Tameside and Glossop Integrated Care NHS Foundation Trust. Board of Directors February Chair's Report

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1 Agenda Item 6 Tameside and Glossop Integrated Care NHS Foundation Trust Appointment of new Non-Executive Director Board of Directors February 2018 Chair's Report I am pleased to be able to confirm that Peter Noble has joined the Board as a Non- Executive Director, from the start of the month. Subject to the approval of the Board, I have asked Peter to join the Audit Committee and the Quality and Governance Committee, together with the Charitable Funds Committee. He will also be a member of the Nomination and Remuneration Committee, in common with all other Non-Executive Directors. External meetings I have been holding a number of meetings through the month to get to know the key people in the local health economy, including- Alan Dow, Chair of the Tameside and Glossop CCG; Steven Pleasant, Chief Executive of Tameside Council and Interim Accountable Officer of the CCG; Adrian Belton, Chair of Stockport NHS Foundation Trust; Diane Whittingham, GM lead for Acute and Specialist Care Topics of conversation have included how to refocus on delivering the agreed outcomes from the Healthier Together programme in a way that mitigates some of the operational, clinical and financial challenges the partners are facing. I have followed Paul Connellan as the Chair of the Care Together Programme Board, which has oversight of the joint working within the local health economy between the Trust, the CCG and the Council; and led my first meeting of the Board during this month. With the Chief Exeutive, I have met with New Charter Housing Group to consider how they can support our activity in the Tameside community. I have also attended the meeting of the North Region's Chairs of provider Trusts; from which the following important points came out- There was considerable pressure on the system in the North, with sustained rises in volume and acuity A number of organisations are struggling to meet agreed financial targets NHS Improvement and NHS England are seeking to work more closely together, and would also like to work more closely with the Care Quality Commission; There was a briefing on the developing national workforce planning, noting that there hasn't been a reduction overall in nursing training applications following the changes in student financial support. However, there are challenges for Trusts in supporting staff who need or want to train for different roles. There was a discussion regarding spend on medical locums, with an indication from regulators that they are looking for a target of no more than 3%. Whilst our spend at about 8% is not an outlier at present, I will be asking the Finance and Performance Committee to review the available assurance that all appropriate steps to manage

2 Agenda Item 6 this are being taken. Working with NHS Improvement on our financial position As the Board is aware, the Tameside and Glossop local health economy, covering both the Trust, the CCG and the relevant aspects of the Council's services, remains financially challenged. During the month, we have also been positively engaged with NHS Improvement in order to ensure that they understand the context to both the Trust's and the local health economy's financial position. We are also working closely with colleagues, both in the local health economy and in Greater Manchester, to develop long-term solutions that ensure the sustainability of this Trust and the local health economy across Tameside and Glossop. Jane McCall Chair

3 TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting on the 22 nd February, 2018 Agenda Item 7 Title Sponsoring Executive Director Author (s) Purpose Previously considered by Chief Executive s Report Karen James, Chief Executive Steve Parsons, Trust Secretary Information N/A Executive Summary: This report updates the Board on environmental developments, not covered elsewhere in the Board s business. Related Trust Objectives Risk Assurance risk impacted upon Legal implications/regulatory requirements Financial Implications Has a quality impact assessment been undertaken? How does this report affect Sustainability? All objectives are related to this paper. The items may relate to a range of risks, both operational and strategic The Trust is expected to follow the national planning guidance in agreeing the annual plan. The Trust is expected to follow the NQB s safe staffing guidance in providing services. None identified N/A If implemented, the national workforce plans will be significant in ensuring sustainable services. Action required by the Board The Board is invited to note the updates contained in the report.

4 National Planning Guidance NHS England and NHS Improvement have published the National Planning Guidance for the NHS planning round for Key points from the guidance are- With respect to A&E performance recovery trajectory, Trust s will be expected to meet 90% by September 2018, and return to 95% by March 2019; On Referral to Treatment standard, the expectation is that the waiting list should not be any higher in March 2019 than in March 2018, along with the expectation to halve the number of patients waiting 52 weeks in the same period; The guidance states that there will be no additional winter funding in 2018/19; The two year national tariff payment system is unchanged, with local systems encouraged to consider payment reform; There is no new detail on how funding for the lifting of the pay cap will be administered; Access to the support of the Provider Sustainability Fund (previously the Stability and Transformation Fund) remains dependent on acceptance of Control Totals. Furthermore access to 30% of the fund remains linked to A&E performance; Similarly, the benefit from a reduction in NHS Resolution's Clinical Negligence Scheme for Trusts (CNST) 'premium' will be taken to directly reduce Control Totals; There is strong encouragement for systems (previously Accountable Care Systems, now Integrated Care Systems) to take a system control total in , with the indication this will be compulsory in It isn't currently clear how such a total would relate to the Control Totals for individual organisations; Of particular note to the Board will be that Greater Manchester is one of the systems identified for possibly having a system Control Total, which would mean that they took primary responsibility for managing the control total compliance within the region. Greater Manchester is currently considering how to respond to this offer, and will have to notify the central bodies of a decision by 1 st March The Trust is required to submit draft plans by 8 th March, and a final submission approved by the Board by the end of April. The Board will be considering the Trust's position on the Control Total that has been offered by NHS Improvement in the private session at this meeting. Safe Staffing Guidance The National Quality Board have issued further guidance on safe staffing indicators in various types of care. Of particular relevance to this Trust are the guidance for adult patients in acute care; maternity services; and district nursing. These are being taken into account in both the Safe Staffing report that the Board sees at every meeting, and in the preparation of the workforce plans that will inform the Trust's annual planning submission. Kirkup Review of Liverpool Community Care Colleagues will be aware that Dr Bill Kirkup has completed his review of the issues identified at Liverpool Community NHS Trust between 2010 and It is a sobering read. They previously found that the Trust experienced significant failing in the care quaility, including an inexperience management and director team. The review found the Trust was focussed on its pursuit to achieve significant cost savings required by its commissioners which affected the quality of care being provided. The review also examined the role of external bodies for overseeing the Trust. The report highlighted the impact of organisational change that was taking place across commissioning and the Strategic Health Authorities. There are some lessons that the Trust should take into account; particularly ensuring that the Directors and the Board have appropriate levels of support

5 available (recommendation 6.1). Consequent on the publication of the report, the Government made a statement to the House of Commons outlining its response. Of note for the Board is the intention to review the operation of the 'Fit and Proper Person' test, with a view to considering whether it should be extended in scope and effect; and that restrictions could be introduced for secondments and similar where there are queries about the conduct of the affected individuals. We await to see the outcomes of this review and any changes in the legislation that arise as a result. Cyber-Security and Resilience Following the WannaCry incident in 2017, NHS England and the Department of Health and Social Security have published updates on cyber-security in the health system. The reports set out expectations of indvidual organisations in the proper management of their information systems; and of course this is backed by ensuring that we comply with the Data Protection Act, and the forthcoming (May 2018) implementation of the General Data Protection Regulation (EU). The Trust continues to take very seriously the need to ensure appropriate cyber-security, in order to protect the sensitive information that is entrusted to us. We continue to carefully monitor the security of our systems, and also the training provided to our staff, in order to minimise the risk of unauthorised access to information; and we are not aware of any concerns being raised by the Information Commissioner's office. Associate Medical Directors I'm pleased to be able to advise the Board that three Associate Medical Directors have now been appointed to support Mr Ryan as Medical Director; Alison Lee (GP) Vicki Howarth (Consultant Histopthologist) Fiona New (Consultant Obstetrician and Gynaecologist)

6 TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 22 nd February, 2018 Agenda Item 8 Title Integrated Performance Report: January 2018 Sponsoring Executive Directors Trish Cavanagh, Director of Operations Brendan Ryan, Medical Director Amanda Bromley, Director of HR Claire Yarwood, Director of Finance Tracey McErlain-Burns, Interim Chief Nurse Author (s) Peter Nuttall, Director of Performance & Informatics Purpose To note/receive/comment on actions to address Previously considered by performance This report has not been considered by any other meeting Executive Summary The Trust reported failure of one of the performance metrics included in the Single Oversight Framework (SOF), the emergency four-hour target. Exception reports are included for the emergency four-hour target; inpatient and Emergency Department discharge summaries; outpatient DNA rate; theatre utilisation; and staff attendance. The report includes additional metrics from the SOF. The dashboard is organised to reflect the CQC s domains of Safe, Caring, Well-led, Effective and Responsive. Related Trust Objectives Risk Assurance risk impacted upon Legal implications/regulatory requirements Financial Implications Objective 1 - All patients receive harm-free care through the delivery of the Trust s Patient Safety Programme. Objective 2 - To improve the quality of patient care through the implementation of the Trust s agreed Quality Strategy. Objective 3 - To improve the patient experience through a personalised, responsive, compassionate and caring approach to the delivery of patient care. Objective 7 - To deliver against the required local and national frameworks in order to meet all the requirements of the Trust s operating licence and the commissioners requirements. Relates to all aspects of Board Assurance Framework and Significant Risk Report. This report indirectly impacts on CQC fundamental Standards of Care and licence requirements. Tameside and Glossop SCF may apply financial penalties for failing to achieve specific performance targets. This is the Medical Director and Chief Nurse Has a quality impact assessment been undertaken? view on the impact of any service change How does this report affect Reflects current risks to the Trust s business Sustainability? and strategic objectives Action required by the Board Alongside the Integrated Performance Dashboard, the report includes exception reports, which respond to the performance data and allow the Executive Team and Trust Board to be assured of, and contribute to, plans to rectify performance and quality issues.

7 This page is intentionally blank INTEGRATED PERFORMANCE REPORT: February 2018 Board (January 2018 performance) Page 2

8 Board of Director s Meeting 22 nd February 2018 Integrated Performance Report 2017/18 Contents Introduction and Performance Summary 4 List of Acronyms 5 Dashboard 2017/18 6 Director of Operations Cancer 62-day target 7 Exception Reports Medical Director Inpatient/ Emergency Department discharge summaries 8 Director of Operations Emergency four-hour target 9 Outpatient DNA 10 Theatre utilisation 11 Director of Human Resources Staff attendance 12 Thresholds for INTEGRATED PERFORMANCE REPORT: February 2018 Board (January 2018 performance) Page 3

9 January 2018 Performance Introduction This report provides the Trust Board with an overview of the Trust s performance across a range of quality and operational indicators for the month of January 2018; and year-to-date performance, along with a RAG rating, to support the Board in evaluating performance against each indicator. The report includes a redesigned dashboard that now includes additional metrics from the Single Oversight Framework. The dashboard is organised to reflect the CQC s domains of Safe, Caring, Well-led, Effective and Responsive. Exception Reports Alongside the Integrated Performance Dashboard, the report includes exception reports, which respond to the performance data and allow the Executive Team and Trust Board to be assured of, and contribute to, plans to rectify performance and quality issues. All serious incidents are reported to Trust Board in Part 2 of the meeting for patient confidentiality reasons; therefore, no exception report is provided for this indicator. January Performance Exception reports are included for the emergency four-hour target; inpatient and Emergency Department discharge summaries; outpatient DNA rate; theatre utilisation; and staff attendance. Mortality In the latest Summary Hospital-level Mortality Indicator (SHMI) publication, THFT has a value of 108 for the period July June The SHMI is, therefore, greater than the mean value of 100, but within the as expected control limits. The hospital s Standardised Mortality Ratio (SMR), for the latest available twelve months, is 89.2, which is better than expected. Stroke Targets The Trust Board is asked to note the Trust s banding of c for the SSNAP (Sentinel Stroke National Audit Programme) national stroke audit for the period August- November 2017, where the poorest performing trusts are classified as e and the best as a. The SSNAP audit includes 44 measures in 10 domains. The Trust s banding for the previous period was d. Medicines Reconciled The recent increased focus on discharges to support patient flow has reduced the time available for medicines reconciliation; however, 74% benchmarks in the upper quartile when performance is compared to the GM and national peer groups. A business case has been approved to increase the number of Clinical Technicians and Prescribing Pharmacists in order to improve medicines reconciliation. Emergency Readmissions within 30 days The 30-day readmission rate was greater than the local target level of 11%, at 12.1%, for the month of December; however, the Trust is rated amber for the year-to-date with performance of 12.1%. Referral-to-Treatment/ Diagnostic Six-Week- Wait Target/ Cancer Waiting Times Targets For January, the Trust met the national Referral-to-Treatment standard (incomplete pathways) with performance of 92.22% against the threshold of 92%. In addition, the Trust reported that no patients had a waiting time of more than 52 weeks at the end of January. The Trust also met the national cancer standards and the diagnostic six-week- wait target (with zero breaches) for the latest reporting months. Outpatient Clinic Utilisation Outpatient clinic utilisation has reduced as a result of seasonal factors, such as increased DNA, and due to the ongoing exercise to rebuild the clinic templates in Lorenzo and the associated data reports. Mandatory Training/ Appraisals The appraisal rate is 86.3%, which is below the required standard of 90%, but within the amber threshold for performance. Performance for mandatory training was 91.1%, so that the indicator is rated as amber meaning that an exception report is not required. INTEGRATED PERFORMANCE REPORT: February 2018 Board (January 2018 performance) Page 4

10 List of Acronyms ADT C DIFF CQC CT CWT DNA DToC ED ENP ESDT ETD FFT GM GMCCN HSMR HAS IAU IR35 ICO MRSA MSA NWAS PTL RAID RCA REACT RIDDOR ROSIER RTT SAFER SALT SCF SHMI SOF SOP SSNAP STAR StEIS TEP TIA TNA VTE WTE YTD Admission, Discharge, Transfer Clostridium difficile Care Quality Commission Computerised Tomography Cancer Waiting Times Did-not-Attend Delayed Transfers of Care Emergency Department Emergency Nurse Practitioner Early Supported Discharge Team Education, Training and Development team Friends & Family Test Greater Manchester Greater Manchester & Cheshire Cancer Network Hospital Standardised Mortality Ratio Hospital Arrival Screen Integrated Assessment Unit Tax legislation relating to workers supplying services to clients via an intermediary Integrated Care Organisation Methicillin-resistant staphylococcus aureus Mixed-sex Accommodation North West Ambulance Service Patient Tracking List Rapid Assessment Interface and Discharge (psychiatry liaison service) Root Cause Analysis Rapid Assessment Emergency Care Team Reporting of Injuries, Diseases and Dangerous Occurrences Regulations Rule Out Stroke in the Emergency Room Referral-to-Treatment Patient Flow Bundle (Senior review; All patients with expected discharge date; Flow of patients at earliest time; Early discharge; Review of patients with extended lengths-of-stay) Speech and Language Therapy Single Commissioning Function Summary Hospital-level Mortality Indicator Single Oversight Framework Standard Operating Procedure Sentinel Stroke National Audit Programme Staff Accident Rate Strategic Executive Information System Trust Efficiency Plan Transient Ischaemic Attack Training Needs Analysis Venous Thromboembolism Whole Time Equivalent Year-to-Date INTEGRATED PERFORMANCE REPORT: February 2018 Board (January 2018 performance) Page 5

11 THFT QUALITY ACCOUNT 2017/18 Quality Dashboard January 2018 SAFE SERVICE PROVISION RESPONSIVE SERVICE PROVISION EFFECTIVE SERVICE PROVISION Target Actual 4-mth Actual Current 1-mth Target Actual 4-mth Actual Current 1-mth Target Actual 4-mth Actual Current 1-mth Key Performance Indicators Key Performance Indicators Key Performance Indicators 17/18 YTD Trend Month Period F'cast 17/18 YTD Trend Month Period F'cast 17/18 YTD Trend Month Period F'cast Mortality 4-hour wait* Stroke SMR (rolling 12 months- to Oct-17) NA Type 1 and Type 3 activity 95% 90.95% 85.85% SSNAP DSC Stroke Indicators NA NA 7 NA NA SHMI (rolling 12 months- to Jun-17) NA Type 1 activity NA 84.94% 74.15% NA NA Number achieved out of 9 (Aug-Nov 17) Infection Prevention & Control Waiting times Efficiency MRSA - actual cases YTD* week incomplete* 92% 92.69% 92.22% Outpatient slot utilisation 92% 87.9% 86.2% C-difficile - actual cases YTD* NA 63 6 NA NA RTT waits- incompletes (>52 weeks) Theatre utilisation (capped) 90% 86.9% 84.6% C-difficile - avoidable cases YTD* - Cancer Discharge Summaries Cancer- Composite Indicator Provisional (Nov-17) A&E (within 48 hours) 8 NA 7 95% 80.9% 60.8% Safer Staffing Number achieved out of 8 (Dec-17) Inpatients (within 48 hours) 95% 81.6% 81.7% RN/RM hrs on shift (% of planned) NA 92.5% 93.06% NA NA Efficiency Outpatients (within 5 days) 95% 90.8% 92.4% HCA hrs on shift (% of planned) NA 104.6% % NA NA Outpatient DNA rate 6.5% 8.41% 8.22% Discharge Summary Quality Audit (Dec-17) 100% NA 93.7% NHS Safety Thermometer Cancelled operations- last-minute (provisional) 0.8% 1.02% 1.04% Harm-free care (all harms) NA 94.0% 93.57% NA NA Urgent operations cancelled for a second time WELL-LED SERVICE PROVISION Harm-free care (new harms) 98.5% 98.3% 97.86% Delayed Transfers of Care- Days NA 6, NA NA Key Performance Indicators Target Actual 4-mth Actual Current 1-mth Patient Safety 17/18 YTD Trend Month Period F'cast VTE risk assessments (provisional) 96% 98.2% 98.42% Stroke Medicines reconciled 95% 83.2% 74% CARING SERVICE PROVISION SSNAP Grading (Aug-Nov 17) B NA C NA on admission (Dec-17) Key Performance Indicators Target Actual 4-mth Actual Current 1-mth People Nutrition risk assessment 95% 97.9% Data Not Available 17/18 YTD Trend Month Period F'cast Mandatory training (Overall) 95% NA 91.1% Emergency re-admissions within 30 days (Dec-17) Failure of safer-surgery process Serious Incidents reported (StEIS) 11% 12.1% 12.1% Patient Experience Qualified Nurse & Midwifery Turnover NA NA 11.65% NA NA FFT positive responses (all) NA 91.14% 91.44% NA NA All Staff Turnover NA NA 11.57% NA NA FFT response rate (A&E/ Inpatients) 20% 20.96% 23.31% A&E Complaints received NA NA NA HAS compliance 95% 94.8% 92.1% 'Duty of Candour' breaches Complaints responded to within 90% 93.2% 91.67% Notify to Handover (30-60mins) (Dec-17) Never Events reported (StEIS) agreed timescale Notify to Handover (>60mins) (Dec-17) Regulation 28 reports (inquests) Ombudsman cases upheld Finance (Period: Apr-Jan-18) Plan ( ) Actual ( ) Variance ( ) Rating A&E Staff Health and Safety Capital Service Capacity (2.8) (3.7) (0.9) 4 Trolley waits in A&E (>12 hrs) RIDDOR incidents reported Liquidity (days) (76.4) (61.6) 15 4 Maternity Calendar days lost (Staff Accidents) NA NA NA I&E margin (20321) (21013) (693) 4 Emergency C-Section rate <15.6% NA 17.50% Staff Accident Rate < Trust Efficiency Savings (206) 4 1-month forecast The one-month forecast is an informed prediction of the next month's performance, which may be based on part-month data, operational intelligence and historical trends. Actual is upto January unless stated otherwise. * Governance indicators, which appear in the Single Oversight Framework 4-month trend People Agency spend (3036) 4 96% 95.00% 94.02% Use of Resources Rating strong improvement Appraisals - rolling 12 mths 90% NA 86.3% Regulatory improvement FFT- Staff Survey (quarterly) Single Oversight Framework (Oct-Dec 17) no change Recommend Treatment (Jul-Sep 17) 80% NA 81% CQC Rating* (Oct-Dec 17) Good - deterioration Recommend Work (Jul-Sep 17) 74% NA 76% strong deterioration Staff Attendance QUALITY ACCOUNT: February 2018 Board (January 2018 performance) Page 6

