Trust Board Thursday 26 August 2010 at 9.30 am. Tutorial Room 4, Education Centre, Upper Maudlin Street, Bristol, BS2 8AE

Transcription

1 Meeting Date & time Venue Trust Board Thursday 26 August 2010 at 9.30 am Tutorial Room 4, Education Centre, Upper Maudlin Street, Bristol, BS2 8AE AGENDA To: Trust Board: John Savage (Chair), Iain Fairbairn, Lisa Gardner, Paul May, Selby Knox, Kelvin Blake, Emma Woollett, Robert Woolley, Jonathan Sheffield, Tony Ranzetta, Steve Aumayer, Paul Mapson, Pat Fields, Deborah Lee Paula Murphy, Peter Wilde, Lis Kutt, Jacquie Cornish, Chris Monk, Mike Nevin No Agenda Item Lead Page No. 1. Apologies Alison Moon Chair - 2. Declaration of Interests - Board Directors to declare any interests 3. Minutes - to agree minutes of the joint meeting held on 28 July 2010 for accuracy Chair - Chair 1 4. Matters Arising 13 Action log 5. Acting Chief Executive s Report - to note Robert Woolley - Performance and Quality 6. Performance & Quality Report to receive and discuss the Summary Performance Report - Access - Workforce - Quality Deborah Lee Tony Ranzetta Steve Aumayer Jonathan Sheffield/ Pat Fields 7. Financial Report - to receive Paul Mapson Separate pages Assurance and Governance Skills for Health to adopt a governance manual Steve Aumayer/ Brian Payne 69 Trust Headquarters Marlborough Street Bristol BS1 3NU

2 No Agenda Item Lead Page No. Strategy & Planning 9. Annual Risk Assessment (Annual Plan) results notification to receive Deborah Lee 95 For information 10. Report of Governance & Risk Management Committee 12 August 2010 to note Jonathan Sheffield Report of the Trust Executive Group: August to note Jonathan Sheffield Any Other Business Chair 13. Date of next meeting : 29 September 2010 Annual public meeting: 22 September 2010 Chair David Seabrooke, Interim Company Secretary Trust Services The person dealing with this meeting is: David Seabrooke, Trust Headquarters Marlborough Street Bristol BS1 3NU

3 Minutes of the Joint Trust Board and Membership Council Meeting held on Wednesday 28th July 2010 Present John Savage Membership Council Public Governors Elizabeth Corrigan Anne Ford Heather England Sian Evans Mo Schiller Jade Scott-Blagrove Mary Hodges Pauline Beddoes Patient and Carer Governors John Steeds Ken Cockrell Jacob Butterly Pam Yabsley Anne Skinner David Aldington Neil Auty Suzanne Green Phil Mackie Wendy Gregory Garry Williams Staff Governors Florene Jordan Belinda Cox Jim Catterall Jan Dykes Chris Swonnell Appointed Governors Sylvia Townsend David Tappin Partnership Governors Frank Palma Jeanette Jones Trust Board Robert Woolley Jonathan Sheffield Paul Mapson Steve Aumayer Tony Ranzetta Paul May Lisa Gardner Kelvin Blake Dr Jackie Cornish Chairman Constituency North Somerset (Governor Representative) North Somerset Bristol Bristol Bristol Bristol South Gloucestershire South Gloucestershire Constituency Local Patients Local Patients Local Patients Local Patients Local Patients Local Patients Tertiary Patients Tertiary Patients Carers of patients under 16 yrs Carers of Patients under 16 yrs Carers of Patients under 16 yrs Constituency Nursing and Midwifery Nursing and Midwifery Medical and Dental Non-Clinical Healthcare Professionals Non-Clinical Healthcare Professionals Bristol City Council Bristol Primary Care Trust (part) Voluntary Group Joint Union Committee Acting Chief Executive Medical Director Director of Finance Director of Workforce and Organisational Development Interim Chief Operating Officer Non Executive Director Non Executive Director Non Executive Director Head of Division Women and Children s (part) Date Tuesday, August 03, 2010 Author V Goodwin Page 1 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 1

4 Dr Chris Monk Dr Lis Kutt Dr Paula Murphy Chris Perry In attendance Ben Hume Cathy Gane Anne Reader David Seabrooke Maria Fox Vicki Goodwin Head of Division - Medicine Head of Division Diagnostics and Therapies (part) Chair Trust Medical Committee Director of Infection, Prevention and Control, representing Chief Nurse Head of Business Planning Young Persons Involvement Worker Assistant Director of Governance and Risk Management Interim Company Secretary Membership Manager Membership PA 80/10 Welcome and Apologies John Savage welcomed everyone to the meeting. He noted the following: Executive vacancies these should be of no concern to Governors as turnover at this level was normal and suitable interim arrangements were being put in place Formally announced the departures of Jonathan Sheffield, Medical Director at the end of September and Irene Gray, Chief Operating Officer in July and wished them well Papers he apologised for acronyms and all should strive to create reports avoiding jargon. Apologies Jason Edgar Lorna Watson Phil Quirk James White Chris Payne Massimo Pignatelli Jane Britton John Newman Deborah Lee Alison Moon Irene Gray Iain Fairbairn Selby Knox Emma Woollett Dr Mike Nevin Dr Peter Wilde Governor - Public Bristol Governor - Carers of patients under 16 yrs Staff Governor - Other Clinical Healthcare Professional Appointed Governor - North Somerset Primary Care Trust Appointed Governor - South Gloucestershire PCT Appointed Governor University of Bristol Partnership Governor - Avon & Wiltshire Mental HealthTrust Partnership Governor - Great Western Ambulance Service Interim Director of Corporate development Chief Nurse Chief Operating Officer Non Executive Director Non Executive Director Non Executive Director Head of Division Surgery, Head and Neck Head of Division Specialised Services It was confirmed that the Trust Board and Membership Council were quorate. 114/10 Declaration of Interests Belinda Cox informed the meeting that she was working with the Safer Bristol Scheme. Neil Date Tuesday, August 03, 2010 Author V Goodwin Page 2 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 2

5 Auty ran a business conducting research into agency costs. 115/10 Minutes The minutes of the meeting of the Trust Board on 28 June were agreed as a correct record with an additional bullet-point in minute 103/10 reflecting the committee s concerns about overperformance on activity. The Board action list was reviewed. The minutes of the meeting of the Membership Council on 27 May were agreed as a correct record, subject to the amendment of members to governors in minute 82/10, reference item a). 116/10 a) b) c) d) e) f) Acting Chief Executive s Report Robert Woolley reported to the meeting on the following: Liberating the NHS (Health White Paper): the Department of Health was bringing out a series of consultation papers and a process would be established for the compilation of a response by the Trust in accordance with the 11 October deadline. Key features emerging so far: The abolition of the primary care trusts and strategic health authorities by 2013 All NHS providers to become Foundation Trusts by 2013 No privatisation, but removal of private patient cap All but specialist commissioning functions transferred to GPs accountable to NHS Commissioning Board A greater focus on patient outcomes over process targets Monitor to become an economic regulator Merger and acquisitions process simplified There was an opportunity for the Trust to take a leadership role in the changes to the healthcare system. The Trust was also developing a plan to engage with the GPs. Governors would discuss the White Paper at the governors informal meeting on 6 September. Board level changes: long term arrangements for the Chief Operating Officer and Medical Director posts would be made when the substantive Chief Executive was appointed in September. Deborah Lee remained as Acting Director of Corporate Development, Tony Ranzetta had started as Acting Chief Operating Officer and arrangements to cover the Medical Director role would be announced in due course. Graham Rich had now left the Trust. Histopathology: the final report was expected at the beginning of October and arrangements were being made for its publication Patient Safety - a lessons learned report would be made following a report on the unauthorised administration of opiates to patients by a nurse practitioner between 2000 and 2002; Robert Woolley assured the meeting that the Trust did not stock this particular drug Homeopathy the Government s response to the Science & Technology Select Committee report had confirmed that contracting these services was a matter for primary care trusts to determine. The Trust would continue to provide homeopathy services on the basis of contracted demand from commissioners. Baby-friendly city Bristol was the first UK city to have been awarded baby-friendly status Date Tuesday, August 03, 2010 Author V Goodwin Page 3 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 3

6 Paul May noted that some local planning functions of primary care trusts would pass to local authorities. Robert Woolley gave assurance that there would be partnership working to respond to this. Frank Palma asked about the pressures to reduce admissions and length of stay and the alternative community provision. Robert Woolley agreed that GPs were likely to be incentivised to use alternative community-based provision; Jonathan Sheffield added that the Trust would work with community providers to shape these services. Neil Auty asked about sources of funding and how negotiations would be conducted under the new arrangements. Robert Woolley stated that while specialist commissioning would be managed nationally, GPs would assemble into consortia. Community pathways would add to the range of available patient pathways and the Trust would work with GPs to co-ordinate activity. Jim Catterall asked about the development of incentives for GPs to reduce hospital admissions by referring patients to community services. Robert Woolley responded that the incentives had yet to emerge; there was however a concern that spending reductions of 25% in allied services would affect services provided by the Trust. 117/10 a) b) c) d) e) f) Governors Report Liz Corrigan presented the governors report. At the last informal governors meeting they had looked at a range of issues including communication, and the way that the governors interact with the Trust. She highlighted: New Governors - Liz formally welcomed the 12 new governors and two returning governors for a second term in office. Vice Chair/Governor Representative At the last Informal Meeting the governors discussed the implications of the current Vice Chair/Governor Representative title and Monitor s suggested title of Lead governor. The governor s proposed the title of Governor Representative. This decision was proposed by Jeannette Jones, seconded by Mary Hodges and voted upon and carried. The Governors agreed the title of Governor Representative. Executive Team departures - on behalf of the governors Liz Corrigan wished Jonathan Sheffield and Irene Gray good luck in their new ventures. Governor Response to the Government s White paper - Liz suggested that the governors work in groups, each taking a section of the white paper and then formulate a joint response after the informal meeting in September in time for the October deadline. Constitutional Changes Other than the changes recommended by the Nominations and Appointments Committee, there were no other suggested changes to the Constitution this year. However Liz Corrigan suggested that the governors should make time to explore the Constitution over the next year. Executive Walk Rounds - Robert Woolley updated the governors on the Executive walk rounds. He felt that a large group of people may restrict staff s ability to talk confidentially to the Executives. He suggested that the governors who are currently signed-up to attend can Date Tuesday, August 03, 2010 Author V Goodwin Page 4 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 4

7 proceed, but in September he aimed to introduce a new quality walk round. Governors will be invited to join these. Liz suggested that the governors should discuss this at the September meeting. g) Governor Involvement - Anne Skinner was concerned that governors have been asked to join Trust-wide committees that are currently fully subscribed. Anne Reader suggested that if any governor is interested in joining any committees that they approach her, and she will contact the group chair to see if any additional governors can join. John Savage confirmed that he welcomes the governors involvement throughout the Trust. The Membership Council received the Governors Report. 118 /10 Performance & Quality Report On behalf of Deborah Lee, Ben Hume introduced the report. Steve Aumayer reported on the workforce section as follows: Workforce numbers, including bank and agency continued to decline Sickness rates were worse than was targeted, but the target and the actual continued to converge Appraisal rates were 4% below the target A detailed action plan was in place to improve compliance with child protection training In relation to the use of bank and agency staff, it was noted that agency staff were often a less expensive way to deliver ancillary roles, for example in Estates & Facilities. It was preferred to use bank staff for nursing and midwifery roles. However, bank staff could be expensive when employed for unsocial hours. In response to a question from Frank Palma about the Agency Workers Directive, Steve Aumayer said that in order to keep the distinction clear who about who is seen as an agency worker s true employer, it was important that workers performed work for other clients in addition to the Trust. In a response to questions from Lisa Gardner about compliance with infection control training and appraisal, Steve Aumayer stated that his directorate continued to work hard to address these issues. The Chair emphasised that the Trust could not afford to lose focus on control of infection. Jonathan Sheffield reported on the Quality section and highlighted the introduction of orthopaedic hot clinics in the emergency department. In the thoracic and colorectal areas, an enhanced recovery pathway had been introduced which helped ensure patients were fit for surgery and this improved recovery rates. The Board also received an account of an actual patient experience. It was noted that hand hygiene compliance was improving and the antibiotic compliance was being emphasised in the trainee doctors induction programme; this was reinforced through the introduction of electronic prescribing. The use of the World Health Organisation pre-surgery checklist continued to be promoted as some theatres were not making use of it frequently enough. Executives were addressing the slippage in the proportion of patient safety walk-rounds completed. Date Tuesday, August 03, 2010 Author V Goodwin Page 5 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 5

8 John Steeds asked about the implementation of patient safety alerts and it was noted that detailed compliance with these was monitored on the Board s behalf by the Governance & Risk Management Committee. Wendy Gregory reported that she had met with Helen Morgan to discuss several issues her family had encountered at the BRI. These covered problems with estates, pharmacology, and delays in fracture diagnosis. Jonathan Sheffield confirmed that an expert diagnosis of all fractures will now be done within 24hrs. Tony Ranzetta presented the patient access section of the report. In June, the Trust had achieved the 62 day cancer standard on GP referrals; however, the Trust expected to fail this target in quarter 1. The possible inclusion of the figures relating to patients seen by the Avon Breast Screening service could have a bearing on the final figure. A reduction in thoracic surgery sessions was being addressed. Performance on two week referrals was improving and breast screening has improved to 82% against a standard of 93%. Capacity would be added to address this. A breach due to capacity should be regarded as a never event. In response to a question from Neil Auty it was noted that patients sometimes chose to delay treatment, which caused the Trust to breach. To help sustain performance on 31 day standards, a need for additional intensive care capacity had been identified and a business case was being considered by the Trust s commissioners. On 18 weeks, there was only one area not achieving 90% for admitted patients and one speciality 95% for non-admitted patients. A recovery plan for cardiology services would be reported to the August Trust Board meeting. On A&E, high levels of attendances continued to be seen; the Trust had achieved the 98% target in quarter one and had performed at 98.8% in July to date. The Trust continued to work with the Emergency Care Intensive Support Team. Chris Perry presented the update on infection control. Cases of C. Diff had been escalated and outbreaks addressed and cases were now reducing. Hand hygiene continued to be audited monthly, supplemented by a 15 minute observational check. The patient survey had reflected on staff s hand hygiene and it was noted that in some areas of the hospital, basins were located outside of patients view. Use of the hand gel at the end of the bed needed to me made more overt. The Trust s standard for new builds included a hand basin by each bed. Paul May emphasised the need to make a priority of infection control training. In response to a question from Kelvin Blake about the availability of cleaning equipment at the Bristol General Hospital, Chris Perry informed the meeting that there was no hydrogen peroxide vaporisation equipment based at the General Hospital, but that it could be provided there where necessary. Pauline Beddoes asked if they linked up with other departments like dietetics to improve the overall good health of the patient. Chris Perry confirmed that they work with other departments to look at patient safety, pressure sores, dietetics and other factors to improve general good health. 119/10 Financial Report Date Tuesday, August 03, 2010 Author V Goodwin Page 6 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 6

9 The Board and Council received a report of the meeting of the meeting of the Board s Finance Committee held on 23 July. Lisa Gardner reported that the Trust had generated a surplus of 1.295m to 30 June and that the Trust s financial Monitor risk rating was being declared as 3 in accordance with the plan. This would move back up to 4 in later quarters. The Trust continued to use non-recurring reserves to cover recurring overspends by divisions. The Trust s earnings before interest, tax, depreciation and amortisation were slightly below plan, due to a provision for C.Difficile fines. A year-end shortfall on cash releasing efficiency savings of was projected. Concerns remained about levels of activity which were higher than provided for by service level agreements; the committee had reviewed a range of risks associated with unplanned activity and non-delivery of key performance indicators. Paul Mapson added that elective activity levels were stable, but increases were mainly through emergency admissions. Provision had been made for performance fines. GPs would in future control the Trust s activity levels although it was not yet clear whether they would continue to be able to exact penalties from providers. Robert Woolley added that the tariff should provide performance incentives whilst avoiding the need for fines. The Board received the finance report. 120/10 Monitor Compliance Framework The Board received an information report detailing changes that Monitor had made to the Compliance Framework, reflecting changes made by the Department of Health to the NHS Operating Framework. This included a change to a 95% threshold for 4hr/A&E and no requirement to certify against the 18 week targets. However, targets reflecting the position originally set out in the NHS Operating Plan remained in place through the NHS Constitution and the Trust s contracts with its commissioners. The Board noted the report. 121/10 Quarter 1 Reports for Monitor Submission The Board received a report setting out draft submissions for finance and governance required by Monitor. The finance self-declaration was 3 in accordance with the annual plan and the governance self-declaration was red because of the anticipated failure to meet the 62 day cancer standard over four consecutive quarters. The submission included the results and turnout of the recent governor elections. Robert Woolley noted that Monitor were not proposing formally to intervene in the Trust s case. The Board approved the draft submissions for Monitor. 122/10 Report of the Trust Executive Group The Board received a report setting out matters considered by the Trust Executive Group during July. Robert Woolley highlighted that head and neck services would centralise at the Trust from spring Paul May requested an update on the work of the transformation programme, which Robert Woolley agreed to provide. 123/10 Updating the Constitution The Board received a report setting out proposals to review the Trust s Constitution to incorporate provisions made by the latest Monitor Model Constitution. The proposals established the annual joint meeting as the main forum for approval of changes sought by the Board and the Membership Council. The report detailed clarifications of the Membership Date Tuesday, August 03, 2010 Author V Goodwin Page 7 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 7

