treatment provided for them. Regulation 18 Consent to care and treatment

Regulated activity

Treatment of disease, disorder or injury Surgical procedures Maternity and midwifery services

Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010 Staffing How the regulation was not being met: The provider had not taken appropriate steps to ensure that at all tine there were sufficient numbers of suitably qualified and experienced persons employed for the purpose of carrying on the regulated activity. Regulation 22 Staffing

Regulated activity Regulation Treatment of disease, disorder or injury

Regulation 20 HSCA 2008 (Regulated Activities) Regulations 2010 Records How the regulation was not being met: Service users were not protected against the risk of unsafe or inappropriate care and treatment arising from the lack of proper information about them by means of the maintenance of: an accurate record in respect of each service user which shall include appropriate information and documents in relation to the care and treatment provided. The registered provider must ensure that records are kept securely and can be located promptly when required. Regulation 20 (1) (a) (2) (a) Records

1


Board of Directors

Title: Nurse Staffing Report

Date: 30th June 2014

Lead: Caroline Ainslie, Director of Nursing

Purpose: This provides the Board with a position report on the planned and actual number of staff on duty for each shift on our in patient wards during May 2014. The paper discusses the reasons for any variance and the actions the Trust have in place to address this.

Key Points: The attached information provides a shift by shift report of planned and actual staff on duty during May 2014. The information is intended to support decision-making, enabling the Board to evaluate risks, seek assurances and support the Executive Team in taking any necessary improvement actions. The Director of Nursing commissioned a nurse staffing review in 2013-14. This used the nationally accepted “Safer Nursing Care Tool”, which considers both the acuity and dependency of patients to determine the appropriate staffing level. In addition the Trust also combined this with benchmarking information and the professional judgement of ward managers. Following this the Trust made an investment in additional nursing staff to increase establishments where this was necessary to support care. All wards are therefore established at the appropriate staffing level to support patient care. This will vary by specialty, but also the changing dependency of patients. However it would not exceed the RCN recommendation of 1 x registered nurse for every 8 patients, above which it is viewed care and patient experience can be compromised. The Trust continues to use a large amount of temporary staff to support safe services, partly as a result of vacancies. Some of this will also be attributed to uplifts in nursing establishments. The Trust is working to fill these with permanent staff. .

Decision required: FOI Status

The Board is requested to review the report and seek assurance on the actions being taken The report will be made available on request

2

1 BACKGROUND

1.1 There have been a number of national reports which have established the importance of adequate nurse staffing levels to safe and effective patient care. The publication by NHS England of the report “How to ensure the right people, with the right skills, are in the right place at the right time: A guide to nursing, midwifery and care staffing capacity and capability” placed a number of obligations on NHS Trusts. This included collecting and publishing staffing information, for in patient wards, on a shift by shift basis.

1.2 The Trust publishes this information in an accessible format through NHS Choices and its own website. In addition the Trust will be standardising practice across wards to display through a patient information board, the name of the ward manager, who is in charge and the staff on duty for each shift.

1.3 Trust Boards will receive regular reporting and be required at least every six months to consider staffing levels, using a validated staffing tool. The purpose in presenting this information is to enable the Board to seek assurance in respect of any staffing issues and to support the Executive in undertaking any necessary improvement actions

2 MAY STAFFING DATA

2.1. It should be noted that this is the first time the Trust has undertaken the reporting of nursing & midwifery staffing using the new national guidance which was first published on 31st

Recognising this, NHS Choices will not initially be applying a red, amber, green, rating to the results. This is due to the difficulty in comparing results between Trusts. As a practical example, if a Trust did set higher staffing levels on its wards, they could be expected to experience greater difficulty in filling each shift over the month.

March 2014.

The following table summarises the actual hours of staffing which was deployed over the month of May, expressed as a percentage of that which was originally planned. The planned cover is based on full bed occupancy.

3

Table1: Staff Hours Covered as % of Planned Rota

2.2 The Trust managed to fill approximately 95% of the planned hours over May in eight of eleven specialties during the daytime shilfts. This fell to six specialties who had 95% of their planned hours covered during nights. Given that this is the first month of collecting and reporting data in this format, caution should be exercised in interpresting the results. Some supernumery nursing hours may not be included in the rota, this will be adjusted for in future reports. In addition any shortfall in staff may be covered by moving staff from wards experiencing less pressure, but may still be recorded in the rota for their home ward.

2.3 Six specialties had in excess of 100% of their planned hours covered for either night or day shifts during the month. There will be a number of reasons for this including, changes in the acuity and dependancy of patients, meaning that rostered hours were increased above plan to provide higher levels of nursing support. This will be investigated further for future reports to ensure more granular exception reporting on the reasons for variance against planned hours.

2.4 Maternity and elderly care wards are currently experiencing the most staffing challenge due to the impact of vacacancies and staff sickness, the latter of which can more difficult to plan for at short notice.

Wards in DepartmentsDay

CoverNight Cover

Integrated Medicine 99.4% 100.1%

Specialist Medicine 93.3% 98.8%

Abdominal Surgery 105.9% 92.9%

Berkshire Cancer Centre 99.9% 109.0%

Head and Neck 106.2% 97.6%

Specialist Surgery/ Theatres a 94.6% 93.7%

Acute Medicine 98.8% 103.0%

Emergency Care 86.5% 94.1%

Maternity and Children's Servi 93.70 65.40

Paediatric s & Neonatal 98.0% 93.1%

Urgent Care 94.7% 101.3%

NETW

ORKE

D CA

REPLA

NNED

CARE

URGE

NT CA

RE

The table shows the %age of actual hours of cover against the planned. Planned hours are based on full bed capacity

4

2.5 The Nursing & Midwifery Programme Board has been established and has a number of projects designed to support effective staffing. This includes skill mix reviews, optimising ward rostering, specialing policy and recruitment & rentension. The Trust also actively engages with it’s commissioners on staffing issues.

3 Recommendations

3.1 The Board is asked to note the contents of the report and endorse the following actions:

a) Review rostering practices to improve the proportion of contracted hours which are used to fill shifts.

b) Optimise the use of NHS Professionals through earlier notification of staffing requirements to better enable filling of shifts c) Performance indicators are in place for ward staffing levels d) International recruitment drives during July and August, in Ireland and Portugal, to fill current and forecast vacancies

e) Implementation of a Recruitment & Retention Strategy to address both hard to fill roles and improve retention to reduce requirement for recruitment

4 Attachments

4.1 Staffing profile for each in-patient ward by shift, presented by Care Group for the month of May 2014

Appendix 1: Urgent Care

Appendix 2: Planned Care

Appendix 3: Networked Care

Agenda Item 9 Appendix 1

Report Period : May 2014

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QualifiedTargets 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6Cover 6 8 7 7 6 7 6 6 6 6 7 6 6 6 7 6 6 6 6 6 6 6 6 6 8 6 6 6 6 6 6

UnqualifiedTargets 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3Cover 3 1 2 2 2 2 3 3 3 3 2 3 3 3 2 3 3 3 3 3 3 2 3 3 1 3 3 3 3 3 3





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QualifiedTargets 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

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Cover 5 5 5 5 5 5 5 5 5 4 5 5 5 5 5 5 5 5 4 5 5 5 5 5 5 5 5 5 5 5 5Unqualified

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1

Agenda Item 10

Royal Berkshire NHS Foundation Trust Board of Directors

Title: Risk Appetite Statement for the Trust

Date: 30 June 2014

Lead: Keith Eales

Purpose: To recommend a risk appetite statement for the Trust.

Key Points:

Risk appetite can be defined as the amount of risk an organisation is prepared to accept in the pursuit of its strategic objectives

The Board evaluation report contained a recommendation that the Trust should complete its work on a risk appetite statement

The Good Governance Institute (GGI) matrix approach, and the practice in other Trusts has been reviewed. A flexible approach has been adopted in drafting a statement for the Trust

The draft statement is submitted for approval and internal and, where appropriate, external communication

Decision required

To agree a risk appetite statement for the Trust


2

1 Background 1.1 Risk appetite can be defined as the amount of risk, on a broad level, that an

organisation is willing to take in the pursuit of its strategic objectives.

1.2 Risk appetite therefore goes to the heart of how an organisation operates and how it wishes to be perceived by key stakeholders including employees, regulators and the public.

1.3 Risk appetites can vary across different types of risk, at different times and

between similar organisations in the same sector. They may also vary between different parts of the same organisation. Factors such as the external environment, people, business systems and policies will all influence an organisation’s risk appetite.

1.4 A risk appetite statement provides

• A clear statement to stakeholders of the nature and extent of the key types of risks an organisation is willing to embrace as part of the delivery of the organisation business plan

• An organisational policy to guide action on the quantifiable level of risk exposure that is considered acceptable

1.5 A well-defined risk appetite should have the following characteristics:

• Reflective of strategy, organisational objectives and business plans • Reflective of the key aspects of the business • Acknowledges a willingness and capacity to take on risk • Is documented as a formal risk appetite statement • Is periodically reviewed and reconsidered • Has been approved by the Board.

1.6 The Good Governance Institute (GGI) has produced a matrix to support better

risk sensitivity in decision taking. 2 Trust Risk Appetite Statement 2.1 The Board evaluation action plan recommended that the Trust adopt a risk

appetite statement.

2.2 Initial consideration has been given to, and discussed with the Executive Risk Committee, a statement based on the GGI approach. However, it is considered that the formulaic approach on which it is based may be prescriptive and might not aid communication of the statement internally or externally.

2.3 An alternative approach has been adopted. This is based on drafting a statement for the Trust, albeit adopting the domains included within the GGI approach. The draft statement is attached as appendix 1. This has been endorsed by the Executive Risk Committee.

2.4 In terms of its use within the Trust, the statement will be

3

• Incorporated into the Trust risk management policy and strategy

• Integrated into the quality impact assessment process to give a context for the completion of QIA’s

• Used by the Executive Risk Committee when reviewing the identification and scoring of risks in the Corporate Risk Register and Board Assurance Framework

• Used as a source document when compiling, updating and reviewing

risk registers

2.5 To support this, the statement will be communicated widely within the Trust, submitted to Care Group and corporate directorate management teams and awareness raised through the risk management training in the organisation.

2.6 The statement will be reviewed annually by the Board.

3 Recommendation 3.1 That the attached risk appetite statement be adopted for the Trust 4 Contact

Keith Eales 0118 3228439

4

Appendix

Trust Risk Appetite Statement

General Statement The Trust appetite to risk is shaped by a number of general and current issues and challenges

• The inherent safety and outcome focussed nature of the activities that it carries out

• The challenging financial climate that the Trust faces and the constraints that this brings

• The inherent challenge in balancing quality, safety and financial effectiveness

• The regulatory focus on the Trust, in particular by the Care Quality Commission and Monitor

These factors, combined, result in the Trust having, generally, a low appetite for risk in terms of quality and patient care, finance, compliance, regulatory requirements and reputational issues. Within this overall approach, the Trust has a greater appetite for taking considered risks, where positive gains are anticipated, in respect of

• The early adoption of new techniques

• Challenges to current working practices

• Pursuing new approaches to service and organisational delivery

• The identification of new income streams This is on the basis of

• Risks being identified, fully assessed and considered manageable

• Clearly identifiable benefits

• The risk of harm or adverse outcomes to service users is low

5

Quality and Patient Care The Trust has a low appetite for risk in respect of the quality and safety of the services provided and the care given to patients. The Trust will not accept risks that materially impact on patient safety. The challenging financial position of the organisation places significant emphasis on the affordability of services and the prioritisation of resources. However, discussions in respect of affordability will fully take account the overall low appetite for risk in respect of quality and patient care. Within this broad statement, the tradition of the Trust as an early adopter of new techniques and practices, and its continuing commitment to research, is recognised. As such, there will be occasions when the Trust will take considered risks in the adoption of new techniques or practices which meet the principles set out in the general risk statement. Finances The Trust has a low appetite for financial investment beyond the resources made available to meet its statutory duties and to deliver the services for which it is commissioned. The financial position of the Trust means that means that resources are generally restricted to existing commitments. In meeting these commitments, value for money and affordability, as well as to outcomes and standards of care, will be paramount in delivering services. The low appetite for risk will not preclude all potential delivery options for securing high standards of care and the best use of resources. Compliance and Regulatory The Trust will seek to avoid regulatory intervention and will only in exceptional circumstances take action which raises a risk of regulatory scrutiny or action. Reputation The Trust has a low risk appetite for actions and decisions that, whilst taken in the interests of ensuring quality and sustainability of the organisation and its patients may affect the reputation of the Trust and its employees. Such actions and decisions will be subject to a rigorous risk assessment and will require wider corporate approval before action is taken. June 2014

1


Board of Directors

Title: Annual Plan Board Statements 2014/15

Date: 30 June 2014

Lead: Keith Eales Craig Anderson

Purpose: To approve self-certification statement as part of the Monitor Annual Plan submission for 2014/15.