12 Integrated Performance Report: Director of Operations Responsive Service Provision: Cancer Waiting Times Target Current Performance 62-day GP Referral to Treatment-Overall: (Reporting Period: Dec 2017) 85% 90.3% 4 Month Trend Previous Performance Forecast Acute trusts are required to support NHS England s commitment to Improving and Sustaining Cancer Performance. One action required of trusts is that they report tumour- site- specific performance against the 62-day cancer target to their Board, irrespective of performance against the aggregate target. This report highlights the Trust s overall and tumour- site- specific performance against the 85% threshold. The period that it relates to is December 2017 and the position stated has been fully validated, in line with the Greater Manchester- wide Reallocation Policy. For the month of December 2017, the aggregate 62-day position was 90.3%, which means that the Trust met the national standard for the month. The breaches in December were the result of: 3 x complex / multi-tumour sites / patient comorbidities. Near Misses Acute trusts are also required to include, in the reports provided to their Board, data relating to patients treated within 48 hours of their breach date. In the month of December four patients were near misses for the following reasons: 4 x complex / multi-tumour sites / patient comorbidities. Treated after day 104 A full breach analysis, and clinical assessment, must be conducted on patients with a total wait greater than 104 days. If harm has been caused by the treatment delay, a full Serious Incident investigation must be undertaken by the treating Trust. In December, zero patients were treated post day Expected date to meet target NA Signed off by Jan Smart Signed off by Trish Cavanagh Page 7

13 Integrated Performance Report Exception Report: Medical Director (1/1) Effective Service Provision: Efficiency Target Current Discharge Summaries- A&E: (Reporting Period: January 2018) 95% Performance 60.8% 4 Month Trend Previous Performance Forecast Discharge Summaries- Inpatients: (Reporting Period: January 2018) ISSUE Performance was below target for both inpatient and Emergency Department discharge summaries in January. Performance against the 95% target for outpatient clinic letters was 92.4% (amber rated) so that an exception report is not required. The ED discharge summary target was not met due to a reduction in the number of summaries completed by the ED clinical staff, exacerbated by resource issues in both the Clinical Coding Team and the ED administration team. It is important to note that discharge summaries for the most urgent patients are prioritised. 81.7% of inpatient discharge summaries were completed within 48 hours in January. ACTIONS The roll-out of the new ecas card will be completed in February/ March. This electronic solution, when fully implemented, will deliver: >99% CAS card completion; 0% loss of CAS cards; and the elimination of the need to scan. It will also automate the completion and dissemination of ED discharge summaries. 1,000 CAS cards were completed, using the electronic CAS card, in the first two weeks of February. The ecas will be rolled out to GP streaming activity from February 12 th, to ED paediatric activity on March 1 st and for the remainder of ED activity by mid-march. Some of the resource freed by completion of the ecas card project will be used to support improved performance against the inpatient discharge summary target. PROPOSED ACTIONS The Medical Director is leading the development of an action plan designed to improve performance against the inpatient metric. ASSESSING IMPROVEMENT Using the bespoke performance reports. ED discharge- summary performance is expected to be >95% for data relating to April Expected date to meet target Quarter Signed off by G Lavelle 95% 81.7% Signed off by Brendan Ryan Page 8

14 Integrated Performance Report Exception Report: Director of Operations (1/3) Responsive Service Provision: Emergency Four-hour Standard Target Current Performance Type 1 and Type 3 activity: (Reporting Period: January 2018) 95% 85.85% 4 Month Trend Previous Performance Forecast ISSUE The Trust did not meet the four-hour emergency- care standard, or the national improvement trajectory requirement of 90%, in January; however, the Trust s performance was the best reported by a GM trust. Lack of physical capacity in the ED to see patients during periods of surge and high demand; An increase of 300 attendances (4%) in January, compared to January 2017; Medical bed-pool occupancy was routinely at 98% leading to reduced capacity on AMU and IAU; Demand continues to grow, a consequence of increased acuity. ACTIONS Regular ED patient reviews by coordinator- of- day and lead consultant; Remodelling of consultant roles to support better the focus on performance and supervision; Recruitment of specialty doctors for ED and ANPs for Ambulatory Care; Expansion of the ambulance triage area; ED streaming to GP available from 10 am to 8 pm; Complete roll-out of electronic Casualty Card in February/ March to improve quality of data/ record keeping and support improved flow; Ambulatory Care project aimed at improving the flow of urgent- care patients and reducing follow- up activity that could be located elsewhere; ANP and trainee ANP commenced in Ambulatory Emergency Care (AEC) in January to enable improved weekend and evening working; GP call handling by Digital Health piloted in three localities; ED Delivery Board reviewing the actions needed to improve, and then sustain performance, in line with GM requirements. Expected date to meet target Quarter Signed off by Anthony Edwards Signed off by Trish Cavanagh Page 9

15 Integrated Performance Report Exception Report: Director of Operations (2/3) Responsive Service Provision: Efficiency Target Current Performance Outpatient DNAs: (Reporting Period: January 2018) 6.5% 8.22% 4 Month Trend Previous Performance Forecast ISSUE The DNA rate for January was 8.22%, which is a similar rate to that reported in January The Trust is currently implementing e-referrals (ERS) for all GP referrals, with 40% of referrals managed electronically in December. The DNA rate is expected to reduce once ERS is utilised by all services. It should be noted that the current DNA rate is significantly reduced from that recorded in previous years (for example, the rate for the year was close to 10%). ACTIONS A full review of the text- reminder service has been undertaken and it has been identified that a number of specialties have historically been excluded from the reminder service. Work is underway to ensure that the service is functioning correctly and a succinct control document is to be provided by the supplier. Contact has been made with peer organisations with low DNA rates to identify potential improvement actions. A review of the booking process, for follow- up appointments in Oral Surgery, is being undertaken. Ongoing reporting and review of short- notice clinic cancellations in place, via the Executive RTT group, as it is believed that there is correlation with increased DNAs. PROPOSED ACTIONS Continue with the ERS roll out; Undertake further review to identify any further initiatives that can be implemented to help reduce DNAs; Undertake review of patient communication, with a view to incorporating DNA information. Expected date to meet target Quarter Signed off by Zoe Maher Signed off by Trish Cavanagh Page 10

16 Integrated Performance Report Exception Report: Director of Operations (3/3) Effective Service Provision: Efficiency Target Current Performance Theatre Utilisation (capped): (Reporting Period: January 2018) 90% 84.6% 4 Month Trend Previous Performance Forecast ISSUE Theatre utilisation reduced to 84.6% in January, mainly as a result of higherthan- usual bed occupancy (98% across the main surgical/ medical bed pool). High bed occupancy created pressure in theatres, leading to an increase in the number of late starts and cancellations (see chart opposite). ACTIONS A number of actions, designed to reduce the incidence of cancellation and late starts, have been initiated. The actions will be managed by the theatre managers and senior nursing team, via an increased presence in theatres throughout the day. The service aims to return utilisation to 90% by the end of March. ASSESSING IMPROVEMENT 1. Performance will be monitored on a weekly basis at the Theatre Utilisation Meeting; 2. Monthly performance will be monitored at the Theatre Excellence Group; 3. Monthly performance reports will be submitted to the Surgical Division and Service Improvement Group. Late Start Audits commenced on 5th February Expected date to meet target Quarter Signed off by Denise Stones Signed off by Trish Cavanagh Page 11

17 QUALITY ACCOUNT EXCEPTION REPORTS: Director of HR (1/1) Caring Service Provision: People Target Current Performance Staff Attendance: (Reporting Period: January 2018) 96% 94.02% 4 Month Trend Previous Performance Forecast ISSUE The staff attendance rate was below the target for January. January s absence rate of 5.98% is 0.12% greater than that of January Short- term sickness is driving the increase in sickness rates since October 2017 (long-term sickness has continued to reduce). In January, absence due to gastrointestinal problems increased significantly, so that it accounted for 6.9% of all absence. PROPOSED ACTIONS The HR Business Partners (HRBPs) are working closely with hotspot areas; i.e. those with high levels of absence and associated costs. Actions include: HRBPs to work with Divisional Management Teams to identify a list of absence cases, based on length, complexity or patterns, for review within their Division. Working with the Infection Prevention Team to undertake a campaign reminding staff and visitors of the importance of washing hands to try to reduce sickness attributed to gastrointestinal illness. Initiating a bi- monthly absence briefing for managers, and other individuals who enter absence into e-roster/esr Connect, to deliver key messages relating to attendance management: including top tips and reminders about why it is important to undertake return- to- work interviews and record absence correctly and in a timely manner. Finalising the provision of a physiotherapist to be available in Occupational Health to enable fast- track appointments for staff. Content of the Attendance Management Masterclass to be reviewed to ensure that managers attending the course are made aware of their responsibilities in managing absence within their teams. Ensuring that areas with high sickness rates are represented at Attendance Management Masterclasses. ASSESSING IMPROVEMENT Improvement in attendance and reduction in associated Agency/NHSP usage; Increase in return- to- work compliance rates. Expected date to meet target Signed off by T Gavin Signed off by Amanda Bromley Page 12

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19 TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 22 nd February, 2018 Agenda Item 9 Title Sponsoring Executive Director Author (s) Purpose Previously considered by Safe Staffing Report (Nursing and Midwifery) Tracey McErlain-Burns, Interim Chief Nurse Tracey McErlain-Burns, Interim Chief Nurse The purpose of this report is to inform the Trust Board of the latest position in relation to Nursing and Midwifery staffing in line with NHS England (National Quality Board) expectations and those of the Care Quality Commission. Other than receipt of the report and comment on whether there is any other information required there are no specific actions for the Board. This report has been generated for the purpose described above and not presented elsewhere. Executive Summary In summary this report details the latest position in relation to nursing and midwifery staffing. The report is shorter this month because several areas of development are due to report in March and April such as the outputs from the Safer Nursing Care Review (adult inpatient wards), midwifery staffing review, and children s ward staffing review, an update on the adult community nursing pilots and the decision on temporary staffing bank rates. The key issue for the Board to be aware of this month is the reduction in CHpPD and the reason for this is explained in the report. There are no actions for the Board to consider in relation to the CHpPD. Subject to the assumptions described the CHpPD should increase next month and once the list of non-ward based nurses has been confirmed a trajectory for further improvement can be calculated. Related Trust Objectives Risk Assurance risk impacted upon 1. All patients and users receive harm free care through the delivery of the Quality & Safety Programme. 2. To improve our patient and service user experience through the delivery of a personalised, caring and compassionate approach to the delivery of care. 3. To develop our staff and future workforce to support the integration and transformation of our services whilst ensuring we recruit and retain talented individuals. CR734/AF The ability to consistently sustain and maintain safe nurse staffing levels is compromised as a result of National Registered Nursing shortages and the impact of National training programmes. This impacts on the organisations nurse staffing vacancies and the ability to consistently deliver high quality, safe care. Page 1 of 7

20 Legal implications/regulatory requirements Financial Implications Has a quality impact assessment been undertaken? How does this report affect Sustainability? NHS England monthly requirement to publish and report Staffing Data The CQC report published 7 th February 2017 states that the Trust must ensure that there are appropriate numbers of nursing staff deployed to meet the needs of patients (medical services). There are no new immediate financial implications Yes where applicable in plans The Trust is required to ensure staffing levels are adequate to meet patient safety and quality requirements. Action required by the Board This report confirms the on-going compliance with the requirement to receive and review information on nursing and midwifery staffing levels at the board each month. The areas of concern remain unchanged; they are the inability to fill shifts with substantive employees and the need to use temporary staffing solutions coupled with the high use of temporary staffing solutions on night shifts because these are the preferred shifts of those workers. It is recommended that the Trust Board receives the report and indicates if there are any further actions and / or information required. Page 2 of 7

21 1. Purpose The purpose of this report is to inform the Trust Board of the latest position in relation to Nursing and Midwifery staffing in line with NHS England (National Quality Board) expectations and those of the Care Quality Commission. 2. Background The last report to Board was presented in January 2018 and this included the December 2017 position. In July 2016, the National Quality Board updated its guidance to provider Trusts which set out revised responsibilities and accountabilities for Trust Boards for ensuring safe, sustainable and productive staffing levels. This report presents the safe staffing position as at 31 January 2018 and confirms on-going compliance with the requirement to publish monthly data of staffing levels for nursing, midwifery and care support worker staff. 3. Nursing and Midwifery fill rates The Trust Board is advised that the Trust continues to meet the monthly obligations to upload safe staffing data to the Unify system. Validation arrangements are in place to ensure that the data uploaded to the national Unify system has been signed off by a senior member of the corporate nursing team, and it is that validated data that is presented to the Board in this report. 3.1 Planned versus actual care hours per patient day. In-patient care hours per patient day (CHpPD) are provided in the heat map attached at appendix 1. Last month the Interim Chief Nurse advised the Board of the requirement to include additional Lord Carter Model Hospital Metrics in the heat map, specifically vacancy rates, sickness rates and annual leave allocation. Due to the timeframes for producing Board reports it is not possible to include vacancy rates and sickness rates both of which are reported on the 15 th of the month however annual leave allocation has been included. With the exception of Registered Nurses on Stamford 1 and Shire Hill both of which allocated a higher percentage of RN annual leave than the roster can accommodate in a month, the majority of wards achieved the ideal levels of leave allocation. The Board will note a drop in the CHpPD from 7.1 to 6.9. There are two reasons for this; firstly CHpPD is a calculation of the cumulative count of the patients in in-patient facilities, across the month, at 23:59 hours divided by the number of staff hours. In January 2018 the cumulative count of patients was 15483; the highest level in the past 12 months. For the purposes of comparison the cumulative count in December was and in January 2017 the count was The second reason from the drop relates to the temporary use of ward 43 as winter escalation capacity. In addition to the cumulative count of there were 173 patients cared for at 23:59 hours on ward 43. Ward 43 was staffed with a combination of substantive, experienced nursing and care support worker colleagues and flexible workers; in total 1417 hours. The Board will recall a previous conversation about new roles such as the ward based pharmacy technician being excluded from the Unify returns. Had the hours provided by those roles on ward 42 and the Dining Companions been added, the CHpPD would have been 7.0. Had escalation into ward 43 not been necessary, the 1417 hours would have been worked across the other wards and this would have resulted in a CHpPD of 7.1. Page 3 of 7

22 Details regarding the non-ward based nursing contribution are covered later in the report. For now, in the context of the CHpPD, non-ward based nurses contributed (within the calculations above) hours of care. Assuming a reduction in the cumulative count of patients at 23:59 hours; less demand for inpatient escalation and an increase in non-ward based nursing contribution in February the CHpPD should be at least 7.1. Month Apr May June July Aug Sept Oct Nov Dec Jan CHpPD Fill rates Last month the Board noted a slightly improved Registered Nurse / Midwife fill rate over a three month period. That position has been sustained in January (Note the graph below). Unregistered (care support worker) day time fill rates have reduced since July but were marginally improved in January. As previously reported this figure is influenced by the children s ward due to the movement of care support workers from days to nights to support the 24 hour opening of the observation and assessment unit. The Board should note that a Children s Unit staffing review is underway driven by this change in service provision. (Note the graph below). Of note, as detailed in the heat map attached, Registered Nursing temporary staffing fill rates, especially on nights are high in two particular areas; ward 31 and ward 42. Both of Page 4 of 7

23 these areas have active recruitment campaigns, and on ward 31 the senior experienced nurses are rotating onto nights to provide leadership. In summary the fill rates for January 2018 are detailed in the table below. The Trust Board has previously been advised of the actions being taken to address the shortfalls in shift fill rates including a focus on retention, creative recruitment, the deployment of non-ward based nurses to vacant shifts and a reduction in the percentage of supervisory hours allocated on the roster to ward based leaders. An update on these actions is included in this report. Day (Jan 18) Night (Jan 18) Average fill rate - registered nurses/midwives (%) Average fill rate - care staff (%) Average fill rate - registered nurses/midwives (%) Average fill rate - care staff (%) Retention The focus on retention was detailed in the report last month. Specifically the Board was advised of the aspiration to reduce Registered Nurse turnover to less than 12% over a rolling 12 month period by 31 March Subject to validation, data available 07 February indicates that overall RN turnover was 11.7% in January This will be verbally confirmed at the Board meeting. Secondly the Board was advised of the launch of the Senior Independent Nurse role. Thus far the Deputy Chief Nurse has received two contacts in the context of that role and is working with both post holders to explore their retention within the ICFT.. 5. Recruitment The most recent recruitment event was held on 27 January with a focus on maternity services and the medical wards. In total 11 offers were made for Registered Nursing positions; three new colleagues being able to commence employment as soon as clearances have been obtained; 7 commencing in September 2018 and the remaining 1 colleague not being available until March Most of the applicants for maternity services (16 out of 19) were student midwives due to register in September On the basis that most student nurses and student midwives attend multiple interviews before determining which position to accept, all have received provisional offers. The remaining three applicants are Registered Midwives, one of who requires return to practice support. Recruitment events are very resource intensive, usually held during the evenings and at weekends with senior HR and nursing / midwifery colleagues volunteering their time. This type of event will continue but over the next few weeks there will be a review of our marketing, the use of our unique selling points and the scope for further campaign reach. In 2017 the Trust considered overseas recruitment and at that time a decision not to pursue this route was taken. Several factors informed that decision including the commence of the Trainee Nursing Associate pilot and levels of turnover at the time. Recognising that overseas nurses require adaptation support it was felt at the time that the substantive Registered Nurses would struggle to train the Nursing Associates, mentor existing students, Page 5 of 7