10 Council s terms of reference. The Constitution currently gave details of the two discretionary committees established by the Board and it was proposed that these should not be referred to here; however it was confirmed that this change in no way affected the committees status. The report also set out a statement of the Chair s and Chief Executive s respective responsibilities which was a requirement of the Code of Governance. A statement of matters reserved to the Board was provided for information and for adoption when the Board reviewed the scheme of delegation. The Board approved the report. 124/10 National Research Ethics Service Hosting Arrangements The Board received a report giving the recommendation of the Finance Committee that, subject to the completion by the Director of Finance of a due diligence review and a legal agreement that the Trust should agree to host this service. The benefit to the Trust was that this re-enforced its role as the leading medical research body in the south-west. The Board approved the recommendation as set out above. 125/10 Review of Governor Sub-Groups Chris Swonnell presented a paper to the Membership Council proposing an amendment to the current structure of the governor sub-groups. At the last Governors informal meeting it was agreed that a review of the sub groups should take place to resolve the overlap with other sub groups. He proposed the following re-structure. The current Involvement sub group becomes a Membership working group, with the other involvement activities transferring to the Quality working group. That certain common practices are adopted by all sub groups, in particular that sub groups are chaired by Governors. The Membership Council agreed: The proposed restructure of the Involvement sub group to become a Membership working group with the other involvement activities transferring to the Quality working group. The Membership council agreed that all working groups be chaired by governors. Details to be discussed at the next Governors Informal meeting on 6 th September /10 National Inpatients Survey 2009 The Board received a report detailing the findings of the survey, which had been the subject of an earlier presentation. Jonathan Sheffield drew attention to the action plan which accompanied the report. 127/10 Corporate Objectives Annual Plan Progress The Board received a report showing generally good progress with the Trust s objectives set out in the annual plan. Paul May highlighted the need to continue with training on infection control in support of objective PE04. Date Tuesday, August 03, 2010 Author V Goodwin Page 8 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 8

11 Frank Palma was concerned by an apparent sudden increase in the levels of serious untoward incidents. Jonathan Sheffield gave assurance that fluctuations in the ratings were a regular feature and that and the report was designed to highlight any adverse trend. 128/10 Bristol Royal Infirmary redevelopment update The board received a report updating it on the progress of this project. Robert Woolley informed the Board that the programme was delayed by 6 months and that there was now a risk to completing the project to co-incide with the opening of the new Southmead hospital in May The delay was due to messages arising from the national Quality, Innovation, Productivity and Prevention (QIPP) programme regarding reducing the reliance on acute hospital beds. The Trust was also investigating a commercial loan to finance the project. Paul Mapson added that the prudential borrowing limit would apply to either publicly or privately derived finance. The Trust had been capping the expenditure on design work for variants to the scheme. The design work completed had shown that value for money reduced in line with reductions to the scale of the proposed scheme. The Trust was therefore working to deliver the model of care shown in the original outline business case on the basis of fewer beds, but providing for new models of care. It was noted that the BRI entrance scheme was currently on hold; charitable funding may need to be sought for this. The Chair emphasised that one of the key benefits of the redevelopment scheme would be to improve the environment for many of the Trust s inpatients. Kelvin Blake asked that governors continue to support the redevelopment scheme within their constituencies. 129/10 a) Reports of Governor sub-committees Nominations and Appointments Committee Jeannette Jones presented the report on behalf of the committee. Revision of Terms of Reference - The Committee proposed revisions to paragraph 10.3 of Annex 7 of the Trust s Constitution: Standing Orders of the Membership Council which set out the composition of the Nominations and Appointments Committee and is reflected in its terms of reference. The amendments have been suggested to allow the Committee to be less restrictive of its governor membership, and to allow the committee to be more flexible in its attendance in order to be quorate. The proposed changes were that the committee should comprise four public patient or carer governors, two Appointed Governors and one Staff Governor. In addition, it was proposed that paragraph be removed: No two governors will be appointed from the same Public constituency, nor from the same class of the Patient and Carer constituency. The Committee also proposed to revise its quorum from four governors plus the Chair to three governors plus the Chair. The Membership Council and the Board accepted the Committee s recommendation to revise the Trust s Constitution to reflect the proposed amendments to the Nomination and Date Tuesday, August 03, 2010 Author V Goodwin Page 9 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 9

12 Appointments Committee s terms of reference. b) c) Non-Executive Director Recruitment and Re-appointments - The Membership Council noted the status of the Non-Executive Director recruitment and future re-appointments. Governor Vacancies on the Committee - There are currently two governor vacancies on the committee: one for a patient governor and one for a public governor. With the imminent Non- Executive Director recruitment campaign, the Committee had agreed to progress filling the vacancies on its current basis rather than wait for the revised Constitution. There have been two expressions of interest from patient governors, and one from a public governor. Mo Schiller had offered to fill the vacancy of public governor on the Committee. It was proposed to conduct a vote with the local patient governors to fill the remaining vacancy on the Committee. The Membership Council noted the status of the Committee vacancies, approved Mo Schiller as a public governor on the Committee, and agreed the proposal to conduct a vote between David Aldington and John Steeds in the local patient constituency to fill the patient governor vacancy. Anne Ford presented the Strategy sub group report for information. There was no report from the Quality sub group. Youth Council Cathy Gane made a presentation on the Youth Council. She covered: Analysis of the Youth Council membership (ages, ethnicity, recruitment of Foundation Trust members etc) Involvement activity (inspecting hospitals and services, ensuring information is young people friendly, research opportunities etc) Two youth council members were recently elected by the public and patient members to be governors. Future reports on youth council activity to the Membership Council will be conducted by Jade Scott-Blagrove and Jacob Butterly. 130/10 Annual Governance Reports The meeting received for information the following: Infection Control Health & Safety Complaints Annual Report and Patient Advice & Liaison Service Annual Report Information Governance Audit and Assurance Committee Annual Report Phil Mackie was concerned to hear that the Disabled Children s Working Group was advertising for a leader for 18.5 hours per week, and felt this warranted a full time post. Steve Aumayer offered to investigate further. Date Tuesday, August 03, 2010 Author V Goodwin Page 10 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 10

13 131/10 Research & Innovation Quarterly Update Jonathan Sheffield highlighted the research funding award of 1.5m to a project led by Dr A V Ramanan. 132/10 Dates of Future Meetings Annual Public Meeting and Annual Members Meeting: 22 September 2010 Membership Council: 4 November 2010 Trust Board: 26 August 2010 Joint meeting: 27 July 2011 Date Tuesday, August 03, 2010 Author V Goodwin Page 11 of 11 Ref K:\Meetings\Board meetings\2010\minutes\july\final Joint meeting 28 July 2010.docx Page 11

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15 Trust Board Action List 2010/11 Ref Date of meeting originating action Minute number Description 13 26/05/10 082/10 OFSTED inspection of Safeguarding - report any relevant recommendations 14 26/05/10 082/10 CHKS - report on benchmarking to Audit & Assurance Committee 15 26/05/10 082/10 Sickness management - improvements being achieved through new policy 16 28/06/10 101/10 Performance Management Framework - board seminar at a future meeting date to come back to Trust Board Action by Alison Moon 14/09/10 Jonathan AAC Sheffield Steve Aumayer 30/11/10 Deborah Lee Date Action completed Comments OFSTED report received; final report from the CQC awaited and some points of clarification required. Audit & Assurance Committee Continue to report To review the effectiveness of the new format 17 28/06/10 102/10 Performance & Quality Report - capacity in intensive care 18 28/07/ /10 Reports on Lessons learned - Airedale and Bradford hospitals 19 28/07/ /10 Updating the Constitution - submit proposals to Monitor 26/08/10 Deborah Lee Pat Fields David Seabrooke Consideration by Strategic Review 1 Page 13

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17 SUMMARY PERFORMANCE REPORT August 2010 Page 15 1

18 CONTENTS PERFORMANCE OVERVIEW: A Performance Overview 3 B Organisational health barometer 4 C Care Quality Commission (CQC) dashboard 10 D Monitor s Compliance Framework ACCESS STANDARDS 1.1 Summary Changes in the period Exception reports WORKFORCE 2.1 Summary Exception Reports Supporting Information QUALITY 3.1 Quality dashboard Summary Changes in the period Exception reports Supporting Information 48 Actual patient experience 48 Quality achievements 50 Examples of learning from recent complaints and incidents 52 Page 16 2

19 CONTENTS SECTION A Performance Overview Summary Trust performance continues to improve with significant improvement reported this month on the prior period. Overall organisational health has improved with a reduction in RED rated measures from 6 in the prior period to 2 in the current period and an increase in GREEN rated measures from 7 to eleven. Notable improvements have occurred in the areas of patient experience, pressure sore incidence and cancer standard achievement. The only deteriorated measure is EBIDTA which has decreased from an AMBER rating of 96% in June to RED rated 90% in this month; this deterioration is due to a reduction in the planned operating surplus arising from a deterioration in the divisional finance positions. Page 17 3

20 PERFORMANCE OVERVIEW SECTION B Organisational Health Barometer Providing a Good Patient Experience ID Indicator Previous Current YTD Thresholds Trend Notes A01 Patient Climate Survey (Overall CQUIN Score) N/A Green: >= 73.0 Red: <72.0 Current month is June A02 Number of Patient Complaints Delivering High Quality Care ID Indicator Previous Current YTD Thresholds Trend Notes B01 Incidence of Pressure Sores (Grades 3 or 4) Green: 0 Red: >= 1 No RAG rating for YTD B02 Number of Inpatient Falls Monthly reduction No RAG rating for YTD Keeping People Safe ID Indicator Previous Current YTD Thresholds Trend Notes C01 Number of Serious Untoward Incidents (SUIs) Monthly reduction No RAG rating for YTD C02 Number of C.Diff and MRSA cases Below Trajectory MRSA and C.Diff cases combined Being Accessible ID Indicator Previous Current YTD Thresholds Trend Notes D01 18 Weeks Admitted Pathways 93.1% 95.0% 93.2% Green: >=90% Red: <85% D02 Number of Cancer Standards Failed Green: 0 Red: >=2 Previous is May 2010 total. Current and YTD is 2010/11 Quarter 1 D03 A&E 4 Hour Standard 98.67% 98.88% 98.28% Green: >=98% Red: <97% Includes Walk In Centre totals for Quarter 1, and estimate for Jul-10 Page 18 4

21 PERFORMANCE OVERVIEW Being Efficient ID Indicator Previous Current YTD Thresholds Trend Notes F01 Elective Length of Stay Reduction Green: <= Red: >= 3.83 Green: <= 5.07 F02 Emergency Length of Stay Reduction Red: >= 5.34 F03 Theatre Productivty Measures to be agreed to align with Making Our Hospital Better Improvement Programme F04 New to Follow-Up Ratio Green: < Red: >2.04 Green = CQUIN, Red = Contract Limiter Valuing Our Staff ID Indicator Previous Current YTD Thresholds Trend Notes G01 Workforce Costs 47,607 95,815 95,815 Reduction from 09/10 monthly avg. Previous is Apr-Jun cumulative. Current is Apr-Jul cumulative. So YTD is the same as Current. G02 Staff Climate Survey G03 Staff Sickness Green: Below Forecast 3.9% 4.1% AND 09/10 No Year To Date measure available this month. Promoting Research ID Indicator Previous Current YTD Thresholds Trend Notes H01 NIHR Income Indicators to be reported from September. H02 Patients Recruited Into NIHR Trials Page 19 5

22 PERFORMANCE OVERVIEW Governing Well ID Indicator Previous Current YTD Thresholds Trend Notes J01 Monitor Governance Risk Rating N/A Green: < 1 Red: >3 J02 Care Quality Commission Assessment Good Good N/A Green: Excellent Red: Poor/Weak Please see Performance Report for further information. Delivering Our Contracts ID Indicator Previous Current YTD Thresholds Trend Notes K01 Financial Performance Against CQUINs K02 Contract Penalties Incurred Managing Our Finance ID Indicator Previous Current YTD Thresholds Trend Notes L01 Monitor Financial Risk Rating Green: >3 Red: <3 For all four financial measures, Current is Current Year To Date and Previous is Previous Year To Date (Apr-Jun). L02 EBIDTA (Compared To Plan) 96% 90% 90% Green: 100% Red: <95% L03 CRES Achievement 77% 78% Green: >=90% 78% Red: <75% L04 Liquidity (in Days) Green: 25+ days Red: <=14 days Notes Unless otherwise stated, Previous is May 2010 and Current is June 2010 YTD (Year To Date) is the total cases/cumulative score for the year so far, from April 2010 up to and including the current month RAG (Red/Amber/Green) rating only applied to YTD where an agreed target number of cases/score exists for the year. Page 20 6

23 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Jun-09 May-09 Apr-09 Mar-09 Jul-09 Jun-09 May-09 Apr-09 PERFORMANCE OVERVIEW Providing a Good Patient Experience Patient Climate Survey (Overall CQUIN Score) Number of Patient Complaints (Formal and Informal) Delivering High Quality Care Pressure Sores (Grades 3 and 4 Combined) Page 21 7

24 Jul-09 Jun-09 May-09 Apr-09 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Jul-10 Jun-10 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Jun-10 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 PERFORMANCE OVERVIEW Keeping People Safe Number of Serious Untomward Incidents (SUIs) Number of C.Diff and MRSA Cases Combined Cases Trajectory Month Reported Being Accessible Referral To Treatment (RTT) - Admitted Clock Stops Within 18 Weeks Monthly Performance Target YTD Emergency Department 4 Hour Throughput (Incuding WIC) Monthly Performance Red Threshold Green Threshold YTD 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 100% 99% 99% 98% 98% 97% 97% 96% 96% 95% Page 22 8

25 Jul-10 Jun-10 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Jul-10 Jun-10 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Jul-10 Jun-10 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 PERFORMANCE OVERVIEW Being Effective Being Efficient 120 Hospital Standardised Mortality Ratio (HSMR) HSMR Upper Confidence Interval Lower Confidence Interval 5.0 Elective Length Of Stay Monthly LOS Green Threshold Red Threshold YTD Emergency Length Of Stay Outpatient New To Follow-Up Ratio 7.0 Monthly LOS Red Threshold Green Threshold YTD 2.5 Monthly Ratio Green Threshold Red Threshold Page 23 9

26 PERFORMANCE OVERVIEW SECTION C Care Quality Commission (CQC) dashboard Thresholds Last Year Year To Current Monthly Performance Quarterly Performance Domain Target Green Red To Date Date Score Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Q1 Q2 Q3 Q4 Health and WellBeing 1 GUM Offer Of Appointment Within 48 Hours 98% 95% 100.0% 99.9% % 100.0% 100.0% 100.0% 99.9% 100.0% 2 Data Quality on Ethnic Group 85% 70% 85.9% 90.9% % 89.5% 90.5% 94.1% 89.8% 94.1% Clinical Quality Patient Focus and Access 3a 60 Minute Thrombolysis Call To Needle Time 68% 48% 100.0% 100.0% 100.0% 100.0% 2 Not Not 3b Primary PCI Minutes Call To Balloon Time 66.7% 70.0% 70.0% 70.0% published published 4 Delayed Transfers Of Care (Acute) 3.5% 5.0% 0.91% 1.36% % 1.25% 1.48% 1.58% 1.30% 1.58% 5 Emergency access 4-hour wait (with Walk in Centre attendances) 98% 97% 98.3% 98.3% % 98.0% 98.7% 98.9% 98.1% 98.9% 6 Rapid Access Chest Pain 2 Week Wait 98% 95% 100.0% 100.0% % 100.0% 100.0% 100.0% 100.0% 100.0% 7a Number of Last Minute Cancelled Operations 0.80% 1.50% 0.92% 1.06% 1.10% 1.13% 1.10% 0.95% 1.11% 0.95% 2 7b 28 Day Readmissions 95% 85% 92.8% 95.3% 97.6% 96.6% 96.4% 90.2% 97.0% 90.2% Total 19 Out of 21 See part two below. Page 24 10

27 PERFORMANCE OVERVIEW Thresholds Last Year Year To Current Monthly Performance Quarterly Performance Domain Target Green Red To Date Date Score Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Q1 Q2 Q3 Q4 Health and WellBeing Clinical Quality Safety 8a Infant Health - Mothers not smoking at the time of birth 87.9% 87.9% 87.5% 88.7% 90.0% 85.1% 90.7% 88.9% 88.6% 88.9% 3 8b Infant Health - Mothers Initiating Breastfeeding 71.3% 71.3% 76.9% 76.1% 74.5% 76.6% 77.1% 76.3% 76.1% 76.3% 9 Participation in Heart Disease Audits 10 Engagement in Clinical Audits 11 Stroke Care 12 Maternity Data Quality Indicator 13 Infection Control - MRSA Bloodstream Cases Against Trajectory Not published Not published Under review Not published Not published Not published To be confirmed Compliant To be confirmed To be confirmed Under review 64.5% 72.1% Not published To be confirmed To be confirmed 3 3 Not scored 3 Audit data to be submitted in Quarter /12 Care Quality Commission Questionnaire to be submitted in Quarter / % 76.9% 78.6% 72.1% Performance indicators to be confirmed Infection Control - C.Diff Infections Against Trajectory National Priorities Patient Focus and Access 15a Referral To Treatment Admitted Under 18 Weeks 90% 80% 91.7% 93.1% 91.2% 93.1% 94.9% 93.3% 93.2% 93.3% 3 15b Referral To Treatment Non Admitted Under 18 Weeks 95% 85% 97.6% 98.2% 97.4% 98.2% 98.6% 98.8% 98.1% 98.8% Final Q1 submssion 16a Cancer - Urgent Referrals Seen In Under 2 Weeks 93% 88% 92.7% 95.0% shown 95.0% 95.0% 0 Cancer - Urgent Referrals Seen In Under 2 Weeks (breast - Target not Final Q1 submssion 16b 93% 88% 84.2% 84.2% 84.2% not initially thought to be symptomatic) in effect shown Cancer - 31 Day Diagnosis To Treatment (First Final Q1 submssion 17a 96% 93% 95.8% 98.0% Treatments) shown 98.0% 98.0% Cancer - 31 Day Diagnosis To Treatment (Subsequent - Final Q1 submssion 17b 98% 93% 99.4% 99.3% 3 Drug) shown 99.3% 99.3% Cancer - 31 Day Diagnosis To Treatment (Subsequent - Final Q1 submssion 17c 94% 89% 93.4% 97.1% Surgery) shown 97.1% 97.1% Cancer 62 Day Referral To Treatment (Urgent GP Final Q1 submssion 18a 85% 80% 79.9% 85.2% Referral) shown 85.2% 85.2% 18b Cancer 62 Day Referral To Treatment (Screenings) 90% 85% 87.7% 90.6% 3 Final Q1 submssion shown 90.6% 90.6% 18c Cancer 62 Day Referral To Treatment (Upgrades) 19 Patient Experience 20 NHS Staff Satisfaction Not published Not published Not published Not 96.7% 100.0% Final Q1 submssion 100.0% 100.0% published shown Not To be To be To be 3 Results of survey available but scoring by CQC to be confirmed in Quarter /11 published confirmed confirmed confirmed Not To be To be To be 3 Results of survey due to be available in draft form in Quarter /12 published confirmed confirmed confirmed Notes: Green thresholds show the level performance has to reach to 'achieve' the required standard set by the Department of Health; Red thresholds show the level below which the Care Quality Commission (CQC) considers a Trust to have 'failed' a target; Where performance is between these two values the target has been 'underachieved'. For some targets the fail threshold has been estimated based upon previous years' thresholds. Where no fail threshold has been published anything below the 'green' threshold is considered to be a fail (and hence the 'red' threshold will be the same as the 'green'). The CQC awards 3 points for each target that is 'achieved, 2 points for a target that is 'underachieved'. These scores are added together to provide an overall score, to derive the Periodic Review (Quality of Services) rating. To be rated 'Excellent' the Trust needs to score at least 19 points for Existing Commitments (of the 7 indicators currently scored) and 33 points for National Priorities (for the 12 indicators currently scored). Total 33 Out of 36 Existing commitments National priorities Overall rating Excellent Excellent Excellent Page 25 11