Key Points: • The Board is required to consider a number of board statements as part of the Annual Plan process and to self certify that each statement is ‘confirmed’ or ‘not confirmed’.

• The Trust is required to make the following declarations to Monitor in accordance with the relevant sections of the NHS provider licence.

- Systems for compliance with licence conditions - Availability of resources and accompanying statement

• On the basis of the supporting analysis provided in respect of the statements it is recommended that the Board should self certify that each statement is ‘confirmed’.

• Responses to need to be submitted to Monitor by 30 June 2014.

Decision required:

The Board is recommended to self certify that each of the Monitor Annual Plan statements for 2013/14 is ‘confirmed’.

FOI Status This report will be made available on request

1 Background

1.1 The Compliance Framework published by Monitor requires foundation trusts to submit an Annual Plan each year. The Plan is used by Monitor primarily to assess the risk that a foundation trust may breach its Licence in relation to finance and governance. Monitor will also assess the quality of the underlying planning processes. The Board approved Part I of the plan in March.

1.2 As part of the submission the Board is required to self certify against a number of prescribed statements as either ‘confirmed’ or ‘not confirmed’.

1.3 The position in respect of three statements was submitted on 30 May. These further statements must be submitted by 30 June.

1.4 If the Board feels it is unable to fully certify a particular statement, the guidance states that the Board

2

‘….should make an alternative declaration by amending the self certification as necessary and including an y significant prospective risks and concerns the FT has in respect of delivering quality services and effective quality governance and

…must provide a commentary explaining the reasons for the absence of a full self certification and the actions it proposes to take to address it.’

Monitor may adjust the relevant risk rating if there are significant issues arising and this may increase the frequency and intensity of monitoring for the Trust.’

2 Comment

2.1 The Board statements are listed in the appendix to this report, together with a commentary supporting a ‘confirmed’ declaration.

2.2 The Board is invited to consider whether it is able to certify each statement or whether further evidence is required. Should the Board be unable to fully certify then amendments to the appropriate statement and supporting commentary should be considered.

3 Recommendation

3.1 The Board is recommended to self certify that the three board statements for 2014/15 can be confirmed.

4 Attachments

4.1 The following is attached to this report:

(a) Self-Certification Statement for June

5 Contact Contact: Keith Eales Phone: 0118 322 8439

3

Appendix 1 Annual Plan Board Statements 2014/15 Statement Lead Commentary

4. Corporate Governance Statement

1. The Board is satisfied that the Trust applies those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of heath care services to the NHS

Keith Eales Governance arrangements follow best practice and are reviewed against the Monitor Code of Governance and other guidance. The system of governance is subjected to review by internal and external audit on an annual basis.

2. The Board has regard to such guidance on corporate governance as may be issued by Monitor from time to time.

Keith Eales The Audit & Risk Committee receives an update at every meeting from external auditors which includes Monitor advice issued. The Chief Executive’s report to the Board also covers national reports, advice and topics.

3. The board is satisfied that the Trust implements: (a) Effective board and committee structures (b) Clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees; and

(c) clear reporting lines and accountabilities throughout its organisation

Keith Eales a) A Board and Committee structure is in place and terms of

reference for each of the committees is reviewed on an annual basis and submitted to the Board for approval.

b) Terms of reference are set for all committees. Matters reserved for the Board, as well as its role in general have been agreed. All directors reporting to the Board have responsibilities set out in job descriptions. In addition, the Board Charter of Expectations sets out the responsibilities of Board Directors.

c) Organisational charts are in place for all corporate and care group directorates which set out reporting lines and accountabilities.

4

Statement Lead Commentary

4. The Board is satisfied that the Trust

effectively implements systems and/or processes: (a) To ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively; (b) For timely and effective scrutiny and oversight by the Board of the Licensee’s operations; (c) To ensure compliance with health care standards binding on the Licensee including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions; (d) For effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licensee’s ability to continue as a going concern); (e) To obtain and disseminate accurate, comprehensive, timely and up to date

Craig Anderson Caroline Ainslie/ Alistair Flowerdew Keith Eales Craig Anderson John Taylor

a) The Trust’s internal control mechanisms and reporting regime to Monitor ensure that this is closely monitored. The Trust is subject to internal and external audit which also monitors performance in this area. b) The Trust Board receives monthly Quality Performance and Care Group Performance reports. This is in addition to specific reports on operational issues. c) The Trust has a governance structure linking the Board, key committees charged with responsibility for oversight of operations (the Clinical Governance Committee, Resources Committee and Audit and Risk Committee), through to the Executive Structure (the Executive, the Quality Performance and Learning Committee, Executive performance meetings with Care Group Clinical Governance and performance meetings). d) The Trusts Standard Financial Instructions, Business Case Policy annual planning process (including quarterly forecasting) and cash management processes ensure the ability of the Trust to continue as a going concern. In addition, a specific paper to confirm going concern is provided to Audit & Risk Committee and Board as part of signing the year end accounts. e) A monthly Quality Report including operational performance and a Finance report is produced for Board which outlines

5


information for Board and Committee decision-making (f) To identify and manage (including but not restricted to manager through forward plans) material risks to compliance with the Conditions of its Licence; (g) To generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and (h) To ensure compliance with all applicable legal requirements

Keith Eales Craig Anderson Keith Eales

performance at Board level and includes a dashboard and a KPI scorecard. Metrics are at granular level by theme, by month and previous year’s outturn. This is supported by Care Group summaries allowing analysis. Prior to the Board, performance is monitored through monthly performance meetings with the Executive team and care groups to discuss finance and workforce and a collective meeting with all three care groups to discuss quality performance. Improved ward to Board reporting is being introduced. f) The Trust identifies key risks through the Board Assurance Framework and the Corporate Risk Register. This identifies any risk to compliance with the conditions of the license. The Operational Plan sets out key risks. g) The Trust has used PwC to provide an independent assessment of our 2014/15 Operating Plan. The Trust undertakes a quarterly forecast as part of our quarterly financial process to also assess delivery against Business Plans supported by monthly performance reviews of Care Groups and Corporate Departments. h) Legal obligations on the Trust are brought to the attention of directors.

5. The Board is satisfied that the systems and/or processes referred to in paragraph 5 should include but not be restricted to systems and/or processes to ensure:

(a) That there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided;

Keith Eales

a) The Nominations and Remuneration Committee has responsibility for overseeing the competence and capability of the management team. On an individual basis, the Trust has an

6


(b) That the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations; (c) The collection of accurate, comprehensive, timely and up to date information on quality of care; (d) That the Board receives and takes in to account accurate, comprehensive, timely and up to date information on quality of care; (e) That the Trust, including its Board, actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and

Caroline Ainslie- please review John Taylor John Taylor Caroline Ainslie

appraisal system. b) Effective clinical engagement throughout the Trust structure ensures that quality of care considerations are integral to planning and decision-making processes. The clinical representation and expertise at Board and Executive level, combined with a clinically led structure places quality of care considerations at the forefront in planning and decision-making processes. c) Quality information is produced by Informatics prior to analysis by the Care Groups and by the Executive. This is triangulated through a collective meeting with all three care groups and the Executive to discuss quality performance. d) A monthly Quality Report including operational performance is produced for Board which outlines performance at Board level and includes a dashboard and a KPI scorecard, highlighting performance below target. Metrics are at granular level by theme, by month and previous year’s outturn. Exception reports are published for consideration of the Board. e) The Trust has an up to date Patient and Engagement Strategy supported by work programmes including KPIs reported to Board. Appropriate channels are in place including: Patient Partnership Programme, Patient Standing Conferences, Patient Groups, local and national surveys, Friends & Family Test, PALS, patient stories reported to Board. The Trust is developing ‘Patient Leaders (monitored by a Patient Leadership Committee. Bi-monthly meetings in place with local Healthwatch. Structured listening events are in place for staff and results used for development of improvement plans and Quality Strategy. Governor-led committees are in place including Clinical Assurance and are attended by Executive and NED colleagues.

7


(f) That there is clear accountability for quality of care throughout the Trust but including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate

Caroline Ainslie f) At Board level, the Medical Director and Director of Nursing have joint responsibility for quality issues to the Board, including assurance on quality governance. The monthly Quality Performance Report and Care Group reports identify and escalate key quality performance issues to the Board. Within the organisation, an incident reporting system is in place, with a structure for the escalation of incidents to speciality Care Group Clinical Governance meetings, the Executive Quality Performance and Learning Committee and to the Executive and Board Clinical Governance Committee.

6. The Board is satisfied that there are systems to ensure that the Trust has in place personnel on the Board, reporting to the Board and within the rest of the organisation who are sufficient in number and appropriately qualified to ensure compliance with the conditions of its NHS provider licence.

Paul Jones The Trust has maintained the required statutory number of Executive and Non Executive Directors to ensure there is appropriate organisational capacity. This has included the appointment of interim and acting up directors where required. Following the commencement of a substantive Chief Executive in August 2014, the Trust will be making substantive appointments for interim roles where this is required. The Trust is undertaking a project to improve workforce planning capability to ensure it has optimal staffing moving forward. The Trust also maintains a process in line with relevant national guidance to conduct robust pre-employment checks on all new hires.

Agenda Item 12

Version 1.0 – June 2014 1

Royal Berkshire NHS Foundation Trust

Trust Board

Title: Standing Financial Instructions

Date: 30 June 2014

Lead: Craig Anderson

Purpose: To update the Board on the outcome of the annual review of the Trust Standing Financial Instructions (SFI’s) and to seek approval for the amendments to the document

Key Points:

Significant changes have been made to the presentation of the main body of the SFI’s, but there has been little change to the underlying content. The updated presentation makes it easier to find relevant content.

All iproc authorisers and cost centre managers will be required to certify that they have read, understood and will comply with the SFI’s

Changes to delegated authorities (Table 1 – marked with track changes on the attached copy)

a) Item1.7: changes to formalise process on disposal of assets

b) Items 2.3 to 2.5: consolidated onto one row

c) Item 2.9: signing of contracts previously only with CEO, now CEO or DOF

d) Items 3.1 to 3.3: approval of income contracts previously only with CEO, now CEO or DOF

e) Items 4.1 and 4.2: consolidated onto one row

f) Item 4.1: to correct the wording from “Board Executive Directors” to “Executive Directors” regarding the maximum delegated authority limit that can may be varied downwards by the CEO or DOF

g) Item 4.1: new requirement for Care Group DOF or Deputy DOF to certify that purchase requisitions over £5,000 are within budget

h) Item 4.6: authorisation of non ward and non clinic based agency now requires authorisation by 2 of 7 of the Exec.

i) Items 5.1 and 5.2: authorisation to recruit now requires authorisation by 2 of 7 of the Exec and includes reference to Board and Executive Remuneration Committees.

Agenda Item 12

Version 1.0 – June 2014 2

j) Item 6.5: authorise the Financial Controller and Deputy Director of Finance to write off debt of up to £5,000.

k) Item 7.1: to authorise the Head of Legal Services to authorise payments up to £10,000 for payments resulting from legal claims.

l) Item 7.4 : includes reference to Board and Executive Remuneration Committees.