24 precept a large cohort of new registrants and enable a well-supported adaptation programme. Having now embedded the Trainee Nursing Associate role and improved retention; reduced turnover it is appropriate to revisit that decision and as such an update will be provided next month. 6. Non-ward based nursing contribution to direct patient care (and Trust Efficiency Programme (TEP) During the Board meeting last month the Interim Chief Nurse advised that she was moving to recommend that all non-ward based nurses contracted to work a minimum of 30 hours per week (in their non-ward based role) should work one clinical shift per month, every month, unless medically exempt. This was supported by the Board. In January 2018 non-ward based nurses worked a total of 28 shifts and contributed hours to direct patient care. A line by line review of all non-ward based nurses is taking place and in February a letter will be sent to all nurses / midwives contracted to work a minimum of 30 hours (in their non-ward based role) explaining the expectation. The expectation has already been discussed at the Nursing and Midwifery Leadership Forum where it received support. 7. Roster approval For the four-week roster period commencing 16 th March, 30 of the 42 rosters (71%) were approved on time. The remaining 12 (29%) were approved within a week of the required date. The Board should note that roster approval compliance is now included in the heat map at appendix 1. For all areas out with that heat map, e.g. areas other than in-patient wards compliance will be reported and managed through the Nursing and Midwifery Temporary Staffing Group. 8. Safe staffing consultations In January 2018 the following Safe, Sustainable and Productive Staffing resources were published by the National Quality Board: An improvement resource for maternity services. An improvement resource for adult inpatient wards in acute hospitals An improvement resource for the district nursing service Each of these improvement resources is being used in the reviews of safe and sustainable staffing. 9. Areas of concern The areas of concern remain unchanged; they are the inability to fill shifts with substantive employees and the need to use temporary staffing solutions coupled with the high use of temporary staffing solutions on night shifts because these are the preferred shifts of those workers. 10. Summary and recommendations This report confirms the on-going compliance with the requirement to receive and review information on nursing and midwifery staffing levels at the board each month. The report is shorter this month because several areas of development are due to report in March and April such as the outputs from the Safer Nursing Care Review (adult inpatient Page 6 of 7

25 wards), midwifery staffing review, and children s ward staffing review, an update on the adult community nursing pilots and the decision on temporary staffing bank rates. The key issue for the Board to be aware of this month is the reduction in CHpPD and the reason for this is explained in the report. There are no actions for the Board to consider in relation to the CHpPD. Subject to the assumptions described the CHpPD should increase next month and once the list of non-ward based nurses has been confirmed a trajectory for further improvement can be calculated. It is recommended that the Trust Board receives the report and indicates if there are any further actions and / or information required. T McErlain-Burns Interim Chief Nurse Page 7 of 7

26 Roster Patient Experience Quality & Safety Registered Safe Staffing Unregistered Safe Staffing Care Hours per Patient Day (CHPPD) Sign off Falls % of % of FFT** Moderate PU* A/L % % of A/L % Planned Actual Planned Actual Actual with approved % of Temp Temp Temp Inpatient Ward Compliments Complaints Positive Harm + MRSA C.Diff (+G2 Fill Rate % Fill Rate % Roster Fill Rate % Temp Fill Rate % Roster Registered Registered Unregistered Unregistered CHPPD Harm 6 wks in Staff Days Staff Staff (%) Incidents only) Days Nights Days Staff Days Nights CHPPD CHPPD CHPPD CHPPD TOTAL *** advance Nights Nights Planned Orthopaedic Unit % Y 93.2% 1.7% 98.9% 20.9% 15.2% 99.6% 6.7% 116.3% 28.0% 9.7% Integrated Surgical Unit % Y 93.6% 2.9% 87.4% 19.9% 16.7% 98.7% 17.2% 102.4% 20.7% 3.0% Emergency Orthopaedic Unit % Y 100.2% 6.9% 91.3% 54.5% 15.7% 91.8% 24.8% 148.4% 38.2% 15.9% Critical Care % Y 99.1% 6.4% 97.5% 29.0% 16.4% 104.8% 5.0% N/A N/A AMU % N 108.3% 17.9% 91.9% 30.7% 13.8% 91.5% 11.5% 100.0% 17.1% 12.2% Acute Cardiology Unit % N Heart Care Unit % N Heat map - Inpatient Ward Areas -January % 13.7% 103.2% 25.9% 13.8% 95.5% 15.5% 99.0% 44.8% 5.4% Ward % N 96.4% 15.9% 95.7% 62.1% 11.7% 94.1% 12.5% 102.4% 13.5% 12.2% Ward % Y 97.8% 11.9% 94.9% 41.3% 16.7% 111.4% 27.5% 135.5% 36.4% 11.9% Ward % N 88.8% 18.8% 95.8% 48.3% 8.1% 95.6% 20.6% 115.1% 42.3% 16.3% Ward % N 80.0% 8.0% 92.7% 73.4% 12.9% 124.4% 43.6% 94.6% 47.9% 12.9% Ward % N 77.2% 12.3% 100.0% 29.2% 13.9% 129.5% 24.8% 135.5% 29.5% 12.4% Ward % Y 79.8% 18.8% 93.6% 51.8% 16.0% 90.9% 12.8% 95.2% 15.4% 11.7% Ward % Y 73.7% 8.5% 75.0% 13.1% 13.2% 85.8% 9.1% 190.2% 33.0% 16.9% Ward 27 (Maternity) % Y 98.3% 21.6% 86.5% 20.5% 16.2% 88.7% 0.9% 111.2% 5.8% 10.5% Neonatal Unit 20 0 N/A Y 99.6% 13.3% 100.0% 14.4% 12.5% 100.0% N/A N/A N/A N/A Children's Unit % Y 86.4% 10.7% 93.0% 16.0% 13.8% 75.5% 5.8% N/A N/A 32.3% Stamford Unit Y 100.5% 10.7% 98.4% 16.5% 18.5% 113.3% 21.2% 99.6% 27.6% 8.4% % Stamford Unit Y 98.4% 11.4% 103.5% 24.5% 11.9% 97.2% 26.6% 108.3% 24.6% 13.8% Shire Hill 2 0 N/A Y 95.1% 21.5% 94.0% 30.1% 20.6% 93.9% 26.8% 83.0% 76.8% 10.7% Inpatient Totals/Averages % % 91.8% N/A 94.6% N/A N/A 98.9% N/A 111.1% N/A N/A Inpatient Wards including additional support Compliments Complaints FFT** Positive (%) Moderate Harm + Incidents Falls with Harm *** MRSA C.Diff PU* (+G2 only) approved 6 wks in advance Fill Rate % Days % of Temp Staff Days Ward 42 with Pharm Tech % N 91.0% 8.0% 92.7% 73.4% 12.9% 124.4% 43.6% 94.6% 47.9% 12.9% Ward 44 with Dining Companions % N 77.2% 12.3% 100.0% 29.2% 13.9% 129.9% 24.8% 135.5% 29.5% 12.4% Trust totals with support % % 93.3% N/A 94.6% N/A N/A 98.9% N/A 111.1% N/A N/A KEY Complaints Moderate Harm + Falls with Harm MRSA CDIFF PU(+G2) Staffing Fill Rates FFT Postive Annual Leave 0 - Green 0 - Green 0 - Green 0 - Green 0 - Green 0 - Green > 90% - Green >95% - Green <9% or >18.1% - Red >1- Amber >1 - Amber >1 - Amber >1 - Red >1- Amber >1 - Amber 80-90% - Amber 90-95% - Amber 9-11% or 17-18%- Amber >2 - Red >2 - Red > 2 - Red >2 - Red >2 - Red < 80% - Red <90% - Red 11-17%- Green *Please note that the PU data contains only the requests for RCA s and not those which have been attributed Trust acquired. ** FFT Total shown does not include Community areas, only inpatient ward areas as shown above. *** All falls with harm are included in the moderate+ harms total. Fill Rate % Nights % of Temp Staff Nights A/L % Roster Fill Rate % Days % of Temp Staff Days Fill Rate % Nights % of Temp Staff Nights A/L % Roster Planned Registered CHPPD Actual Registered CHPPD Planned Unregistered CHPPD Actual Unregistered CHPPD Actual CHPPD TOTAL

27 TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 22 nd February, 2018 Agenda Item 10 Title Significant Risk and BAF Report Sponsoring Executive Director Karen James, Chief Executive Author (s) Purpose Previously considered by John Fletcher, Acting Director of Quality & Governance For discussion and agreement of future actions For approval To note/receive Service Quality and Operational Governance Group Executive Summary The Significant Risk report provides details on all identified significant risk exposure through the Risk Register and Board Assurance Framework across services provided by the Trust. Related Trust Objectives Impacts on all Trust Objectives Risk Assurance risk impacted upon Impacts on all BAF and Risk Registers Legal implications/regulatory requirements Financial Implications Has a quality impact assessment been undertaken? Referred to if necessary in the paper Referred to if necessary in the paper Referred to if necessary in the paper How does this report affect Sustainability? Reflects current risks to the Trust s business and strategic objectives Action required by the Group The Trust Board is asked to discuss and consider the current position in relation to significant risks Page 1 of 32

28 February 2018 Significant Risk and BAF Report 1.0 Summary Narrative of Significant Risk and BAF Paper This paper provides members with a report on the significant risk exposure through the Risk Register and Board Assurance Framework across services provided by the Trust. The report incorporates the target risk score and timescales for achieving the target score with focussed attention on the gap between the current and target risk scores. A review of target risk scores is ongoing to ensure achievement is realistic and possible within the short to medium term. Alongside these changes there have been focussed development sessions to support the review in the context of the above requirements and the revision of the Risk Management Strategy Policy and Guidance. The risks included in this report have been subject to review by the responsible directors in discussion with the Quality and Governance Unit. The risks have been consistently and systematically reviewed in light of the regulatory requirements and mapped against the Trust s Strategic plans and responses to regulatory oversight which contain specific actions against identified risks. The Treatment Plans for these risks have been reviewed by responsible Directors and leads to ensure reflection of the assertive improvement work and current mitigations. Horizon scanning for future risks to provide foresight and insight is continually taking place with systematic examination of information to identify potential threats, and vulnerabilities, and detect opportunities and options to reduce existing risks. Where applicable necessary third party assurances are referred to. 1.1 The Trust has identified a range of significant risks to its strategic objectives, which are currently being mitigated, the impact of which could have a direct bearing on compliance with NHS Improvement Provider Licence, CQC registration or the achievement of corporate objectives, should the mitigation plans be ineffective. Currently, the significant risks relate to the following areas: Discharge processes and the management of the Urgent Care Pathway across the whole health economy Health economy capacity to manage patient flow and Urgent Care impacting on Emergency Department pressures Finance (Cost control, TEP delivery and liquidity) Information Technology Staffing, Recruitment and Retention Third party decisions /Transition to Integration Tissue Viability Children s Services and Safeguarding Children Training and Supervision The main controls and action plans for each significant risk have been reviewed and collated in the Trust s Risk Register. The Trusts significant risks are aligned with the Board Assurance Framework (BAF). Page 2 of 32

29 Updates against the significant risks included in the BAF and Risk register are summarised in the analysis table in Appendix 1. Detailed information including mitigations of all the significant risks and BAF risks identified at the time of the report are provided in Appendix The BAF has been aligned to the 2017/18 Corporate Objectives and updated through scheduled reviews by the Executive Directors reported and agreed where required by Trust Board. The report reflects the revision of the BAF aligned to the principal objectives agreed by the Board and includes consideration of the potential impact of Greater Manchester Health and Social Care Devolution and external reconfiguration and the iterative development of Models of Care between acute, community, primary and social care providers. We continue to keep a line of sight on these and emergent risks through the Care Together Programme. The risks associated with Healthier Together implementation, Greater Manchester Health and Social Care Partnerships and the Care Together programmes are aligned through the BAF as they emerge and are identified. The Director of Operations continues to oversee development of risk assessments related to the five Neighbourhoods for inclusion in the risk register related to the areas of Trust accountability as these work streams become operational. 1.3 New Significant Risks There is one new significant risk identified since the previous report to Trust Board. This risk was presented to the Risk Management Group in January The Group requested a further review by the Interim Chief Nurse. As a result of the review by the Interim Chief Nurse the risk description has been clarified as detailed below and the risk score is 16. CR4453 Specialist Safeguarding Children and Young People resources are under pressure due to vacancies and the pace of change associated with the Tameside Children Safeguarding Improvement plan. The risk score is scored at 16 and the target score is 8 resulting in a gap score of 8. Controls and mitigation plans are detailed in Appendix 2 of this report. 1.4 Reduction in Risk Scores CR4201 Healthier Together This risk has been reduced from 20 to 15 and is under review by the Division of Surgery Women and Children following discussion at the Risk Management Group. The Group requested the Division clarify the risk to the service and service users rather than focus on the financial aspects of the risk. CR4398 Lack of nursing home beds in the health economy impacting on the Trust s ability to avoid delayed transfer of care. This risk has been reviewed by the Director of Operations and the risk score reduced from 20 to 16. The reduction in score is based on current data and intelligence. 1.5 Increased Risk Scores There are no increases to the scores of risks previously received in this paper Page 3 of 32

30 1.6 Other Notable Changes / Update The Quality and Governance Committee reviewed all the BAF risks for which the Committee had responsibility at the February 2018 meeting. The Committee confirmed the risk scoring of the BAF risks. Following discussion at the Audit Committee in February the presentation of the detailed risk tables in Appendix 2 are being reviewed in order to consider how better presentation of risks, controls and mitigations can focus on those which significantly impact on the management of the risks and comprehensively capture sources of external assurance for actions taken by the Trust. 2.0 Recommendations Members are requested to 1) Review and consider the current significant risks, identified controls, and mitigations within the report. Page 4 of 32

31 Appendix 1 Summary of risks and analysis Risk Lead Key: CEO: Chief Executive DoHR: Director of Human Resources MD: Medical Director DoE: Director of Estates CN: Chief Nurse DoP: Director of Performance & Informatics DoO: Director of Operations DoQG: Director of Quality & Governance DoF: Director of Finance BS: Board Secretary Risk Matrix Sub-Committee Key: AC: Audit Committee SQOGG: Service Quality & Operational Governance Group CoG: Council of Governors IPCG: Infection Prevention & Control Group QGC: Quality & Governance Committee ISB: Internal Safeguarding Board FPC: Finance & Performance Committee IMTG: Information Management &Technology Group EMT: Executive Management Team IG: Information Governance Group TB: Trust Board RMG: Risk Management Group OG: Operational Group Consequence Likelihood Insignificant Minor Moderate Major Catastrophic Rare Low/Unlikely Possible High/Likely Almost certain Direction of travel Change since previous review Escalated De escalated Unchanged Target achieved Gap Score Matrix (Difference between Target Score and Current score) Gap score 0 Gap score 1 5 Gap score 6 9 Gap score 10 Gap score > 10 Risk target achieved Tolerable Close monitoring Concern Serious Page 5 of 32

32 BAF Ref (AF) / Risk Ref (CR) Description Analysis of Risk Sub Committee Executive Lead Current Risk Score Risk Target Risk Target Gap Risk Appetite Guide Risk AF 1.23 (734) The ability to consistently sustain and maintain safe nurse staffing levels is compromised as a result of National Registered Nursing shortages. This impacts on the organisations nurse staffing vacancies and the ability to consistently deliver high quality, safe care This risk remains at 20 and continues to be challenging. The Trust has been actively addressing staffing and has been utilising a number of strategies to maintain consistent staffing levels, which include recruitment fast track events, review of skill mix, and the recognition of competencies. The Trust is one of 20 organisations working with NHSI to develop processes to meet challenges around staffing particularly for registered nurses with a robust retention improvement plan. QGC CN DoHR Low Risk AF 1.24 (3483) Increased demand for non-elective care is resulting in high levels of bed occupancy. This could result in a reduced positive patient experience and the potential to impact on workforce and finances The risk score remains in excess of the target score and continues to be closely monitored, The achievement of the target score is dependent on the transformation of services and pathways across the Health Economy. The Trust continues to engage with other service providers and to progress models of care to improve capacity and patient flow and roll out the programme of Home First (admission avoidance and discharge to assess) QGC CN Moderate Risk AF 5.1 (4059) Failure to deliver Trust efficiency programme (TEP) The risk was reviewed at Finance and Performance Committee in October 2017 when it was proposed that the score remained at 20 due to the value of the programme delivery historically on a non-recurrent basis. The TEP is monitored by the Finance and Performance Committee. FPC DoF Moderate Risk AF 5.4 (3482) Medical Staffing The ability to recruit to Consultant and Middle Grade posts due to national shortages in certain specialties i.e. Radiology, Medicine and A&E. This may impact on patient experience and the ability to provide safe care This risk continues to be challenging and has remained static as it is influenced by the national picture and availability of workforce. There still remains a significant operational risk profile against the BAF risk as the organisation continues to meet challenges in relation to medical staffing particularly speciality medical QGC DoHR MD Moderate Page 6 of 32