28 PERFORMANCE OVERVIEW SECTION D Monitor s Compliance Framework Thresholds Year To Quarterly Performance Number Target Green Red Date Q1 Q2 Q3 Q4 to date Q2 forecast Notes 1 Infection Control - MRSA Bloodstream Cases Against Trajectory 0% 0% Infection Control - C.Diff Infections Against Trajectory 0% 0% Current Forecast Q2 Governance rating score Achieved Achieved Monitor Compliance Framework Weighting 1.0 3a Cancer 62 Day Referral To Treatment (Urgent GP Referral) 85.0% 80.0% 85.2% 85.2% 85.0% 3b Cancer 62 Day Referral To Treatment (Screenings) 90.0% 85.0% 90.6% 90.6% 90.0% 3c 4a 4b 4c 5 6 Cancer 62 Day Referral To Treatment (Upgrades) Cancer - 31 Day Diagnosis To Treatment (Subsequent - Drug) Cancer - 31 Day Diagnosis To Treatment (Subsequent - Surgery) Cancer - 31 Day Diagnosis To Treatment (Subsequent - Radiotherapy) - from January 2011 Maximum time of 18 weeks from Referral To Treatment, in aggregate and by specialty, for admitted patients Maximum time of 18 weeks from Referral To Treatment, in aggregate and by specialty, for non-admitted patients Not published Not published 100.0% 100.0% 93.0% 98% 95% 99.3% 99.3% 99.0% 94% 91% 97.1% 97.1% 94.0% 94% 91% Not applicable 90% 80% 93.1% 95% 85% 98.2% Not applicable No longer scored No longer scored No longer scored No longer scored No longer scored No longer scored No longer scored No longer scored Not applicable No longer scored No longer scored Combined 62-day target not achieved for four consecutive quarters, so weighting is quadrupled. Target not yet published 90% target achieved in all except 1 specialty (i.e. compliant) 90% target achieved in all except 1 specialty (i.e. compliant) Achieved Achieved Not currently scored No longer scored 7 Cancer - 31 Day Diagnosis To Treatment (First Treatments) 96% 93% 98.0% 98.0% 97.0% 8 Emergency Care 4 Hour Throughput (including WIC) 95% 94% 98.3% 98.1% 98.9% 98.1% Target reduced to 95% Achieved Weighting 0.5 9a Cancer - Urgent Referrals Seen In Under 2 Weeks 93% 90% 95.0% 95.0% 96.0% 9b Cancer - Symptomatic Breast in Under 2 Weeks 93% 90% 84.2% 84.2% 93.0% Achieved Weighting MRSA Screening 100% 100% 96.4% 96.6% 95.8% 97.0% Minute Thrombolysis Call To Needle Time 68% 48% 100.0% 100.0% Self certification against healthcare for patients with learning disabilities (year-end compliance) Agreed standards met Notes: The score for a target with a 1.0 weighting is quadrupled if not met in three or more successive quarters. An automatic red rating is applied if the 4-hour standard fails to be achieved in any quarter in a 12-month period. Plan in place Plan in place Levels of screening currently below target agreed with PCT. Required standard forecast to be achieved in all six criteria. Not achieved Achieved Achieved Green 0.5 Page 26 12

29 ACCESS 1.1 SUMMARY The following section provides a summary of the Trust s current performance against the national access standards, and position against Monitor s Compliance Framework, as at the end of July. In continuing to meet the 31 and 62-day cancer standards, alongside the 4-hour emergency access standard, the Trust currently has an Amber-Green Governance Risk Rating, which is the second lowest risk rating out of four. Action plans are in place to achieve a Green rating at the end of the second quarter of the year. The Trust is currently achieving thirteen (13), under-achieving four (4) and failing one (1) of the national targets used by Monitor, and formerly the Care Quality Commission 1, to assess the performance of acute trusts (see the table below). Achieving (13) Underachieving (4) - MRSA bacteraemia rates - 31-day cancer standards - 62-day cancer standards - Clostridium difficile rates 2 - Emergency access 4 hour wait - Ethnic group data quality - 18-week Referral to Treatment Time (RTT) Trust aggregated performance - 2-week wait urgent GP referral cancer standard - Genito-Urinary Medicine (GUM) 48-hour access - Rapid access chest pain clinic waiting time (2 weeks) - 28-day readmission Delayed transfers of care - Infant health breastfeeding initiation and non smoking rates - Maternity Hospital Episode Statistics data quality (HES) - Cancelled operations - Access to healthcare for patients with learning disabilities - MRSA screening - 18-week Referral to Treatment Time specialty level performance Failing (1) Not reported/scored (6) - Breast symptomatic cancer standards - Participation in heart disease audit 3 - Stroke care 6 - Engagement in clinical audit 4 - Experience of patients 5 - NHS Staff Satisfaction Survey 5 - Reperfusion times 6 1 Until further announcements are made the Trust is continuing to monitor itself against the indicator-set previously used by the CQC, using the thresholds published in the NHS Operating Framework unless where otherwise stated. 2 The above shows performance against the national Clostridium difficile targets 3 There will be ongoing submission of data throughout the year but the final submissions will not be made until May It is expected that a special data collection exercise will be undertaken in April 2011 for this indicator 5 Surveys will be undertaken later in 2010/11 Page 27 13

30 ACCESS Summary of performance against the national standards During the first quarter of the year the Trust met the 62-day referral to treatment times standards for both GP referred and screening patients, and in so doing met the commitment it gave to Monitor in January. In both cases the forecast level of performance following final validation of cancer pathways by other providers, was accurate to within 1%. The Avon Breast Screening patients treated by other providers and for the first time reported as originating from the Trust as the host for the service, added an additional 7% to the estimated performance. This was at the upper end of 4 to 8% originally forecast (based upon volumes of screening patients treated each quarter in 2009/10), and was sufficient to take performance above the 90% standard. This is the first quarter the Trust has achieved both 62-day standards since the new cancer standards came into effect in January last year. In meeting these standards, along with the A&E 4-hour maximum wait and 31-day cancer standards, it is expected to be confirmed that the Trust has been given an Amber-Green rating for governance in quarter 1. Using the Care Quality Commission s 2009/10 framework it is estimated that the Trust would be rated as Excellent for national commitments and Excellent for national priorities, giving an overall rating of Excellent for its Quality of Services. This is the highest rating for three years. For further details of the scoring for each of the national targets, please see the dashboard at the front of this section of the report Monitor s Compliance Framework Three standards within Monitor s Compliance Framework are currently not being met, giving an overall score of 1.5 and a rating of Amber-Green. Further details of the corrective action being taken to achieve compliance against the following three standards are provided in the Exception Reports: Cancer symptomatic breast patients (cancer not initially suspected) 2-week wait (weighted 0.5). Methicillin Resistant Staphylococcus Aureus (MRSA) elective screening (weighted 0.5) Access to healthcare for patients with learning disabilities (weighted 0.5) The requirements for the standard relating to access to healthcare for patients with learning disabilities has now been finalised by Monitor. The details of six criteria were published by the CQC earlier this year, and Monitor has confirmed that a minimum of level 3 compliance (protocols/mechanisms in place but only partly implemented) is required for each of the six criteria to enable a Trust to self-certify it has reached the minimum standard. The monitoring period for this standard is now quarterly. The Trust is currently not meeting level 3 compliance in two of the six criteria. The learning disabilities standard is therefore currently assessed to be not met. The forecast for the end of quarter 2 is to be compliant with all of the above targets, with the exception of the MRSA elective screening standard. In addition to continuing to meet the cancer standards, this will give the Trust a green rating for governance. 6 Target threshold not yet confirmed Page 28 14

31 ACCESS 1.2. CHANGES IN THE PERIOD Performance against the following national standards changed significantly compared with the last reported period: 18-week RTT admitted Referral to Treatment Time specialty level achievement (two specialties not met in July, compared with one in June) see tables below Ethnic Group data quality (up from 90.5% in June to 94.1% in July) Last-minute cancelled operations (down from 1.10% in June to 0.95% in July) 28-day readmission (down from 96.4% in June to 90.2% in July) although year-to-date still above 95% standard Cancer 62-day GP referrals (up from 81.9% in May to 86.9% in June) Cancer 62-day screening (up from 85.7% in May to 90.5% in June) Stroke care (up from 76.9% in May to 78.6% in June) Operating Framework target 60%; the new target set for this for March 2011 is expected to be confirmed as 80% 18-week Referral to Treatment Time (RTT) Admitted (July 2010) Non-admitted (July 2010) Specialty Under 18 Weeks Total treated Percentage under 18 Weeks Specialty Under 18 weeks Total treated Percentage Under 18 Weeks CARDIOLOGY % CARDIOLOGY % DERMATOLOGY % DERMATOLOGY % E.N.T % E.N.T % GASTROENTEROLOGY % GENERAL MEDICINE % GENERAL MEDICINE % GERIATRIC MEDICINE % GYNAECOLOGY % GYNAECOLOGY % OPHTHALMOLOGY % NEUROLOGY % ORAL SURGERY % OPHTHALMOLOGY % OTHER % ORAL SURGERY % RHEUMATOLOGY % OTHER % THORACIC MEDICINE % RHEUMATOLOGY % TRAUMA & ORTHOPAEDICS % THORACIC MEDICINE % UROLOGY % TRAUMA & ORTHOPAEDICS % Grand Total % UROLOGY % % Page 29 15

32 ACCESS 1.3. EXCEPTION REPORTS Exception reports are provided for the three Monitor Compliance standards not being met, along with last-minute cancelled operations and 18-week referral to treatment times standard (specialty level) performance. An exception report is also provided for the Clostridium difficile infection rates. The Trust is currently meeting the nationally set standard, and the summary table is for this reason showing the target as being met. However, the national contract requires trusts to improve on last year s performance and sets financial penalties for a failure to do so. This target is not currently being achieved, and therefore a further exception report is being provided: 1) Cancer symptomatic breast patients (cancer not initially suspected) 2-week wait 2) MRSA elective screening 3) Access to healthcare for patients with learning disabilities 4) Last-minute cancelled operations 5) 18-week Referral to Treatment Time specialty level performance (ENT and Cardiology admitted) 6) Clostridium difficile infection rates improvement on last year s performance Page 30 16

33 ACCESS A1. EXCEPTION REPORT: Cancer standard (symptomatic breast patients cancer not initially suspected) 2-week wait RESPONSIBLE DIRECTOR: Chief Operating Officer Description of how the target is measured: The number of breast patients referred and seen by a specialist within 2 weeks, as a percentage all breast patients referred during the period. These figures exclude those patients referred by their GP with an urgent suspected cancer. Care Quality Commission (CQC) measurement period: Quarterly; monthly submissions and a quarterly refresh of the submissions Monitor measurement period: Quarterly Performance during the period, including reasons for exceptions: Breach analysis of June s reported data showed the following: 82% of patients were seen within 2 weeks against the 93% target 11% (9 patients out of 15 breaching) chose to wait longer than 2 weeks 7% (6 patients out of 15 breaching) waited longer due to insufficient outpatient capacity to see all patients within 2 weeks July s performance is expected to be confirmed as 92%, with 1% of patients breaching due to lack of capacity. Of the patients currently breaching the 2-week wait standard for choice reasons, around half of these patients chose to wait longer as they could not accept the one date offered within 2 weeks due to work commitments. This suggests some choice related breaches could be avoided if a wider range of dates were offered. Recovery plan, including expected date performance will be restored: With the additional capacity established for the quarter, and actions being taken to further reduce the number of patients choosing to defer, it is forecast that the 93% target will be met for quarter 2 as a whole. To achieve the 93% standard the following actions are being taken: Contact trusts that are routinely achieving the standard to identify good practice (Action complete) Centralise the booking of all new breast appointments to the Cancer Fast Track Office (Mid September) Change appointment booking protocols to standardise booking for fast-track and symptomatic breast 2-week wait referrals, and clarify the process when appointments aren t available (End August) Implement direct booking of appointments via Choose & Book (indirect booking currently implemented), ensuring a choice of appointments Page 31 17

34 ACCESS are always available within the two week window of appointments shown (Mid September) Increase the number of days on which breast appointments are available for symptomatic patients (Mid September) Continue to work with the Primary Care Trust to encourage GPs to advise their patients that they will be offered dates to be seen within two weeks (Ongoing) Progress against the recovery plan: Two keys areas of good practice were identified from other providers: 1) the range of dates offered within two-weeks, and 2) telephoning patients to offer appointment dates. Two of the trusts in the South West that are routinely achieving well above the 93% standard are able to offer more than one appointment within 2 weeks of referral and run clinics most days of the week. This was viewed by those trusts as being important to consistently achieving the standard. The Trust recently changed its booking practices to telephone all patients where they can be contacted via that route. The remainder of the above action plan focuses on offering a greater range of choice of dates to patients. Page 32 18

35 ACCESS A2. EXCEPTION REPORT: MRSA elective screening RESPONSIBLE DIRECTOR: Chief Nurse Description of how the target is measured: The number of elective patients attending a pre-operative assessment clinic which were screened for MRSA, as a percentage of all elective patients attending a pre-operative assessment clinic. Analysis will be undertaken of the reason for any patient not being screened. Only where the reason for failure to screen is accepted by the PCT (e.g. in the case of a patient refusing to be swabbed) will such patients be excluded from the reported figures. Only patients registered with GPs within the Bristol, North Somerset and South Gloucestershire catchment area are reported against this standard, due to the arrangements that are in place for tertiary referred patients to be screened by the referring hospital. Care Quality Commission (CQC) measurement period: Not applicable Monitor measurement period: Quarterly assessment of performance against the PCT agreed standard Primary Care Trust (PCT): Monthly submission Performance during the period, including reasons for exceptions: Breach analysis of July s reported data showed the following: 95.8% of elective patients attending pre-operative assessment were seen screened for MRSA 8 patients in total were not screened, three of these were in gynaecology, two colorectal, one vascular surgery and one urological surgery. In addition, one cardiology patient was not screened for clinical reasons. Recovery plan, including expected date performance will be restored: Establish a weekly information report to identify patients that have attended pre-operative assessment for whom a swab has not been submitted to the laboratory, enabling arrangements for swabbing to be made prior to the patient s admission Divisions have addressed the failure to follow protocol with individual members of staff It is expected that 100% of patients should be able to be screened from October onwards. Progress against the recovery plan: The weekly information report has been established from week commencing 7 th August. Page 33 19

36 ACCESS A3. EXCEPTION REPORT: Access to healthcare for patients with learning difficulties RESPONSIBLE DIRECTOR: Chief Nurse Description of how the target is measured: There are six published criteria that need to be met for a Trust to declare itself as compliant with this standard. Any criteria not currently being met are detailed in the next section of the Exception Report. Care Quality Commission (CQC) measurement period: Annual self certification by trusts Monitor measurement period: Quarterly assessment against the six criteria (minimum level 3 achievement against each - Protocols/mechanisms are in place and at least partially implemented) Performance during the period, including reasons for exceptions: At the end of the first quarter the Trust had not yet reached level 3 compliance against the two following standards: 1) In accordance with the Disability Equality Duty of the Disability Discrimination Act (2005), does the trust provide readily available and comprehensible information (jointly designed and agreed with people with learning disabilities, representative local bodies and/or local advocacy organisations) to patients with learning disabilities about the following criteria: treatment options (including health promotion) complaints procedures, and appointments To reach level 3 compliance information needs to be available for at least two of the three listed above. 2) Does the trust have protocols in place to routinely include training on learning disability awareness, relevant legislation, human rights, communication techniques for working with people with learning disabilities and person centred approaches in their staff development and/or induction programmes for all staff? Recovery plan, including expected date performance will be restored: The actions are as follows: Develop a training protocol for ensuring the best access to acute care at University Hospitals Bristol, in consultation with the local department of Social services and specialist learning disability services by end of September Ensure as a minimum two of the three types of patient information, in an approved format, are available to patients with learning disabilities Page 34 20

37 ACCESS (Action complete) It is expected the Trust will be able to declare compliance against the remaining standards by the end of September 2010, which will enable compliance with this standard to be declared for quarter 2. Progress against the recovery plan: A literature search has been completed of policies and protocols already implemented by Trusts (concentrating in particular on those which have been in place for six months or longer and so are already in practice). Advice from two former national leads on policy for people with Learning Disabilities has also been sought. From this, two exemplar protocols have been identified and the Trust is looking to adapt these for immediate local implementation. Training in these protocols will be taken forward as part of the Trust-wide mandatory programme for safeguarding children and safeguarding adults (in keeping with the practice in other Trusts who are already compliant with the national standards for access for those with a learning disability). This standard will therefore be partially implemented by the end of quarter 2 in line with the progress expected by Monitor. Page 35 21