Decision required:

The Board is asked to APPROVE the updated SFI’s as tabled

Contact: Phone:

Craig Anderson, Director of Finance 0118 322 8833

Attachment Standing Financial Instructions

Standing Financial Instructions – updated May 2014 Page 1 of 37 1

Trust Standing Financial Instructions

Standing Financial Instructions of the

Royal Berkshire NHS Foundation Trust

As Revised in June May 2014

Approved by the Trust Board 3029 JuneMay 2014



Table of Contents

Table of Contents 2

Introduction including definitions 3

Powers of Authority and Delegation 5

Corporate Responsibilities of all Trust employees and staff 7

Responsibilities of the Chief Executive 10

Responsibilities of the Director of Finance 15

APPENDIX A - RESERVATION OF POWERS TO THE BOARD OF DIRECTORS

AND DELEGATION OF POWERS 27

Certification 37



Introduction Purpose These Standing Financial Instructions (SFIs) are issued for the regulation of the conduct of the Foundation Trust (including its subsidiary and charity), its Directors, staff, officers and agents in relation to all financial matters. They explain the financial responsibilities, policies, processes and procedures adopted by the Trust. They are designed to ensure that its financial transactions are carried out in accordance with the law, Government policy and best practice in order to achieve probity, accuracy, economy, efficiency and effectiveness in the way in which the Trust manages its finances. They identify the financial responsibilities which apply to everyone working for or on behalf of the Trust. They do not provide all the detailed procedural advice. These statements must therefore be read in conjunction with the detailed financial procedure notes and other policies referred to within this document. All Trust policies are available on the Trust internal website or from the finance function. All financial responsibilities, policies, processes and procedures relating to the Trust and subsidiaries must be approved by the Director of Finance. Authority and Compliance These SFIs have been compiled under the authority of the Board of Directors of the Foundation Trust. They have been reviewed by the Trust Audit and Risk Committee and by the full Board of Directors and have their full approval. All staff employed by the Trust will comply with these instructions at all times. Failure to comply will result in disciplinary action up to and including dismissal. These SFIs supersede all previous editions. All breaches of these regulations, including evidence of fraud or irregularity will be investigated in accordance with the Trust’s Human Resources and Local Counter Fraud Policy (CG155). Any significant breaches of Financial Regulations will be referred to the Director of Finance and the Audit Committee. The Director of Finance will consider the necessary course of action, which may in certain circumstances include taking disciplinary action. In the event that a staff or Board member becomes aware of an irregularity or breach of any of the SFIs, or systematic breach or abuse of the levels of delegated authority, and is concerned about the reporting or notification of such actions through the normal management channels, the Trust has a clear ‘Raising Concerns at Work (Whistleblowing) Policy (CG055)’ on the intranet which should be followed in such circumstances. All such matters will be reported to Audit Committee by the Director of Finance.



Certification All Officers with iproc authority and all Officers who are cost centre managers will be required to certify that they have read, understood and will comply with these SFI’s. The form this certification will take is appended to these instructions. In the absence of such a certification then iProc and cost centre authority will be removed. Definitions CEO Chief Executive Officer

DOF Director of Finance

HMRC Her Majesty’s Revenue and Customs PO Purchase Order

Employee An officer who is paid through the Trust payroll system

Officer All employees, temporary staff, agency staff or self-employed consultants of the Trust, including nursing and medical staff, and consultants practising upon Trust premises for whatever reason.

Scheme of Delegation The system of delegated powers from the Board of Directors to enable appropriate officers of the Trust to manage the day to day activities.

Trust Approved Procurement Systems

Oracle i-procurement; JAC; Ingenica; NHS Supplies; NHS Professionals

Wherever the title CEO, DOF, or other nominated officer is used in these instructions, it should be deemed to include such other officers who have been duly authorised to represent them. However, it is a fundamental tenet of these instructions that no officer of the Trust is empowered in any way to provide authorisation to represent themselves to persons who are not under their organisational control, unless specifically authorised within these SFIs.



Powers of Authority and Delegation

Principles of delegated powers of authority and Schemes of Delegation The Board of Directors will delegate responsibility for the performance of its functions in accordance with the Scheme of Delegation adopted by the Trust. The Board of Directors have determined that they shall reserve for their sole approval certain financial transactions based around types or values as set out in the Scheme of Delegation. Those aside, all executive powers are vested in the CEO, who in turn will provide delegated powers to relevant officers. The CEO and DOF will, where appropriate, delegate their detailed responsibilities but will remain accountable for financial control. The Scheme of Delegation is a collection of schedules setting out various powers of authority delegated to a post holder. The first schedule sets out Board of Directors powers and the extent to which they are delegated to the CEO and other Executive Directors. Separate schedules will be retained by the DOF setting out the powers delegated to identified post holders. A full record of each scheme of delegation will be reviewed at least annually to ensure all authorised individuals understand and are fulfilling their responsibilities. Board of Directors The Board of Directors have retained sole rights to approve all financial transactions with a value in excess of the level specified for this purpose in the Scheme of Delegation, subject to the exclusion of any item covered by specific delegated authority. This applies to individual transactions and to term contracts for the provision of goods, services or capital works over a period of time. The only exception to this instruction is on the extremely rare occasions where time is a critical factor. Then the Board of Directors can instruct the CEO to approve specified transactions that are required in the interest of the Trust. In such circumstances the CEO must provide a full report to the Board of Directors at the next available opportunity. The Board of Directors acts as corporate trustee for all charitable funds. The Board of Directors delegates the management of the charitable funds to the Charity Committee. The Board of Directors are responsible for ensuring appropriate governance arrangements are in place for the Trust’s wholly owned subsidiary company, Healthcare Facilities Management Services Limited. The Board of Directors will maintain adequate policies and safeguards to prevent bribery and ensure compliance with the requirements of the Bribery Act 2010. (nb. The key policies affected are those relating to gifts/hospitality/sponsorship; staff recruitment and disciplinary; conflict of interests and declaration of interests).



Chief Executive Within the SFIs, it is acknowledged that the Board of Directors is responsible for ensuring that the Trust meets its obligation to perform its functions within the available financial resources. The CEO has overall executive responsibility for the Trust’s activities and is responsible to the Board of Directors for ensuring that its financial obligations and targets are met. Further, the CEO is recognised by Statute as the Accounting Officer of the Trust and as such can be called upon to report to Parliament for all actions undertaken by the Trust. Save for the requirements under Board of Directors powers, the CEO is provided with full operational powers to approve financial transactions within the Trust and to delegate such powers as per the Scheme of Delegation. Director of Finance The CEO delegates powers to the DOF in his/her role as a first line budget holder responsible for the Finance Directorate. In addition to these, the DOF is provided with further powers to manage the approval of financial transactions initiated by other directorates across the Trust, and other financial transactions on behalf of the Trust. The Board of Directors instruct that the DOF is required to implement the Trust’s financial policies, ensure that detailed financial procedures and systems are established, incorporating the principles of separation of duties and internal control to supplement these instructions, and ensure that sufficient records are maintained to show and explain the Trust’s transactions, in order to disclose the financial position of the Trust at any time. In relation to any officer who is involved in a financial or procurement process or function, the DOF shall set out the requirements, the manner in which the officer discharges his/her duties and the form in which financial records are kept. All finance and procurement processes must be to the standard and satisfaction of the DOF.

In addition to these, the DOF is provided with further powers to control the approval of financial transactions relating to the Trust capital programmes, in accordance with the Schemes of Delegation.



Corporate Responsibilities of all Trust employees and staff The SFIs set out specific Trust policies and procedures across a number of areas and all officers must comply with these requirements in all cases. Where exceptions are deemed necessary, prior approval from the DOF must be obtained, as set out in the SFIs It is not possible to govern all the financial affairs of the entire Trust through a single set of instructions. Therefore, these Instructions make reference in a number of areas where it is considered appropriate for the CEO or the DOF to develop, on behalf of the Trust, a series of detailed policies, procedures and processes, which are not included in these Instructions. In such cases it is the responsibility of all employees of the Trust to ensure they understand fully the existence, contents and requirements of all such policies and procedures and to comply with them on the basis that they have received full authority from the Board of Directors. Guidance on the existence and relevance of policies and procedures to specific situations is available on the Trusts internal website or is available from the CEO, the DOF or the Deputy DOF. If you are unsure as to the most appropriate course of action in a particular situation then consult one of these sources, especially so if you are about to make a financial commitment on behalf of the Trust, because breach of these requirements will be regarded as a disciplinary offence.

You must comply with principles of Public Sector Values You should be committed to the highest standards of corporate and personal conduct in all aspects of their work within the Trust, based on recognition of public service values. There are three crucial public service values which must be understood and accepted by everyone working in the Trust:

Accountability - everything done by those who work in the Trust must be able to stand the test of parliamentary scrutiny, public judgements on propriety and professional codes of conduct. Probity - there is a requirement for an absolute standard of honesty in dealing with the income, assets and financial interests of the Trust. Integrity should be the hallmark of all personal conduct in decisions affecting patients, staff and suppliers, and in the use of information acquired in the course of Trust duties. Openness - there must be sufficient transparency about Trust activities to promote confidence between the Trust and its staff, patients and the public. All staff must disclose possible conflicts of interest.



You have a duty of stewardship Proper stewardship requires value for money to be high on the agenda of the Board of Directors and all officers, so

You must - Safeguard the Trust’s financial resources.

Financial resources may take the obvious tangible form of fixed assets, income and cash as well as others that are less clear, such as lost or foregone income through failure to notify income sources or lost opportunities to earn or recover income due to the Trust.

- Conduct Trust business as efficiently, effectively and economically as possible.

- Comply with the Trust’s policies and processes covering all aspects of money, assets and other Trust resources.

- Avoid unauthorised acts that may result in the Trust incurring liabilities (directly or indirectly) or which may diminish the value of any of the Trust’s assets (including the Trust’s brand or reputation).

- Report all new income sources immediately to the DOF.

- report damage to or losses of the Trust’s premises, assets, supplies or other resources must be reported to the DOF immediately in accordance with procedures of Losses and Special Payments

- Inform either the DOF or the Local Counter Fraud Officer if you discover or suspect a loss that you think may be fraud. You should fully understand the Trust’s Human Resources and Local Counter Fraud Policy (CG155)

- Send all signed copies of contracts (however described) are lodged with Procurement within one month of formal approval.

- Only order goods and services through the Trust’s Approved Procurement Systems (unless authorised in writing by the DOF to do otherwise).

- Upon delivery of goods or services immediately record the receipt on the relevant Trust Approved Procurement System.

- Quote a valid Trust PO number to suppliers when placing an order for goods or services.

- comply with the Trust’s Guidance on Hospitality, Gifts & Commercial Sponsorship

You must not - Incur expenditure for which there is not an

approved budget, unless authorised to do so by the DOF, CEO, or Board of Directors, as appropriate.

- Use a budget for a purpose other than that for which it was provided, unless authorised to do so by the DOF, or CEO, as appropriate.

- Approve any contract or transaction which binds the Trust to credit finance commitments without the clear written prior authority of the DOF. This includes all Executive and Care Group Directors of the Trust and all other officers.

- Order any goods or services, including agency staff, other than by using one of the Trust Approved Procurement Systems, unless previously authorised to do so by the DOF.

- Order goods or services directly from suppliers. Procurement will negotiate contracts which will provide catalogues of goods and services, from which orders may be raised. These instructions provide clear guidance on purchasing and contract tendering and these must be followed. In exceptional circumstances, where senior officers of the Trust wish to operate direct ordering procedures, the approval of the CEO and DOF must be obtained.



Compliance with rules of delegated powers of authority The Board of Directors has absolute authority for the conduct of the financial affairs of the Trust, but has established a system of delegated powers to enable appropriate officers of the Trust to manage the day to day activities. This system of delegated powers is referred to throughout these Instructions as the Scheme of Delegation. The high level Scheme of Delegation is included as Appendix A to these Instructions. The detailed scheme of delegation, including lower level authorities, must be approved by the DOF and a full register will be maintained by the DOF.

The principles of the Scheme of Delegation • Approval limits will be determined based on an assessment of need in each specific area. • An Officer who is not Staff cannot hold responsibility for approvals unless pre-authorised by the

DOF • All delegated powers must remain within the limits set out in Scheme of Delegation. • An officer must not approve a transaction outside their written delegated power. • A power is delegated on condition that it cannot be further delegated at that same level of

power, except in cases of temporary holiday cover, when it can be delegated to another officer who already holds delegated power at that level. Delegation over and above this must be requested in writing in advance to the DOF.

• Only the DOF may delegate powers to officers outside of his/her direct control. • All proposed powers, or variation to powers, of delegation, other than temporary holiday cover,

must be provided in writing and duly authorised by the DOF. • Officers with delegated authority on iproc must set up in advance a vacation rule for period they

will be absent from the office • Applications for other short term powers must be requested in writing by the delegating officer,

and approved by the DOFirector of Finance prior to the period for which approval is sought. • Only the CEO and DOF are authorised to sign and authorise extensions to supplier contracts. • Where a member of the Board of Directors is through incapacity unable to utilise their authority

or appropriate delegation, the CEO and DOF will implement an interim arrangement until the next available Board Meeting. At that meeting a formal arrangement will be agreed.