33 BAF Ref (AF) / Risk Ref (CR) Description Analysis of Risk staff. Sub Committee Executive Lead Current Risk Score Risk Target Risk Target Gap Risk Appetite Guide CR4183 CR4278 There is a risk of delayed patient diagnosis and/or treatment as a result of lack of availability of radiologists/radiology staff in the service. The availability of radiologists remains a challenge to the organisation and information published in October from the Royal College of Radiologists regarding workforce census implicated that this will remain challenging nationally. QGC DoO Low CR4012 Banking Trojans now using Locky Ransomware and potential for data to be unavailable due to encryption of files The risk remains challenging and the Trust is continuing to monitor ransomware threats and implement software to mitigate the risk. The risk score reflects continued ransomware threats and vulnerabilities whilst software becomes fully active across all areas. IMTG DoP&I Moderate Risk AF 2.2 (3485) Failure to deliver 2017/18 financial plans (Capital, Revenue. Cash) approved by Trust Board Mitigations include the recent establishment of a Recovery Board which is a subgroup of the Finance and Performance Committee. The Recovery Board is monitoring the financial plans in detail. It is anticipated that actions the risk score will reduce once the Recovery Board takes traction. FPC DoF Moderate Risk AF 2.8 (3526) Failure to achieve VFM services and financial sustainability. This risk was reviewed by the Finance and Performance Committee in October The committee recommended that the score and target score remain 20 and 15 respectively. FPC DoF Moderate Risk AF 4.2 (3488) Failure to ensure on-going compliance with terms of NHS Improvement Provider Licence requirements The risk score was reviewed at Finance and Performance Committee in October 2017 The Committee proposed that the score remained at 20 with a target score of 15. The Committee also agreed that this risk owned by Trust Board and the Chief Executive rather than the Audit Committee and DOF as decisions regarding this are made at Trust Board level of the organisation. These changes have been TB CE Moderate Page 7 of 32

34 BAF Ref (AF) / Risk Ref (CR) Description Analysis of Risk reflected in this version of the Significant Risk and BAF Report. Sub Committee Executive Lead Current Risk Score Risk Target Risk Target Gap Risk Appetite Guide CR4439 Risk that we will not have the appropriate level of registered skilled nurses/practitioners in the A&E department to appropriately manage advanced life support situations (EPALS training). This risk emerged through the Division of Medicine and Clinical Support Services in September 2017 and the risk likelihood increased in November 2017 when it was identified that the planned training was not going to be available. Mitigations are in place to reduce the risk. 6 places have been booked for training in February Discussions are taking place to explore whether the Paediatric team can support the service. Rotas are planned to include at least one EPALS trained practitioner. The issue is being discussed weekly as part of Senior nurse team meeting with the Chief Nurse QGC CN Low Risk AF 5.3 (4316) If pressure ulcer prevention policies and interventions are not consistently implemented there is a risk that patients are developing pressure ulcers resulting in avoidable patient harm. This risk relates to the Trusts Patient Safety Programme and improvement programme for pressure ulcer prevention. The implementation of a Scrutiny Group Process and separate Pressure Ulcer Prevention Group being closely monitored and evaluated by the Chief Nurse who will now be actively chairing the Scrutiny Group. The Trust has been exploring alternative mattresses to support the reduction of pressure ulcers and training and education is ongoing. QGC CN Low CR4342 The impact of revised working as a consequence of Tameside Children s Improvement Board responding to the findings of the Ofsted inspection. It is likely that some services will need to respond to a demand greater than the current capacity especially in the Safeguarding Team, School Nursing, Health Visiting service and Paediatric The risk was reviewed by SQOGG in October 2017 the score remained at 16. The decision was made by SQOGG members that this risk should be monitored by the Risk Management Group as part of the schedule of routine reporting and monitoring of the significant risk and Divisional risk reports. RMG CN Low Page 8 of 32

35 BAF Ref (AF) / Risk Ref (CR) Description Medical Team Analysis of Risk Sub Committee Executive Lead Current Risk Score Risk Target Risk Target Gap Risk Appetite Guide CR4453 Specialist Safeguarding Children and Young People resources are under pressure due to vacancies and the pace of change associated with the Tameside Children Safeguarding Improvement plan. This risk was presented by the Division of Surgery Women and Children at the January Risk Management Group meeting and a further review requested by the Interim Chief Nurse. As a result of the review the score was reduced from 20 to 16 and the controls and assurance and gaps in assurance reviewed and amended. QGC CN Low CR1894 linked with CR4183 Trust may be unable to provide one stop Breast Service if Breast radiologist cannot be recruited to vacancies. This could lead to a delay in diagnosis and treatment The Division has reviewed this risk and the risk rating has been maintained to reflect the current adhoc, fragile provision of cover of this service. QGC DoO Moderate CR3618 Linked with risk AF1.24 (3483) If demands on the service outstrip capacity this may result in inability to deliver the 4 hour Emergency Access Standard. This risk score remains in excess of the target score and continues to be closely monitored. The target score reflects the target agreed by Trust Board however it is also acknowledged the achievement of the target score is challenging in the short to medium term and dependent on the completion of longer term programmes for the transformation of services across the health economy. The Trust continues to engage with other service providers and to progress models of care. OG DoO Moderate Page 9 of 32

36 BAF Ref (AF) / Risk Ref (CR) Description Analysis of Risk Sub Committee Executive Lead Current Risk Score Risk Target Risk Target Gap Risk Appetite Guide CR4398 Lack of nursing home beds in the health economy impacting on the Trust s ability to avoid delayed transfer of care This risk was identified by the Director of Operations and the Interim Chief Nurse both of whom are working to address these with the Single Commissioner. The risk was reviewed in February 2018 and the risk score reduced from 20 to 16 based on the improvement in DTOC data and mitigation plans. QGC DoO Moderate Risk AF 1.22 (3481) If medical staff do not have the relevant skills and training support and supervision there is a risk that care will not meet standards of safe practice impacting on patient experience, the quality of care and outcomes. This risk remains challenging and is impacted on by the numbers of substantive senior medical staff available to provide continuity and a further in depth review of progress set for Q4 2017/18, mitigations and a treatment plan are in place. QGC DOHR Moderate CR1501 The provision of a 24 hour Observation and Assessment Facility on the Children s Ward requires a higher level of nursing recourse; the resource available does not meet RCN guidelines Risk was presented to December Divisional Safety & Quality Group. Rolling Recruitment of Paediatric Nurses continues. The risk was reviewed by the Chief Nurse in January and February 2018 and clarity added to the risk description. QGC CN Low Risk AF 4.8 (3491) Failure to have in place an IM&T infrastructure and service supporting the organisational objectives This risk score remains at 15 and has been static at 15 throughout this financial year to date. There are a number of longer term mitigation plans requiring training and development of the IM&T Infrastructure going forward. IMTG DoP Moderate CR4201 Healthier Together - Risk that the Trust will be in breach of its financial control limit due to the significant stranded costs caused by the reconfiguration of emergency and elective (cancer) general surgery as This risk has been reduced from 20 to 15. The Risk Management Group has asked for a review of the wording of this risk at Divisional level to identify more clearly the risk to specific services/service users. The Group also identified that the description needed to be QGC DoF Low Page 10 of 32

37 BAF Ref (AF) / Risk Ref (CR) Description part of the Healthier Together Programme across Greater Manchester. Analysis of Risk reworded in the context of the financial implications Sub Committee Executive Lead Current Risk Score Risk Target Risk Target Gap Risk Appetite Guide Page 11 of 32

38 Appendix 2 Detailed Risk Tables Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 2, Corporate Objective 3, Risk Description: The ability to consistently sustain and maintain safe nurse staffing levels is compromised as a result of National Registered Nursing shortages. This impacts on the organisations nurse staffing vacancies and the ability to consistently deliver high quality, safe care Graph of Risk over time Risk Appetite Target score Risk score BAF Ref: AF1.23 Date entered on register: 04/02/14 Assurance Committee Quality & Governance Committee Current Risk Score (L x C) Risk Direction 4 x 5 = 20 Unchanged Target Risk Rating Target Gap Score 2 x 5 = Concern None low Moderate High Significant Risk ID number: CR734 Executive Director Lead Chief Nurse, Director of HR Last received at Q&G committee: February 2018 Date of next review: March 2018 Rationale for current score: Current operational processes and daily staffing reviews Date When Target Risk score expected to be achieved It is estimated that the Trust should reach the target score by May Controls: Training Needs Analysis and Workforce Strategy Sickness Policy and monitoring. Use of Agency staff to bridge the gap Temporary staff management monitoring. Assistant Chief Nurse daily reviews. Workforce Model and implementation of alternative methods of care delivery. Training of other groups of staff to support registered nurses i.e. Theatres Scrub practitioners, Therapists. Robust retention plan and work with NHSI Capacity and demand being reviewed through review of roles within nursing and clinical services Staffing monitoring via Quality Account dashboard and HR metrics. Recruitment open days/evenings with fast track recruitment processes. Daily close monitoring and management of staffing, escalation process and provision of cover by Senior Nursing staff. Completion of staffing levels/incident reports forms to enable analysis of impact. Monitoring of KPI s including HR monthly paper to Trust Board. Safe Staffing reports to Trust Board Keep in touch events Kate Granger nurses / International recruitment programme Review of Clinical Nurse Specialist resources resulting in a programme to support ward nursing service delivery. This will be implemented by the allocation of clinical Nurse Specialists to support substantive ward based staff for 1 shift per month. Development of Masterclass/CPD as art of retention Mitigating actions: (what more should we do? Risk source Operational performance, incidents and complaints Rational for Risk appetite; The Trust is not willing to risk the ability of the organisation to delivery safe effective care or compliance with regulatory requirements Assurance: (how do we know if the things we are doing are having an impact and can we validate or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?): Safe Staffing Report to Board Recruitment shortages and actions highlighted. Unity Return Model Hospital (Lord Carter Work Programme) and Care Hours per Patient Day (CHPPD) Senior Nurse and Midwifery Forum Reports to Divisions NHSP monthly contract monitoring meetings E Rostering programme Incident reporting and analysis of complaints. Staff Survey Executive and Non-Executive Quality Walk Rounds HR & OD Workforce Group External Regulator Reports and Inspections Reports to: Trust Board Executive Management Team Quality & Governance Committee Gaps in assurance and actions not being actioned Decision of other parties and availability of temporary staffing to meet demands. Anticipated effect of controls Reported at Board meeting aligned to performance trajectory and performance Page 12 of 32

39 Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 3, Corporate Objective 4, Corporate Objective 5, Corporate Objective 6, Risk Description: Increased demand for non-elective care is resulting in high levels of bed occupancy. This could result in a reduced positive patient experience and the potential to impact on workforce and finances. BAF Ref: AF1.24 Assurance Committee Quality & Governance Committee Current Risk Score (L x C) 4 x 5 = 20 Target Risk Rating 2 x 5 = 10 Date entered on register: 04/09/14 Risk Direction Unchanged Target Gap Score 10 Concern Risk ID number: AF 3483 Executive Director Lead Chief Nurse Last received at Q&G committee: February 2018 Date of next review: March 2018 Graph of Risk over time Target score Risk score Risk Appetite None low Moderate High Significant Rationale for current score: Current Reported performance information and impact on patient flow Date When Target Risk score expected to be achieved It is expected that the risk score will reduce incrementally as mitigations gain traction and that the target score will be achieved in May 2019 Controls: Working in partnership with external agencies to develop services which support admission avoidance Daily review of all patients to support a reduction in length of stay Internal escalation plans in place to maintain safe and effective care during periods of increased pressure Seeking to source additional capacity within care homes Continue the underpinning projects to support admission avoidance and discharge to assess Admission avoidance Team in place Digital Health in place to avoid unnecessary ED attendances Primary Care Streaming commenced Extended NWAS bay to support triage Development of further IT support to facilitate co-ordination within the ED Reviewed staffing rotas to ensure less variation in skill mix Expansion of the ambulatory model Medical specialities in reaching into ED IV therapy team within the community supporting admission avoidance Focused work with patient flow across the organisation Rational for Risk appetite The Trust is not willing to risk the ability of the organisation to delivery safe effective care or compliance with regulatory requirements Assurance: (how do we know if the things we are doing are having an impact) Daily monitoring of bed capacity and ED Waiting times Waiting List Steering Group Activity Planning Monthly contract performance reporting to Executive Management Team & Board Monthly finance and activity reporting to Board MIAA audits Monthly submission of DTOC data Trust/Social Services Director level interface meetings A&E Delivery Group Transformation leads Page 13 of 32

40 Organisation risks related to ED shared with NHSI and GMHSP and funding sought for additional capital Improvement work underway to support ambulance handover Mitigating actions: (what more should we do?) Development of integration strategy and further models with key partners Implementation of Recovery Plan by all partners Risk source Third party review and internal monitoring, incidents, complaints and claims and performance Gaps in assurance and actions not being actioned Third party action by other parties and stakeholders has impact upon organisation. Delays in delivery due to funding Anticipated effect of controls (Expected /risk score reduced) Reported at Board meeting aligned to performance trajectory and performance report Page 14 of 32

41 Strategic Priority (Objective) Corporate Objective 6, Risk Description : Failure to deliver Trust Efficiency Programme BAF Ref: AF5.1 Assurance Committee Finance & Performance Committee Date entered on register: 19/07/16 Risk ID number: AF4059 Executive Director Lead Director of Finance Current Risk Score (L x C) 4 x 5 = 20 Target Risk Rating 2 x 5 = 10 Risk Direction Unchanged Target Gap Score 10 Concern Last received at F&P committee: January 2018 Date of next review: February 2018 Graph of Risk over time Target score Risk score Risk Appetite None low Moderate High Significant Rationale for current score: Current Trust position against target Date When Target Risk score expected to be achieved May 2018 Controls: Benchmarking with other organisations to ensure challenge and appropriateness of TEP Review of Lord Carter Report to ensure TEP reflects outputs of reports Ensuring valuing care efficiency programme is communicated effectively across the organisation Divisional structures performance manage delivery of TEP Mitigating actions: (what more should we do?) Revised programme of financial management Certify that all material non-recurrent TEP s have also been subject to a rigorous QIA Fully develop schemes to deliver the TEP target on a recurrent basis. Develop and submit to regulators milestones and financial modelling Review of clinical coding and impact on income. Risk source Strategic Insight and Foresight Rational for Risk appetite To be confirmed following Board development session Assurance: (how do we know if the things we are doing are having an impact and can we validate or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?): TEP Assurance Meeting Operations Board Finance and Performance Committee Trust Board Divisional Performance Groups Internal Audit VFM work covers arrangements in place to deliver TEP Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Level of recording of non-recurrent TEP versus recurrent TEP. Timely planning of TEP programme to ensure future delivery. Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score reduced) Reported at Board meeting aligned to performance trajectory and performance report Page 15 of 32

42 Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 3, BAF Ref: AF 5.4 Date entered on register: 15/09/14 Risk Description: Medical Staffing The ability to recruit to Consultant and Middle Grade posts due to national shortages in certain specialties i.e. Radiology, Medicine and A&E. This may impact on patient experience and the ability to provide safe care. Graph of Risk over time Target score Risk score Assurance Committee Quality & Governance Committee Current Risk Score (L x C) 4 x 5 = 20 Target Risk Rating 2 x 5 = 10 Risk Appetite None low Moderate High Significant Risk Direction Unchanged Target Gap Score 10 Concern Risk ID number: AF3482 linked to CR1549 Executive Director Lead Director of Human Resources Medical Director Last received at Q&G committee: February 2018 Date of next review: March 2018 Rationale for current score: There is a national shortage of Consultant and Middle Grade doctors in some specialties therefore there is additional reliance on Locum and Agency staffing to provide full staff compliment Date When Target Risk score expected to be achieved Local and National agendas and changes influence the Trust s ability to achieve this target provisional date May 2019 Controls: Workforce strategy Sickness Policy and monitoring Use of Agency and Locum staff to bridge the gap Temporary staff management monitoring Senior Managers receive daily staffing report summaries Capacity & Demand being reviewed through job planning process Robust job planning process Staffing monitoring via Quality Account dashboard and HR metrics. International recruitment Mitigating actions: (what more should we do?) Reports to Board and Executive Team Continuous recruitment in to the vacant posts is underway and to continue under monitoring Weekly monitoring of KPI s Stronger links to the annual Trust planning process Lack of workforce availability at an operational level leading to difficulty in recruitment Risk source Operational performance Rational for Risk appetite The Trust is not willing to risk the ability of the organisation to delivery safe effective care or compliance with regulatory requirements Assurance: (how do we know if the things we are doing are having an impact and can we validate or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?): Improvement Plan HENW Review Action Plan monitored by Educational Governance and SQOGG Reports to Medical Staffing Group HR & OD Workforce Group Medical Staffing Expenditure Review Group (MSERG) Gaps in assurance and actions not being actioned (what additional assurances should we seek?) No gaps in assurance identified however implementation of real time operational management requires consistent application of agreed systems and processes by all staff at all levels across all divisions Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score reduced) Reported at Board meeting aligned to performance trajectory & report Page 16 of 32

43 Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 3 Risk Description There is a risk of delayed patient diagnosis and/or treatment as a result of lack of availability of radiologists/radiology staff in the service. (This is related to risk CR770, reduced sustainability of Radiology Services). This risk is multifaceted and impacts on activity and the ability of the department to undertake investigations within timescales, particularly to support the cancer pathways report investigations within timescales quality of service provided delivery of key objectives budgetary control reduction of backlogs (see risk no. 1880) Workload pressures stress on the current workforce due to long working hours/complexity of work Graph of Risk over time Target score Risk score BAF Ref: AF1.23 & CR3482 Assurance Committee Quality & Governance Committee Current Risk Score (L x C) 4x5 = 20 Target Risk Rating 2x5 = 10 Risk Appetite None low Moderate High Significant Date entered on register: 05/12/16 Risk Direction Unchanged Target Gap Score 10 Concern Risk ID number: CR4183 Executive Director Lead Director of Operations Last received at Q&G committee: February 2018 Date of next review: March 2018 Rationale for current score: Current reported performance information Date When Target Risk score expected to be achieved TBC Controls: (what are we currently doing about the risk?) use of locum and agency radiologist reporting and direct clinical sessions EG ultrasound scanning and Breast interventions Radiographer reporting advanced practice Consultant Radiographer in post planned development of additional radiographer advanced practice outsourcing of CT and MR scanning and reporting use of WLI and ECP s Mitigating actions: (what more should we do?) Scoping exercise to identify possibility of support from local organisations across GM. Continue to review of options to widen scope of practice/skill set of radiographer staff in the mid to longer term Risk source Risk register, and Operational performance Rational for Risk appetite The Trust is not willing to accept risk with the preference being for maintaining service stability Assurance: (how do we know if the things we are doing are having an impact and can we validate or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?): Reports to Divisional Governance meeting SQOGG Deep dive into sample of clinical incidents where potential harm were identified Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Locum cover not sustainable in the long term due to high cost implication locum availability heavy reliance on very small substantive Consultant Team Anticipated effect of controls To be monitored closely to ensure impact is minimised Page 17 of 32