38 ACCESS A4. EXCEPTION REPORT: Last-minute cancelled operations RESPONSIBLE DIRECTOR: Chief Operating Officer Description of how the target is measured: 1) The number of patients whose operation was cancelled at last minute for non clinical reasons, as a percentage of all admissions. Care Quality Commission (CQC) measurement period: Annual, with quarterly submissions. Monitor measurement period: Not applicable Performance during the period, including reasons for exception: The last-minute cancelled operations standard has not been achieved so far this year. The reasons for cancellation in July 2010 were as follows: 47% of cancellations resulted from a ward bed not being available to admit the patient to (including cancellations reported due to lack of theatre time, which usually result from delays in identifying beds prior to cases being operated upon). 19% of cancellations were due to another patient being prioritised either due to lack of time or an emergency patients needing to take priority Recovery plan, including expected date performance will be restored: To revitalise efforts to eliminate last-minute cancellations a project is being undertaken within Cardiac Surgery led by the Divisional Manager. This is using more detailed information gathered from theatres to target the reasons for cancellation. Clinical leads have been identified for each work-stream, with the key areas of focus being ways to avoid the following reasons for cancellations (percentages shown related to the first quarter of the year): Ward bed not available (26% cancellations) Case over-running in theatre (25%) Theatre staff not available (8%) Emergency case coming in overnight resulting in staff not being available to operate during the day (8%) Intensive care/high dependency bed not available (8%) Once the cardiac surgery project is underway and has identified the key learning points, the plan for rolling-out to other specialties will be developed. At this point a forecast for when performance will be restored will be confirmed. Progress against the recovery plan: Progress against the cardiac surgery action plan to be included in future reports. Page 36 22

39 ACCESS A5. EXCEPTION REPORT: 18-week Referral to Treatment Time (RTT) (specialty level performance only) RESPONSIBLE DIRECTOR: Chief Operating Officer Description of how the target is measured: The number of patients on 18-week pathways admitted as part of their treatment that were treated within 18 weeks of being referred, as a percentage of all 18-week admitted patients. In 2009/10 the proportion of specialties for admitted and non-admitted pathways for which the 90 and 95% targets (respectively) were achieved was one of several indicators used to assess 18 week performance. Care Quality Commission (CQC) measurement period: Quarterly. Monitor measurement period: Not applicable Performance during the period, including reasons for exception: In July the 18-week referral to treatment target was not achieved for at least 90% of admitted patients, in the following national specialties: Adult Ear, Nose & Throat (ENT) Cardiology Adult ENT failed to achieve the 90% in July (and quarter 2 as a whole) as a result of theatre lists having to be cancelled in June due to staff shortages. The cancelled patients had to be rebooked in July and as a result other patients delayed into August. However, the specialty overall has a manageable number of patients waiting over 18 weeks and is therefore forecast to get back on track by the end of the quarter. During 2009/10 cardiology achieved over 90% against the admitted target, and also achieved the 90% standard in the first quarter of this year. However, since April the number of patients waiting over 18 weeks has doubled from 40 to a peak of 80 patients at the end of June. The area of particular concern around achievement of the maximum 18-week wait for electrophysiology (EP) and some GUCH (Grown Up Congenital Heart) patients. The problems identified are as follows: Growth in demand for the EP service due to the appointment of a specialist in the field, with an associated increase in complexity of cases A planned repatriation of cases that in 2009/10 needed to be sent by referring trusts to other providers Insufficient capacity to meet this level of demand, even with additional sessions, as undertaken in 2009/10. Page 37 23

40 ACCESS Recovery plan, including expected date performance will be restored: A two-step plan has been developed by the Division focusing efforts on reducing the backlog of long waiters as well as ensuring enough capacity is available in the longer term to routinely meet demand. Aims and objectives The aim of the plan is to achieve a sustainable position from the start of January In order to achieve and maintain a sustainable level of performance the number of over 18-week waiters within cardiology needs to be reduced to a maximum of 30 cases (i.e. the recommended level for the number of patients treated per week). Also, the number of patients exceeding an 18-week wait prior to treatment needs to be no greater than 10% of a week s activity. During September to December, the aim is to therefore to provide sufficient capacity to treat an additional 50 cases from the backlog, and to reduce the numbers of patients being added to the backlog by 7 cases per week (120 cases), making a total of 170 cases. Approach Capacity will be provided by a combination of extra in-house sessions, but also by offering patients dates for treatment at other hospitals. The final details of this outsourcing are being confirmed, but Southampton, Barts and The London Heart Centre and University College London Heart Hospital are being actively considered. At present these hospitals have agreed in principle to undertake an additional 78 cases in total. This figure is subject to clinical review by the receiving hospital, and also patient choice. Agreement will be sought to transfer more cases (to take the total up to 140) later in quarter 3. This, in combination with undertaking an additional 30 cases in-house, will meet the projected capacity requirement of 170 cases. The Division is also considering how to manage demand and not accept work if performance cannot be maintained, whilst continuing with its clinical strategy to develop the regional EP service and offer treatment to patients that has previously had to go to London hospitals. A sustainable position going forward relies on having additional in-house EP capacity. This can be achieved by the appointment of another EP consultant and commissioning the vacant catheter laboratory at the BHI, for which a separate business case is being prepared. Actions: Quarter 2 (August/September): Review the order in which patients are being booked for treatment to ensure it is as efficient as possible, in terms of reducing waiting times Continue to limit elective cancellations wherever possible Finalise plans and agree contracts to offer patients the opportunity to be treated at other providers Quarter 3 (October, November, December): Offer all appropriate patients the opportunity to be treated at other providers Finalise and obtain approval for the business case for an additional electrophysiology consultant, with the associated equipment required to equip the catheter laboratory Appoint additional consultant and set-up the lab to provide additional capacity required to meet demand on an ongoing basis Page 38 24

41 Percentage of patients treated within 18 weeks Number of patients ACCESS The following performance trajectory has been developed. This is at present in draft form and will be revised once final arrangements have been firmedup with other providers. A projection of the quarter figures will be included in the next revision % Forecast and actual 18-week RTT (admitted) performance for Cardiology 100 Forecast and actual number of over 18-week RTT waiters for Cardiology 90.0% % 70.0% 60.0% 50.0% 40.0% Jan-10 Progress against the recovery plan: Actual Forecast Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Actual Forecast Performance is on track for achievement of the admitted standard within ENT from the end of this quarter. Performance against the Cardiology performance trajectory will continue to be reported each month. Oct-10 Nov-10 Dec Page 39

42 ACCESS A6. EXCEPTION REPORT: Clostridium difficile infection rates (performance against last year s levels and local stretch targets) RESPONSIBLE DIRECTOR: Chief Nurse Description of how the target is measured: Number of confirmed C. difficile infections identified from admitted patients (aged 2 years and above, and where the sampling interval is greater than 28 days for the same patient), excluding those samples not attributed to acute trusts as per the data definition in the Department of Health's Vital Signs guidance (e.g. cases identified within 3 days of admission). Care Quality Commission (CQC) measurement period: Monthly Monitor measurement period: Quarterly Performance during the period, including reasons for exceptions: In the national contract trusts that have more cases of C. difficile than in the previous year receive a financial penalty. This is separate to the national target for 2010/11 of 180 cases, previously agreed with NHS Bristol, which is currently being met. There were twelve C. difficile cases in July (12), which is above the threshold of eight set for achievement of the required level in the national contract. The Women s and Children s Division was the only Division to not exceed their threshold for cases in the month. Analysis of the specific strains of Clostridium difficile showed that of seven specimens sent for further investigation six were not related, indicating that the recent increase is due to general increased incidence of infection as opposed to an outbreak and specific infection spread. Detailed analysis of the cases identified failures in isolation of patients at the recognition of potentially infectious diarrhoea Recovery plan, including expected date performance will be restored: The following actions have been taken to restore performance: Management and reporting escalated to outbreak status from June 2010 Weekly operational meeting review of all currently affected inpatients and new cases Monitoring of completion of stool charts increased from monthly to weekly Monitoring of failure to isolate within the agreed four hour target increased to weekly from monthly These actions are expected to have an immediate effect on performance, with levels of infections returning to the target monthly by the end of August 2010 and recovery to within the year to date target by the end of September Page 40 26

43 ACCESS Progress against the recovery plan: All actions within the recovery plan have been completed with the subsequent de-escalation from outbreak status for external purposes on 12 th August. Projected outturn for August (based on cases up to and including 16/08) is 2 cases. Internal management continues at an intensified level. Page 41 27

44 WORKFORCE 2.1 SUMMARY A summary of the Trust s workforce performance is shown below. Achieving (2) Underachieving (1) - Workforce Costs compared with June 2010 and budget - Workforce Numbers compared with June 2010 and budget - Sickness compared with target Failing (2) Not reported/scored (1) - Bank and agency compared with target - Appraisal compared with target and previous month - Turnover (no target) Page 42 28

45 WORKFORCE 2.2 EXCEPTION REPORTS W1. EXCEPTION REPORT: Sickness absence RESPONSIBLE DIRECTOR: Director of Workforce and Organisational Development Description of how the standard is measured: Sickness absence compared with annual targets by Division. Sickness absence figures are shown as percentage of available fte (full time equivalent) absent. Performance in the period, including reasons for the exception: New and more challenging targets have been set by Divisions for sickness absence for 2010/11. This month Women s And Children s have reduced sickness absence compared with the previous month, and together with Diagnostic and Therapies, have achieved the monthly target for July UHB Surgery Head and Neck Diagnostic and Therapies Medicine Specialised Services Women and Children Trust Services (exc Facilities and Estates) Facilities and Estates July 2009 actual absence 4.5% 4.6% 4.2% 4.9% 4.6% 4.1% 2.7% 6.0% Target July % 3.6% 4.0% 3.8% 3.6% 3.4% 2.8% 6.3% Absence July % 4.7% 2.4% 4.4% 3.5% 3.4% 3.2% 6.9% Recovery plan, including expected date performance will be restored: Continued implementation of the Supporting Attendance policy throughout 2010/11. Action plans developed and implemented to deal with staff survey issues affecting motivation. Progress against recovery plan: Policy focus ongoing. Staff Survey action plans on target Page 43 29

46 WORKFORCE W2. EXCEPTION REPORT: Bank and Agency usage RESPONSIBLE DIRECTOR: Director of Workforce and Organisational Development Description of how the standard is measured: Bank and agency usage in Full Time Equivalent (FTE) compared with targets set by Divisions for 2010/11 Performance in the period, including reasons for the exception: Trust-wide bank and agency usage for July 2010 is 26% above target. Figures for each Division are shown below. The biggest discrepancy between target and performance is in Medicine Division, where bank and agency usage is 46% above the target. This is linked with higher than target sickness levels. However, the bank and agency target in Medicine was particularly challenging, to achieve less than 50% of the usage for the same month in Trustwide, the usage in July 2010 is 25% lower than July 2009 usage. Bank and Agency (fte) UHB Surgery Head and Neck Diagnostic and Therapies Medicine Specialised Services Women and Children Trust Services (exc Facilities and Estates) Facilities and Estates Actual July Target July Actual July Recovery plan, including expected date performance will be restored: Bank and agency usage is monitored at a divisional level at board level and quarterly reviews. The recovery plan includes Divisional restrictions on bank and agency usage in areas which are over established unless absences take skill mix below agreed safe level. Guidelines for Medicine Division on usage of bank and agency including details of minimum staffing levels and approaches to be considered before bank/agency cover is booked. All nursing bank in Medicine Division authorised at matron level. Progress against recovery plan: Medicine Division has reduced their bank and agency usage in each of the last two months, but is unlikely now to achieve their targeted reduction for 2010/11. Page 44 30

47 WORKFORCE W3. EXCEPTION REPORT: Appraisal compliance RESPONSIBLE DIRECTOR: Director of Workforce and Organisational Development Description of how the standard is measured: Numbers of staff appraised annually target 80% across the Trust Performance in the period, including reasons for the exception: All Divisions are below the 80% target. Trust wide appraisal coverage has reduced to 74.8% this month. Division Mar 10 Apr 10 May 10 Jun-10 Jul-10 Diagnostic and Therapies 82.0% 80.9% 76.2% 76.2% 72.6% Medicine 74.0% 75.2% 79.1% 78.2% 78.7% Specialised Services 78.2% 81.1% 76.2% 70.3% 71.5% Surgery Head and Neck 74.7% 74.0% 76.6% 76.8% 79.7% Women s and Children s 79.5% 80.3% 75.4% 76.4% 74.8% Trust Services (exc Facilities and Estates) 74.1% 76.5% 68.8% 66.5% 62.2% Facilities and Estates 80.7% 81.4% 76.3% 79.3% 75.4% UH Bristol Total 77.4% 78.1% 75.8% 75.6% 74.8% Recovery plan, including expected date performance will be restored: Each Divisional team reminded of the requirement to achieve 80% and to report in month for reasons for non compliance. This will be monitored monthly at TOG. Progress against recovery plan: Ongoing. Page 45 31

48 Thousands WORKFORCE 2.3 SUPPORTING INFORMATION This report provides an outline of the Trust s position against key workforce standards for the month of July 2010 and year to date performance for 2010/ Summary Workforce Costs ( ) Workforce Numbers (FTE) and Projections 2010/ , / /2011 Total Employed / Projections (FTE) Total Budgeted Posts / Projections (FTE) Grand in Post inc Agency and Bank / Projections FTE 25,000 7,300 24,500 7,200 24,000 7,100 23,500 7,000 23,000 22,500 6,900 22,000 6,800 21,500 Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 6,700 Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Sickness % Appraisal % Target absence 2010/11 Actual Absence 2010/11 Absence 2009/ / /11 Target 80% across the trust 5.5% 88% 86% 5.0% 84% 4.5% 82% 80% 4.0% 78% 3.5% 76% 74% 3.0% 72% 2.5% Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 70% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Page 46 32

49 WORKFORCE Changes in the period Performance is monitored against the following indicators o workforce costs o workforce numbers o turnover o sickness o bank and agency usage o appraisal numbers Indicators on a rolling programme o Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) o European Working Time Directive (EWTD) o statutory and mandatory training The following dashboard shows key workforce information indicators RAG (Red, Amber, Green) rated. Exceptions defined by amber and adverse trend outside of tolerance limits. Indicator RAG Rating 7 See Exception Commentary Reports section Workforce Costs Workforce Numbers G o G Workforce expenditure reduced by 2.9 % compared with June 2010, and was within 0.2% of the workforce budget. This is an improvement on last month when workforce costs were 0.7% over budget. No increase in total workforce compared with June Workforce numbers were within 0.2% of the budget for July Turnover Rolling voluntary turnover remained stable at 7.7%. Sickness 0.2 percentage points higher than the previous month across the trust. 0.2 percentage points above A the monthly target for 2010/11. However, this month is closer to the target than last month, when the difference between target and actual rate was 0.4 percentage points. Bank/Agency Increase of 2.2 fte bank and agency compared with last month. Divisions set challenging targets for R 2010, and this is reflected in the July 2010 usage, which is 26% above target. However, the June 2010 usage was 34% higher than target, which means this month, the usage is closer to the target. Appraisal Appraisal rates remain below 80% with a reduction in the last month by 0.8 percentage points to R 74.8% See exception report See exception report See exception report 7 Note: RAG rating reflects whether the indicator has achieved the target. The direction of the arrow shows the change from last month. The colour of the arrow reflects whether actual this month is closer (green) or further to the target than last month. Please note that all targets rated above are set by Divisions, with the exception of appraisal. Page 47 33

50 WORKFORCE Monthly forecast and overview Measure Jul- 09 Aug- 09 Sep- 09 Oct- 09 Nov- 09 Dec- 09 Jan- 10 Feb- 10 Mar- 10 Apr- 10 May- 10 Jun- 10 Jul - 10 Jul 10 Forecast Budgeted Posts (fte) Total Employed (fte) Sickness Rate (%) 4.5% 4.1% 3.9% 4.4% 4.7% 4.9% 5.1% 4.6% 4.9% 4.3% 3.8% 3.9% 4.1% 3.9% Agency (fte) Admin & Clerical Agency (fte) Ancillary Staff Agency (fte) Nursing & Midwifery Bank (fte) Admin & Clerical Bank (fte) Ancillary Staff Bank (fte) Nursing & Midwifery Appraisal (%) 81.9% 81.5% 84.5% 84.4% 82.5% 81.0% 81.4% 81.5% 77.4% 78.1% 75.8% 75.6% 74.8% 80.0% Rolling Average Turnover (%) Rolling Average Voluntary Turnover (%) 17.8% 17.8% 17.6% 17.5% 17.3% 17.2% 17.0% 16.9% 16.6% 16.4% 16.2% 16.0% 15.9% 9.3% 9.2% 9.0% 8.8% 8.6% 8.4% 8.2% 8.1% 8.0% 7.9% 7.8% 7.7% 7.7% Vacancy Rate (%) 4.0% 4.6% 4.8% 4.6% 4.3% 4.5% 4.6% 4.4% 4.5% 3.9% 4.5% 4.8% Bank Nursing & Midwifery % unfilled 11.7% 9.8% 11.6% 12.4% 2.7% 3.8% 2.0% 3.4% 3.0% 3.4% 2.0% 1.8% 2.0% Bank Nursing & Midwifery Unfilled Shifts Notes Turnover measures the number of leavers expressed as a percentage of the average number of staff in post in the defined period. Vacancy measures the number of vacant posts as a percentage of the budgeted establishment. The Sickness Rate is expressed as a percentage of total whole time equivalent (fte) staff in post. Page 48 34