• If the CEO is incapacitated the Chairman and DOF will implement an interim arrangement until the next available Board Meeting. At that meeting a formal arrangement will be agreed.

The DOF may reject any delegation of powers if in his opinion, there is a financial risk to the organisation or it may result in a reduction of financial control or it may affect the Trust reputation with respect to counter-fraud.

Failure to comply with these principles, or a material breach thereof, will be recognised as a disciplinary offence. Where such a breach results in clear financial loss, the employee may be personally liable to compensate the Trust.



Responsibilities of the Chief Executive

Annual Plan The CEO, with the assistance of the Commercial Director and DOF, shall compile and submit to the Board of Directors strategic plans and operational plans as required by the Board of Directors and which meet the requirements of the Independent Regulator (as described in Monitors published Guidance, Directions and Risk Assessment Framework). The operational plan shall be reconcilable with the annual submission of Monitor’s Operational, Strategic and Financial proforma in its Annual Plan Review The CEO shall require the DOF to report to the Board of Directors any significant in-year variance from the budget and to advise the Board of Directors on action to be taken. The DOF shall also be required to compile and submit to the Board of Directors, any and all such financial estimates and forecasts, of both revenue and capital nature as may be required from time to time. As a consequence, the DOF shall have full and complete right of access to all budget holders on financial related matters. All Officers shall provide the DOF with all financial, statistical and other relevant information as necessary for the compilation of such budgets, estimates and forecasts, in accordance with the timetable required by the DOF.

Budgets The DOF shall, on behalf of the CEO, and in advance of the financial year to which they refer, prepare and submit all revenue and capital budgets within the forecast limits of available resources and planning policies to the Board of Directors for its approval. The CEO shall require the DOF to devise and maintain systems of budgetary control. All officers shall comply with the requirements of those systems. The systems of budgetary control shall incorporate the reporting of, and investigation into, financial, activity or workforce variances from budget. The DOF shall be responsible for providing budgetary information and advice to enable the CEO and other officers to carry out their budgetary responsibilities.

The CEO may delegate management of a budget or part of a budget to officers to permit the performance of defined activities. The Scheme of Delegation shall include a clear definition of individual and group responsibilities for control of expenditure, exercise of virement, achievement



of planned levels of services and the provision of regular reports upon the discharge of those delegated functions to the CEO. In carrying out their duties no officers shall exceed the budgetary limits set them by the CEO.

Except where otherwise approved by the CEO, taking account of advice of the DOF, budgets shall be used only for the purpose for which they were provided and any budgeted funds not required for their designated purpose shall revert to the immediate control of the Trust. Expenditure for which no provision has been made in an approved budget and which is not subject to funding under the delegated powers of virement shall only be incurred after authorisation by the CEO and DOF or the Board of Directors as appropriate. The DOF shall keep the CEO and the Board of Directors informed of the financial consequences of changes in policy, pay awards and other events and trends affecting budgets and shall advise on the financial and economic aspects of future plans and projects. Any in year changes to budgets must be approved in advance by the DOF, or by the Deputy DOF or a Care Group DOF, as set out separately in the delegation of authority for budget virements. Contracts for the provision of Healthcare Services The Board of Directors will approve standard terms and conditions for legally binding contracts, on the basis of which the Trust will provide healthcare services. Any variations to the standard terms and conditions will be approved in accordance with the Scheme of Delegation. The CEO is responsible for negotiating contracts for the provision of services to patients in accordance with the budget. The CEO nay decide to delegate this to other officers but in all instances those undertaking the negotiating In carrying out these functions, the CEO should take into account the advice of the DOF regarding costing, and pricing of services, and both the Commercial Director and Finance Director on matters relating to payment terms and conditions of service agreements. Contracts should be so devised as to achieve activity and performance targets, minimise risk, and to maximise the Trust's opportunity to generate income. The Trust will produce a reference cost tariff in accordance with NHS guidelines. The Trust will comply with the Department of Health Guidance on setting prices for the provision of NHS healthcare (i.e. Payment by Results Guidance) as far as this allows. Other prices and tariffs must be approved by the DOF with advice, where relevant, from the Commercial Director.



The DOF shall ensure that a summary of the Trust’s contract income is reported annually to the Board of Directors. The DOF shall also produce regular reports detailing actual and forecast contract income with a detailed assessment of the impact of the variable elements of income. Any pricing of contracts at marginal cost should be undertaken by the DOF in accordance with a policy and tariff reported to the Board of Directors. All copies of signed contracts will be retained by the Head of Procurement and registered on the Trust contract register. It is essential all staff ensure signed copies of all contracts (however described) are lodged with Procurement within 1 month of formal approval. Capital Expenditure The CEO is ultimately responsible for all capital expenditure of the Trust, including expenditure on assets under construction. To discharge this duty, the CEO will arrange for the issue of a Scheme of Delegation for approval of capital commitments, and will arrange for the development of detailed policies and procedures covering all aspects of capital investment management, including scheme appraisals, contract awarding, contract management and financial control. The CEO shall provide executive delegation to the DOF to control programmes for capital expenditure, including assets under construction, within the restrictions of Scheme of Delegation. All expenditure on capital assets will be authorised in line with Scheme of Delegation. Any commitment in excess of the limits currently specified shall be referred to CEO the Chief

Executive and the Board of Directors respectively for approval before such commitment is made. Tendering and Contracting The CEO has overall responsibility to ensure that the Trust applies the principles of Value for Money in the procurement of goods, services and capital programmes. The CEO shall liaise with the DOF to develop processes and procedures for competitive selection in all procurement exercises. The CEO shall ensure that these procedures are open and clearly demonstrate fair and adequate competition. In particular, the processes and procedures will incorporate NHS and Trust requirements for disclosure of any commercial sponsorship or inducements offered by or received from actual or potential suppliers to the Trust. The CEO shall establish procedures covering the receipt, safe custody and formal opening of tenders received and appropriate records to be maintained in connection with the full tender exercise. All copies of signed contracts will be retained by Procurement and registered on the Trust contract register. It is essential all staff ensure signed copies of all contracts (however described) are lodged with Procurement within 1 month of formal approval.



Risk Management and Insurance The CEO shall ensure that the Trust has a programme of risk management which will be approved and monitored by the Board of Directors, by using the Trust Assurance Framework. The programme of risk management shall include:

a) processes for identifying and quantifying risks and potential liabilities; b) engendering among all levels of staff a positive attitude towards the control of risk; c) management processes to ensure all significant risks and potential liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk; d) contingency plans to offset the impact of adverse events; e) audit arrangements including external audit, internal audit, clinical audit and health & safety review; f) arrangements to review the risk management programme. The existence, integration and evaluation of the above elements will provide a basis to make statements on the effectiveness of internal control within the Annual Report and Accounts as required by current guidance. The DOF shall ensure that appropriate insurance arrangements exist to mitigate the risks of the Trust across all areas, and that documented procedures cover these arrangements. Retention of Documents The CEO shall be responsible for maintaining archives for all documents required to be retained under the direction contained in HSC1999/053. A summary of the retention periods for key documents and records will be produced. A copy of the document will be available to all members of staff. The documents held in archives shall be capable of retrieval by authorised persons. Documents held under HSC1999/053 shall only be destroyed at the express instigation of the CEO; records shall be maintained of documents so destroyed. The DOF shall provide advice on the retention of financial records. Detailed policies covering money, assets and other Trust resources



The CEO, in consultation with the DOF will develop, maintain and monitor detailed policies, procedures and instructions covering all aspects of the security of money, assets and other Trust resources Patients’ Property The Trust has a responsibility to provide safe custody for money and other personal property handed in by patients, in the possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival. The CEO shall be responsible for ensuring patients or their guardians, as appropriate, are informed before or at admission that the Trust will not accept responsibility or liability for patients’ property brought into the Trust premises, unless it is handed in for safe custody and a copy of an official patients’ property record is obtained as a receipt. The CEO shall require the DOF, in conjunction with the Care Group Directors, to provide detailed written instructions on the collection, custody, investment, recording, safekeeping and disposal of patients’ property for all staff whose duty it is to administer the property of patients. Hospitality The CEO shall be responsible for maintaining comprehensive records of all offers of hospitality accepted by officers., both accepted and rejected. The record shall be in a form designed by the DOF and completed records shall be available for inspection by the designated auditors or DOF, at all reasonable times.



Responsibilities of the Director of Finance General The DOF shall prepare, document and maintain detailed financial policies, procedures, processes and systems incorporating the principles of separation of duties and internal control to supplement these Instructions. The DOF shall require in relation to any officer who carries out a financial process, that the form in which the records are kept and the manner in which the officer discharges his/her duties shall be to the satisfaction of the DOF. The DOF shall ensure appropriate arrangements are in place to pay and recover tax, and shall be responsible for seeking professional advice in this regard, as necessary. Income The DOF is responsible for designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, collection and income coding of all monies due. The DOF is also responsible for ensuring the prompt banking of all monies received. The DOF is responsible for approving and regularly reviewing the level of all fees and charges other than those determined by the Department of Health or by Statute. Independent professional advice on matters of valuation shall be taken as necessary. All employees must inform the DOF promptly of any and all money due arising from transactions which they deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions. The DOF is responsible for the appropriate recovery action on all outstanding debts. Income not received should be dealt with in accordance with losses procedures. Overpayments should be detected (or preferably prevented) and recovery initiated. The DOF is responsible for approving the form of all receipt documents, agreement forms, or other means of officially acknowledging or recording monies received or receivable. The DOF is responsible for the provision of adequate facilities and systems for officers, whose duties include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys and for coin operated machines. The DOF is responsible for proscribing systems and procedures for handling cash and negotiable securities on behalf of the Trust. Official money shall not under any circumstances be used for the



encashment of private cheques. All cheques, postal orders, cash etc., shall be banked intact. Disbursements shall not be made from cash received, except under arrangements approved by the DOF.

The holders of safe keys shall not accept unofficial funds for depositing in their safes unless such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss, and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss. No contract relating to the provision of Private Patient treatment should be signed without confirmation being provided to the DOF that the contract will not be actioned to the detriment of NHS patients. Annual Accounts and Reports The DOF, on behalf of the Trust, will prepare financial returns in accordance with the guidance given by the Independent Regulator and the Treasury, the Trust’s accounting policies, and International Financial Reporting Standards. The DOF, on behalf of the Trust, will prepare and certify Annual Report and Accounts, and submit them and any report of the auditor on them, for laying before Parliament. Following this, copies of the documents must be sent to the Independent Regulator. The Trust’s Annual Report and Accounts must be audited by an auditor approved by the Council of Governors in accordance with the appointment process agreed by the Trust. The Trust will publish an Annual Report and Accounts, in accordance with guidelines on local accountability, and present it at a public meeting. The document will include inter alia, the Audited Annual Accounts of the Trust. The Annual Report and Accounts will be sent to the Independent Regulator. Bank and GBS Accounts including charitable funds The DOF is responsible for managing the Trust’s banking arrangements and for advising the Trust on the provision of banking services and operation of accounts. This advice will take into account guidance and directions issued from time to time by the Independent Regulator. The Board of Directors shall approve the banking arrangements. The DOF is responsible for all bank accounts and Government Banking Service (GBS) accounts. The DOF is responsible for ensuring payments made from bank or GBS accounts do not exceed the amount credited to the account except where arrangements have been made. Further he must report to the Board of Directors all arrangements made with the Trust’s bankers for accounts to be overdrawn.