44 Strategic Priority (Objective) Corporate Objective 4, Corporate Objective 6 BAF Ref: AF4.8 Date entered on register: 05/04/16 Risk Description : Banking Trojans now using Locky Ransomware and potential for data to be Assurance Committee unavailable due to encryption of files Information Management & Technology Group Graph of Risk over time Target score Risk score Current Risk Score (L x C) 4 x 5 = 20 Target Risk Rating 2 x 5 = 10 Risk Appetite None low Moderate High Significant Risk Direction Unchanged Target Gap Score 10 Concern Risk ID number: CR4012 Executive Director Lead Director of Performance & Informatics Last received at IM&T group: January 2018 Date of next review: February 2018 Rationale for current score: Current IM&T infrastructure and local intelligence Date When Target Risk score expected to be achieved Unable to quantify at this time as ongoing assessment is being undertaken in respect of ransomware threats and additional IM&T risks transferred or arising out of the integration of services Controls: (what are we currently doing about the risk?) ITIL (Information Technology Infrastructure Library) change Control process in place. IM&T Group structure. Risk Assessment in place with plans to mitigate. Strengthened structure to support service flow and ownership within IT. Purchase of software to reduce the risk further (Sophos Cloud) This has been deployed and will take time to become fully effective Mitigating actions: (what more should we do?) All user communication Propose to block macro s at point of entry into the Trust for all communications Review options to enforce disablement of Macros within Office or quarantine s with macros from none trusted sites User Training Information Security as part of mandatory training Some PC s will require manual intervention to allow effective deployment of software Risk source Operational performance Rational for Risk appetite The Trust is not willing to accept risk with the preference being for maintaining delivery systems Assurance: (how do we know if the things we are doing are having an impact and can we validate or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?): Monitoring of data/incidents. Executive Management Team Board Reports Exception Reports Audit Internal & External Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Ultimately the solution is operator reliant. Knowledge and Skills Gaps Anticipated effect of Continued stability and prevention of incidents. Embedding of best practice re user responsibility. Improved understanding, communication and visibility Page 18 of 32

45 Strategic Priority (Objective) Corporate Objective 6 BAF Ref: AF2.2 Date entered on register: 15/09/14 Risk Description: Failure to deliver 2017/18 financial plans (Capital, Revenue. Cash) approved by Assurance Committee Trust Board Finance & Performance Committee Current Risk Score (L x C) Risk Direction 4 x 5 = 20 Graph of Risk over time Target score Risk score Target Risk Rating 2 x 5 = 10 Risk Appetite None low Moderate High Significant Target Gap Score 10 Serious Risk ID number:af3485 Executive Director Lead Director of Finance Last received at F&P committee: January 2018 Date of next review February 2018 Rationale for current score: Current financial performance. Service model for financial sustainability being implemented Date When Target Risk score expected to be achieved The delivery of the financial plan for 2017/18 should be achieved by April 2018 however this should be assessed in the context of the longer term financial plan Controls: Continued use of appropriate NHS Reference Costs information led by the Finance Department to ensure control and rigor of TEP delivery Finance Team work with budget holders to drive down costs and increase income and contribution margin and, with clinical teams, to exploit opportunities and repatriate activity and develop new markets Established Governance structure Ensure Divisional teams work with finance to review income, expenditure and TEP variances and to identify root cause analysis and where appropriate update systems and controls. Improvements to clinical coding team Standing Financial instructions Establishment of a Recovery Board which is a subgroup of the Finance and Performance Committee. The Recovery Board is monitoring the financial plans in detail. Mitigating actions: Revised programme of financial management Certify that all material non-recurrent TEP s have also been subject to a rigorous QIA Fully develop schemes to deliver the TEP target on a recurrent basis. Develop and submit to regulators milestones and financial modelling Review of clinical coding and impact on income. Risk source Strategic Insight and Foresight Rational for Risk appetite The Trust not willing to risk the ability of the organisation to achieve NHS Improvement requirements and financial sustainability Assurance: Weekly EMT Performance and financial reports to Board Review of assurance and management structure/ meetings for TEP delivery Ensure PIDs and QIA are completed for each scheme Establish a recovery plan for all schemes not achieving targets Ensure Divisional infrastructure regularly review TEP Schemes, complete recovery plan and identify new schemes either in mitigation or for next financial year TEP programme alongside Improvement Plan to ensure they complement each other 2016/17 programme developed. Contractor meetings with the single Commissioner MIAA Audit Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Level of recording of non-recurrent TEP versus recurrent TEP. Timely planning of TEP programme to ensure future delivery Anticipated effect of controls Reported at Board meeting aligned to performance trajectory and performance report Page 19 of 32

46 Strategic Priority (Objective) Corporate Objective 6, Risk Description : Failure to achieve Value For Money (VFM) services and financial sustainability BAF Ref: AF2.8 Assurance Committee Finance & Performance Committee Current Risk Score (L x C) 4 x 5 = 20 Target Risk Rating 3 x 5 = 15 Date entered on register: 28/05/14 Risk Direction Unchanged Target Gap Score 5 Tolerable Risk ID number: AF3526 Executive Director Lead Director of Finance Executive Team Last received at F&P committee: January 2018 Date of next review: February 2018 Graph of Risk over time Target score Risk score Risk Appetite None low Moderate High Significant Rationale for current score: The Trust is currently working to a deficit plan, therefore is not currently financially sustainable Date When Target Risk score expected to be achieved The achievement of this for all services will only be realised with the achievement of a fully Integrated Care System provisional target date May 2019 Controls: Standing Financial Instructions (SFI s) in place Routine monthly service and financial meetings Regular monthly reporting to Executive Team and Board Monthly TEP reporting to Executive Team /Board Contract performance meetings Planned process Scheme of Delegation. Budgetary Systems and Procedures Appropriate insurance protection established Activity Planning income and activity Mitigating actions: (what more should we do?) Divisional action plans and recovery plans where required Implementation of CPT plan and formation of an integrated Care organisation Risk source Strategic Insight and Foresight Rational for Risk appetite The Trust is not willing to risk the ability of the organisation to achieve NHS Improvement requirements and financial sustainability Assurance: (how do we know if the things we are doing are having an impact and can we validate or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?): Strategic plan in place to work with other organisations to ensure sustainability going forward Audit Committee Finance and Performance Committee Trust Board Report. Internal and External Audit Reports to Audit Committee Annual (External) Audit. Annual Report to Trust Board on Financial Plans and Budgets for the new year Gaps in assurance and actions not being actioned (what additional assurances should we seek?) No gaps in assurance identified Anticipated effect of controls Reported at Board meeting aligned to performance trajectory and performance report Page 20 of 32

47 Strategic Priority (Objective) Corporate Objective 5, Corporate Objective 7 BAF Ref: AF4.2 Date entered on register: 15/09/14 Risk ID number: AF3488 Risk Description : Failure to ensure on-going compliance with NHS Improvement Provider Licence requirement Assurance Committee Trust Board Executive Director Lead Chief Executive Current Risk Score (L x C) 4 x 5 = 20 Risk Direction Last received at Trust board: January 2018 Target Risk Rating 3 x 5 = 15 Target Gap Score 5 Tolerable Date of next review: February 2018 Graph of Risk over time Target score Risk score Risk Appetite None low Moderate High Significant Rationale for current score: Current IM&T infrastructure and local intelligence Date When Target Risk score expected to be achieved The achievement of this for all services will only be realised with the achievement of a fully Integrated Care System provisional target date May 2019 Controls: (what are we currently doing about the risk?) Board reporting in line with FT provider licence requirements Board Financial reporting procedures fit for purpose FT metric performance framework Regular contact with Monitor and Board reporting re actions taken to maintain authorisation Mitigating actions: (what more should we do?) Agreement of achievable controls totals Continuous implementation of required actions by all staff at levels required Implementation of action plan re TEP identification and implementation of Trust Improvement Programme and Agreed Monitoring action Risk source NHS Improvement Provider licence requirements and Regulatory Monitoring Rational for Risk appetite The organisation is not prepared to accept risks to the ability of the Trust to maintain compliance with the Provider licence Assurance: Regular contact with NHS Improvement and Board reporting re actions taken to maintain authorisation Trust Board seminars Board Reports Financial governance infrastructure MIAA Audit review of Annual Report Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Control total not agreed Anticipated effect of controls It is anticipated that current controls and mitigations will align performance to ensure compliance Page 21 of 32

48 Strategic Priority (Objective) Corporate Objective 5, Corporate Objective 7 Risk Description : Risk that we will not have the appropriate level of registered skilled nurses/practitioners in the A&E department to appropriately manage advanced life support situations (EPALS training). BAF Ref: Assurance Committee Quality and Governance Committee Current Risk Score (L x C) 4 x 4 = 16 Target Risk Rating 1 x 4 = 4 Date entered on register: 22/09/17 Risk Direction unchanged Target Gap Score 12 Serious Risk ID number: CR4439 Executive Director Lead Chief Nurse Date last received at Q&GC: February 2018 Date of next review: March 2018 Graph of Risk over time Target score Risk score Risk Appetite None low Moderate High Significant Rationale for current score: Current reported training performance information Date When Target Risk score expected to be achieved March 2018 Controls: (what are we currently doing about the risk?) 6 places booked for training in February 2018 Investigating if Paediatric team can support Rota planned to include at least one EPLS trained practitioner Discussed weekly as part of Senior nurse team meeting with the chief Nurse Mitigating actions: (what more should we do?) Extra training slots required - timescale TBC Risk source Risk Assessment Assurance: (how do we know if the things we are doing are having an impact) Daily escalation as part of the daily staffing review Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Roster review Anticipated effect of controls (when reduction is risk trajectory expected /risk score reduced) Department has suitable complement of EPALs staff Page 22 of 32

49 Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 2 BAF Ref: AF5.3 Date entered on register: 02/05/17 Risk Description: If pressure ulcer prevention policies and interventions are not being Assurance Committee consistently implemented there is a risk that patients are developing pressure ulcers resulting in Quality & Governance Committee avoidable patient harm Graph of Risk over time Target score Risk score Current Risk Score (L x C) 4 x 4 = 16 Target Risk Rating 2 x 4 = 8 Risk Appetite None low Moderate High Significant Risk Direction Unchanged Target Gap Score 8 Close Monitoring Risk ID number: CR4316 Executive / Divisional Lead Chief Nurse Last received at Q&G committee: February 2018 Date of next review: March 2018 Rationale for current score: Identification of pressure ulcers, aggregated data which demonstrates improvements are required. Date When Target Risk score expected to be achieved September 2018 Controls: (what are we currently doing about the risk?) Pressure Ulcer Prevention policy and procedures in place Skin Care bundle launched and implemented in May 2017, along with the Quality Care tool (replacing the intentional rounding tool). Monitoring of performance and review of pressure ulcer RCA s through Pressure Ulcer scrutiny Group. This will be chaired by the Chief Nurse from November Audit and Safety Thermometer programme Key Metrics monitored Training and development sessions Work led by the Chief Nurse in relation to addressing the effectiveness of pressure ulcer prevention introduction of new dynamic mattresses RCA generates a local individualised action plan and there is also an overarching action log monitored at the Pressure Ulcer Scrutiny group. RCA timescale monitoring in place to ensure more timely learning and actions as a result of the outcomes of RCA's. Establishment of the Trust Pressure Ulcer Prevention Committee. The on-going aims, report structures, outcomes, and work plans have been agreed at this committee and update provided to the PSPB. Mitigating actions: (what more should we do?) Monitoring of improvement Risk source Incidents Rationale for Risk appetite The Trust does not have an appetite for the potential outcomes of the risk related to patient harm and is contrary to the Trust s Corporate Objective 1. Assurance: (how do we know if the things we are doing are having an impact) Complaints and incident data Feedback posted on public websites. Feedback from GPs and other Health Professionals Monitoring of KPI s and Safety Thermometer Programme Ward Metric Audit of compliance with Skin Care Bundle and Quality Car Tool to be undertaken and evaluated in Q3/Q4 2017/18 Trial evaluation and outcomes Gaps in assurance and actions not being actioned None known Anticipated effect of controls It is anticipated that the risk score will reduce incrementally as assurance is obtained of improvement Page 23 of 32

50 Strategic Priority (Objective) Corporate Objective 1, 2, 3, 4, 5, 6 BAF Ref: Date entered on register: 26/05/17 Risk ID number:cr4342 The impact of revised working as a consequence of Tameside Children s Improvement Board responding to the findings of the Ofsted inspection. It is likely that some services will need to respond to a demand greater than the current capacity especially in the Safeguarding Team, School Nursing, Health Visiting service and Paediatric Medical Team Assurance Committee Risk Management Group Current Risk Score (L x C) 4 x 4 = 16 Risk Direction Divisional Lead Chief Nurse Date last received at Q&GC February 2018 Target Risk Rating 2 x 4 = 8 Target Gap Score 8 Close monitoring Date of next review: March 2018 Graph of Risk over time Target score Risk score Risk Appetite None low Moderate High Significant Rationale for current score: Incidents Date When Target Risk score expected to be achieved July 2018 Controls: (what are we currently doing about the risk?) Children s Services and Safeguarding Children Board in Tameside Action Plan Review of ICO interface with other services Safeguarding Board Monitoring Updates from Children s Services and Safeguarding Children Board in Tameside. Planning for the integration of the ICFT Safeguarding Teams Working with the Single Commissioner to develop a business case for investment Mitigating actions: (what more should we do?) Risk source Clinical Risk Rationale for Risk appetite The importance of understanding the impact this may have on quality & safety. Assurance: (how do we know if the things we are doing are having an impact) SQOGG Risk Management Group Gaps in assurance and actions not being actioned Anticipated effect of controls (when reduction is risk trajectory expected /risk score reduced) It is anticipated that this score will incrementally reduce as mitigations take effect Page 24 of 32

51 Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 2, Corporate Objective 3, Corporate Objective 4, Corporate Objective 5, Corporate Objective 6 Risk Description: That Children are receiving the appropriate levels of safeguarding. Specialist Safeguarding Children and Young People resources are under pressure due to vacancies and the pace of change associated with the Tameside Children s Safeguarding improvement plan. BAF Ref: Divisional Lead Deputy Chief Nurse Current Risk Score (L x C) 4 x 4 = 16 Risk Direction NEW Risk ID number: CR4453 Assurance Committee QGC Integrated Safeguarding Committee Date of last review: January 2018 Target Risk Rating 2 x 4 = 8 Target Gap Score 8 Close monitoring Date of next review: April 2018 Graph of Risk over time Target score Risk score Risk Appetite None low Moderate High Significant X Rationale for current score: Risk Assessment based on intelligence and staff feedback Date When Target Risk score expected to be achieved 31/3/18 Controls: (what are we currently doing about the risk?) Monthly review of LAC provision and achievement of statutory requirement: programme in place for implement. Development of an integrated safeguarding team. Development of an integrated safeguarding annual work plan to include audit of metrics for the purpose of assurance. Review of the safeguarding structures. Maintenance of preparations for CLAS instruction Provision of safeguarding supervision Exec leadership engagement with Tameside Children s Board/Improvement Board. Internal safeguarding group chaired by the Chief Nurse as executive lead for safeguarding; obtaining assurance that the Trust has robust safeguarding processes in place. Mitigating actions: (what more should we do?) Weekly meetings chaired by the Chief Nurse to ensure that the Trust is assured that processes are in place to safeguard children and is prepared for CLAS inspection. Continue to integrate the acute and community safeguarding children's teams. Review of safeguarding children's teams structure to ensure adequate resources to deliver mandatory requirements Engagement of services across the organisation to ensure each area can provide assurance regarding their requirements for safeguarding children. Continue the partnership work to improve timeliness of initial health assessments for looked after children. Ensure there is daily input from Health into the safeguarding children's HUB. Risk source Risk Assessment Rationale for Risk appetite Preference for safe delivery options. Assurance: (how do we know if the things we are doing are having an impact) Trust Board Quality & Governance Committee Integrated Safeguarding Committee Gaps in assurance and actions not being actioned Safeguarding performance dashboard. Anticipated effect of controls (when reduction is risk trajectory expected /risk score reduced) To be agreed in line with Trust approach Page 25 of 32

52 Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 2, Corporate Objective 3, Corporate Objective 4, Corporate Objective 6 Risk Description : Trust may be unable to provide one stop Breast Service if Breast radiologist cannot be recruited to vacancies. This could lead to a delay in diagnosis and treatment. Linked with Risk AF3482 BAF Ref: Assurance Committee Quality and Governance Committee Date entered on register: 21/08/12 Risk ID number:cr1894 Executive Director Lead Executive Director of Operations Medical Director Current Risk Score (L x C) 4 x 4 = 16 Risk Direction unchanged Last reviewed at Q&GC February 2018 Target Risk Rating 3 x 4 = 12 Target Gap Score 4 Tolerable Date of next review: March 2018 Graph of Risk over time Risk Appetite Target score Risk score None low Moderate High Significant Rationale for current score: There is a national shortage of Staff in some specialties therefore there is additional reliance on Locum and Agency staffing to provide full staff compliment Date When Target Risk score expected to be achieved December 2018 Controls: (what are we currently doing about the risk?) Failed recruitment on 2 separate occasions for Consultant Radiologists. Breast radiology cover for annual leave and sickness provided by Locums from other local Trusts. WLI's offered to our single handed breast Consultant. Partnership working is being explored to offer robust solution. Recruitment of Consultants from abroad via agencies is being explored also. This risk has been reviewed and aligned with the risks and mitigations of risk 1.23 AF3482. Medical Staffing - The ability to recruit to Consultant and Middle Grade posts due to national shortages in certain specialties i.e. Radiology, Medicine and A&E. This may impact on patient experience and the ability to provide safe care Mitigating actions: (what more should we do?) Continue to seek partnership recruitment solutions Risk source Operational performance Rational for Risk appetite To be agreed in line with Trust approach Assurance: (how do we know if the things we are doing are having an impact) Continued unaffected provision of services. Assurances from patient / service user feedback and complaints data Performance data Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Anticipated effect of controls (when reduction is risk trajectory expected /risk score reduced) To be agreed in line with Trust approach Page 26 of 32