51 Patient Safety QUALITY 3.1 QUALITY DASHBOARD Thresholds Monthly Performance Green Red Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 MRSA screening - elective 100% <95% 93.1% 97.3% 99.1% 95.8% MRSA screening - emergency >=95% <80% 60.1% 58.2% Hand Hygiene Audits >=95% <80% 96% 98% 97% 97% 97% Antibiotic compliance (C diff dashboard) >=95% <80% 72% 70% 69% 77% 81% Infection Control Matrons checklist (C diff dashboard) >=95% <80% 94% 94% 95% 95% 93% Cleanliness monitoring overall Trust score >=95% <70% 89% 95% 97% 96% 97% Cleanliness monitoring very high risk areas >=95% <70% 95% 96% 96% 97% 97% Cleanliness monitoring high risk areas >=95% <70% 94% 95% 97% 96% 96% GRE bacteraemias <=2 >= Incidents Serious Untoward Incidents RPM IPM Never Events 0 >= Number of in-patient falls RPM IPM Falls Repeat in-patient falls Falls of in-patients aged over 65 RPM IPM Falls of in-patients aged over 65 with cognitive impairment Pressure Ulcers Total Pressure Ulcer incidence per 10,000 bed days Percentage of hospital acquired pressure ulcers NOT GRADED AT ALL 0% >0% 20% 15% 0% 20% Number of hospital acquired grade 2 pressure ulcers Number of hospital acquired grade 3 pressure ulcers 0 >= Venous Thromboembolism CQUIN Number of hospital acquired grade 4 pressure ulcers 0 >= % adult in-patients who have had a VTE risk assessment CQUIN >=90% <50% 51.7% 60.0% 68.6% 63.0% 59.1% % adult in-patients who received thrombo-prophylaxis >=90% <60% 67.8% 73.0% 70.3% 64.0% 69.7% Nutrition Patients with nutritional screening within 24 hours >=80% <50% 64.0% 66.6% Safety Checklist CQUIN Leadership WHO Surgical safety checklist compliance in theatres >=95% <95% 95.7% 89.4% 84.5% 78.5% 95.7% Number of Executive Director Patient Safety Walk-arounds >=6 < % actions completed within 2 months of patient safety walk-around >=80% <60% 22% 67% 3% 24% 14% Page 49 35

52 Patient Experience Clinical Effectiveness QUALITY Thresholds Monthly Performance Green Red Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 HSMR Hospital Standardised Mortality Ratio <80 >= NICE Guidance Length Of Stay Learning Disability Single Sex Accommodation Quarterly measures to be determined Reduction in elective length of stay CQUIN <=3.64 >= Reduction in emergency length of stay CQUIN <=5.07 >= LD risk assessment of patients with known learning disability with 48 hours of hospital admission >=75% <75% 80% 71% 86% 83% HSMR is two months behind Breaches of same sex accommodation Total Patient Experience CQUIN Score >=73.0 < Patient Experience CQUIN Complaints/ Compliments Involvement in decisions about treatment/care >=63% <55% 61% 61% 60% 63% Hospital staff available to talk about worries/concerns >=55% <43% 50% 54% 50% 53% Privacy when discussing treatment >=79% <71% 79% 79% 77% 82% Informed about medication side effects >=58% <40% 42% 39% 43% 41% Informed about who to contact if worried about condition after leaving hospital >=94% <83% 81% 73% 76% 79% Number of Complaints per month % complaints re Clinical Care <40% >=45% 42% 39% 41% 25% 32% % resolved within agreed local resolution plan >=98% <90% 97.4% 92.4% 94.2% 92.7% 93.2% Number of complainants disatisfied with response Number of Compliments Please note that there is a 1-month time lag for the Patient Experience data Page 50 36

53 QUALITY 3.2 SUMMARY A summary of the Trust s performance against selected quality metrics is shown below. Achieving set threshold - Hand Hygiene Audits - Cleanliness monitoring overall Trust score - Cleanliness monitoring very high risk areas - Cleanliness monitoring high risk areas - Glycopeptide Resistant Enterococci (GRE) Bacteraemias - In-patient falls (Please note the falls data is one month in arrears) - Falls in in-patients over 65 - Number of hospital acquired grade 4 pressure ulcers - Number of hospital acquired grade 3 pressure ulcers - WHO surgical safety check list compliance in theatres - Hospital Standardised Mortality Ratio - Reduction in elective length of stay - Learning Disability risk assessment of patient with known learning disability within 48 hours of admission (quarterly) - Number of breaches in single sex accommodation standard - Patient Experience scores relating to the discharge survey for May are confirmed, and those for June are provisional - % complaints re clinical care Thresholds not met or no change on previous month - Antibiotic compliance - Matrons checklist (C difficile dashboard) - Serious Incidents - % of adult in-patients who had a Venous Thrombo-Embolism (VTE) risk assessment (not met) - % adult in-patients who received thrombo-prophylaxis (not met) - Reduction in emergency length of stay - % complaints resolved within agreed timescale (no change) Quality metrics requiring attention - MRSA screening-emergency - Never Events - Number of executive director patient safety walk-arounds - % actions completed with 2 months of safety walk-around - Percentage of hospital acquired pressure ulcers not graded at all Quality metrics with thresholds not yet finalised or which are being reported quarterly - Nutritional screening (quarterly) - Total pressure ulcer incidence per 10,000 bed days (baseline being established) - Number of hospital acquired grade 2 pressure ulcers - Implementation of National Institute Clinical Excellence (NICE) guidance (Data not available) - Total Number of Complaints (The threshold will been re- Page 51 37

54 QUALITY calculated based on combined formal and informal complaints.) - Number of complainants dissatisfied with the response - Number of compliments - Repeat in-patient falls (recording methodology being revisited to ensure consistent capture of data) Performance against Clinical Quality Indicator (CQUINs) quality dashboard metrics A summary of the performance against the key CQUINS indicators is shown below: Percentage of adult in-patients who had a Venous Thrombo-Embolism (VTE) risk assessment. Performance of 59.1% against the required figure of 90% to be achieved by the end of Q4 2010/11. Reduction in elective length of stay/ A further decrease on previous months figure to 3.52 days against a target of 3.64 days by the end of Q4 2010/11 (the target of 3.64 days represents a 5% reduction on 2009/10 outturn). Reduction in emergency length of stay Decrease on previous months figure to 5.12 days against target of 5.07 days by the end of Q4 2010/11 (5.07 days represents a 5% reduction on 2009/10 outturn). WHO surgical safety checklist compliance in theatres. Performance of 95.7% against the required figure of 90% to be achieved by the end of Q3 2010/11. Patient Experience scores relating to the discharge survey. Confirmed patient experience index score for May of 72.5, with a provisional figure for June of 74.3 against a target score of Page 52 38

55 QUALITY 3.3 CHANGES IN THE PERIOD Performance against the following indicators changed significantly compared with the last reported month: One Never Event occurred in July WHO surgical safety check list compliance in theatres (significantly up from % in June to % in July) Antibiotic prescribing compliance (up from % in June to % in July) % of adult in-patients who had a Venous Thrombo-Embolism (VTE) risk assessment (down again from % in June to % in July) Hospital Standardised Mortality Ratio (decrease on previous month). However the Trust has received a letter from the Care Quality Commission identifying the Trust as a mortality outlier for coronary angioplasty. This potential concern is currently being fully investigated. % actions completed with 2 months of safety walk-around (down from % in June to % in July) Patient Experience overall score (provisional figures are significantly up from % in May to % in June) Page 53 39

56 QUALITY 3.4 EXCEPTION REPORTS Exception reports are provided for the 8 indicators which are red rated and require attention or are amber rated and are (or have recently been) of particular concern. 1) MRSA screening emergency 2) Antibiotic prescribing compliance 3) Never Events 4) Percentage of adult in-patients who had a Venous Thrombo-Embolism (VTE) risk assessment 5) Percentage of adult in-patients who received thrombo-prophylaxis 6) Percentage of hospital acquired pressure ulcers not graded at all 7) Number of executive director patient safety walk-arounds 8) Percentage of actions completed with 2 months of safety walk-around Page 54 40

57 QUALITY Q1 EXCEPTION REPORT: MRSA emergency screening RESPONSIBLE DIRECTOR: Chief Nurse Description of how the standard is measured: MRSA emergency screening measures the number of patients admitted as emergencies who are screened on or immediately after admission Performance in the period, including reasons for the exception: This is the first formal report of MRSA emergency screening. Compliance is currently at 75.2% Trust-wide with Divisional compliance shown in the table below. Screened Not Screened MEDICINE 71.1% 28.9% SPECIALISED SERVICES 92.9% 7.1% SURGERY, HEAD & NECK 82.2% 17.8% WOMEN & CHILDREN'S 72.9% 27.1% Trust Total 75.2% 24.8% 100% compliance to MRSA emergency screening is a national requirement from December Recovery plan, including expected date performance will be restored: The Trust-wide data are being analysed at Department/local level to inform further follow up and actions. It is anticipated that this level of information will be available in September 2010 The MRSA screening policy has been revised and was ratified by the Trust Executive Group in July This will be issued in August 2010 with awareness raising of the emergency screening requirement included within the implementation plan A staged increase in compliance is planned with the aim of achieving 85% in September, 95% compliance in October and 100% compliance in November Page 55 41

58 QUALITY Q2 EXCEPTION REPORT: Antibiotic prescribing compliance RESPONSIBLE DIRECTOR: Chief Nurse Description of how the standard is measured: Antibiotic compliance measures the compliance with the three elements of the antibiotic prescribing bundle (i.e. prescription in line with policy; indication stated; course length stated). Performance in the period, including reasons for the exception: The overall percentage compliance to antibiotic prescribing improved from 77% in June to 81% in July. Compliance improved in Medicine and Women and Children s Divisions with a slight decrease in Specialised Services and Surgery Head and Neck Divisions. Compliance failures continue predominantly in recording indication for the prescription and the course length. Recovery plan, including expected date performance will be restored: The revised antibiotic prescribing chart has been introduced from the beginning of August New junior medical staff have received focused training at their induction sessions The Medical Director has instructed Consultant Medical Staff to review antibiotic prescribing on each Board and Ward round To allow for the change of medical staff in August, further improvements are expected in September. Page 56 42

59 QUALITY Q3 EXCEPTION REPORT: Never Events RESPONSIBLE DIRECTOR: Jonathan Sheffield Description of how the standard is measured: Never Events are defined as events which are serious, largely preventable patient safety incidents that should not occur if available preventative measures have been implemented. The National Patient Safety Agency identifies a core list of never events each year. The Never Event relevant to this serious incident is: intravenous administration of mis-selected strong potassium chloride. Performance in the period, including reasons for the exception: One Never Event occurred in July in the Adult Intensive Care Unit when a patient s intravenous line was inadvertently flushed with 1ml of strong Potassium Chloride instead of Normal Saline. The reason for the exception is not yet confirmed. Recovery plan, including expected date performance will be restored: A full root cause analysis investigation is being conducted by a Consultant from outside of the division and a corporate Patient Safety Manager and will be reported to Clinical Risk Assurance Committee in September. Any action identified from this investigation will be put into an action plan in due course. The Board should note: The National Patient Safety Agency issued a safety alert PSA 01 on the use of strong Potassium Injections in The Trust is fully compliant with the requirements of this alert (restriction of clinical areas where stock is maintained, separate storage facilities to common diluents, rationalisation of potassium infusions and training) in addition the Trust also requires that the injections are treated as a controlled drug and the requirements are detailed in a written policy. Page 57 43

60 QUALITY Q4/Q5 EXCEPTION REPORT: Percentage of adult in-patients having a Venous Thrombo-Embolism (VTE) risk assessment carried out against a target of 90% by Q4 2010/11 Percentage of adult in-patients receiving thrombo-prophylaxis RESPONSIBLE DIRECTOR: Medical Director Description of how the standard is measured: VTE risk assessment is a national CQUIN currently measured by reviewing five in-patients within 24 hours of admission per clinical area per week. There is a requirement to move to a census method of data collection by the end of July. The e-handover system is being considered as a tool for this purpose. % adult in-patients receiving thrombo-prophylaxis is measured by reviewing five in-patients within 24 hours of admission per clinical area per week Performance in the period, including reasons for the exception: The data for % of patients risk assessed has reduced again to 59.1% during the month of July. Since the VTE Project Nurse came into post the data capture from wards has become more comprehensive and is presenting an increasingly accurate picture. 69.7% of adult in-patients received thrombo-prophylaxis against a threshold of 90%, an improvement on the previous months figure. Recovery plan, including expected date performance will be established: These results have been circulated to Divisional Boards for action. VTE training and expectations featured in the induction of 180 new medical staff on 4 th and 5 th August. Additional ward based training is being delivered by the VTE Project Nurse. Page 58 44

61 QUALITY Q6. EXCEPTION REPORT: Percentage of Hospital Acquired Pressure ulcers not graded at all RESPONSIBLE DIRECTOR: Chief Nurse Description of how the standard is measured: Pressure Ulcers identified at nursing/medical assessment are graded 1-4 (Grade 1 being red discolouration, Grade 2 being a break or partial loss of skin, Grade 3 being tissue damage through the superficial layers, Grade 4 involving the most serious tissue damage). Pressure Ulcers are reported as patient safety incidents and their reduction is a CQUIN for 2010/11. The target is that all pressure ulcers will be graded so that valid numbers of pressure ulcers for each grade will be captured. Performance in the period, including reasons for the exception: Overall pressure ulcer acquisition in the Trust decreased in July with no reported grade 3 hospital acquired ulcers. The completion of root cause analysis and referral to the Tissue Viability Specialist Team has highlighted the need for further staff awareness in categorising pressure ulcer grade that is being addressed as part of the recovery plan. Recovery plan, including expected date performance will be restored: A pictorial chart of pressure ulcer grading has been developed and will be distributed to wards early September. This chart also outlines the actions to take for each grade of pressure ulcer Tissue viability link nurses have been set an objective of pressure ulcer awareness training with all ward and department staff October to December Each Division is hosting a link nurse meeting in October at which the tissue viability link nurses will be trained to cascade the training. Improvements in categorising pressure ulcers are expected from October onwards. Page 59 45

62 QUALITY Q7/Q8 EXCEPTION REPORT: Number of executive director patient safety walk-arounds Percentage of actions completed with 2 months of safety walk-around RESPONSIBLE DIRECTOR: Chief Executive Description of how the standard is measured: Q8. Number of executive director patient safety walk rounds carried out against a locally set target of 6 per month. Q9. % of actions completed within 2 months of identifying the total number of actions required as a percentage of the total number of actions identified against a locally set target of 80%. Performance in the period, including reasons for the exception: Number of walk rounds carried out in July 2010 = 5 Number of walk rounds that should have taken place = 9 1 walk round was cancelled by the Executive and has been re-scheduled for August walk rounds were cancelled by the Executives and to date not re-scheduled. 1 walk round was cancelled by the Ward who are currently having a major refurbishment so this has been scheduled for September 2010 when the refurbishment is completed. % of actions completed within 2 months = 14% of May s actions completed by end of July 2010 In total 7 walk round actions were identified during the month of May Two of these actions relate to the Division of Women s and Children s Services and five of these relate to the Division of Surgery, Head and Neck. Recovery plan, including expected date performance will be established: The number of Executive Walk Rounds being cancelled or re-scheduled is increasing, although the number actually carried out per month is slowly improving. The Chief Executive has reiterated the importance of the Patient Safety walk-around to the executive team and their Personal Assistants to minimise the risk of further cancellations. All Acting Executives are carrying out walk rounds so no Executive should need to do more than the number planned at the beginning of To date we have 4 areas or wards whose walk rounds have been cancelled and not yet re-scheduled. It is expected performance will be established by October. The target for completion of actions and the reasons for this has been reiterated to those with outstanding actions there has been an increase in the Page 60 46

63 QUALITY amount of feedback received. Further changes to the walk round process will take place in the next couple of months. This will include the Patient Safety Team being more actively involved in the walk round by providing some back ground information on the area/ward the Executive is visiting and a change to the documentation to be completed ensuring the Patient Safety Topics listed are those that the Trust needs to focus on at present as determined by National Targets and Local Incident Information. It is expected performance will be significantly improved by October. Page 61 47

64 QUALITY 3.5 SUPPORTING INFORMATION Actual patient Experience The mother of a young patient contacted the Patient Advice and Liaison Service to complain about aspects of her daughter s care. The family live outside of Bristol and make a lengthy journey each time for their 13 year old daughter s ongoing treatment for Crohn s Disease, a chronic condition, which is being treated with a range of medicines. Some of the medicines prescribed are restricted for prescription by GP s in the local area. The complaint letter (copied to the local MP) set out a series of events over several months involving UH Bristol, the patient s GP practice and the Primary Care Trust covering the area the where the family live. The family have struggled to get repeat prescriptions from the hospital and the GP has been unable to prescribe certain medicines due to the local prescribing restrictions. The family had experience significant stress over the difficulties in obtaining the correct medicine for their daughter s condition. They felt that bureaucracy and arguments over costs were interfering with their child s care. An example of a sequence of events experienced by the family is set out below: Prior and during the patient s hospital admission, the family liaised directly with their GP surgery and were assured that the medications would be available for the patient once she was discharged. Just prior to discharge, the GP surgery phoned the family to say there was a problem and the hospital needed to issue one of the medicines. The hospital wrote to the GP advising them of the patient s requirements and issued enough medication for the patient to manage until the medication was available form their local pharmacy as agreed. When the patient s father arrived at the pharmacy on the agreed day, he was told that the medication could not be provided as it was the hospital s responsibility and the GP would explain this to them. They were advised by the GP practice to obtain the medication from Bristol necessitating a 64 mile round trip. The patient s mother complained to her GP and after much discussion, the prescription was filled the following day. Approximately one month later, the repeat prescription for a different medicine was presented to the local pharmacy and the family were telephoned and advised that this medication could not be provided locally and would also have to be provided by the hospital. The patient s mother was clear that the aim of her complaint was: To resolve the prescribing issues once and for all so that the family would not have to go through the same difficulties in obtaining medicines every time there is a treatment regime change. That the prescribing leads work to develop consistency of practice across the NHS when it comes to classifying drugs. That there are some best practice guidelines established so that when issues do arise, and that patients interests are paramount. Page 62 48

65 QUALITY That there is a more effective electronic information sharing system around medication and treatment between primary and secondary care teams across different Pacts, rather than the reliance of letters being copied to the surgery and another hospital involved. That reception staff at the surgery have some training upon the impact they might have upon patients or their relatives when dealing with difficult issues. The complaint investigation identified that each of the parties involved felt it was another s responsibility to arrange the medications which required differing levels of authorisation based on toxicity of drug requiring senior level (consultant) prescribing and also cost. Also variations in restricted prescribing across wider regional area had not been fully communicated to hospital staff, who were unaware of the current medications on red status for this area. The fact that the medication had previously been provided by the GP team (from the perspective of the GP as a one-off) led the consultants to assume that this would be possible on an ongoing basis. Actions taken by UH Bristol as a result of the complaint: The Head of Pharmacy at the Children s Hospital is to review the system communication of traffic light system across the region with Drug and Therapeutics Committee and identify areas for improvement The Head of Pharmacy will also write to all Primary Care Trust prescribing leads requesting an update is provided whenever there are changes to their restrictions lists. The Consultant team will provide the family with hospital prescriptions or arrange medications through their local district hospital. A system was also put in place whereby the specialist Gastroenterology Nurse will liaise with family on an ongoing basis to ensure prescribing systems are appropriate and working. The Gastroenterology team will review other red drugs used to ensure that department are clear on restrictions and other patients are not experiencing similar problems. Page 63 49