The DOF has sole authority to open, operate and close accounts with banks, Building Societies and the Government Banking Service where Trust funds are received or expended. It shall be a disciplinary offence for any officer of the Trust outside the organisational control of the DOF to operate any such account. The DOF will report to the Audit and Risk Committee of any changes to the Trust bank accounts including the opening / closing of accounts and changes in signatory panel. The DOF will prepare detailed instructions on the operation of bank and GBS accounts which must include the conditions under which each bank and GBS account is to be operated, the limit to be applied to any overdraft, and those authorised to sign cheques or other orders drawn on the Trust's accounts. The DOF will advise the Trust’s bankers in writing of the conditions under which each account will be operated. The DOF will review the banking arrangements of the Trust at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the Trust’s banking business. Competitive tenders should be considered at least every 5 years. The results of the tendering exercise should be reported to the Board of Directors. The Audit and Risk Committee will review this on behalf of the Board of Directors. Where officers of the Trust wish to manage non-exchequer Trust funds such as ward funds or funds from donated sources, they are required to operate under the control of the Trust Charitable Funds who will operate the accounts on their behalf. All funds donated must be passed to Finance and only banked in the Trust Charitable Funds. No donations shall be passed to another charitable fund. It is not appropriate for any officer of the Trust to hold any such account in their own names as it creates a lack of openness in the handling of such funds and may allow that officer’s integrity to be called into question. The only exception to the above will be where the DOF has expressly issued written authorisation to officers to maintain accounts which have been deemed acceptable, such as accounts for social or sports clubs. The DOF will maintain a register of such accounts, and the details will be reported annually to the Audit and Risk Committee. Cash Management and Investments The DOF will produce cash management, treasury management and investment policy (Treasury Policy - CG401), in accordance with guidance received from the Independent Regulator, for approval by the Board of Directors. The investment may include investment by forming, or participating in forming, bodies corporate, and/or otherwise acquiring membership of bodies corporate.



The Treasury policy (CG401) will set out the DOF’s responsibilities for advising the Board of Directors on investments and reporting periodically to the Board of Directors concerning the performance of investments held. The DOF will prepare detailed procedural instructions on the operation of investment accounts and on the records to be maintained. External Borrowing and Public Dividend Capital The DOF will advise the Board of Directors concerning the Trust's ability to pay interest on, and repay the Public Dividend Capital and any proposed commercial borrowing, within the limits set by the Foundation Trust’s authorisation. The DOF will authorise and is also responsible for reporting periodically to the Board of Directors concerning the Public Dividend Capital and all loans and overdrafts. Any application for a loan or overdraft will only be made by the DOF or by an employee acting on his/ her behalf, and in accordance with the Scheme of Delegation, as appropriate. The DOF will prepare detailed procedural instructions concerning applications for loans and overdrafts. All short-term borrowings should be kept to the minimum period of time possible, consistent with the overall cash flow position. Any short term borrowing requirement in excess of one month must be authorised by the DOF. All long-term borrowing must be consistent with the plans outlined in the current budget. Capital Expenditure The DOF shall be responsible for preparing detailed procedural guides for the financial management and control of expenditure on capital assets, including the maintenance of an asset register in accordance with the minimum data set as specified in the Capital Accounting Manual. The DOF shall implement procedures to comply with guidance on valuation contained within the Capital Accounting Manual, depreciation and revaluation. The DOF shall establish procedures covering the identification and recording of capital additions. The financial cost of capital additions, including expenditure on assets under construction, must be clearly identified to the appropriate budget holder and be validated by reference to appropriate supporting documentation. The DOF shall also develop procedures covering the physical verification of assets on a periodic basis. The DOF shall develop policies and procedures for the management and documentation of asset disposals, whether by sale, part exchange, scrap, theft or other loss. Such procedures shall include



the rules on evidence and supporting documentation, the application of sales proceeds and the amendment of financial records including the asset register. All capital schemes will be subject to the procedures as set out in the Capital Investment Manual, Concode and Concise guidelines governing control of capital programmes in the NHS (available on the Department of Health website) , together with approved local guidelines. Where appropriate, alternative measures of control deemed appropriate may be adopted by the Trust on the advice of the DOF, following discussion with the CEO. Where material these will be brought to the attention of the Board of Directors. Payment of Staff The DOF shall make arrangements for the provision of payroll services to the Trust, to ensure the accurate determination of pay entitlement and to enable prompt and accurate payment to employees.

The DOF shall be responsible for establishing procedures covering advice to managers on the prompt and accurate submission of payroll data to support the determination of pay including, where appropriate, timetables and specifications for submission of properly authorised notification of new employees, amendments to standing pay data and terminations. The DOF will issue detailed procedures covering payments to staff including rules on handling and security of bank credit payments. Tendering and Contracting for Goods and Services The instructions in this section concern purchasing decisions for goods and services required where the Trust needs to enter into formal tendering and contractual arrangements. All purchasing must be undertaken through one of the Trust Approved Purchasing Systems, unless explicit approval to alternative arrangements have been agreed in advance by the DOF. The DOF shall advise the Board of Directors regarding the setting of thresholds above which quotations or formal tenders must be obtained. This will take into account legal requirements to comply with European Community and GATT rules on public procurement. These shall be set out within Schemes of Delegation. The DOF shall be responsible for establishing appropriate procedures to ensure that competitive tenders are invited for the supply of goods and services under contractual arrangements wherever possible. These shall include the procedures to be followed in the event of competitive tendering of in-house services. In such circumstances it must be ensured that no member of the in-house tender group may participate in the evaluation of the tender.



The DOF shall maintain lists of firms from whom the Trust may invite tenders and quotations. These lists shall be kept under frequent review and shall include all firms who have applied for permission to tender. All firms will be assessed by Finance on their technical and financial competences. In this regard, the DOF shall be responsible for establishing procedures to carry out financial appraisals, and shall instruct the appropriate requisitioning directorate to provide evidence of technical competence. Where there are no, or insufficient, contractors listed which are suitable to be invited to tender for a particular contract, only after receipt of evidence as to their technical and financial competence will a contractor be invited to tender and be selected for inclusion on the list. The DOF shall be consulted as regards financial competence and a suitable officer within the Finance Directorate who will provide advice on financial status and recommended contract limits. Where there are no, or insufficient, contractors listed which are suitable to be invited to tender for a particular contract, any contractor invited to tender shall only be selected for invitation after receipt of evidence as to its technical and financial competence and inclusion on the approved list. All contract negotiations must be undertaken with the involvement of a member of the Procurement Team. All employees must demonstrate effective and efficient use of resources in awarding contracts, ideally through the use of competitive selection. Where by exception it is considered competitive selection to be inappropriate, undesirable or not possible, approval for single quote exercises in accordance with financial limits set out under the Scheme of Delegation may be requested in writing to the DOF. These powers are provided by the CEO and it is expected that they shall be exercised in exceptional cases only. The DOF shall advise the Board of Directors of circumstances where it would be appropriate for goods or services to be obtained under contract from sources that have not been subject to competitive selection. The outcome of the waiver process will be monitored by the Audit and Risk Committee on behalf of the Board of Directors.

The grounds where such single quote actions may be authorised are as follows, although approval is not to be regarded as automatic and each case shall be treated on its own merit:

• Where the requirement is ordered under existing contracts which themselves were sourced under competitive selection.

• Where the estimated expenditure or income would not warrant formal tendering procedures or competition would not be practicable taking into account all the circumstances. The limits for such single quote exemptions are set out in Schemes of Delegation.

• Where in the opinion of the Director of Finance, or the Chief Executive if in excess of financial limits set out in Schemes of Delegation, it is considered against the interest of the Trust to enter into open competitive selection procedures. This may include procurement exercises where time is a critical factor in the interest of the Trust.

• For the supply of proprietary goods or services for which it is not possible or desirable to obtain competitive quotations.



• Where in the opinion of the Director of Finance, or the Chief Executive, according to the financial limits set out in Schemes of Delegation, it is considered against the interest of the Trust to enter into open competitive selection procedures. This may include procurement exercises where in the opinion of the Director of Finance time is a critical factor in the interest of the Trust.

• Separate authorisation arrangements, as set out in the Scheme of Delegation, shall apply to maintenance or other contracts for existing goods or assets where the Trust is contractually tied to specific companies. Details of such contracts shall be recorded in a register by Procurement.

• The extent to which relevant officers can exercise these powers is set out in the Scheme of Delegation. All officers of the Trust must be aware that single quote actions are to be the exception to the preferred procedures of competitive selection, and in all cases they must be able to fully explain their rationale before a decision is authorised. Records shall be maintained to enable the use of single quote and other non-competitive actions to be monitored and reported upon to the Audit and Risk Committee at least annually.

In all cases the DOF shall keep appropriate records of single quote actions including a full justification of the reasons why competitive selection procedures were not adopted. The CEO shall require the DOF to monitor the use of single quote actions in the awarding of contracts and to report to the Audit and Risk Committee on the extent of the use of single quote and other non-competitive actions. Procurement and Purchasing The DOF shall advise the Board of Directors regarding the setting of thresholds above which quotations or formal tenders must be obtained. This will take into account the obligation on the Trust to comply with the European Union Procurement Directives, the Public Contract Regulations 2006 (as amended from time to time) and the GATT rules on public procurement. These shall be set out within the Scheme of Delegation. The DOF shall prepare procedural instructions on the obtaining of goods, services and works, incorporating the thresholds set by the Trust. The DOF shall determine that no goods, services or works, other than works and services executed in accordance with a contract and purchases from petty cash, shall be ordered except on an official order, raised following receipt by the ordering officer of a properly authorised requisition, and suppliers/contractors shall be notified that they should not accept orders unless on an official form. Official orders shall be consecutively numbered, in a form approved by the DOF and shall include such information concerning prices or costs as may be required. The order shall incorporate an obligation on the contractor to comply with the conditions thereon as regards delivery, carriage, documentation, variations, etc.

Formatted: Font: Bold





Order requisitions shall only be issued to and approved by officers so authorised by the Scheme of Delegation. Lists of authorised officers shall be maintained by the DOF. The DOF shall ensure that no order shall be issued for any item or items for which there is no budget provision, unless authorised by the DOF on behalf of the CEO. Goods and services for which Trust contracts are in place should be purchased within those contracts. Any purchasing request outside of such contracts must be referred in the first instance to the Head of Procurement for approval. All copies of signed contracts will be retained by the Head of Procurement and registered on the Trust contract register. It is essential all staff ensure signed copies of all contracts (however described) are lodged with Procurement within 1 month of formal approval. Payment of Suppliers The DOF shall be responsible for the proper payment of all supplier invoices and claims. The DOF shall establish and communicate procedures to ensure that all officers provide prompt notification of all money payable by the Trust arising from transactions which they initiate, including contracts, leases, tenancy agreements and other transactions. The DOF shall establish detailed procedures covering the approval of invoices for payment.

The DOF shall develop procedures for the prompt payment of invoices once verified for settlement. Such procedures will include the taking of settlement discounts where offered, and rules covering independent control and security of payment transactions. The DOF will implement procedures to retain approval of all payments made in advance of receipt of the related goods or services. Stores and stocks All stores and stocks maintained by the Trust in wards, clinics or main stores must comply with the systems of control designated and approved by the DOF. Overall responsibility for the control of stores and stocks shall be delegated to the DOF by the CEO. The day-to-day responsibility may be delegated to departmental employees and stores managers/ keepers, subject to such delegation being entered in a record available to the DOF.

The DOF shall set out procedures and systems to regulate the stores including records for receipt of goods, issues, and returns to stores, and losses. All employees with day-to-day responsibility for stores must maintain such records to enable the value of the stockholding to be ascertained at any time. The DOF will ensure adequate physical stocktaking arrangements exist and there shall be a physical check covering all items in store at least once a year to confirm the value of the stockholdings with the system records.



Where a complete system of stores control is not justified, alternative arrangements shall require the approval of the DOF.

All employees with day-to-day responsibility for stores shall ensure systems are in place to minimise any losses from obsolete, slow moving or unserviceable items. The DOF shall ensure a system is in place to review stockholdings for slow moving and obsolete items and for condemnation, disposal, and replacement of all unserviceable articles. All employees shall report to the DOF any evidence of significant overstocking and of any negligence or malpractice. Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods. All write offs must be approved by the DOF and reported to the Audit and Risk Committee at least annually. All managers must order and requisition all goods and services through the Trust’s Oracle i-Procurement System or such other systems as specified by the DOF. The only exception to this instruction is where managers have the express written permission from the DOF to do otherwise. As a part of this process managers are required to ensure the accurate and timely recording of the receipt of goods and services on the relevant approved Procurement System. Financial Systems The DOF shall be responsible for the accuracy and security of the computerised financial data of the Trust. This supplements the responsibility of the Director of Corporate affairs for Information Governance across the Trust in respect of non-financial data. In terms of the Trust’s financial systems, the DOF shall ensure that:

• Appropriate controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system.