53 Strategic Priority (Objective) Corporate Objective 2 Corporate Objective 6 BAF Ref: AF 1.24 Date entered on register: 02/12/14 Risk ID number: CR3618 Risk Description : If demands on the service outstrip capacity this may result in inability to deliver the 4 hour Emergency Access Standard Assurance Committee Operational Group Executive Director Lead Director of Operations Current Risk Score (L x C) 4 x 4 = 16 Target Risk Rating 3 x 4 = 12 Risk Direction unchanged Target Gap Score 4 Tolerable Last received at Operational Group February 2018 Date of next review: March 2018 Graph of Risk over time Target score Risk score Risk Appetite None low Moderate High Significant Rationale for current score: Current Reported performance information and impact on patient flow Date When Target Risk score expected to be achieved Reduction of risk is expected to be incremental and the risk achieve target score in May 2019 Controls: Additional ED Management Support and Infrastructure. Extended out of hours management presence. Bed meetings. Additional staffing (all services) Breach analysis and system resilience work. Back to the 90 s focussed patient flow work and learning from this work Action plan developed for ward areas following back to the 90 s initiative Mitigating actions: (what more should we do?) Daily management oversight on a patient by patient basis. On site management support overnight. In-reach from medical consultants to ED Trust wide focussed work regarding patient flow System resilience work Risk source Strategic Insight and Foresight Rational for Risk appetite The Trust is not willing to risk the ability of the organisation to delivery safe effective care Assurance: (how do we know if the things we are doing are having an impact and can we validate or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?): Emergency Department daily performance report Bed meeting reports Executive Team reports Board reports Divisional action plans and analysis of information Improvement Board Actions Detailed Improvement Plan and system resilience work. Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Impact of Third party action and third party decision e.g. impact of Primary care and Local Authority Anticipated effect of controls Reported at Board meeting aligned to performance trajectory and performance report Page 27 of 32

54 Strategic Priority (Objective) Corporate Objective 4, Corporate Objective 5 Risk Description Lack of nursing home beds in the health economy impacting on the Trust s ability to avoid delayed transfer of care. BAF Ref: AF1.24 Assurance Committee Quality & Governance Committee Current Risk Score (L x C) 4 x 4 = 16 Target Risk Rating 3 x 4 = 12 Date entered on register: 03/07/17 Risk Direction De-escalating Target Gap Score 4Tolerable Risk ID number: CR4398 Executive Director Lead Director of Operations Last received at Q&G committee: February 2018 Date of next review: March 2018 Graph of Risk over time Target score Risk score Risk Appetite None low Moderate High Significant Rationale for current score: Current reported performance information Date When Target Risk score expected to be achieved April 2018 Controls: (what are we currently doing about the risk?) Weekly Exec Service management meetings ICFT with Single Commission/adult social care. Transformation Schemes Home First/Direct Home/Discharge to assess. Supportive working with Care homes Discussions at Joint Management Team regards how neighbourhoods can support care homes Digital health supporting admission avoidance from care homes. Mitigating actions: (what more should we do?) Continued discussions and development and implementation of mitigation plans with the Single Commissioner Continued collaboration with Care Homes through the Single Commissioners Care Home Group Risk source Risk register, and Operational performance Rational for Risk appetite The Trust is not willing to accept continued long term disruption to patient flow and patients who are medically fit for discharge being kept in hospital beds longer than appropriate. Assurance: Reports to EMT QGC Monthly DTOC return Daily DTOC information Review of GM HSCP re discharges/dtoc MIAA report Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Dependent on other stakeholders implementing changes RN vacancies nationally impacting on nursing home closures. Anticipated effect of controls To be monitored closely to ensure mitigations are taking effect Page 28 of 32

55 Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 6 BAF Ref: 1.22 Date entered on register: 15/09/14 Risk Description If medical staff do not have the relevant skills and training support and supervision there is a risk that care will not meet standards of safe practice impacting on patient experience, the quality of care and outcomes. Assurance Committee Quality and Governance Committee Current Risk Score (L x C) 3 x 5 = 15 Target Risk Rating 1 x 5 = 5 Risk Direction Target Gap Score 10 concern Risk ID number: CR3481 Executive / Divisional Lead Director Of Human Resources Last received at Q&G committee: February 2018 Date of next review: March 2018 Graph of Risk over time Target score Risk score Risk Appetite None low Moderate High Significant Rationale for current score: Based on internal compliance reports Date When Target Risk score expected to be achieved April 2018 Controls: (what are we currently doing about the risk?) All key policies and procedures held on Intranet Document control system. Mandatory Training requirements and review annually of training needs analysis Educational Governance Group to coordinate and systematically apply educational governance HEENW action plan and requirements. Revised appraisal system embedded to strengthen the systems for development and skill identification Revalidation processes and metrics Mitigating actions: (what more should we do?) Monitoring of improvement Greater Manchester Mandatory Training Implementation Working Group are looking at efficiencies in core skills training which the Trust is participating in. Risk source External Review Rationale for Risk appetite The Trust has a preference for safe delivery of skills training and supervision but will tolerate a low degree of inherent risk Assurance: (how do we know if the things we are doing are having an impact) Third party assurance received from MIAA Audit regarding the medical staff revalidation process provides assurance around the revalidation element. It is anticipated that further implementation of the agreed action plan and mitigations will mitigate and reduce the risk to an organisationally acceptable level. Education, Training and Development Group is established and embedding Divisional ownership Gaps in assurance and actions not being actioned None known Anticipated effect of controls It is anticipated that the risk score will reduce incrementally as assurance is obtained of improvement Page 29 of 32

56 Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 2, Corporate Objective 3, Corporate Objective 4, Corporate Objective 5, Corporate Objective 6 Risk Description : The provision of a 24 hour Observation and Assessment Facility on the Children s Ward requires a higher level of nursing recourse; the resource available does not meet RCN guidelines Graph of Risk over time Target score Risk score BAF Ref: Assurance Committee Quality and Governance Committee Current Risk Score (L x C) 5 x 3 = 15 Target Risk Rating 2 x 3 = 6 Risk Appetite None low Moderate High Significant Risk Direction Target Gap Score 9 Close monitoring X Risk ID number: CR1501 Executive/Divisional Lead Interim Chief Nurse / Divisional Assistant Chief Nurse last received at Q&G Committee: February 2018 Date of next review: March 2018 Rationale for current score: Date When Target Risk score expected to be achieved 30/05/18 Controls: (what are we currently doing about the risk?) Benchmarking the model of care and the nursing resource. Use of NHSP as required; increased number of Ward Staff now on NHSP and new starters have joined NHSP. Rolling recruitment program including interviews on-going basis for recruitment to increase. Effective sickness/absence management. Annualised hours. Review of the current acuity tool. Mitigating actions: (what more should we do?) To continue with recruitment drive and bank staff. Discussed at Children's Governance meeting regarding the Consultant who is on Hot week to be supportive and visible reviewing the patients on the O&A Unit and the Ward. Consultant to share this at the Consultant meeting to ensure staff junior doctors and the nursing staff are supported. Review the number of in-patients beds following the increase in observation and assessment facilities. Escalate concerns to Divisional Quality and Safety Governance Assurance meeting. Staffing papers to be reviewed by Directorate manager, Matron and Manager for the Children's Services and then for resubmission to the Interim Chief Nurse. Risk source Risk Assessment Rationale for Risk appetite Preference for ultra-safe delivery options. Assurance: (how do we know if the things we are doing are having an impact) Reviewing of off duty on a daily basis. SQOGG Divisional Safety & Quality Group Paediatrics Governance Group Gaps in assurance and actions not being actioned Increased levels of staff sickness; staff are tired, at risk of 'burn out' due to covering extra shifts. NHSP does not cover all off duty gaps. Current shortage of experienced and newly qualified Paediatric Nurses nationally. Despite on-going and focused sickness management, sickness on the unit is increasing. ICFT does not currently need an evidence-based acuity tool in paediatrics. This is presently being explored. Anticipated effect of controls (when reduction is risk trajectory expected /risk score reduced) To be agreed in line with Trust approach Page 30 of 32

57 Strategic Priority (Objective)Corporate Objective 4, Corporate Objective 6 BAF Ref: AF4.8 Date entered on register: 15/09/14 Risk Description: Failure to have in place an IM&T infrastructure and Service supporting the Assurance Committee organisational objectives. Information Management & Technology Group Graph of Risk over time Target score Risk score Current Risk Score (L x C) 3 x 5 = 15 Target Risk Rating 2 x 5 = 10 Risk Appetite None low Moderate High Significant Risk Direction Unchanged Target Gap Score 5 Tolerable Risk ID number: AF3491 Executive Director Lead Director of Performance & Informatics Last received at IM&T group: January 2018 Date of next review: February 2018 Rationale for current score: Current IM&T infrastructure and local intelligence Date When Target Risk score expected to be achieved Awaiting confirmation of timescale Controls: (what are we currently doing about the risk?) Director of Performance and Informatics Leadership. ITIL (Information Technology Infrastructure Library) change Control process in place. IM&T Group structure. Risk Register in place with plans to mitigate. Strengthened support service flow and ownership within IT Mitigating actions: Production of a detailed 1-3 year roadmap with 4-5 at a holistic level. Review of roadmap at key junctions, changes in business strategy or 6-monthly. Alignment of resource structure to meet the business model. Identification and mitigation plans reported via the risk board. IM&T Group in place to support developments across the Trust. Single points of failure to be identified and mitigated against. Departmental business plans in place in the event of an IT outage. Skills gaps to be addressed through training matrix. Funding for some elements of disaster recovery requirements Risk source Operational performance Rational for Risk appetite The Trust is not prepared to accept risks to the achievement of acceptable outcomes Assurance: Significant reduction in number of unscheduled outages impacting Trust services. Executive Management Team Board Reports Exception Reports Audit Internal & External (MIAA) Third party reviews and feedback Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Lack in business understanding of the infrastructure supporting key services. Financial constraints. Technical refresh programme supporting the business strategy. Business strategy is not in place. Business leads not engaging with IT through Change Control and Service Desk. Skills Gaps. IM&T Group Anticipated effect of controls Continued stability as experienced over the last twelve months. Embedding of best practice utilising the ITIL model. Improved understanding, communication and visibility Page 31 of 32

58 Strategic Priority (Objective) Corporate Objective 1, Corporate Objective 4, Corporate Objective 5, Corporate Objective 6. Risk Description : Healthier Together Risk that the Trust will be in breach of its financial control limit due to the significant stranded costs caused by the reconfiguration of emergency and elective (cancer) general surgery as part of the Healthier Together Programme across Greater Manchester. Unless recurrent transformational funding is agreed the loss of income to the Trust would be far greater than the levels of costs which could be safely extracted. Currently GM is proposing to fund 2 years non-recurrent stranded costs which would leave the organisation in serous financial deficit Graph of Risk over time Target score Risk score BAF Ref: AF2.6, AF2.8 Assurance Committee Quality & Governance Committee Current Risk Score (L x C) 3 x 5 = 15 Target Risk Rating 2 x 5 = 10 Risk Appetite None low Moderate High Significant Date entered on register: 03/01/17 Risk Direction De-escalating Target Gap Score 5 Tolerable Risk ID number: CR4201 Executive Director Lead Director of Finance Last received at Q&G committee: February 2018 Date of next review: March 2018 Rationale for current score: Reconfiguration across Greater Manchester effecting services and financial income Date When Target Risk score expected to be achieved Awaiting confirmation of timescale Controls: (what are we currently doing about the risk?) Continue to engage with the Healthier Together Clinical Advisory Group and inform the Trust Executives of any significant financial and/or clinical implications. Ensure identified actions are worked through and completed Mitigating actions: (what more should we do?) Continue to attend HT clinical advisory group Input into key work streams, finance, human resources, cancer MDT. Contribute to and complete the outline business case and identification of stranded costs vs costs which can be influenced. Completion of detailed bottom up analysis of stranded costs vs costs to be extracted. Risk source Operational performance and finance Rational for Risk appetite The Trust is not willing to accept risk with the preference being for maintaining financial stability Assurance: (how do we know if the things we are doing are having an impact and can we validate or evidence e.g.: Inspections; Committees; Working Groups; Reports; Monitoring Returns etc?): Monitoring of data and financial position. Executive Management Team Board Reports Gaps in assurance and actions not being actioned (what additional assurances should we seek?) Ultimately the controls are third party reliant. Anticipated effect of controls (when is a reduction in risk trajectory expected /risk score reduced) Continued transformation and financial awareness. Page 32 of 32

59 Agenda Item 11 KEY ISSUES AND ASSURANCE REPORT Quality and Governance Committee February, 2018 The Committee draws the following matters to the Board s attention- Issue Committee Update Assurance received Action Timescale Electronic CAS-card system The Committee received a detailed presentation on the introduction of the new system The Committee obtained positive assurance that the system was effective and comprehensive; and that it was being introduced with strong staff support Full implementation in the Emergency Department March 2018 Children s Safeguarding The Committee received a presentation on the Trust s work to comply with statutory obligations in this area, including in partnership with other agencies The Committee had assurance that there was grip on the issues, whilst recognising that there were areas where improvement was required. The Committee particularly noted the need to have a closer engagement in the relevant arrangements in the Derbyshire part of the Trust s area. Presentation on Adult Safeguarding March 2018 Pressure Ulcers The Committee received a presentation on current work on the identification and prevention of Grade 3/4 pressure ulcers. There was positive assurance regarding the steps being taken, but the Committee was not able to say that positive outcomes were more likely at this stage. It was noted that there was a plan to improve performance, led by the Chief Nurse. Continued monitoring. Full further presentation in Q1 to review progress/ implementation of actions May 2018 Board Assurance Framework The Committee reviewed the updated list of risks within the oversight of the Committee. The Committee had reasonable assurance that the risks were being effectively managed and mitigated The Committee asked the Secretary to ensure that the work-plan for the Committee reflects the priority risks under the Committee s management March 2018

60 Agenda Item 11 Issue Committee Update Assurance received Action Timescale Aggregated Learning The ratio of complements to complaints was very encouraging. Work was being undertaken to see if analysis of complements and complaints related to attitude was possible. Assurance will be available following the analysis, if it can be performed. Follow up April 2018 Specific issues related to physical security for staff colleagues on a ward were noted The Committee were assured that appropriate protections for staff and patients were in place The Committee discussed changing the format of the report to have more focused information provided. N/A Structure of report to be reviewed March 2018 Patient Experience The Emergency Dept continues to be performance-managed to meet the target for Friends and Family Test returns There was assurance that the performancemanagement continues to focus attention in the Dept. The Committee awaits an improvement in the percentage of patients making the returns Review for next quarter May 2018 The Trust continues to achieve 95% positive responses in the FFT N/A Continued monitoring Duty of Candour The Committee noted that HM Coroner would be issuing a Prevention of Future Deaths notice to a third party regarding a patient at the Trust. No action required Assurance gained includes the Committee receiving evidence that: i. The extent of the issue has been quantified; ii. The impact is included in all internal and external reporting iii. There are processes in place to learn from the occurrence, and measures have been put into place to prevent them happening again

61 TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 22 February 2018 Agenda Item 12 Title Sponsoring Executive Director Author (s) Purpose Previously considered by Director of Finance Report - Month 10 (January) Claire Yarwood, Director of Finance Finance Team Discussion and Endorsement This paper has been reviewed by the Finance and Performance Committee Executive Summary: For the financial position for the six months to January 2018 the Trust is reporting a net deficit of 21.0m, which is c. 0.6m worse than plan. Related Trust Objectives Risk Assurance risk impacted upon Legal implications/regulatory requirements Financial Implications Has a quality impact assessment been undertaken? How does this report affect Sustainability? 6 To deliver against the required local and national regulatory frameworks as part of the Greater Manchester Health and Social Care Devolution, securing the best economy efficiency and effectiveness in use of resources the Trust spends to deliver services both directly and through partner organisations. 723 Failure to meet, deliver the Trust s financial plan In breach of licence None None Sustainability is subject to the outcome of the system wide review by the CPT Action required by the Board The Board are asked to discuss the contents of the report, recognise the risk and endorse the actions required.

62 Executive Summary Month Ten (January 2018) Summary of Performance For the financial period to the 31st January 2018, the Trust is reporting a net deficit of c. 21.0m, which is c. 0.7m worse than plan. In January the Trust has failed to deliver the in month savings target for the second month running by c. 0.4m and is behind against its YTD target by c. 0.2m. Key I&E issues: The level of medical agency expenditure is providing a financial pressure for the Trust, however the Trust is currently forecasting to achieve the NHSI agency cap. The Trust has received two tranches of income relating to the Autumn Budget, Tranche 1 equates to 0.6m which must be used to reduce the planned deficit. Therefore the full year plan net deficit has moved from 24.4m to 23.8m. The second tranche relates to 0.7m for support of winter pressures. The Trust has a number of escalated beds that are unfunded. Income on smaller clinical contracts is falling. The Trust needs to continue to reduce variable costs to offset where ever possible the loss of income. Failure to deliver the Trusts efficiency target. Key Balance Sheet issues: The January month end cash balance was c. 0.7m above the expected 1.2m plan The Trusts capital expenditure was c. 0.4m behind plan for January, the key delays relating to slippage on replacement of medical equipment, it is still expected that the capital programme will be delivered. Key Risks: The Trust has agreed with NHSI that it will deliver the planned deficit. As a result of the Trust not signing up to the NHSI control total, there will be no access to STF or capital monies for A&E Streaming or from the Digital fund As the Trust is planning for a deficit, there is a requirement for a DH loan to fund it. The Trust is subject to a higher interest rate for borrowing as it has not agreed a control total. The Trust needs to ensure it delivers cost reduction in line with reductions in clinical activity. The Trust is paying escalated rates to clinical staff due to significant gaps in the rota, as a result of a high level of vacancies and a change in the tax regulations. At the end of 2016/17, the Trust had loan liabilities of 54.8m. It is anticipated this will increase to 78.1m in 2017/18. The Trust will be required to repay part of this liability in To do this the Trust will require a new loan, which could be at a higher interest rate than the current loan. 1