66 QUALITY Quality Achievements Division of Diagnostics and Therapies Clinical Pathology Accreditation (CPA) Within Pathology, both Biochemistry and Haematology have had full CPA status confirmed following their 4 yearly assessment visit earlier this year. Histology, after their 1 year review, have also had their status confirmed. All Pathology disciplines have CPA full compliance (Microbiology via the Health Protection Agency service). This adds to the Medicines and Healthcare products Regulatory Agency compliance confirmed for our Blood Transfusion Service, following an assessment visit in January. We have full compliance with all regulatory requirements covering our Pathology services. Medicines Reconciliation Medicines reconciliation is the process of compiling an accurate list of a patient s current medication, writing a prescription according to this list and the patient s clinical situation, while ensuring all additions, deletions and amendments are clearly documented. The medicines reconciliation work in UH Bristol was previously very limited so investment was made in the Pharmacy service to focus on acute medical patients. In the Medical Assessment Unit and Short Stay Unit the medicines reconciliation has now been raised to an average of 77% largely due to the work of a pharmacist and pharmacy technician. The impact of this work has been monitored and significant improvements in medication safety have been documented. New UH Bristol Prescription Chart A new adult short stay medicine administration chart, or drug chart, has been designed and was implemented on 1 st August A new drug card was required to improve clarity with prescribing, pharmacy interventions and documentation of administration of medicines. help the trust work towards national guidelines e.g. oxygen prescribing and National Patient Safety Agency requirements formalise good practice, for example, on documentation of issues relating to medicines reconciliation. There are numerous new features and training has been cascaded in the implementation programme. Developments include a revised allergy box, better medicines communication, further detail regarding non administration of medicines, patient discharge information, a separate page for antibiotics, a section for oxygen prescribing, a revised area to record the risk assessment for venous thromboembolism and prophylaxis prescribed, improved prescriber information. Page 64 50

67 QUALITY Medicines and Healthcare products Regulatory Agency (MHRA) inspection July UH Bristol Pharmacy holds licenses with the Medicines and Healthcare products Regulatory Agency (MHRA) for - Manufacturing Specials (i.e. pharmaceutical products) - Investigative Medicinal Products (i.e. clinical trial materials) - Wholesale Dealing (i.e. pharmaceutical supply) These licenses therefore cover the preparation of pharmaceutical products in the BRI, the preparation of radiopharmaceuticals, the preparation of investigative medicinal products for clinical trials, and the storage and supply of medicines. The full written MHRA report has not yet been received, but the initial verbal report was positive and complimented both staff and processes. The MHRA classify issues identified as critical, major and minor. There were no critical issues in any areas, and only 1 major issue which focussed upon control and segregation of products, so managing within the space constraints to store and label materials in an orderly manner. There was 1 minor issue recorded for the supply of medicines, 6 for manufacturing / quality control, and 3 for radiopharmacy. Overall, the inspection was extremely thorough and has been helpful in focussing attention upon areas of importance for patient safety. The inspectors also addressed future plans with the challenge of implementing new IT systems and their expectation that this will require significant implementation support in order to maintain the safety of current work processes. An action plan has been drafted which will be revised and submitted to the MHRA on receipt of the official inspection report. Introduction of a Physiotherapy Bronchiectasis Outpatient Service This allows patients with bronchiectasis (a chronic lung condition) to receive earlier intervention, including advice and strategies on self-management of their condition and to receive physiotherapy treatment in a multi-disciplinary setting. This will provide a better quality service more in line with national guidelines, reduce admissions and promote better self management Introduction of Late-Shift Model for Cardiac Physiotherapy. Following a review of the demands and needs of patients, a Late-Shift model has been introduced to improve access to cardiac physiotherapy. Page 65 51

68 QUALITY Examples of Learning from Recent Complaints and Incidents SUMMARY EXAMPLES OF LESSONS LEARNED FROM COMPLAINTS C1 Patient s medication was left on his bedside table for him to administer himself. Patient was unable to do this and on many occasions his family found medication on the floor, under his bed, or in the bedside locker. Incidents have been discussed with all nursing staff on ward. Staff have been reminded that when the drug chart is signed this is to say that the medication has been administered to the patient. Nursing staff have also been reminded of their Code of Conduct in relation to this issue and the impact this can have on patients if their medication is not taken correctly. C2 Patient s family frequently asked for information about his condition, care and ongoing needs. Staff were unable to provide answers or explanations and although on occasions stated they would find out, they often didn t return with answers. The importance of good communication within the whole team has been discussed with staff. Staff advised that they must seek information requested from families if they do not know the answers and ensure this is reported back in a timely way. C3 Nutritional risk assessment was not carried out until four days after patient was admitted. When the assessment was carried out this was inaccurate. Family offered to come into the hospital to help patient during meal times, which was refused by staff, although no support given by nursing staff on ward. Ward staff to undergo additional teaching in the completion and action of nutritional risk assessments. Productive meal time rules to be discussed with ward staff, so in future family members will be allowed onto the ward to support patients with eating. Page 66 52

69 QUALITY SUMMARY EXAMPLES OF LESSONS LEARNED FROM INCIDENTS I1) Baby born prematurely and in poor condition. Failure to respond appropriately to the deterioration in an expectant mother s condition and therefore failure to escalate to senior medical staff in the Delivery Suite. Need to undertake a comprehensive risk assessment each time a patient is reviewed to ensure that the plan of care is appropriate Communication within the team needs to be improved Recommendation to conduct a literature review regarding the management of pre-labour rupture of membranes between weeks gestation and review the UH Bristol Guideline for management of pre-labour rupture of membranes following the literature review, with a focus on expectant management of pre-labour rupture of membranes between weeks gestation I2) Power failure occurred and the Uninterrupted Power Supply (UPS) backup failed to activate. To ensure all equipment with internal battery power is always on charge and an additional power fuse should be incorporated so as to protect the main incoming supply so that if failure of UPS should occur again. Recommendation to install emergency lighting in the treatment room area and to source an alternative location for the UPS in basement of BRI. Page 67 53

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71 Trust Board Meeting Date: 26 August 2010 Agenda Item Title of Report Skills for Health Governance Manual Abstract Skills for Health (SfH) is the licensed UK Sector Skills Council for Health. It was established in 2002 and in 2004 was licensed by the UK Government through the UK Commission for Employment and Skills as a Sector Skills Council. Skills for Health is hosted by the University Hospitals Bristol NHS Foundation Trust (UHBFT) and its powers, duties and responsibilities are derived from the Trust s Constitution and Code of Accountability, which it must comply with. It has its own independently appointed Chair and Chief Executive and a separate governing board. It remains directly accountable to its various funding bodies and therefore operates as a quasi-autonomous body. UHBFT s Director of Workforce and Organisational Development (Steve Aumayer) is a member of the SfH Board. A recent governance review carried out for Skills for Health in February 2010 recommended that a single comprehensive governance framework should be established. The Governance Manual provides a more up to date and coherent framework to supersede existing documentation and more accurately reflect current arrangements and good governance practice. This has been agreed by Skills for Health s Board subject to the approval of UHBFT s Board and will take immediate effect once approved. Both UHBFT s Director of Finance and Director of Workforce and Organisational Development, Paul Mapson and Steve Aumayer have also had prior sight of the manual. The manual includes a clearer table of delegated authorities and sets out the remit of new standing sub-committees of SfH s Board. In particular, the table of delegations in section four and the scheme of delegation (for contracts and SLAs) enhance the assurance to UHBFT s Board by explicitly specifying the limits of authority. Taken together, the measures contained in the new manual strengthen and build upon existing arrangements. Page 69

72 Recommendations UHBFT Board is invited to approve the revised Governance Manual for Skills for Health. Prepared by: Name & Title Dan Wood, Lead Manager (Skills for Health) Presented by: Name & Title Steve Aumayer, Director of Workforce and Organisational Development (University Hospitals Bristol NHS Foundation Trust) Brian Payne, Executive Director of Strategy and Corporate Services (Skills for Health) Appendices Appendix 1 title Appendix 2 title Previous Meetings Please insert the date the paper was presented under to the relevant group Exec Team Audit & Assurance Committee Governance Risk and Risk Management Finance Committee Trust Executive Group Other Meeting (Please state) Skills for Health Board agreed subject to UHB Board approval 14/07/10 In completing this report, I confirm the following matters have been considered: a) Implications for the NHS Constitution b) Implications for CQC registration c) Implications for corporate objectives d) Financial implications of the recommendations e) Equalities Impact Any material considerations are reported overleaf. Page 70

73 Skills for Health Governance Manual Incorporating mission, values, aims, principles, and accountability, roles, responsibilities, code of conduct for Board Members, business, delegated powers and reference to standing orders, the Nolan Principles and prime financial policies. Authors: Classification: Scope: Brian Payne (Executive Director, Strategy and Corporate Services) Denise Morris (Director of Finance) Fionnuala Palmer (Programme Manager) Daniel Wood (Lead Manager, Executive Support) Policy Organisation-wide Replaces: Hosting and Corporate Governance Arrangements Agreement between United Bristol Healthcare Trust and Skills for Health 01/07 To be read in conjunction with: Board procedures manual Review date: July 2012 Issue status Version 1 Issue number: 1 Issue date: July 2010 subject to UHBFT approval Authorised by: SfH Board (TBC 14 July 2010) Authorisation date: 14/07/2010 (subject to UHBFT approval) Document for public display: Yes After this document is withdrawn from use it must be kept in archive for 10 years Archive: Corporate Policy Document Archive Date added to archive: 14/07/2010 Officer responsible for archive: Brian Payne (Executive Director, Strategy and Corporate Services) Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 1 Page 71

74 Contents Background Mission, Values, Aims, Principles, and Accountability... 4 Mission... 4 Values... 4 Aims... 4 Principles... 5 Accountability Roles, Responsibilities and Code of Conduct for Board Members... 6 Introduction... 6 The Board and Member Appointments... 6 Overall Purpose of Skills for Health... 7 Main Functions... 7 The Chair... 8 Vice Chair... 9 Corporate Responsibilities of Members... 9 Responsibilities of Individual Members Terms of Office Removal from Board Membership Personal Liability of Members Committees and Advisory Groups Board Effectiveness The Chief Executive Skills for Health as an Employer Skills for Health s Business and Delegated Powers Introduction Scheme of Delegation Appendix 1 SfH Board Standing Orders Appendix 2 The Nolan Principles Appendix 3 SfH Internal Governance and Structure Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 2 Page 72

75 Background Skills for Health is the UK Sector Skills Council for Health (SSC). It was established in 2002 and became a fully licensed Sector Skills Council in It is one of the original 25 Sector Skills Councils which are all licensed by the UK Government through the UK Commission for Employment and Skills (UKCES). Skills for Health receives funding from the four UK Health Departments, the UK Commission for Employment and Skills, the Education Act Regulatory Bodies and the sector itself. In 2010, it employed over 250 people and had an annual budget in excess of 37 million. Skills for Health is different from most other Sector Skills Councils in that it is not a legal entity in its own right. It is hosted by the University Hospitals Bristol NHS Foundation Trust and its powers, duties and responsibilities are derived from the Trust s Constitution and Code of Accountability, which it must comply with. It has its own independently appointed chair and Chief Executive and a separate governing board and it remains however directly accountable to its various funding bodies. It therefore operates as a quasi-autonomous body. This Corporate Governance Manual sets out the responsibilities and procedures that form the basis of the system of governance adopted by Skills for Health. It should be read in conjunction with the Service Level Agreement which exists between The University Hospitals Bristol Foundation Trust and Skills for Health and the trust s constitution and code of accountability. These documents are the combined means by which the boards of both organisations can assure themselves and their wider stakeholders of the mechanisms in place to align their governance arrangements and provide the basis for a robust and healthy operating environment. This work draws on best practice as identified by the NHS Institute for Innovation and Skills, and recent work by the Department of Health. Where appropriate, quotations are included from the following published documents: The Healthy NHS Board. Principles for Good Governance (2009) NHS FT Code of Governance (2009) Introductory Guide to NHS Foundation Trust Finance and Governance (2007) NHS Audit Committee Handbook (2005) Good Governance. A Code for the Voluntary and Community Sector (2005) Code of Accountability in the NHS (2004) The Higgs Report: Review of the role and effectiveness of non-executive directors (2003) Integrated Governance II: Governance Between Organisations (2008) These five sections are supplemented by detailed documents given as appendices. Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 3 Page 73

76 1. Mission, Values, Aims, Principles, and Accountability Mission Skills for Health s mission is to help the whole UK health sector develop a skilled, flexible and productive workforce to improve the quality of health and healthcare. Values We are health service centred We are workforce focussed The needs and choices of individuals and patients are at the heart of our work A competent, flexible workforce is key to delivering health and healthcare Improving skills benefit employers and the whole workforce Productivity is important to everyone Everyone is valued Integrity Ongoing learning We seek to make a positive difference Partners count Everyone in the health workforce is valued All types of work are valued and celebrated We strive to work with integrity Everyone has a right to fulfil their potential within their abilities, preferences and local circumstances throughout their working life We seek to ensure that we do make a positive difference to health and healthcare and that people enjoy and are enthused by learning processes and the work experience Working with others is a key to our success and the success of the health sector Aims Through its governance arrangements, the Board of Skills for Health aims to ensure that it maximises the impact of its work while: acting within the authorities delegated to it; complying with relevant legislation and regulation; effectively discharging the duties of a Sector Skills Council across the UK; maximising the impact of its work across the Health Sector; meeting the requirements of its funding bodies; maximising the value of the skills, knowledge and experience of Board members; and clearly articulating the roles and responsibilities of Board members as representatives of Skills for Health. Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 4 Page 74

77 Principles In its governance, the Board and senior staff will at all times: observe the highest standards of propriety involving impartiality, integrity and objectivity in relation to the stewardship of funds, the management of the organisation and the conduct of business. pursue the organisation s strategic priorities: promoting the development of a skilled, productive and flexible workforce for the health sector. protect the organisation s assets and avoid inappropriate risk; using funds and assets only to further the organisation s agreed priorities and ensuring that work is performed in the most economical, efficient and effective way, within available resources, and with validation of performance achieved wherever practicable. be publicly accountable for the activities of the organisation, stewardship of funds and the extent to which the objectives of the organisation have been met. be consultative in style, and open and responsive to all stakeholders. ensure that there is an effective system of internal control in place to enable the organisation to meet its objectives. Skills for Health will adhere to these principles in its management of public funds and in the conduct of its business. The Governance Manual will be reviewed regularly, to ensure that it remains fit for purpose and that it continues to reflect the values, aims and principles outlined above. Accountability Skills for Health demonstrates its accountability to its stakeholders through: annual meetings between the Chair and Chief Executives of both SfH and University Hospitals Bristol NHS Foundation Trust to review the effectiveness of the hosting arrangement; through providing regular reports to the University Hospital Bristol NHS Foundation Trust Finance and Audit Committee and through incorporating details of its financial transactions in the accounts of the Trust consulting with its stakeholders on matters of health policy to ensure that the organisation reflects the views of employers; publishing a strategic plan which outlines priorities and the plans for achieving them; publishing reports of its Board meetings on its website (effective from 24 th November 2010); reporting to the UK Commission for Employment and Skills regarding its impacts and outcomes in relation to its agreed objectives as the Sector Skills Council for Health; and as part of its relicensing process, it is subject to independent performance assessment by the UK Commission for Employment and Skills. Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 5 Page 75

78 2. Roles, Responsibilities and Code of Conduct for Board Members Introduction Skills for Health is not a legal entity in its own right. It operates as a quasi autonomous body, with its powers derived from the Constitution and Code of Accountability of the University Hospitals Bristol NHS Foundation Trust. The scope, function and powers of Skills for Health are set out in this manual which is approved by the trust and in the trust s scheme of delegation. The Board and Member Appointments The Board of Skills for Health is employer led. It has employer representation from across the sector and all four nations and there is representation from the four UK Health Departments. The Board is led by an independent chair who is appointed by the Board following recommendation from an appointment panel. Membership of the appointment panel will be agreed by the Board. Direct employer members of the Board are identified through open UK-wide advertisement and search. The TUC member of the Board shall be appointed from a selection of candidates nominated by the TUC, after interview by a panel agreed by the Board. The Chief Executive of Skills for Health is an ex-officio member of the Board. The overall number and breakdown of members is determined by the Board itself. The number as at June 2010 is indicated below. It is expected that the total number of Board members would not exceed 17. Sector Area Board membership Nos. Chair Appointed by the Board following 1 open UK advertisement and search CEO of SfH Ex-officio 1 Host Body Vice-Chair UHBFT Director of Workforce and Organisational Development Appointed by Board from the employer members of the Board 1 0* Director From each UK Health Department 4 Direct employers TUC member Appointed by a sub committee of Board, to include Chair following open UK advertisement and search from NHS, Independent and Voluntary sub sectors Appointed by competitive interview following nominations from the TUC 8* 1 Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 6 Page 76

79 The members of Skills for Health Board together constitute its Board. They are responsible for setting the organisation s values, standards, strategy and priorities, for agreeing budgets and for holding the Chief Executive and senior officers to account for their leadership, management, delivery and operations through regular assessment of performance. Additional UHBFT Board representatives may be invited to attend for relevant items and do have right of attendance, though this is normally exercised in exceptional circumstances. Overall Purpose of Skills for Health As defined by the UKCES, Sector Skills Councils (SSCs) are independent, employer-led, UK-wide organisations designed to build a skills system that is driven by employer demand. As determined by the UKCES: Sector Skills Council has four key goals: Reducing skills gaps and shortages; improving productivity, business and public service performance; increasing opportunities to boost the skills and productivity of everyone in the sector s workforce, including action on equal opportunities; and improving learning supply, including apprenticeships, higher education and National Occupational Standards (NOS). As the Sector Skills Council for Health, Skills for Health s overall purpose is to help the whole UK health sector develop a skilled, flexible and productive workforce to improve the quality of health and healthcare. It achieves this by being the authoritative voice on skills issues and by providing employers and the workforce with proven solutions and tools. Main Functions As the authoritative voice on skills issues SfH: Meets, listen and respond to employers and stakeholders; Understands skills needs and represents them; Champions effective investment in skills in the sector; Conducts focused workforce research for employers ; Provides intelligence on the Labour Market to help employers predict workforce trends; and Influences education and training supply to ensure that employers get the right staff with the right qualifications. Skills for Health offers employers and the workforce proven solutions and tools, with the expertise and experience to use them effectively. These solutions and tools help to deliver: Version [1] Issue [1] [July 2010] A more flexible workforce; A more productive workforce; Fewer skills gaps; Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 7 Page 77