• Adequate controls exist such that the computer operation is separated from development, maintenance and amendment.

• An adequate management (audit) trail exists through the computerised system and that such computer audit reviews as he/she may consider necessary are being carried out.

The DOF shall ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy will be obtained from them prior to implementation. The DOF shall ensure that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.



Where another health organisation or any other agency provides a computer service for financial applications, the DOF shall periodically seek assurances that adequate controls are in operation. The DOF shall satisfy himself / herself with regard to any computer systems which have an impact on corporate financial systems that:

• data produced for use with financial systems is adequate, accurate, complete, timely ,and appropriate for the requirements of the operation of the Trust financial systems;

• all systems are closed down with adequate cut off processes at each month end; • all processes occur in line with the Trust financial month end timetable • a management (audit) trail exists; • Finance staff have open and complete access to such data; and • such computer audit reviews as are considered necessary are being carried out. Audit The Board of Directors shall establish an Audit and Risk Committee which will provide an independent and objective view of internal control by examining Internal and External Audit reports, reviewing financial systems, ensuring compliance with Standing Financial Instructions and reviewing schedules of losses and compensations and making recommendations to the Board of Directors. Where the Audit and Risk Committee feel there is evidence of ultra-vires transactions, or of improper acts, or if there are other important matters that the Committee wish to raise, the chairman of the Committee should raise the matter at a full meeting of the Board of Directors. Exceptionally, the matter may need to be referred to the Independent Regulator. It is the responsibility of the DOF to ensure an adequate internal audit service is provided and the Audit and Risk Committee shall be involved in the selection process when an internal audit service provider is changed. In line with their responsibilities as set out in HSG(96)12, the CEO and DOF shall monitor and ensure compliance with Secretary of State Directions on fraud and corruption. The Trust shall nominate a suitable person to carry out the duties of the Local Counter Fraud Specialist as specified by the NHS fraud and corruption manual and guidance. The Local Counter Fraud Specialist shall report to the DOF.

The DOF is responsible for:

• ensuring there are arrangements to review, evaluate and report on the effectiveness of internal financial control by the establishment of an internal audit function;

• ensuring that the internal audit is adequate and meets the NHS mandatory audit standards; • deciding at what stage to involve the police in cases of misappropriation and other irregularities

(subject to earlier sections of these Instructions);



• Ensuring that an annual audit report is prepared for the consideration of the Audit and Risk Committee and the Board of Directors. The report must cover:

o progress against plan over the previous year, o major internal financial control weaknesses discovered, o progress on the implementation of internal audit recommendations, o strategic audit plan covering the coming three years, o a detailed audit plan for the coming year.

The DOF or designated auditors are entitled without necessarily giving prior notice to require and receive:

• access to all records, documents and correspondence relating to any financial or other relevant transactions, including documents of a confidential nature;

• access at all reasonable times to any land, premises or employee of the Trust; • the production of any information, cash, stores or other property of the Trust under an

employee's control; and • Explanations concerning any matter under investigation. Any lack of co-operation in these matters, by any member of staff, will be considered a disciplinary matter and may result in dismissal. Whenever any matter arises which involves, or is thought to involve, irregularities concerning Information, cash, stores, or other property or any suspected irregularity in the exercise of any function of a pecuniary nature; the DOF must be notified immediately. The Head of Internal Audit will normally attend Audit and Risk Committee meetings and has a right of access to all Audit and Risk Committee Members, the Chairman and CEO of the Trust.

Staff Expenses The DOF shall be responsible for establishing procedures for the management of expense claims submitted by Trust employees. The DOF shall arrange for duly approved expense claims to be processed through the Trust payroll system, unless separately approved by the DOF or the Deputy Director of Finance (ensuring appropriate entries are made to the relevant cost centre. Expense claims shall be authorised in accordance with the Scheme of Delegation. The DOF shall refer to the Trust’s general policies on staff expenses and may reject expense claims where there are material breaches of Trust policies. In this regard the DOF shall liaise with the CEO where appropriate. Fraud The Board of Directors recognises that in extreme cases financial loss may be the result of fraud (i.e. intentional deception to secure unlawful gain) or corruption. While the Board of Directors has every confidence in the integrity of Trust employees, it has a duty to put in place controls to



minimise the opportunity for illegal appropriation of Trust resources. Accordingly, the DOF shall ensure appropriate compliance with the Secretary of State’s Directions to NHS Trusts regarding counter-fraud measures, which are referred to in these instructions. The DOF will ensure that procedures are in place that specify the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it. For losses apparently caused by theft, arson, neglect of duty or gross carelessness, except if trivial, the DOF will notify the Board of Directors. The DOF will also ensure that procedures are in place that specify the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it. The Trust Human Resources and Local Counter Fraud Policy (CG155) will be updated regularly by the DOF. Losses and special payments The DOF will establish a procedure for Losses and Special Payments. Credit Finance arrangements including leasing commitments There are no grounds where any employee of the Trust can approve any contract or transaction which binds the Trust to credit finance commitments without the clear written prior authority of the DOF. This includes all Executive and Care Group Directors of the Trust and all other officers. The Board of Directors has provided the DOF with sole authority to enter into such commitments, although these powers can be delegated by him/her to appropriate officers under his/her organisational control. This instruction applies to potential or actual leasing agreements and Hire Purchase undertakings which must be sent to the DOF for prior approval. No officer of the Trust outside the organisational control of the DOF has any powers to approve such commitments. Failure to comply with this instruction shall be a prima facie breach of any officer’s contract of employment.

Joint Finance Arrangements with Local Authorities Payments to and arrangements with local authorities made under the powers of the NHS Act 2012 shall comply with procedures laid down by the DOF which shall be in accordance with the Act.



APPENDIX A RESERVATION OF POWERS TO THE BOARD OF DIRECTORS AND DELEGATION OF POWERS INTRODUCTION The Code of Accountability for NHS Boards requires the Board of Directors to draw up a schedule of decisions reserved to itself and to ensure that management arrangements are in place to enable the clear delegation of its other responsibilities. This document therefore sets out the powers reserved to the Board of Directors and the Scheme of Delegation, together with tables of financial limits and approval thresholds. However, the Board of Directors remains accountable for all of its functions, including those which have been delegated, and would therefore expect to receive information about the exercise of delegated functions to enable it to maintain a monitoring role. All powers of the Trust which have not been retained as reserved by the Board of Directors or specifically delegated, shall be exercised on behalf of the Board of Directors by the CEO. The Scheme of Delegation identifies any functions which the CEO shall perform personally and those delegated to other directors or officers. All powers delegated by the CEO can be re-assumed by him/her should the need arise. The Scheme of Delegation shows only the ‘top level’ of delegation within the Trust. The Scheme is to be used in conjunction with the system of budgetary control and other established procedures within the Trust. POWERS RESERVED FOR THE BOARD OF DIRECTORS 1. General Enabling Provision 1.1 The Board of Directors may determine any matter it wishes in full session within its statutory

powers. 2. Regulation and Control 2.1 Approval, suspension, variation or amendment of Standing Orders, Standing Financial

Instructions, schedule of matters reserved to the Board of Directors, scheme of delegation of powers from the Board of Directors to officers, and other arrangements relating to standards of business conduct.

2.2 Specification of financial and performance reporting arrangements. 2.3 Approval of the Trust’s Treasury Policy (CG401) and authorisation of institutions with which

long term cash surpluses may be held.



2.4 Requiring and receiving the declaration of directors’ interests which may conflict with those of the Trust and determining the extent to which that director may remain involved with the matter under consideration.

3. Appointments Subject to the relevant section of the Foundation Trust Constitution: 3.1 The appointment and agreement of the terms of reference of Board Committees. 3.2 The appointment of Deputy Chairman. 3.3 Through its Remuneration Committee, appraisal, disciplining and dismissal of Board Directors. 3.4 Through its Nominations Committee, the appointment of Board Executive Directors. 3.5 The appointment of consultant medical and dental staff. Ratification of unanimous

recommendations of Appointment Committees is delegated to the CEO. 4. Policy Determination 4.1 The approval of management policies including personnel policies incorporating the

arrangements for the appointment, removal and remuneration of staff. 4.2 The approval of strategy, annual plans, strategic plans and annual budgets. 5. Direct Operational Decisions 5.1 The approval of the acquisition, disposal or change of use of land and / or buildings (subject to

the Independent Regulator’s approval in the case of property designated as ‘protected’ in the Foundation Trust authorisation).

5.2 The approval of transactions with a value in excess of that currently specified in the table of financial limits as requiring Board of Directors approval, and which are not covered by any specific delegated authority.

5.3 The final approval of action on litigation against or on behalf of the Trust. 5.4 The approval of loans with repayment periods in excess of one year. 6. Financial and Performance Reporting Arrangements 6.1 Continuous appraisal of the affairs of the Trust by means of the receipt of reports as it sees fit

from directors, committees and officers of the Trust. 6.2 Approval of the Trust’s Annual Report and Account, including the annual accounts, prior to

submission to the Council of Governors.

Standing Financial Instructions (CG101) – updated May 2014


TABLE 1: SCHEME OF DELEGATION OF POWERS FROM THE BOARD OF DIRECTORS TO OFFICERS OF THE TRUST 1.0 Capital & Asset Purchases (including

capital funded via lease finance or charitable grants)

Delegation Arrangements Additional Information

1.1 Approval of the overall Trust Capital Budget and any in-year variations

Board of Directors

1.2 Approval of overall budget allocation to individual capital projects and monitoring

Capital Investment Group (CEO, DoF, CGDs, MD, DoN, DoEF, or nominees)

Monthly report to Board of Directors

1.3 Approval of individual capital projects within the overall Capital Budget (including approval of variations)

Up to £350,000 Between £350,000 - £700,000 Over £700,000

Director of Finance Chief Executive Officer Board of Directors

Exercised through review by the Capital Investment Group. All asset leasing or financing arrangements (whatever value) must also be approved by the Director of Finance.

1.4 Management of individual capital projects Allocated Capital Project Manager Project Monitoring by Capital Investment Group

1.5 Management of assets under construction Allocated Capital Project Manager Project Monitoring by Capital Investment Group

1.6 Maintenance of Trust Asset register Director of Finance 1.7 Approval of Asset Disposals

Land & Buildings (any value) Other – where the asset has a residual value or there is a potential write off of value Other – where the asset has no residual value and there is no write off of value

Board of Directors Director of Finance Care Group Director after notification to the Head of Procurement

The Head of Procurement is responsible for ensuring the Trust receives best value from disposals and so must be notified of potential disposal where an asset may have any value. The Director of Finance must always be informed, by way of an Asset Disposal Form, of any asset disposals to enable the asset register to be updated. The Financial Controller must confirm on the Asset Disposal Form the residual book value of the asset.

1.8 Capital Budget Approval Process Director of Finance



2.0 Contracts for Expenditure Delegation Arrangements Additional Information 2.1 Financial appraisal of companies

identified as potential tenderers Director of Finance

May be delegated to Head of Procurement

2.2 Maintenance of list of approved potential suppliers

Director of Finance Delegated to Heads of Procurement

2.3 Authorisation of less than the requisite number of quotes and/or tenders, including single tenders/quotes:

For individual contracts up to £350,000 For individual contracts between £350,000 and £700,000 For individual contracts over £700,000


Regular report to the Board of all recorded incidents of between £350,000 and £700,000

2.4 Monitoring the use of single tender/single quote action

Audit and Risk Committee on behalf of the Board of Directors

2.5 Receipt of Tenders Director of Finance 2.6 Opening of Tenders Any two from the list of trust Officers

authorised by the Director of Finance to open tenders”

As defined by Director of Finance, ensuring independence from Procurement Process

2.7 Permission to consider late tenders

Chief Executive With advice from Director of Finance

2.8 Tender ratification and award, including authorisation of any actions resulting from post tender clarification:

Up to £350,000 Between £350,000 and £700,000 Over £700,000


Post tender clarification will be led by Director of Finance or his delegate. Process overseen by Head of Procurement

2.9 Signing of Contracts (including letters of intent)

Chief Executive or Director of Finance All building/works projects above £500,000 should be sealed: Other contracts may be sealed if in the interest of the Trust

2.10 Approval of variation or extensions to the use of existing approved contract

After taking advice from the Head of Procurement

All Contract Variations Variations of over 5% where the revised contract value is between £350,000 and £700,000 Variations of over 5% where the revised

Director of Finance and if above limits the CEO or Board Chief Executive Officer Board of Directors



contract value is over £700,000 2.11 Sealing of Documents Chairman ( or Deputy Chairman in the

absence of the Chairman) and one Executive Director of the Board

3.0 Contracts for Income Delegation Arrangements Additional Information 3.1 Approval of Healthcare Contracts Chief Executive or Director of Finance Following acceptance of commercial terms

by Director of Finance 3.2 Approval of all other income contracts

including research & development Chief Executive or Director of Finance This may be delegated to the Director of

Finance 3.3 Approval of variations to Acute healthcare

and all income contracts Chief Executive or Director of Finance

3.4 Authorisation of individual Credit Notes relating to healthcare contracts

Invoicing adjustment to “on-account” invoicing under NHS Standard Contract. Otherwise: E.g. if relating to a pricing discount or loss of potential income then: Up to £350,000 Between £350,000 and £700,000 Over £700,000

Director of Finance Director of Finance Chief Executive Officer Board of Directors

Authorisation of Credit Notes below £5,000 may be delegated by the Director of Finance

3.5 Approval and variation of all contracts for recharges of costs and income generation

Director of Finance Training income and Training recharges will be managed in accordance with a policy approved by the Director of HROD

4.0 Purchasing and Payments (excluding

Capital) of Budgeted Expenditure Delegation Arrangements Additional Information

4.1 Authorisation of Requisitions (limits include irrecoverable VAT)

NOTE: Delegated authority to commit the Trust is only available where the proposed expenditure is within budget. Written authority is required from the Director of Finance before incurring expenditure above the budgeted limit.