63 Financial Overview - Dashboard 2

64 Financial Overview Forecast Assessment Month Ten Financial overview Forecast by Division Forecast Note The Executives recognise the need to achieve the financial plan agreed by the Board and will be taking actions to reverse the current run rate. Internal forecast currently suggest a year-end deficit of circa 0.7m, which is a 0.4m improvement from the month 9 internal forecast. A Recovery Board has been established, chaired by the Non Executive Chair of the Finance and Performance Committee, and this Board will monitor the delivery of the recovery plan. Divisional I&E Position Annual Budget SUM Forecast Expenditure Year End Variance Previous Forecast Movement Variance COMMUNITY SERVICES 29,611 28,449-1,162 1,175 CORPORATE 55,267 54, INCOME - 198, ,681 2,345 2, MEDICINE & CLINICAL SUPPORT SERVICES 71,203 75,020 3,817 3, RESERVES , SURGERY / WOMEN & CHILDRENS 60,799 58,786-2,013-1, TRANSFORMATION 5,732 4,582-1,150-1, I&E Position 23,730 24, , Key Information Income/Transformation The underspend in Transformation is offset by an underachievement in income. Without Transformation, Income would be underachieving by just under 1.2m. Recovery Plan A series of speciality deep dives have been undertaken as part of the Trusts financial recovery. The recovery board is reviewing the output. The deep dives have resulted in savings equating to c. 0.5m in year. TEP - Work is progressing on the Trust Efficiency Programme to bridge the gap to 2017/18 and recurrent TEP target. Theme groups have been invited to the Executive Team meeting and the Finance and Performance Committee to present an action plan to bridge the gap to plan. Key Issues/Risks Medical Staffing Pay Medical staffing pay is forecast to spend over 2.8m more than in 2016/17. This is a mixture of increase in vacancies in key areas (Radiology, General Medicine and A&E middle grade) and increased rates of pay for agency, locum and bank staff. The key areas have been targeted within the deep dive reviews. TEP Currently the forecast for TEP is a shortfall of 0.5m, failure to deliver this target creates a pressure on the Trusts position both in 2017/18 and 2018/19. 3

65 Recovery Plan Recovery plan overview Key Information The plan outlines the Trusts key mitigation items expected to deliver which will result in the Trust delivering its planned deficit for 2017/18, this is currently showing a shortfall of c 0.1m. The relates to unplanned increases in expenditure in month 10, although it should be noted that the forecast is for the Trust to achieve the planned deficit. 4

66 Valuing Care Productivity and Efficiency Programme Financial overview - Forecast In Year -0.4m Forecast Shortfall 0.1m Movement from M9 forecast Recurrent -1.2m Forecast Shortfall 30k Movement from M9 forecast Key Messages: Profile of delivery In year The Trust is currently behind of its YTD plan by 0.2m. To deliver the forecasts the Trust will need to deliver a further 1.1m in year and 1.1m recurrently. As at January, the FYE of schemes delivered equates to 86% ( 8.9m) in year and 66% ( 6.6m) Recurrently. Valuing Care: Every Patient & Every Pound Counts

67 Financial Summary Performance Pay Expenditure: 0.06m Overspend YTD Slippage on Transformation vacancies 0.75m (F) Medical Overspends relating to significant vacancies 2.8m (A), particularly within A&E, Medicine, Gastro, Obs & Gynae and Radiology. Vacancies within Community and Corporate services 1.1m (F) Vacancies within Surgical division (Theatres, Wards and Outpatients) 1.1m (F) Other Income: c. 5.6m overachievement YTD:- Exceptional item 1.5m (F): Donated asset income for the Tameside McMillan Unit. This does not count against the Trust planned deficit. PFI rebate 0.8m (F): The Trust negotiated a reduction to its PFI contract in 2017/18 Other income for EMIS 0.8m (F), this is offset by overspends on pay and non-pay expenditure. Winter Tranche 1&2 funding: 0.45m (F) Provisions released 1.5m (F) in line with Recovery plan actions. General Expenditure/Non Pay: c. 3.2m overspend YTD:- Overachievement on non-clinical income and the overspend on non-pay, are primarily offsetting areas. 6

68 Pay Analysis Rolling 12 month Pay by Type Month 10 Pay In month actual by Division by Type Month 10 Key Messages: YTD to January pay expenditure c. 0.1m below plan. The Transformation programme and use of commercial sector and other movements are masking the True impact of the Trusts pay position. Without these pay would be overspent YTD by nearly 0.8m. General Medicine, Urgent Care and Specialist Medicine equate to 56% (c. 5.1m) of the Trusts Agency expenditure to Month 10. Medicine and Clinical Support Services division is c. 2.7m overspent, whilst Surgery, Women's and Children is 1.3m underspent on pay. 7

69 Clinical Income - Contract Analysis Key Messages: Overall, clinical income is under plan by 3m to month 10. The Trust has a block contract in place with Tameside and Glossop CCG, Tameside MBC and NHS England for Specialist Services. Of the reported underperformance 1.9m relates to an underachievement in Transformation Income which is offset with an underspend in Expenditure, this is due to delayed starts with agreed schemes All Other Commissioners includes Transformation funding of 3.7m year to date. Elective procedures are down compared to the same period last year where we saw a reliance on using the commercial sector to achieve our RTT performance. 8

70 Pay Analysis Total Bank and Agency Key Messages Total spend on bank and agency staff for January 2018 is 1.7m which is c. 0.3m more than last month. Bank usage is increasing as the Trust looks to promote use of the bank for both Medical and Nursing staff and consequently it is important to review the impact on Agency and fill rates of rotas. At the current forecast, the Trust will achieve the revised NHSI cap by 0.2m, it should be noted that the Tranche 2 winter monies has resulted in an increase in Agency staff costs which has been reflected in the Month 10 forecast position. Trust Total Agency Spend/Cap The Trust has been assigned a year end ceiling of 11.5m total agency spend for 2017/18. Planned agency expenditure has been profiled based on the average of monthly expenditure over the last year. The current forecast for the Trust is that it will achieve the revised cap by c. 0.2m. The Trusts bank expenditure has gone up by c. 97k per month in 2017/18 compared with 2016/17, as the focus continues to migrate Agency staff to the Trusts bank. 9

71 Cash Flow, Capital Expenditure and Debtor and Creditor Analysis Key Messages: Cash: The January month end cash balance was 0.6m above the 1.2m plan, this is within the allowed balance and relates to a receivable payment being received within the last couple of days of the month. The overall level of cash is forecast to remain at circa 1m across the next 13 weeks. Peaks in cash balances during this period reflect cash timing of receipt of monthly contract payments from NHS commissioners and payment to suppliers. Capital: In month, 372k of capital expenditure has been incurred. Major scheme in 2017/18 includes a lift installation. Debtors: The current NHS debt has now been collected since the end of January with the over 30 days being chased. The Local Authority debt is to be settled in March Loans: The Trust is anticipating requirement of a 21m loan to support the deficit, the remainder of the deficit was funded from Sustainability and Transformation funding owed from 2016/17 received in year. The total distressed loan liability the Trust will have at year end is 78.8m. Creditors: The creditor balances are predominantly current balances which will be settled in line with the Trust s payment terms. This is currently at 60 days due to the low levels of cash the organisation can maintain whilst operating in a deficit. Public Sector Payment Compliance (Target 95%): Total 30 Days Greater 30 Days NHS Value ( '000) 39,498 33, % 5, % NHS Number 1, % 1, % Non NHS Value ( '000) 93,592 64, % 26, % Non NHS Number 33,220 13, % 19, % 10

72 Statement of Financial Position (formerly Balance Sheet) as at 31st January 2018 Period Ending 31st March 2017 '000s 30th Sep 2017 '000s 31st Oct 2017 '000s 30th Nov 2017 '000s 31st Dec 2017 '000s 31st Jan 2018 '000s Dec - Jan Movement '000s 31 March 2017 Actual ' Sep 2017 Actual ' Oct 2017 Actual ' Nov 2017 Actual ' Dec 2017 Actual ' Jan 2017 Actual '000 Dec - Jan Movement '000 Non Current Assets Property, plant and equipment 83,735 83,969 83,844 83,601 83,398 83,391 (7) PFI: Property, plant and equipment 36,666 36,246 36,176 36,106 36,036 35,967 (69) Trade and Other Receivables > Accrued Income (CRU Income grt than > Prepayments - PFI Related 4,289 4,637 4,696 4,753 4,812 4, Total Non Current Assets 125, , , , , ,940 6 Current Assets Inventories - Stock - Finished Goods 1,430 1,717 1,869 1,847 1,761 1, Trade & Other Receivables:- > NHS Trade Receivables 3,665 3,540 2,496 2,753 2,392 2, > Non NHS Trade Receivables 2,235 1,771 1,857 2,728 2,160 2, Provision for doubtful debt (594) (248) (248) (242) (557) (682) (125) > PDC Dividend Receivable > Other Receivables (125) > Accrued Income 5,844 1,083 1, ,406 1, > Prepayments - Non PFI Related 1,287 3,035 3,111 3,194 3,414 3,235 (179) Cash 2,945 1,834 1,873 1,619 2,250 1,861 (389) Total Current Assets 17,129 13,383 12,678 13,461 13,472 13, Current Liabilities Trade & Other Payables:- > NHS Trade Creditors (1,899) (1,702) (1,182) (876) (997) (1,013) (16) > Non NHS Trade Creditors (3,612) (3,819) (3,771) (4,187) (3,151) (3,089) 62 > Other Creditors (6,992) (7,409) (7,661) (7,471) (7,409) (7,246) 163 > Capital Creditors (704) (211) (304) (192) (257) (314) (57) Other Liabilities:- > Accruals (10,862) (11,267) (11,584) (11,392) (11,293) (11,662) (369) > Deferred Income (2,342) (6,997) (6,467) (5,758) (5,238) (4,459) 779 >PFI Leases (1,336) (1,336) (1,336) (1,336) (1,336) (1,336) 0 >PDC Dividend Creditor Provisions (149) (182) (184) (194) (169) (187) (18) Total Current Liabilities (27,897) (32,924) (32,490) (31,406) (29,850) (29,306) 544 Net Current Assets/Liabilities (10,768) (19,541) (19,812) (17,945) (16,378) (15,550) 828 Non Current Liabilities Other Financial Liabilities:- > Deferred Income 0 0 > PFI Leases (53,594) (52,924) (52,811) (52,701) (52,587) (52,474) 113 > Interim Revenue Support Loan - DOH (54,801) (59,801) (61,601) (64,801) (67,801) (70,401) (2,600) Provisions (694) (638) (648) (648) (677) (690) (13) Total Non Current Liabilities (109,089) (113,363) (115,059) (118,150) (121,065) (123,565) (2,500) TOTAL ASSETS EMPLOYED 5,559 (7,363) (9,458) (10,977) (12,509) (14,175) (1,666) Financed By Taxpayers Equity PDC 53,285 53,285 53,285 53,285 53,285 53,285 0 Revaluation Reserve 35,287 35,287 35,287 35,287 35,287 35,287 0 I&E Reserve (83,013) (83,013) (83,013) (83,013) (83,013) (83,013) 0 I&E reserve 2017/18 0 (12,922) (15,016) (16,536) (18,069) (19,734) (1,665) TOTAL TAXPAYERS EQUITY 5,559 (7,363) (9,457) (10,977) (12,510) (14,175) (1,665) 11

73 Agenda Item 13 KEY ISSUES AND ASSURANCE REPORT Finance and Performance Committee February, 2018 The Committee draws the following matters to the Board s attention- Issue Committee Update Assurance received Action Timescale Financial Recovery Board Reported that the FRB were assured of progress, although there was 65k slippage. There were challenges remaining to achieve the in-year target FRB last meeting in March 2018 March 2018 M10 financial position Performance was slightly behind plan for the period to the end of January 2018 Management forecasts show marginally worse performance in year than plan. Committee assured that management confident that the plan can be met at the year-end Report to the Board February 2018 A significant part of the capital plan remained, but this was in accordance with the plan Assurance that capital was expected to be spent as planned Performance against the agency cap was noted. Committee discussed sickness absence, and welcomed the move to emphasise operational management rather than it being an HR function Trust Efficiency Programme, Committee reviewed progress, noting that significant savings had been made but the programme was 0.4M behind overall, and 1.2M fewer recurrent savings had been delivered The Committee had positive assurance regarding the delivery of the programme overall in year. It noted that the failure to fully deliver recurrent savings would increase financial pressure in future years. Report to the Board February 2018 Transformation Schemes The Committee received a detailed report on the benefits and savings accrued from transformation schemes The Committee had positive assurance that the transformation schemes are delivering patient care benefits; but not delivering cashreleasing savings Continued monitoring September 2018

74 Agenda Item 13 Issue Committee Update Assurance received Action Timescale Planning Guidance The Committee discussed the national planning guidance for the planning round, and potential impacts Board discussion in private session Executive team to ensure costs of delivering the cancer requirements are identified and revised plan developed if required February 2018 April 2018 Control Total offer The Committee received and discussed the Control Total offered by NHS Improvement for the year Discussion in private Board session February 2018 Trust Efficiency Programme, 2018/19 The committee received a detailed report on how the 2018/19 TEP is being developed utilising benchmarking information and comparison to Model Hospital The Committee was assured that all opportunities for efficiency while maintaining quality and safety are being explored and pursued. 2018/19 Plans and Budget The Committee explored the potential implications of the Planning Guidance and control total on Trust annual planning for 2018/19 Discussion in private Board session February 2018 Assurance gained includes the Committee receiving evidence that: i. The extent of the issue has been quantified; ii. The impact is included in all internal and external reporting iii. There are processes in place to learn from the occurrence, and measures have been put into place to prevent them happening again

75 Agenda Item 14 KEY ISSUES AND ASSURANCE REPORT Audit Committee February, 2018 The Committee draws the following matters to the Board s attention- Issue Committee Update Assurance received Action Timescale Internal Audit reports Received one IA review report, on Medical Devices IA reported Substantial Assurance Monitor management actions on usual 6-month cycle July 2018 Noted the review of Care Together undertaken for the CCG Audit Committee The review provided substantial assurance on the programme s internal processes. However, the Committee identified a potential gap in linking the Programme Board to Trust Board. Executive team to review options for information flow to Trust Board, with the Programme Management Director April 2018 Reference Costs Audit The Committee received the results of the annual reference cost assurance exercise The Trust is materially compliant with the requirements, and has robust processes in place. Some minor improvements were identified during the process No actions required External Audit update The Committee received the technical update from KPMG The Committee noted that the new requirements for reviewing SHMI data quality in the Quality Report could lead to a scope restriction, as the auditors may have difficulty reviewing how data is handled centrally (after submission). No actions required.

76 Agenda Item 14 Issue Committee Update Assurance received Action Timescale BAF and Significant Risks Annual Accounts Timetable 2017/18 Board Standing Orders Standing Financial Instructions Losses and Special payments Asset valuations The Committee received and reviewed the combined BAF and Significant Risk register The Committee received and reviewed the proposed final accounts timetable The Committee reviewed the draft revision of Standing Orders The Committee reviewed the draft revision of the SFI s Update for Q3 (October to December 2018) received Committee received a paper outlining the process for asset valuation to support the annual report process The Committee noted that the Board expected to have a development session regarding risk management processes The Committee approved the final accounts timetable The Committee was satisfied they were appropriate and recommended them for approval The Committee was satisfied they were appropriate, subject to minor textual amendment, and recommended them for approval No causes for concern were identified. The Committee endorsed the approach proposed. Board seminar session to consider- Better definition of risk appetite (should there be defined numeric boundaries?) Focus on gap score as the main guide Whether target scores accurately reflect the minimum achievable score Whether the system effectively records controls, effectiveness and alternative actions No actions required Consideration by Council Consideration by Board April st March th March 2018 Consideration by Board April 2018 No actions required No actions required Assurance gained includes the Committee receiving evidence that: i. The extent of the issue has been quantified; ii. The impact is included in all internal and external reporting iii. There are processes in place to learn from the occurrence, and measures have been put into place to prevent them happening again

77 TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 22 nd February, 2018 Agenda Item 15 Title Sponsoring Executive Director Author (s) Purpose Previously considered by Emergency Preparedness Resilience & Response (EPRR) Core Standards Assessment Mrs Trish Cavanagh Director of Operations Mike McCluskey Fire Safety & EPRR Manager To note and approve Previous Core Standards Assessments have been brought to Board each year since Executive Summary: Since 2013 the Trust has been required to report on the Emergency Preparedness Resilience and Response (EPRR) Core Standards. The purpose of this process is to assess the preparedness of the NHS, both commissioners and providers, against common NHS EPRR Core Standards. Provider organisations are asked to undertake a self-assessment against the relevant individual core standards and rate their compliance. These individual ratings will then inform the overall organisational rating of compliance and preparedness. Organisations are required to take a statement of compliance to their Board meeting and publish this statement in their annual report. Related Trust Objectives Risk Assurance risk impacted upon Legal implications/regulatory requirements Financial Implications Has a quality impact assessment been undertaken? How does this report affect Sustainability? To deliver against the required local / national regulatory frameworks and standards. The ability of the Trust to respond to a range of incidents such as major incident response & business continuity Issues where the Trust may lose vital resources which impact on the delivery of critical services. This is a regulatory requirement of the NHS England EPRR framework 2013 No financial implications. No quality impact assessment has been undertaken; however the Trust did undertake an internal audit review of EPRR by Mersey Internal Audit Agency for which significant assurance was attained. The Trust is required to ensure EPRR standards are adequate to meet patient safety and quality requirement especially during emergency events and disruptions. Action required by the Board, The Trust Board is requested to note the outcome of the assessment and the level of compliance. 1

78 Emergency Preparedness Resilience & Response (EPRR) Core Standards Context 1.1 Since 2013 the Trust has been required to report on the Emergency Preparedness Resilience and Response (EPRR) Core Standards. As in previous years NHS England lead the process via Local Health Resilience Partnerships (LHRP) in order to seek assurance that both NHS providers and NHS England are prepared to respond to emergencies and are resilient in relation to continuing to provide safe patient care. The format and process this year followed that of previous years. The purpose of this process being to assess the preparedness of the NHS, both commissioners and providers, against common NHS EPRR Core Standards. 1.2 Provider organisations are asked to undertake a self-assessment against the relevant individual core standards and rate their compliance. These individual ratings then inform the overall organisational rating of compliance and preparedness with a statement of compliance being shared with the Board. Provider organisations are also required to publish their statement of compliance in their annual report. 1.3 The NHS EPRR assurance process concludes with a submission to the NHS England Board in March Once this has been accepted by that Board, NHS England will be in a position to provide national EPRR assurance for 2017/18 to the Department of Health and the Secretary of State for Health. 2. Assessment Process 2.1 The assessment process took place between July and October 2017 and has been reported to the EPRR group, following which the Trust was required to prepare an improvement plan and complete a statement of compliance. The compliance statement (Appendix 1) was sent to Greater Manchester Commissioners Support Unit on 1st November The Trust reported substantial compliance against the sixty core standards which was similar to that of other providers across Greater Manchester. Substantial compliance indicates that between 1 and 5 standards require additional work before full compliance can be achieved. 3. Trust Improvement Plan 3.1 The improvement plan attached (Appendix 2) shows that there were four standards at the time of submission in October 2017 which required action. Progress is monitored by the EPRR group and in one to one meetings between the Trust s Accountable Emergency Officer (Director of Operations) and the Fire Safety & EPRR Manager. Furthermore, the Trust takes part in a peer review of the core standards with all other acute trusts within Greater Manchester to ensure that there is a consistent approach to how each core standard achieves a satisfactory rating. 3.2 Following the submission in November actions have been undertaken to address those areas requiring improvement and at the time of this report there is one remaining action which relates to business impact assessment and this will be completed by the end of March