80 Employees with better skills at all levels; More rewarding jobs; and A better patient experience. They are based on unique workforce competences identified and managed by Skills for Health that are: Recognised across the UK; Transferable; Quality assured; and Used to develop recognised qualifications based on employer needs. Skills for Health recognises that to do this it needs to work with partners across the sector and in every UK country. The Chair The post is advertised on a UK basis with suitable candidates interviewed by a panel agreed by the Board. The Chair is normally appointed for three years with the option to extend this appointment for a further three years. In exceptional circumstances, the Chair s term may be extended for a further three years, making a maximum possible term of nine years. Decisions on reappointment and exceptional circumstances will be taken by the Board, following advice from its Appointments and Remuneration Committee. There are two main components to the Chair s role: Leadership to provide leadership to the Board and to ensure that members fulfil their duties and responsibilities for the proper governance of the organisation. Support to support, and where appropriate, to challenge the Chief Executive and ensure that the Board as a whole works effectively with officers. The Chair presides at Board meetings. S/he ensures that these are held at least four times every year; at regular intervals throughout the year and that they are accurately recorded. The Chair also: ensures that [all] members are able to be fully involved in the work of the Board; reviews the performance of individual members and ensures that all members are fully briefed on the terms of their appointment and on their rights, duties and responsibilities; ensures that the Board s effectiveness is reviewed annually in accordance with this Governance Manual; ensures that the Board maintains appropriate representation and an appropriate blend of complementary skills and experience; agrees the objectives and undertakes annual appraisals of the Chief Executive following consultation with other members. Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 8 Page 78

81 The effectiveness of the Chair will be reviewed through a process approved by the Board. Vice Chair For the purposes of enabling the proceedings of Skills for Health to be conducted in the absence of the Chairman, Board Members may appoint an employer member of the Board for such a period (as specified on appointment), not exceeding the remainder of their term of office as a member of the Board. Any member so elected may resign at any time by giving notice in writing to the Chairman and the members of the Board may thereupon appoint another employer member as Vice Chairman. Where the Chairman of Skills for Health has died or has ceased to hold office, or is unable to perform their duties as Chairman owing to illness, or absence, or any other cause, the Vice Chairman shall act as Chairman until a new Chairman is appointed or the existing Chairman is able to resume their duties, as the case may be. References to the Chairman shall, so long as there is no Chairman able to perform their duties be taken to include reference to the Vice Chairman. The Vice Chairman will also be available to Board members to raise any issues or concerns that they feel unable to raise with the Chairman. Corporate Responsibilities of Members The Board regulates its own proceedings, and has approved Standing Orders for that purpose (see appendix 1). All members are equally responsible for the Board s actions and decisions, and have equal status; they do not have any individual authority. Members are bound by an overriding duty, both individually and as a Board, to act reasonably at all times in the interests of the organisation and of its present and future beneficiaries. As a Board, members are responsible for directing the affairs of the organisation, and for ensuring that it is efficiently run, and delivering its objectives for the purposes for which it has been set up. Board members responsibilities include: ensuring that high standards of corporate governance are observed at all times and that the organisation complies with the powers and authority delegated to it by University Hospitals Bristol NHS Foundation Trust and with the requirements of the UK Commission for Employment and Skills; contributing to and ensuring that the organisation has a clear vision, mission and strategic direction and that it is focused on achieving these; setting or approving plans and budgets and reviewing performance against them; ensuring that risks are identified and managed effectively; establishing and maintaining effective arrangements for carrying out the organisation s objectives, including delegating to staff within a clear framework of strategic control, consulting interested parties on significant developments and responding to their views, and facilitating good communication with stakeholders. Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 9 Page 79

82 Responsibilities of Individual Members Individual members should at all times follow the Nolan Principles (set out in Appendix 2). They should also comply with the principles set out in Section 1 and be aware of their responsibilities described in this document. The Board from time to time may appoint individual members to serve on its sub-committees. In that event, the relevant member will take an active involvement in that work area(s), will seek to reflect their own knowledge and expertise, and contribute to discussions on the subject at Board meetings. Members must not use information gained in the course of their work with Skills for Health for personal gain, nor seek to use the opportunity to promote their own or other parties private interests. They should not disclose information or documents which they have obtained through their position as a member without speaking first to the Chairman. Where appropriate the permissions of other members may need to be sought as well as advice from the Chief Executive. In the event that members do make reference to their work as a member of Skills for Health, they should advise the Chairman or Chief Executive accordingly. All members should ensure that they are fully familiar with their role and responsibilities and procedures on declarations, and avoid conflicts of interest. Details of these, and the organisation s rules on gifts and hospitality, are in the Trust s Standing Orders. Terms of Office Members of the Board are normally appointed for three years with the option to extend appointments for a further three years. In exceptional circumstances, a member s term may be extended for a further three years, making a maximum possible term of nine years. Decisions on reappointment and exceptional circumstances will be taken by the Board, following advice from its Appointments and Remuneration Committee. Removal from Board Membership Any Board Member can resign from the Board by giving notice. Any Board Member who does not attend three consecutive meetings of the Board shall be liable to be removed from membership following discussion with the Chair. Any Board Member resigning from relevant employment, or changing job within the sector should discuss their new situation with the Chair (or in the case of the Chair with the Chief Executive and the Board) to determine whether continued membership is appropriate. Personal Liability of Members Although any legal proceedings initiated by a third party are unlikely to be brought against individual members, in exceptional cases, proceedings (civil or criminal) may be brought against individual members. For example a member could be personally liable if he or she acts unreasonably, recklessly or commits a breach of trust, which results in a Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 10 Page 80

83 loss to a third party or to the organisation. In order to reduce such risks, members should familiarise themselves with this manual and with the Constitution and Code of Accountability for the host Trust. A member who misuses information gained by virtue of his or her position may be liable for breach of confidence under common law or may commit a criminal offence under insider dealing legislation. However, an individual member who acts honestly and reasonably and in good faith should not incur any personal liability in an individual capacity. The University Hospitals Bristol NHS Foundation Trust indemnifies members who act honestly and reasonably and in good faith against any action taken or threatened against them. The Chairman and Chief Executive will ensure that legal advice is provided to any member for the purposes of further clarification of their statutory position. Committees and Advisory Groups The Board may from time to time appoint committees and advisory groups, with such membership and terms of reference as the Board deems appropriate. The committees and advisory groups exercise functions delegated to them, provide more detailed consideration and scrutiny of specific work areas and advise the Board. As part of its review of governance arrangements, the Board will consider the membership structure of its committees at least every two years. The Standing Orders of Skills for Health, as far as they are applicable, shall apply with appropriate alteration to meetings of any committees established by the Board. In which case the term Chairman is to be read as a reference to the Chairman of the committee as the context permits, and the term member is to be read as a reference to a member of the committee also as the context permits. Each committee shall have terms of reference and powers and be required to comply with certain conditions (for example reporting back to the Board), as the Board shall decide. Terms of reference for each committee shall have effect as if incorporated into the Standing Orders (see Appendix 1). Committees may not delegate their executive powers to a sub-committee unless expressly authorised by the Board. The Board shall approve the appointments to each of the committees which it has formally constituted. The appointment of Board members to committees comes to an end on the termination of their term of office as Board members. The following Standing Committees of the Board have been established. Finance Committee to review and challenge financial plans including the long term financial proposals and annual budgets and performance against budget; to ensure that Skills for Health meets the highest standards of financial management and accountability for the use of public funds and to ensure alignment of financial proposals with the strategic aims and intentions of the organisation. Appointments and Remuneration Committee - to oversee succession planning for Board members; the development of recruitment and appointment processes and support arrangements for Board members; the development of processes for Board and committee development and to advise on the recruitment, succession planning or removal of the SfH Chief Executive and members of the senior team and, within the Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 11 Page 81

84 context of established policies, the level of remuneration for those posts and discretionary pay awards. Governance and Risk Assurance to ensure the highest possible governance standards for Skills for Health; promote a culture of risk management and to monitor compliance with the governance manual. Strategic Development Committee - to develop approaches to strategic planning; identify mechanisms which provide assurance to the Board on the successful implementation of strategic plans and to explore and recommend opportunities for expanding the Skills for Health business model. Board Effectiveness The Board will ensure that: every year, it sets aside time to reflect on its own performance and functioning as a team; the performance of individual members is regularly assessed and appraised; performance of the Chair is assessed and appraised; the performance of sub-committees, any standing groups and other bodies is similarly appraised and reviewed; and the results of these appraisals shall inform any necessary changes and improvements, to inform the creation of appropriate development programmes, and to guide member renewal and recruitment. The Chief Executive The Chief Executive has responsibility for maintaining a clear division of responsibilities between the Board and the senior management team. He or she provides an effective link between Board and senior team, informing and implementing the strategic decisions of the Board. The Chief Executive is responsible for: the day to day work of the organisation and for its officers; designing the overall strategy for Skills for Health, to be agreed with the Board; ensuring that the Chairman and Board have timely, accurate and clear information, as required, to carry out their responsibilities; ensuring that appropriate advice is given to the Board on all matters relating to financial propriety and regularity, for keeping proper records and for the efficient and effective use of resources; the overall organisation, management and staffing of the organisation and for its procedures on financial and other matters including conduct and discipline of its officers. This involves the promotion, by leadership and example, of the values embodied in the Nolan Principles. The Chief Executive is authorised to determine the scheme of delegation and any procedures at sub-board level within his/her delegated limits of authority. Skills for Health s delegated powers are outlined in Section 4 of this document. Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 12 Page 82

85 3. Skills for Health as an Employer Skills for Health s most valuable asset is its people. It will seek to enhance their skills and experience and is committed to their development in all ways relevant to its work. Skills for Health will seek to set an example of best practice as an employer and is committed to offering all staff equality of opportunity. It will ensure that its employment practices promote diversity and treat all individuals equally. Skills for Health will ensure that it employs suitably qualified staff who will discharge their responsibilities in accordance with its high standards. All staff will be made aware of the Strategic Plan, including its aims and objectives, and all relevant internal management and control systems which relate to their area of work. In filling senior staff appointments, Skills for Health will satisfy itself that an adequate field of qualified candidates is considered, and resolves always to consider the merits of full open competition, which will normally be used for the recruitment of candidates. Skills for Health will promote its employment policies and will ensure that its employees have access to such expert advice and suitable training opportunities as they may require in order to exercise their responsibilities effectively. Skills for Health will ensure that its recruitment practices and management of staff provide for the appointment and advancement on merit on the basis of equal opportunity for all applicants and staff. It will also aim to ensure that the behaviour of its employees reflects the values, aims and principles detailed above. Skills for Health shall promote the codes of conduct for all staff and will promulgate effective whistle-blowing procedures to ensure that staff have a means through which any concerns that they may have can be voiced. Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 13 Page 83

86 4. Skills for Health s Business and Delegated Powers Introduction This section describes the roles and powers reserved for the Board in relation to the activities and objectives of Skills for Health and those delegated to the Chief Executive. The Board has delegated to the Chief Executive specific matters which would otherwise be reserved to the Board under this section. The Board authorises the Chief Executive to appoint another staff member or staff members to act on her or his behalf. References in these arrangements to the Chief Executive include any person to whom the Chief Executive has delegated authority. Powers are delegated to the Chief Executive and staff on the understanding that they would not exercise delegated powers in a manner that in their judgment was likely to be a cause for concern for the Board or its stakeholders. Scheme of Delegation The following tables illustrate the organisation s Scheme of Delegation. It should be read in conjunction with the University Hospitals Bristol NHS Foundation Trust s Standing Orders, Standing Financial Instructions and Organisational Scheme of Delegation. Subject Corporate Governance Reserved to UHBFT Board Approval of policies. Amendment of standing orders. Decisions on delegated powers to SfH Reserved to the Skills for Health Board Approval of procedures. Approval of SfH Internal Audit plan within the context of the powers delegated to SfH by UHBFT, approval of the Corporate Governance Manual, Standing Orders and Financial Policies. Adaptation of Finance, HR and FoI procedures within the spirit of UHBFT policies to local need. (Written procedures to be shared with UHBFT on request). Delegated to/responsibility of the Chief Executive Responsibility for all matters of organisational structure. The Chief Executive is authorised to delegate authority to other members and will prepare and maintain a comprehensive scheme of delegation for the organisation. Strategy and Planning Consideration and approval of SfH s Strategic Plan. Preparation of the organisation s Strategic Plan for consideration and approval of the Board. Version [1] Issue [1] [July 2010] Consideration and approval of SfH s Annual Operational Plan and annual Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue Preparation of Operational Plans and annual budgets in line with Skills for Health s Strategic Plan, 14 Page 84

87 UHBFT Annual Report and Accounts (encompassing SfH Finances) budgets. Consideration and approval of a medium term financial plan. Variations to the approved budget where the variation would have a significant impact on the overall approved levels of income and expenditure. Approval of SfH year end Management Accounts. containing proposed work programmes for audit, across Skills for Health. Preparation of a medium term financial plan. Variations to the approved budget where the variation would not have a significant impact on the overall approved levels of income and expenditure. Drawing up management accounts for Board information and consideration Performance Management Determination and approval of arrangements for performance management and consideration of regular monitoring reports. To keep the Board informed of any significant variance from the approved plans and budget and of progress in achieving objectives. To report significant successes or failures and internal issues of significance including senior appointments, structural changes and accommodation changes Risk Assurance HR Issues Version [1] Issue [1] [July 2010] Development of policies and procedures. Approval of SfH s Risk Management arrangements and consideration of reports of the Governance and Risk Assurance sub- Committee. Sign off internal Audit plans. Appointment of the Chief Executive and Executive Directors. Decisions relating to the Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue To maintain the system of internal control and assurance framework within the organisation and to provide the Board and Governance and Risk Sub- Committee with assurance on its ongoing effectiveness and appropriateness, including the best use of its resources and application of its resources for the purposes given. To advise the Board subcommittees of any material changes thereto. The structure of the Executive Team, subject to Board approval. All appointments and implementation of HR 15 Page 85

88 Chief Executive s contract terms and remuneration will be taken by the Remuneration Committee. policies and procedures below the level of Executive Director Board Administration Approval of the structure of the Executive Director Team proposed by the Chief Executive. The Remuneration Committee approves the remuneration of members of the Executive Team in line and compliant with NHS guidance The cycle of Board meetings, the composition of Board agendas and approval of minutes of Board meetings. Ensure the Board is supported to function properly through a Board Secretariat. To make recommendations for the cycle of Board meetings, and for the composition of agendas for meetings. To prepare draft minutes and maintain efficient overall arrangements for the administration of SfH Board meetings and associated sub committees Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 16 Page 86

89 Skills for Health Scheme of Delegation - Signatures on Contracts and Service Level Agreements Contracts & Tendering Delegation Limits / Authorities Delegated Authority for Signature Authorised Officer Legally Binding Income Contracts e.g. UKCES Core Contract Above 2,500,000 Chief Executive of UHB NHS FT e.g. UKCES NOS/ Below 2,500,000 SfH Chief Executive OR SfH Director of Finance Income Service Level Agreements e.g. DOH Core Contract Above 2,500,000 Chief Executive of UHB NHS FT e.g. Other DOH Below 2,500,000 SfH Chief Executive OR SfH Director of Finance Legally Binding Expenditure Contracts All contracts Above 50,000 SfH Chief Executive AND SfH Director of Finance All contracts Between 5,000 and 50,000 SfH Director of Finance (Following compliance with Competitive Tendering, Quotation and Procurement regulations and guidelines) Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 17 Page 87

90 Expenditure below 5,000 do not require a legal contract to be enacted Expenditure Service Level Agreements (within public sector only) Expenditure below 5,000 do not require a SLA to be enacted Above 500,000 Between 250,000 and 500,000 SfH Chief Executive Between 5,000 and 250,000 SfH Director of Finance Approval by Executive Team AND Signed by EITHER SfH Chief Executive OR SfH Director of Finance To Note: ONLY those Directors above have authority for signing Contracts and Service Level Agreements Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 18 Page 88

91 Appendix 1 SfH Board Standing Orders Introduction The Board of Skills for Health has responsibility for ensuring appropriate use of its resources for achievement of its objectives. These Standing Orders (SOs) have been drawn up to regulate the proceedings of the organisation so that members can fulfil their obligations. They are effective from [DN: insert approval date] Standing Orders, together with Delegated Powers and Financial Policies, provide a procedural framework within which the organisation discharges its responsibilities and obligations. They deal with the business of the organisation, procedure at meetings of the Board and any committees or panels, delegation of powers, declaration of interests and standards of conduct. The Delegated Powers and Financial Policies have effect as if incorporated into the Standing Orders. Members and employees should be aware of the existence of these documents and, where necessary, be familiar with their detailed provisions. Place of Business The principal place of business of Skills for Health is Goldsmiths House, Broad Plain, Bristol BS2 0JP. Meetings The Board will meet at least four times each financial year, and more often as necessary. Skills for Health Board meetings not subject to the provisions of the Public Bodies (Admission to Meetings) Act 1960 that govern the public meetings of other NHS bodies. Business to be Transacted The Chief Executive is responsible for proposing agendas for approval by the chair. Agendas for meetings shall include declarations of interest as a standing item. Quorum The Board will be quorate providing at least 9 members are present. Records of Attendance A meeting of the Board may be held either in person or by suitable electronic means agreed by the Board in which all participants may communicate with all the other participants The Board Secretary shall record the circumstances of any member attending a meeting by telephone or video conferencing facility. The Board Secretary shall record the names of all members present at a meeting in the minutes of the meeting. Substitute members Any member of the Board shall be able to send a substitute member to a single Board meeting who shall have the power of proxy-voting for the full member, providing always that such substitute membership has been agreed prior to the meeting with the Chief Executive. Chairmanship of Meetings At any meeting of the Board, the Chairman, if present, shall preside. If the Chairman is absent from the meeting the Vice-Chairman, if there is one and they are present, shall preside. If the Chairman and Vice- Chairman are absent, the members present shall choose an employer member to preside. If the Chairman is absent from a meeting temporarily on the grounds of a declared conflict of interest the Vice-Chairman, if present, shall preside. Voting If a vote is required or sought it will normally be decided on the basis of a simple majority expressed by hand. If required by any member a vote will be taken by paper ballot with a decision made on the basis of a simple majority of votes cast. Any member can ask for their vote to be recorded, including the fact that the member abstained from voting. The Chair (or Vice-Chair in the Chair s absence) shall have a casting vote. Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 19 Page 89