Heads of Corporate Departments, Care Group Directors and Care Group Directors of Finance have key responsibilities for monitoring budgets and ensuring budget holders are aware of this limitation on approvals.

The maximum delegated limits which may be varied downwards by the CEO or DOF are:

Expenditure of £5k and above to be certified as being within budget by the Care Group DOF or by the Deputy Director of Finance



Up to £5,000 Up to £90,000 Up to £350,000 Up to £500,000 Above £500,000

Schemes of delegation within these limits may be determined by Care Group Directors, DoEF and Heads of Corporate Departments but such delegation must be approved by DoF before implementation. Executive Directors (including Care Group Directors) With restricted powers of delegation Director of Finance Chief Executive Board of Directors

To be notified to the Director of Finance who will report to the Audit and Risk Committee All expenditure over £5,000 to be confirmed within Budget by Care Group Finance Director for Care Group spend or by Deputy Director of Finance for Corporate Departments spend. Specific arrangements for delegating authority for amounts below £20,000 but only if agreed by the DOF and where it can be demonstrated that financial control will not be compromised. To be notified to the Audit Committee

4.2 Authorisation of individual invoices due for payment where the approved order process has not been followed

Not Allowed All purchases should be made via Trust i-proc ordering system. Only in extenuating circumstances should such invoices be presented for authorisation to the DOF or the Deputy Director of Finance

4.3 Authorisation of petty cash payments Authorisation by line manager (must be budget manager or have delegated authority)

4.4 Authorisation of expenses claims Authorisation by line manager (must be budget manager or have delegated authority)

Only via Trust On-line System

4.5 Authorisation of time sheets Authorisation by line manager (must be budget manager or have delegated authority)

4.6 Authorisation of Agency expenditure Non ward and non clinic based agency staff: approval by any 2 of CEO, DOF, Director of Nursing, Director of Workforce and Organisational Development, Medical Director and Chief Operating Officer



Ward and clinic based agency staff: ordered through NHS Professionals or iproc

4.7 Authorisation of Overtime and additional hours

Pre-Authorisation only via Trust On-line System

5.0 Staff appointments Delegation Arrangements Additional Information 5.1 Clinical appointments To be approved by any two of CEO, DOF,

Director of Nursing, Director of Workforce and Organisational Development, Medical Director and Chief Operating Officer Board Remuneration Committee and/or Executive Remuneration Committee approval also required as per their Terms of Reference.

No appointment can be made unless it is within the budgeted establishment and the appointment has followed the process as established by the Director of Workforce and Organisational Development

5.2

Non-clinical Appointments To be approved by any two of CEO, DOF, Director of Nursing, Director of Workforce and Organisational Development, Medical Director and Chief Operating Officer Board Remuneration Committee and/or Executive Remuneration Committee approval also required as per their Terms of Reference.

No appointment can be made unless it is within the budgeted establishment and appointment has followed the process as established by the Director of Workforce and Organisational Development

6.0 Income and Debt write off Delegation Arrangements Additional Information 6.1 Invoicing Director of Finance All invoices to be raised by the Finance

Department 6.2 Requests for Invoicing to be raised Budget Managers may raise a request for

Finance to generate an invoice. For clarity no-one outside of Finance is authorised to raise an invoice.

All requests for invoicing should be passed to Finance.

6.3 Authorisation of discounts, credit notes (non healthcare income)

Director of Finance See under 3.4 for Credit Notes related to Healthcare income

6.4 Collection of Debts and use of Debt Collection agencies

Director of Finance

6.5 Authorisation of Individual Debt write off This delegation also applies to the effective write off through lack of invoicing for income



to which the Trust is entitled. Whether it occurs through action, lack of action or the passing of time

Less than £5,000 Less than £100,000 Between £100,000 and £200,000 Over £200,000

Financial Controller or Deputy Director of Finance Director of Finance Chief Executive Board of Directors

To be reported to the Audit and Risk Committee.

7.0 Losses and Special Payments Delegation Arrangements Additional Information 7.1 Authorisation of Individual Losses and

Special Payments

Less than £10,000 Less than £100,000 Between £100,000 and £200,000 Over £200,000

Head of Legal Services for payments resulting from legal claims Director of Finance Chief Executive Board of Directors

Up to £10,000 delegated to the Head of Legal Services for payments resulting from legal claims. To be reported to the Audit and Risk Committee

7.2 Authorisation of Clinical Negligence Payments

Director of Finance To be reported to the Audit and Risk Committee

7.3 Monitoring of losses and Special Payments

Audit and Risk Committee On behalf of the Board of Directors

7.4 Authorisation of early retirement, redundancy and all other termination payments to staff

Less than £100,000 Between £100,000 and £200,000 Above £200,000

Director of Finance Chief Executive Board of Directors Board Remuneration Committee and/or Executive Remuneration Committee approval also required as per their Terms of Reference.

Payroll Department require confirmation of approval from both Director of Workforce and OD and Director of Finance prior to making payment.Only after advice from the Director of HR

8.0 Budgetary Control Delegation Arrangements Additional Information 8.1 Delegation of Budgets Chief Executive and Director of Finance 8.2 Request for Budget Virement Initiator and recipient Budget Manager To be approved by CGDoFs 8.3 Authorisation of Budget Virement Director of Finance This may be delegated by the DoF to the

Deputy Director of Finance or the CGDoFs



8.4 Overall Trust Budget and planning process

Director of Finance

9.0 Stores and stock controls Delegation Arrangements Additional Information 9.1 Management and Control Systems for

Stores and stocks Director of Finance Delegated to Head of Procurement.

Orders may be generated automatically based on agreed minimum and maximum stock quantities.

10.0 Bank Account and Payment Methods Delegation Arrangements Additional Information 10.1 Opening of Bank Accounts Director of Finance 10.2 Signing of cheques, BACS schedules and

PGO authorisation Director of Finance This may be delegated within the Finance

Department.

11.0 Bank Account and working Capital Facilities Fees and Charges Delegation Arrangements Additional Information

11.1 Approval of Fees and Charges Director of Finance 12.0 Standards of Business Conduct Delegation Arrangements Additional Information 12.1 Maintenance of register of interests and

secondary employments

Board of Directors All other staff

Chief Executive Chief Executive

Maintained by the Director of Corporate Affairs

12.2 Maintenance of gifts and hospitality registers

Board of Directors All other staff

Chief Executive Chief Executive

Maintained by the Director of Corporate Affairs

13.0 Insurances Delegation Arrangements Additional Information 13.1 Insurance arrangements Director of Finance



4.0 Fraud and irregularity Delegation Arrangements Additional Information 14.1 Counter Fraud and corruption work Director of Finance It is expected that Internal Audit would be

involved in any investigation. 14.2 Investigation of suspected cases of

irregularity not related to fraud or corruption

Director of Workforce and Organisational Development

15.0 Investments Delegation Arrangements Additional Information 15.1 Approval of Treasury Policy (CG401) Board of Directors After review by the Audit and Risk Committee 15.2 Investment Decisions Director of Finance

16.0 Borrowings Delegation Arrangements Additional Information 16.1 Approval of Loans and Loan Facilities,

(including working capital facilities) Board of Directors

16.2 Use of Loans and Loan Facilities as approved by the Board of Directors

Director of Finance

16.3 Use of Leasing and non-conventional funding

Director of Finance

Feb 2014 Revision - Version 4.0 Page 37 of 37


Certification. I xxxxxxxxxxxxxxxxxxxxxx certify that I have read, understood and will comply with the Standing Financial Instructions dated June 2014xxxxxxxxx. Signature: _______________________________________ Date: ___________________________________________

1


Board of Directors

Title: Staff Survey Results

Date: 30th June 2014

Lead: Paul Jones, Interim Director of Workforce and Organisational Development

Purpose: The attached paper formally presents to the Board a brief summary of the results and the process for implementing action plans to address any improvements.

Key Points: Of 28 Key Findings in the National Staff Survey, the Trust improved in 23 of the areas. Five areas of improvement are statistically significant and include an increase in the number of staff appraised; more staff receiving Equality and Diversity as well as Health & Safety Training; more effective team working and fewer staff experiencing discrimination at work. Deterioration was seen in 3 areas (none of which is reported as statistically significant). The 3 deteriorating findings are: more staff working extra hours; more staff saying hand washing materials aren’t available and fewer staff reporting incidents/near misses. The recommendation of the Trust as a place to work or receive treatment has increased since 2012. This will support CQUIN payments relating to improvement in this measure totalling £70k.

Overall Staff Engagement at the Trust has improved since 2012 and on this measure the Trust is now ranked as 11th best out of 140 Acute Trusts. Also of note is the Trusts standing as the 2nd

best Acute Trust on measures for staff motivation.

Planned Care demonstrated the biggest in year improvement, with better results on 24 key findings in 2013 as compared to their results in 2012. Although direct comparison was not possible, the results for Estates & Facilities are also noteworthy in being above average for the Trust.

Decision required: FOI Status

The Board is requested to note the contents of this report and approve the action plan The report will be made available on request

1 BACKGROUND

2

1.1 The National 2013 NHS Staff Survey was conducted in November 2013, and published in February. Locally, 459 RBFT employees responded to the survey from a sample of 832. The response rate of 55% was an increase of 6% from last year’s response.

1.2. In the National survey results are presented as 28 Key Findings (KF) which are structured around 4 of the 7 pledges to staff in the NHS constitution

1.3 In the data tables presented below,

Denotes a positive upwards trend; Denotes a positive downwards trend

Denotes a negative upwards trend, Denotes a negative downwards trend

2 STAFF RECOMMENDATION OF THE TRUST AS A PLACE TO WORK OR

RECEIVE TREATMENT

2.1. Staff recommendation of the RBFT as a place to work or receive treatment has increased since 2012. The overall 2013 score on this key finding was 3.87 (3.82 in 2012), where the scale is 1: Unlikely to recommend to 5: Likely to recommend. On this finding, the Trust is ranked 22nd

out of 140 Acute Trusts. The key finding is formed by the component questions below.

Question/Key Finding Trust Score 2012

Trust Score 2013

Trend 2012/13

Average for acute trusts 2013

Measure Description

Q12a: Care of Patients is my organisations top priority

73 76 68 % agreeing or

strongly agreeing

Q12b: My organisation acts on concerns raised by patients


strongly agreeing

Q12c: I would recommend my organisation as a place to work


strongly agreeing

Q12d: If a friend or relative needed treatment, I would be

happy with the standard of care provided by this organisation


strongly agreeing

2.2 Improvements in Question 12d (above) are linked to CQUIN payments for 13/14. Improved Trust performance on this measure since 2012 will secure £70k CQUIN payments as part of the National Friends and Family CQUIN.

3

3 STAFF ENGAGEMENT

3.1 Measures of Staff Engagement rank the Trust 11th

out of 140 Acute Trusts with an overall score of 3.88 (3.82 in 2012) where the scale is 1: poorly engaged and 5: highly engaged. The overall finding is formed by the key findings below which look at the component parts of engagement in terms of staff involvement, motivation and advocacy.


Trust Score 2013

Trend 2012/13

RBFT ranking (out of 140 Acute Trusts)

Acute Trust Average

2013

Measure Description

KF22 Staff Ability to contribute towards

improvements in work 70 73 12 68 %

KF25 Staff Motivation at Work

3.95 4.01 2 3.86

1: Not Enthusiastic or absorbed 5:Enthusiastic/Absorbed

KF24 Staff Recommendation of the trust as a place to work

or receive treatment

3.82 3.86 22 3.68

1: Unlikely to recommend 5: Likely to recommend

4 AREAS OF IMPROVEMENT AND DETEROIRATION IN STAFF SURVEY FINDINGS SINCE 2012

4.1 In 2013, no statistically significant deterioration in Trust performance is reported on any Key Finding

4.2 Three Key Findings are showing a dip in performance as indicated below (but not reported as statistically significant) deteriorations.

4


Trust Score 2013

Trend 2012/13

RBFT Ranking (out of 140 Acute Trusts)

Acute Trust Average

2013

Measure Description

KF5: % of staff working extra hours

67 68 81 70 %

KF 12 % of staff saying hand washing materials are always available

66 60 69 60 %

KF14 % of staff reporting errors, near misses or incidents witnessed in the last month

89 85 137 90 %

4.3 In addition,Trust performance is ranked as slighlty worse than average on 3 further key findings although in year improvements are evident since 2012


Trust Score 2013

Trend 2012/13


Acute Trust Average

2013

Measure Description

KF10 % receiving health and safety training in last 12 months*

56 70 104 76 %

KF 16 % experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months*

19 17 14 15 %

KF17 % experiencing physical violenece from staff in last 12 months*

4 3 15 2 %

*Denotes a finding that was one of the Trusts bottom 5 ranking findings in the 2012 survey

4.4 Since 2012 statistically significant improvement has been seen in 5 Key findings (details provided below)

5


Trust Score 2013

Trend 2012/13


Acute Trust Average 2013

Measure Description

KF7 : % appraised in the last 12 months

81 88 41 84 %

KF10 : % receiving Health and Safety

training in the last 12 months*

56 70 104 76 %

KF26 : % having Equality and Diversity training in the last 12

months*

44 63 61 60 %

KF28 : % experiencing discrimination in the last

12 months* 16 10 72 11 %

KF4: Effective team working

3.71 3.83 20 3.74

(1: Ineffective Team

Working, 5: Effective Team

Working)

*Denotes a finding that was one of the Trusts bottom 5 ranking findings in the 2012 survey

4.5 In addition, improvement (although not reported as statistically significant) has been achieved in a further 18 Key findings (results for each key finding are presented in section 6.

4.6 All five of the bottom ranking Trust scores in the 2012 survey are showing improvement in 2013 (with 3 of the improvements statistically significant).

5 STAFF EXPERIENCE RELATIVE TO PATIENT SAFETY AND PATIENT EXPERIENCE INDICATORS

5.1 The 2012 summary report provided an analysis of findings of staff experience relative to patient safety and patient experience indicators. This analysis has been replicated for the 2013 findings. Five of the identified measures have shown in year improvement, three are showing no change and one a deterioration. In terms of Q18e, relating to the effectiveness of Trust response to errors and near misses, a 1% deterioration is reported, but Trust performance remains above the National average.

6

2013 Staff Survey Data 2012/13

RBFT Trend 2012

Score 2013 Score

Average (Median) for Acute Trusts

Description of Scale

Fairness and Effectiveness of Procedures for Reporting Errors, Near Misses or Incidents (Core

Survey Questions) Q18b My organisation encourages us to report errors, near misses or incidents 84 87 86%

% agreeing or strongly agreeing with the statement

Q18e When errors, near misses or incidents are reported, my organisation takes action to ensure that they do not happen again 66 65 61%


Raising Concerns at Work (Core Survey Questions)

Q19 % saying if they were concerned about fraud, malpractice or wrongdoing they would know how to report it No Change 84 84 89%


Team Based Working (Core Survey Questions)

Q4b Team members have a set of shared objectives 80 84 78%


Individual Contribution to Patient Care (Core Survey Questions)

KF1 % of staff feeling

satisfied with the quality of work and patient care they

are able to deliver No Change 83 83 79% %

Senior Managers and Leaders (Core Survey Questions)

Q11d Senior Managers act on staff feedback 30 33 29%


Q11e Senior Managers where I work are committed to patient care 55 62 52%


Patient Experience Safety Indicators (Local Survey Questions)

Overall, patients are treated with respect by staff in my organisation 76 87 n/a


Patient Safety is a priority for staff in my organisation No Change 85 85 n/a


7

6 KEY STAFF SURVEY FINDINGS BY TRUST AREA

6.1 Full staff survey findings, broken down in line with theTrust structure are presented in full in Appendix 1.

6.2 Summary details of performance relative to Trust structure are provided below:

Number of staff participating in survey

Response rate (%)

Number of key finding improvements since 2012

Number of key finding deteriorations since 2012

Number of unchanged key findings

Planned Care 139 59.4 24 3 1

Networked Care

103 57.9 11 16 1

Urgent Care 135 47.2 20 6 2

Corporate Services

34 73.9 10 17 1

Estates and Facilities

48 54.5 n/a n/a n/a

6.3 Comparative data for Estates and Facilities for 2012 is not available, however Estates & Facilities performance on 17 of the 28 key findings is above the Trust average for 2013 – with particularly high levels of staff engagement and recommendation of the Trust as a place to work and receive treatment.

7 Recommendations

7.1 The Board is asked to note the contents of the report and agree:

a) Each Care Group and Corporate Function to identify 2-3 improvement actions based on their results. Action plans should be informed by a listening exercise or focus group with staff to agree what improvements would make the most difference.

b) To provide a positive feedback loop, a progress report on what impact has resulted from the improvement actions will be presented to the Resourcing Committee in 6 months.

8 Attachments

8.1 The full survey results are available on request:

Updated: 17 June 2014 1

Royal Berkshire NHS FT – Board Work Plan Agenda Item 14

Jan 2014 Feb

Mar Apr May June July September October

Regular business

Executive Report (ED) IPR (JT) Q&S (AF/CAi) Schedule of SIs (AF) DoF (CA) Minutes and actions (KE) Board Work Plan (KE)



Chief Executive Report (AF) Quality Performance Report (CAi/JT) Care Groups Performance (LB/SE/PM) Schedule of SIs (AF) DoF (CA) Minutes and actions (KE) Board Work Plan (KE)






Strategic/ Major

EPR (JT) TBC Final IBP Post Engagement (JT) Capital Programme Update TBC (CA)

Budget 2014/15 (CA)

Quality Strategy (CAi)

Annual Report and Accounts and quality Accounts) (CA/KE/AF)

Strategic Plan 2014-19 (JT)

IM & T Strategy (TW)

Maternity Strategy (SE)

Integrated Business Plan Update (JT) Estates Strategy (PH) TBC

Other

Nursing Recruitment plan (LL/CAi) Staff immunisation update (LL)

Quarterly workforce report (LL)

Decon business case (PM)

Quarterly Budget forecast (CA) Maternity HDU (SE)

Medical Records (BR) Quarterly Budget forecast (CA)

Quarterly workforce report (PJ)

Quarterly Budget forecast (CA)

Updated: 17 June 2014 2

Jan 2014 Feb

Mar Apr May June July September October

Urgent care investment plan (SE)

Pre-op and extra ward business case (PM)

Bracknell Clinic Break even position (LB) Interventional radiology business case (SE)

Governance

Monitor Quarterly Return (CA) Board evaluation review (KE)

Corporate Risk Register and BAF (KE) Board evaluation review (KE)

Equality & Diversity (LL) Post-Francis Action Plan (CAi) Board evaluation review (KE)

Corporate Risk Register and BAF (KE) Monitor Quarterly Return (CA) Board evaluation review (KE)

SFI review (CA) Board evaluation review (KE)

Board evaluation review (KE) SFI review (CA)

Quality Governance Framework Update (CAi/JT) Corporate Risk Register and BAF (KE) Monitor Quarterly Return (CA) Board evaluation review (KE)

Quality Governance Framework Update (CAi/JT) Standing Orders Review (KE) Board evaluation review (KE)

Quality Governance Framework Update (CAi/JT) Corporate Risk Register and BAF (KE) Monitor Quarterly Return (CA) Board evaluation review (KE)

briefing

June 2014

Duties of directors to provide financially sustainable health and care systems With trusts required to submit two and five year operational and strategic plans in the context of unrelenting financial pressures, balanced with the requirements of safeguarding and improving patient care, what are the duties of directors to the creditors of the trust? In the commercial world directors of a company can expose themselves to personal liability to a company’s creditors under the provisions of the Insolvency Act 1986, where they have allowed the company to trade beyond the point at which the directors should have realised that there was no reasonable prospect of avoiding being unable to pay creditors in full. Moreover where a normal trading company is confronted by a real prospect of insolvency then the directors duties to act in the best interests of the shareholders are subordinated to acting in the best interests of the creditors. The good news is that the Insolvency Act 1986 does not apply to foundation trusts. When it comes to responsibility for financial decisions then in the absence of dishonesty or woeful incompetence, the directors of a trust are unlikely to be exposed to claims brought against them personally by the individual creditors of the trust. Any such claim is likely to be misconceived and liable to be struck out by a court. This is because the directors’ duties are owed to the trust and are enforceable by the trust and not by its’ creditors. It would of course be possible for a foundation trust to take action against its directors (or former directors) if it considered they had failed in their duties to the trust, including the new statutory duty to act with a view to promoting the success of the corporation. This duty is very similarly worded to the duty of a Companies Act director to promote the success of his company, but the test is subjective – which means a director can in theory escape liability under this duty provided his intention was to promote the success of the corporation, which also means that it will be difficult to make a successful claim in all but the most extreme circumstances. While the insolvency regime does not apply to foundation trusts the NHS Foundation Trust Code of Governance is based on the principles and provisions of the Combined Code of Corporate Governance but amended to make the code consistent with the public service values of trusts. The code is not mandatory but is best practice advice and included in the principles are:

1 that the board ensure that the necessary financial and human resources are in place for the trust to meet its main priorities and objectives;

2 that the board ensures that the trust meets its obligations to its members, patients and other stakeholders; and

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3 that all directors have joint responsibility for every decision of the board regardless of their individual skills or status.

While neither the code nor the legislative framework provides any guidance on what a board should do when confronted by insolvency, the principles of good governance are of universal application whatever the sector. However, this is subject to the very important proviso, that it is unlikely that critical and/or immediately essential duties to patients can, or should, ever be subordinated to duties to creditors. That does not mean that the duties to patients outweigh the duties to creditors in all circumstances. A board confronted by financial difficulty must take an active approach to address its financial challenges and be fearless in protecting the interests of all stakeholders. Knowing that liabilities are being incurred to creditors when there is no certainty of being able to meet those liabilities is not going to be regarded as good governance. In circumstances where information (including financial information) is provided to the sector regulator Monitor in compliance with a foundation trust’s statutory obligations, managers should take all reasonable steps and exercise all due diligence to make sure such information is accurate, so as not to fall foul of the Enterprise Act 2002. Provisions in force from April this year make it an offence to pass false or misleading information to Monitor, and managers may find themselves personally liable if they know, or ought to have known, that such information has been provided. Some readers may have heard of claims being brought for misfeasance in public office. While this is a developing area, a claim on this basis requires proof of malice or bad faith in the exercise of a power, or the deliberate omission to act, by a public officer. A well run board acting in genuine pursuit of the public good is unlikely to be exposed to a misfeasance claim. Readers will also not be surprised to hear that directors will almost certainly be personally liable if they have acted fraudulently or made an explicitly personal promise to a creditor. The Company Directors Disqualification Act 1986 does apply to directors of trusts. Where the conduct of a director is deemed ‘unfit’ then a director can be disqualified from being either directly or indirectly involved in the management of a trust or company for a period of between 2 and 15 years.

Jamie Wheatley Partner for Mills & Reeve LLP +44(0)1223 222206 [email protected]

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