92 Minutes The Director shall arrange for minutes of the proceedings of every meeting of the Board and its committees to be drawn up. They will contain a summary of the discussion, any reported conflicts of interest, matters approved, actions agreed and the date and time of the next meeting. They will also include details of any professional advice obtained. Minutes will be submitted to the Chairman for agreement by the Board at the following meeting. No discussion shall take place upon the minutes except upon their accuracy or upon matters arising from the minutes. Any amendments to the minutes shall be agreed and recorded at the following meeting of the Board. Once agreed, the version, including any amendments required by the Board, shall be signed by the Chairman. Minutes shall be circulated in accordance with the Board s wishes. Urgent Business Any five members of the Board shall have the right to request the Chair and Chief Executive to call a special meeting of the Board for any specified purpose within two months of such a request being made. Such a request will be put in writing to the Chief Executive and the Chair and the Chief Executive or Chair shall be able to call the meeting without agreement from the other individual. Such a request for an additional meeting will need to be in writing and signed by a minimum of five Board members. Committees The Board may establish standing or ad hoc committees or advisory groups, consisting of such numbers and for such purposes as the Board may determine. The provisions of these Standing Orders shall apply where relevant to the operation of all committees, unless these Standing Orders specify otherwise. They shall not apply to advisory groups. Membership of Committees The appointment of committee members shall be a matter for the Appointments and Remuneration Committee to propose, and effective following the approval of the Board. Senior managers may be appointed as members of or required to attend committees in an advisory capacity. In addition, and subject to the approval of the Board, a committee may co-opt such other person or persons, as they deem necessary for the proper execution of their duties. All such appointments shall be reported to the Board for ratification. A person who is not a member of the Board of Skills for Health may participate in discussion and advise but may not take part in any decision on the exercise of any functions unless the Board so determines, and unless the members form a majority of those taking part in any decision. Dates and venues of committee meetings shall be set in advance and notified to all Board members. The Board will determine the minimum number of committee meetings to be held each year. Additional committee meetings may be called at any time by the chairman of the committee. Details of all business to be transacted at committee meetings shall be sent to any member of the Board who has specifically requested them. Any Board member shall be entitled to attend as an observer of any meeting of any committee of which he/she is not a member, subject to there being no conflict of interest. Quorum At any meeting of a committee, the quorum of members who must be present (whether in person or by telephone or video link) shall be set out in the terms of reference for that committee. Reporting The chairman of the committee shall provide written minutes of the discussion and recommendations of the committee meetings to the next appropriate meeting of the Board. The record should indicate any professional advice that the committee may have obtained in the course of its work. Declaration of Interests The Chairman and all board members should declare any conflict of interest that arises in the course of conducting Skills for Health business. Skills for Health maintains a register of member s interests to avoid any danger of board members being influenced, or appearing to be influenced, by their private interests in the exercise of their public duties. All Board Members, the Chief Executive and Executive Team will complete the register of all interests affecting their membership or employment with Skills for Health. This should include, as a minimum, personal direct and indirect financial interests, and should also include such interests of close family members. Indirect financial interests arise from connections with bodies which have a direct financial Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 20 Page 90

93 interest, or from being a business partner of, or being employed. The register will be maintained by the Director of Finance and will be available for open inspection by the Board at any time. Notwithstanding such a register, Board Members will be expected to indicate any possible conflict of interest when discussing issues at the Board or any committee or sub-committee of it, and if necessary, or required by other members, should withdraw from any discussion and vote on such an issue. Register of Interests All Board Members, the Chief Executive, Executive Team Members and other senior staff shall be expected to complete a register of all interests affecting their membership or employment with Skills for Health. Such a register will be maintained by the Director of Finance and will be available for open inspection by the Board at any time. Notwithstanding such a register, Board Members will be expected to indicate any possible conflict of interest when discussing issues at the Board or any committee or sub-committee of it, and if necessary, or required by other members, should withdraw from any discussion and vote on such an issue. Procedure at Meetings If any member has a direct or indirect interest as defined in the Standing Order above in any contract, proposed contract or other matter and is present at a meeting of the Board or a committee at which the contract or other matter is the subject of consideration, he/she shall, at the meeting and as soon as possible after its commencement, disclose the fact. The member shall not take part in the consideration or discussion of the contract or other matter or vote on any question with respect to it unless, exceptionally, the Board considers the interest to be of a nature which brings no risk of a real or perceived conflict of interest. Where, in accordance with the above, a member does not participate in the consideration of a matter, he or she shall normally withdraw from the meeting during that item of business unless expressly invited to remain in order simply to provide information. The disclosure of interest shall be recorded in the minutes of the meeting. Standards of Conduct Members are required to comply with the seven Nolan Principles as described Appendix 2 of the organisation s Corporate Governance Manual. Staff are required to comply with the standards of conduct set out in the organisation s policies. Use of Information No member shall use information gained in the course of his or her work with Skills for Health for personal gain nor seek to use the opportunity of their position to promote their own or other parties private interests. Members should at all times avoid behaving in a manner which might bring the organisation into disrepute. Gifts, Hospitality and Other Expenditure No member may corruptly solicit or accept any gift or consideration as an inducement for doing or refraining from doing or showing favour or disfavour to any person in an official capacity. Members should exercise the utmost care in accepting hospitality or gifts where there could be a real or perceived conflict with their official duties at Skills for health. They should declare in the hospitality register all such gifts or hospitality (whether accepted or not). As a general principle, Board members should set an example to their organisation in the use of public funds and the need for good value in incurring public expenditure. The use of Skills for Health monies for hospitality and entertainment, including hospitality at conferences or seminars, should be carefully considered. All expenditure on these items should be capable of justification as reasonable in the light of the general practice in the public sector. Appointments No member shall solicit any employment by Skills for Health for any person with intent to bypass due process. This Standing Order shall not preclude a member from giving written testimonial of a candidate s ability, experience or character for submission to the organisation. Relatives of Members Members shall disclose to the Chief Executive any relationship with a candidate for a staff appointment of whose candidature he/she is aware. The Chief Executive shall report to the Board any such disclosure made. On appointment, members should disclose to the Chief Executive whether they are related to any other member or holder of any office within the organisation. Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 21 Page 91

94 Indemnity Skills for Health is a public body, hosted by an NHS trust, and therefore part of the NHS. As such, Board Members have no independent legal liability but are expected to act at all times within the spirit and regulations of the public sector and UHBFT in particular. Members will be bound by the Standing Orders and Standing Financial Instructions of UHBFT and can seek advice on any issues from the Trust Chief Executive, Director of Workforce and Organisational Development or Director of Finance. Acting outside of the Standing Orders and Standing Financial Instructions, or in a way unacceptable to the public sector may render the Board Member liable for dismissal and disqualification from Board Membership. Provided that a member has acted honestly and reasonably and in good faith, the trust will indemnify him/her against any personal liability that may be incurred by him/her in the execution or purported execution of Board functions, save where the member has acted recklessly. Amendment of Standing Orders These Standing Orders or any of them may be amended by alteration, addition or deletion provided that: amendment or variation of the standing orders does not contravene the powers and authority delegated to Skills for Health by the University Hospitals Bristol NHS Foundation Trust or the provisions of the Memorandum of Understanding between Skills for Health and the University Hospitals Bristol NHS Foundation Trust; at least five days notice shall be given of the proposed amendment; the amendment shall be approved by a majority of not less than two-thirds of the members present and voting at the meeting in which it is moved; The Board shall review Standing Orders annually. The review shall include all other documents having effect as if incorporated into standing orders. Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 22 Page 92

95 Appendix 2 The Nolan Principles As an SSC we are committed to adhering to the seven key principles of public life as outlined by the Nolan report 1 Selflessness - Holders of public office should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their families or their friends. Integrity - Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that may influence them in the performance of their official duties. Objectivity - In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. Accountability - Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. Openness - Holders of public office should be as open as possible about all their decisions and the actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. Honesty - Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. Leadership - Holders of public office should promote and support these principles by leadership and example. 1 (The First Report of the Nolan Committee on Standards in Public Life, 1995) Version [1] Skills for Health Governance Manual Issue [1] Approved version will be held on the intranet [July 2010] Check with intranet that this printed copy is the latest issue 23 Page 93

96 Appendix 3 SfH Internal Governance and Structure Skills for Health is governed by a Board of 17 members including strong representation from major employers. The Board ensures the application of public service codes of conduct and accountability across the organisation. The Board will determine from time to time appropriate mechanisms to engage with key stakeholders UHBFT Board Skills for Health Board 17 members 9 = quorum Appointments and Remunerations Finance Governance and Risk Strategic Development Version [1] Issue [1] [July 2010] Skills for Health Governance Manual Approved version will be held on the intranet Check with intranet that this printed copy is the latest issue 24 Page 94

97 Trust Board Meeting 26 th August 2010 Agenda Item Title of Report Annual Risk Assessment 2010/11 (Annual Plan) - Results Notification Abstract Following the submission of the Trust s Annual Plan 2010/11 in May 2010, Monitor has informed the Trust of their assessment. The Trust has not been selected for a second-stage review of its Annual Plan. Monitor s Annual Risk Assessment for 2010/11 includes a: - Financial Risk Rating of 4 and a; - Governance Rating of Amber Green. The Financial Risk Rating is consistent with the Annual Plan. The Governance Rating is different to that submitted in the Annual Plan 2010/11 (Amber Red). This is due to technical changes in Monitor s Compliance Framework for 2010/11 that reduces the monitoring of certain performance targets. This Monitor assessment relates to the Annual Plan. In terms of the operational delivery of the Annual Plan, the Trust s commitment is to work towards achieving a Green rating for inyear performance. The Executive Summary (Appendix 2) describes Monitor s assessment of the key risks facing the Trust, including 62-day Cancer target performance and financial and activity pressures. Recommendations The Board is asked to note the outcome of this Assessment. Prepared by: Name & Title Ben Hume, Head of Business Planning Presented by: Name Deborah Lee, Director of Corporate Development Page 95

98 & Title Appendices Appendix 1 Feedback Letter from Monitor Appendix 2 Annual Plan Review: Executive Summary Previous Meetings Please insert the date the paper was presented under to the relevant group Exec Team Audit & Assurance Committee Governance Risk and Risk Management Finance Committee Trust Executive Group Other Meeting (Please state) 18 th August 2010 In completing this report, I confirm the following matters have been considered: a) Implications for the NHS Constitution b) Implications for CQC registration c) Implications for corporate objectives d) Financial implications of the recommendations e) Equalities Impact Any material considerations are reported overleaf. Page 96

99 29 July 2010 Mr Robert Woolley Acting Chief Executive University Hospitals Bristol NHS Foundation Trust Trust HQ Marlborough Street Bristol BS1 3NU 4 Matthew Parker Street London SW1H 9NP T: F: W: Dear Mr Woolley 2010/11 Annual Plan I am writing to you in relation to the 2010/11 Annual Plan review (APR). As you are aware, Monitor changed its annual plan review process for 2010/11 to enable it to assess whether NHS foundation trusts are effectively planning for the future and to make a more informed judgement about the risks to the Terms of Authorisation for individual trusts. As previously communicated, under the new APR process all NHS foundation trusts are subject to a stage one review (a two day desk top review of annual plans completed in July). Following this, a number of trusts will be subject to a more indepth review during August. The purpose of this change was to allow Monitor to spend more time focussing on plans where: - there are apparent weaknesses in the planning processes, including a failure to demonstrate an understanding of the effect that proposed actions may have on financial performance and the quality of care provided; and/or - plans demonstrate risks to the Terms of Authorisation, including financial stability or wider healthcare or governance issues. We have now completed the stage one review on your 2010/11 Annual Plan and, based on your return, your Trust has the following annual risk ratings for 2010/11: Financial Risk Rating 4 Governance Rating Amber-Green You will note that your governance rating shown here is different to the governance rating that you submitted. This is because an over-ride has been made, to reflect the changes to Monitor s Compliance Framework as set out in David Bennett s letter to you dated 2 July Page 97

100 These ratings will be published on Monitor s website in early August. We will also publish on our website, under your entry in the Public Register of NHS foundation trusts, a new 2010/11 Schedule 2 (Mandatory Goods and Services), Schedule 3 (Mandatory Education and Training) and Schedule 5 (Limit on Borrowing). Copies of these schedules are attached and, in the event you have any queries or comments, I should be grateful if you would revert to me in the next five days. Monitor will continue to assess the risks to the Trust s Terms of Authorisation through the returns provided by you as part of its normal quarterly monitoring process which commences with the review of quarter one in August We will publish an update to the risk ratings following this review. University Hospitals Bristol NHS Foundation Trust has not been selected for a stage two review. However, it is important that the Trust Board continues to monitor the risks to its terms of Authorisation and takes appropriate mitigating action where necessary. Recognising the significant level of Cost Improvement programmes (CIPs) that need to be delivered across the Health Sector, all Trust Boards should assure themselves that where CIPs are being implemented, the quality of services is being improved and that the Trust can continue to deliver safe services. It should be noted that where an NHS foundation trust qualifies for a Stage 2 review, but is already subject to in-depth external analysis or where Monitor has chosen to understand the plans better during the regular regulatory process, it may be excluded from a Stage 2 review. For your information I also attach the Executive Summary which is derived from our analysis of your Trust s Annual Plan. I would emphasise that the cut off date for this was the conclusion of our Annual Plan fieldwork during July. Consequently subsequent discussions which may have taken place are not reflected. As in previous years, Monitor intends to publish a summary of findings from the Annual Plans that have been submitted which will include aggregated information from all NHS foundation trusts and the emerging themes from our review. We intend to publish the information contained in this document during August We would welcome any feedback you have on the APR process and how it can be improved for 2011/12. In particular, we understand some Trusts have had difficulty with the templates. Your feedback will help us improve these for next year. Please katherine.cawley@monitor-nhsft.gov.uk or me with your comments. If you have any queries in relation to any of the above, please contact me by telephone on or by (Rupinder.Singh@monitor-nhsft.gov.uk) at the earliest opportunity. Page 98

101 Yours sincerely Rupinder Singh Senior Compliance Manager cc: Dr John Savage, Chairman Mr Paul Mapson, Finance Director Page 99

102 University Hospitals Bristol NHS Foundation Trust 2010/ /13 Annual Plan Review Q1 Q2 Q3 2010/11 FRR Governance AG 2011/ /13 FRR 4 3 Continue monthly monitoring of the 62 day cancer target. Financial Summary m Actuals Plan Plan Plan Revenue (Total) Employee Expenses (294.9) (301.8) (297.9) (287.1) Drugs (33.6) (34.8) (36.8) (38.9) PFI operating expenses Other costs (118.2) (122.0) (117.9) (114.4) EBITDA Depreciation and amortisation (17.6) (19.2) (19.0) (19.3) Net interest (0.3) (0.3) (0.7) (1.6) Other (25.4) (10.0) (11.7) (11.7) Net Surplus / (Deficit) (4.3) Liquidity Liquidity rating of 4 in 10/11 forecast represents 32 days liquidity. This is broadly maintained in each year of plan. Working capital facility of 37.5m in place for 10/11 and forecast to be remain unutilised. Long term borrowing limit 71.9m EBITDA % Income % 8.0% 7.2% 7.6% 7.5% CIP % of operating costs 2.5% 3.3% 3.9% 4.0% Net Surplus / (Deficit) (4.3) Change in working capital (5.9) (3.0) (2.7) (0.2) Non cash I&E items Cashflow from operations Cashflow from investing activities (23.7) (29.3) (47.3) (53.1) Cashflow before financing (13.8) (18.6) Cashflow from financing activities 0.4 (12.6) Net increase/(decrease) in cash 7.9 (10.4) (1.6) (1.2) Loans drawn down at 31 March 10 Financial. Key risks 6.4m Cash at period end Cash and Cash equivalents at PE Mitigating actions/next steps Track record of over-performance could persist within the context of a tightening financial envelope and potentially ineffective demand management measures. Ability to deliver 52m of CIP schemes over the 3 year plan is a challenge in the context of CIP slippage in 09/10 against a relatively less demanding target. FTFF loan of 59m to enable Bristol Royal Infirmary development remains to be secured. Contract reflects an increase in activity to reflect trends and is therefore considered to be robust. Trust has included 6m of contingencies in 10/11 to provide for various risks including CIP slippage. Trust s Bristol Royal Infirmary project is dependent on FTFF funding. The Trust should assess the risk of committing funds to this scheme in advance of a decision by FTFF. Governance and Quality of Plan Key risks Mitigating actions/next steps The Trust has declared a risk of failing both elements of the 62 day cancer target (Drug and Surgery), two week wait from referral to first seen (symptomatic breast patients) cancer target, and the 4 hour A&E target resulting in a score of 2.0. However, due to the changes in Monitor s Compliance Framework the Trust s declaration has been overridden to remove the A&E risk. As a result, the Trust s governance score is now 1.5 and GRR is Amber/Green. Acting Chief Executive in place since December 09 following Graham Rich s resignation. As the Trust was red rated for governance at Q4 09/10 arising from 3 consecutive quarterly failures against the 62 day cancer target, it will remain on monthly monitoring. Should the Trust not achieve its trajectory for compliance against this particular target, Monitor will consider escalation to determine if this represents a significant breach of the Trust s terms of Authorisation. The Trust is in the process of appointing a substantive CE. Robert Woolley is currently Acting Page Chief 100Executive. 0