79 3.3 At the time of submitting the plan the main concern for the Trust was in regard to EPRR core standard fifty nine which requires that the Emergency Department holds the required number of Powered Respirator Protective Suits (PRPS). These are used to protect staff if a patient presents with possible contamination by a hazardous chemical. Trusts are supplied with these through NHS England and there was a delay in the replacement programme which has since been resolved and new PRPS suits are now available within the Emergency Department. 4. Deep Dive Governance Arrangements 4.1 In addition to the sixty core standards, during 2017 the EPPR assessment included a deep dive centred on governance arrangements (Appendix 3). Since this was not to be used as part of the return it is not included in the improvement action plan. The only standard which the Trust reported as an amber in this section related to the issue of publishing results of the 2016/17 NHS EPRR assurance process in the annual report. Trusts have not been asked to include this previously in core standard returns. This will now be included in future reports and therefore meet the standard. 5. Recommendations 5.1 The Trust Board is invited, to note the content and details of the report 3

80 APPENDIX 1 4

81 APPENDIX 2 Organisation: TAMESIDE & GLOSSOP INTERGRATED CARE NHS FT Plan owner: MIKE MCCLUSKEY FIRE SAFETY AND EPRR MANAGER, TRISH CAVANAGH ACCOUNTABLE EMERGENCY OFFICER Core Standard reference 8 9 Core Standard description Duty to maintain plans - Incidents and emergencies (Incident Response Plan (IRP). Duty to maintain plans - corporate and service level Business Continuity Improvement required to achieve compliance DEVELOPMENT OF INCIDENT RESPONSE PLAN MANAGERS TO ATTEND BUSINESS CONTINUITY TRAINING AND UPDATE THEIR BUSINNESS IMPACT ANALYSIS (BIA). 12 Duty to maintain plans Pandemic flu REVIEW AND UPDATE OF PANDEMIC FLU PLAN 59 The organisation has the expected number of (Powered Respirator Protective Suits)PRPS suits (sealed and in date) available for immediate deployment should they be required AT THE TIME OF THE ASSESSMENT IN OCTOBER 2017, THE TRUST WAS AWAITING DELIVERY OF NEW PRPS. Action to deliver improvement THE TRUST NOW HAS AN INCIDENT RESPONSE PLAN (IRP) HENCE THE AMBER RATING REPORTED IN OCTOBER 2017 IS NOW COMPLETE. THE IRP INCLUDES ACTION CARDS AND PROCESSES TO IMPROVE RESPONSE TO A RANGE OF POTENTIAL INCIDENTS. THIS WILL BENEFIT IN PARTICULARLY 1 ST AND 2 ND ON CALL MANAGERS OUT OF NORMAL ROUTINE HOURS. TRUST BUSINESS CONTINUITY (BC) POLICY IS ON THE TRUST INTRANET. DEPTS ALSO CARRY OUT THEIR BUSINESS IMPACT ASSESSMENTS AND DEVELOP ACTION CARDS. THE TRUST IS CURRENTLY REVIEWING BC ARRANGEMENTS. DEPTS ARE PROVIDING NEW (BIAs) BUSINESS IMPACT ANALYSIS. ALSO TRUST RESPONSE PLANS ARE BEING REFRESHED; THIS INCLUDES INCIDENT RESPONSE GUIDANCE DOCUMENT AND ACTION CARDS. THE TRUST HAS PANDEMIC FLU PLAN, ALSO A FLU GROUP HAS CONVENED TO DISCUSS SPECIFIC ISSUES AROUND RESPONSE AND HOW PATIENTS WILL BE MANAGED. THE TRUST HAS UPDATED ITS FLU ARRANGEMENTS. 12 NEW SUITS WERE DELIVERED IN DECEMBER 2017 WHICH NOW MEANS STAFF AT A&E ARE ABLE TO DON PRPS IF REQUIRED TO DECONTAMINATE SELF PRESENTING PATIENTS AT THE A&E DEPT. Deadline COMPLETE COMPLETE COMPLETE 5

82 APPENDIX 3 EPRR Core Standards Deep Dive Governance DD1 DD2 DD3 DD4 DD5 DD6 The organisation's Accountable Emergency Officer has taken the result of the 2016/17 EPRR assurance process and annual work plan to a pubic Board/Governing Body meeting for sign off within the last 12 months. The organisation has published the results of the 2016/17 NHS EPRR assurance process in their annual report. The organisation has an identified active Board/Governing Body member who formally holds the EPRR portfolio for the organisation. The organisation has an internal EPRR oversight/delivery group that oversees and drives the internal work of the EPRR function The organisation's Accountable Emergency Officer regularly attends the organisation s internal EPRR oversight/delivery group The organisation's Accountable Emergency Officer regularly attends the Local Health Resilience Partnership meetings. YES BY GILLIAN PARKER, THIS WAS SIGNED OFF AND TAKEN TO BOARD WITH AN ACTION PLAN, THE TRUST ATTAINED SUBSTANTIAL COMPLIANCE. NO, THIS WILL BE INCLUDED IN FUTURE ANNUAL REPORTS TRISH CAVANAGH HOLDS THIS AS THE DIRECTOR OF OPERATIONS. BRENDAN RYAN MEDICAL DIRECTOR IS ALSO CONSULTED. TRUST EPRR GROUP FORMALLY MEETS QUARTERLY. TRISH CAVANAGH IS ALSO THE ACCOUNTABLE EMERGENCY OFFICER AND ATTENDS THE EPRR GROUP AS DID GILLIAN PARKER PREVIOUSLY IN THE GREATER MANCHESTER LHRP, TRISH CAVANAGH IS REPRESENTED BY AN ACUTE REPRESENTATIVE FROM ANOTHER TRUST AND SO, IS NOT REQUIRED TO ATTEND 6

83 TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 22 nd February, 2018 Agenda Item 16 Title Sponsoring Executive Director Author (s) Purpose Previously considered by Better Births Report Tracey McErlain-Burns, Interim Chief Nurse Tracey McErlain-Burns, Interim Chief Nurse with contribution from Nicola Horrocks, Head of Midwifery. The purpose of this report is to advise the Trust Board of the Better Birth Review (2016) and to highlight progress towards achieving the provider recommendations and areas of challenge. The Board should receipt the report and note the recommendation that further assurance should be obtained via the Quality and Governance Committee in 6 months. This report has been generated for the purpose described above and not presented elsewhere. Executive Summary This report outlines the details of the Better Births (National Maternity) Review (2016) led by Baroness Julia Cumberlege. It summarises the conclusions of that review and provides a high level overview of the recommendations relating to provider services. The report draws attention to local progress and two specific challenges namely the ability to offer the choice of a midwifery-led service and the digitisation of records. Related Trust Objectives Risk Assurance risk impacted upon 1. All patients and service users receive harm free care through the delivery of the Quality & Safety Programme. 2. To improve our patient and service user experience through the delivery of a personalised, caring and compassionate approach to the delivery of care. 3. To develop our staff and future workforce to support the integration and transformation of our services whilst ensuring we recruit and retain talented individuals. None directly applicable Legal implications/regulatory requirements Financial Implications Has a quality impact assessment been undertaken? NHS England, Care Quality Commission, Health Education England, NHS Improvement, NICE and Public Health England The ICFT is considering a business case for the development of an alongside midwifery led unit. This will be included in the business case and relevant development plans.

84 How does this report affect Sustainability? The National Maternity Review requires that all providers are able to offer most women three choices of birth place by Action required by the Board The Board should receipt the report and note the recommendation that further assurance should be obtained via the Quality and Governance Committee in 6 months. 1. Purpose

85 The purpose of this report is to advise the Trust Board of the Better Birth Review (2016) and to highlight progress towards achieving the provider recommendations and areas of challenge. The Board should receive the report and note the recommendation that further assurance should be obtained via the Quality and Governance Committee in 6 months. 2. Background The Better Births (National Maternity Review) Review led by Baroness Julia Cumberlege was published in The review created a vision that Every woman, every pregnancy, every baby and every family is different. Therefore, quality services (by which we mean safe, clinically effective and providing a good experience) must be personalised. The review was commissioned in 2015 by Simon Stevens, Chief Executive of NHS England on behalf of the national organisations who authored the Five Year Forward View 1 to consider how our maternity services needed to change to meet the needs for the population and to ensure learning from the Morecambe Bay investigation could be embedded throughout the NHS. The review was asked to review the UK and international evidence and make recommendations on safe and efficient models of maternity services, including midwife-led units; to ensure that the NHS supports and enables women to make safe and appropriate choices of maternity care for them and their babies; to support NHS staff including midwives to provide responsive care and to pay particular attention to the challenges of achieving the above in more geographically isolated areas, as highlighted in the Morecambe Bay Investigation. In light of the Five Year Forward View there was also a requirement to ensure that the tariff-based NHS funding system supported the choices that women make, rather than constrain them and as a result make it easier for groups of midwives to set up their own NHS Funded midwifery services. The review reached a number of conclusions which can be summarised as: Too much data of questionable relevance is being collected, too often incomplete and inaccurate. The quality of maternity services has been improving but not all are provided to a consistent, high level of quality. The safety of maternity services must be improved. There is a clear need for improvement however the prevalent lack of open culture stands in the way of improvement. The recognition and care of those with mental health problems around birth is not consistently effective. Women s experience of maternity care is generally positive, but there are reservations over the availability of choice and the provision of care following birth. The review generated 26 recommendations for local providers, clinical commissioning groups, NHS England and the Department of Health. These 26 recommendations were aligned to 7 concepts; personalised care; continuity of carer; safe care; better postnatal and perinatal mental health care; multi-professional working; working across boundaries and a payment system that fairly and adequately compensates providers for delivering high quality care. 1 NHS England, Care Quality Commission, Health Education England, NHS Improvement, NICE and Public Health England.

86 At the time of publication the Tameside and Glossop Integrated Care NHS Foundation Trust undertook a review of the actions necessary to meet the provider recommendations. As detailed in the Chief Executive s Report to Board in January 2018 a number of senior clinicians and clinical leaders from within the Tameside and Glossop service are involved in national and Greater Manchester working groups to influence system improvement and the Interim Chief Nurse is a member of the GM and Eastern Cheshire Maternity Transformation Board involved in the production of a maternity services transformation strategy. 3. Local Progress The following recommendations in the Better Births Review need to be addressed at provider level: Every woman should develop a personalised care plan with their midwife Every woman should have a midwife who is part of a small team of 4 to 6 midwives Each team of midwives should have an identified obstetrician Community hubs should enable them to access care in the community The woman s midwife should liaise closely with obstetric, neonatal and other services Provider organisation board should designate a board member as the board lead Boards should promote a culture of learning and continuous improvement. There should be rapid referral protocols in place Teams should collect data on the quality and outcomes of their services Postnatal care must be resources appropriately. Maternity services should ensure smooth transition between midwife and obstetric care Multi-professional training should be standard Use of electronic maternity records should be rolled out Multi-professional peer review of services Providers and commissioners should come together in local maternity systems covering 500,000to 1.5 million. Professionals, providers and commissioners should come together in larger clinical networks. Examples of the progress made locally include the use of hand held records for all women which include a personalised plan of care; the development of geographical community midwifery teams; the appointment of a dedicated risk management midwife; revised investigation pathways to ensure openness and learning; the further development of an established enhanced midwifery service with a focus on meeting the needs for vulnerable women and the implementation of multi-disciplinary learning. Whilst progress is being made against most of the recommendations locally progress with the offer of choice of place of birth and digitisation of records are proving most challenging. Better Births states that most women should have access to three types of birthplace by 2020 the options being home, a free-standing midwifery led unit, a co-located / alongside midwifery unit and an obstetric unit. Currently Tameside is the only provider in Greater Manchester to only offer two choices; home or an obstetric unit. A business case for a co-located / alongside midwifery led unit has been developed. Approval for this is awaited in order to meet the requirement to be able to offer three choices by 2020.

87 In relation to the need to provide electronic records with the potential to share records with other providers involved in the woman s care, options are being explored with this being an area of focus in the Maternity Transformation Strategic Implementation Plan. 4. Summary and Risks The ICFT has a provisional plan for an alongside midwife led unit which will need to be decided upon in 2018/19 and reflected in the midwifery workforce plans. An early decision on the alongside midwife led unit is likely to support midwifery recruitment and retention. In anticipation of the decision multi-professional training plans will need to be developed under the leadership of the Head of Midwifery and the Clinical Director. Whilst systems will exist to enable digitalisation and sharing of records, the costs of those have not yet been assessed. In responding to the Greater Manchester and Eastern Cheshire Maternity Transformation Strategy the ICFT has highlighted this specific area of risk and flagged concern about the requirement to have continuity of carer, albeit acknowledged that there are pilots taking place to establish continuity of carer models of care. 5. Recommendations It is recommended that the Board receives this report and requires the Quality and Governance Committee to provide a further update and assurance in 6 months.

88 TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 22 nd February, 2018 Agenda Item 17 Title Sponsoring Executive Director Author (s) Purpose Previously considered by Greater Manchester Health and Social Care Transformation Programme Update Karen James Stephanie Sloan To provide the Trust Board with an update on the work programme of the Greater Manchester Health and Social Care Partnership transformational unit and planning for 2018/19. Executive Management Group Executive Summary: The paper provides the Trust Board with an outline of the Greater Manchester Health and Social Care Partnerships transformation programme to deliver the strategic plan (Taking Charge) and their proposed plans for assessing programme maturity in 2018/19. Related Trust Objectives Risk Assurance risk impacted upon Legal implications/regulatory requirements Financial Implications Has a quality impact assessment been undertaken? How does this report affect Sustainability? This report relates to: Objective 4 To continue to align and redesign our hospital, community, social care, primary care, mental health and voluntary/community sector services in order to facilitate our integrated Neighbourhood approach. Objective 6 To deliver against the required local/national regulatory frameworks and standards in addition to securing the most effective and efficient use of resources to deliver services that we provide directly or indirectly through our partner organisations. AF3.1(3530) Planning Failure to plan effectively in order to identify clinical services and organisational model to inform strategic intentions, to identify criteria for selection of future partners (if appropriate) and the consequential impact upon Self-determination in respect of the future of the hospital. AF3.3(3532) Failure to identify and/or deal with external opportunities and threats, particularly in the context of choice and not maintaining and securing place in the market This report imparts on the Trust complying with the terms of its Provider license No direct financial implications. NA This report does not directly impact on the Trust s sustainability Action required by the Board The Board is asked to discuss the Greater Manchester programme and proposed planning for

89 Greater Manchester Health and Social Care Partnership Transformation 1. Introduction Programme Update 1.1. The paper provides the Trust Board with an outline of the Greater Manchester Health and Social Care Partnerships transformation programme to deliver the strategic plan (Taking Charge) and their proposed plans for assessment and implementation planning in 2018/ The Greater Manchester Health and Social Care Partnership (GMH&SCP) is the body made up of the 37 NHS organisations and councils in the city region, which is overseeing devolution and taking charge of the 6bn health and social care budget. There are ten localities within the Greater Manchester (GM) footprint, each locality is responsible for developing their own locality plans to achieve the aims of integrated, sustainable care across the region, Tameside and Glossop is one of these localities In 2015 GMH&SCP published its five year strategic plan Taking Charge of our Health and Social Care in Greater Manchester. This described the vision for GM as a devolved health and social care economy to deliver the fastest and greatest improvement in the health and wellbeing of the 2.8 million population of GM, creating a strong, safe and sustainable health and care system that is fit for the future This Plan has been built from the ten locality plans, provider reform plans and a range of GM strategies and plans to ensure delivery of the national must do priorities, and it forms the GM sustainability and transformation partnership (STP) plan The way in which GM proposes to implement the Taking Charge strategic plan is outlined in the Taking Charge Implementation and Delivery Plan. This paper summarises the GM programme and updates the Trust Board on GM plans to ensure key programmes are aligned to each other and across locality plans and support delivery of both the GM objectives and national priorities. 2. GMH&SCP Transformation Programme The programme of transformation across GM is described as the GM Transformation Portfolio, as it reflects a range of programmes that have emerged and are in development across the system. The GM Transformation Portfolio comprises: The 10 individual locality plans 5 GM transformation theme programmes 5 GM led cross-cutting clinical redesign programmes Individual Locality Plans The 10 localities in GM have plans in place, as required as part of operational planning , to deliver the nationally mandated must do s and for the integration of health and social 2

90 care. GM aims to align the transformation of health and social care to the wider reform of GM public services. However the initial priority for GM has been to align the place-based integration approach to the locality development of LCOs GM Transformation themes The GM Transformation Portfolio has 5 transformation themes around which Taking Charge is structured. These five themes are GM s response to the national five year forward view. The Trust s strategic aims identified in the five year Strategic Plan Beyond Patient Care to Population Health are aligned to these themes. Appendix one provides details on each GM theme and alignment to the five year forward view and the Trust strategy. Below is a summary of the five themes; Transformation theme 1 - Radical upgrade in population health and prevention. The main sections of this programme of work are structured around 5 pillars: Start well, Live well, Age well, people-powered health and system reform. A detailed population health plan has been developed which incorporates schemes to deliver against these 5 pillars. Transformation theme 2 - Transforming community based care & support In many parts of GM, local integrated care organisations have already started working better together. Theme 2 focusses on three key areas: Development of Local Care Organisation s (LCO s) GM aim to support development of LCO s across localities and to work with stakeholders to agree the LCO design principles and ensure that as the models develop within each locality, that they are aligned to the wider public service reform place-based integration agenda. Each area will develop and design their own delivery models however there will be core features of these new organisations. 3

91 A revised Primary Care Strategy which sets the direction of travel for primary care transformation and is aligned to the 10 Greater Manchester locality plans. Adult Social Care. The 10 Greater Manchester local authorities are developing a social care core offer (including new models of care) that will support a significant pan GM transformation programme. Transformation theme 3 - Standardising acute and specialist services. Hospitals across GM are working together across a range of clinical services to respond to the way care is being transformed in localities; to deliver seven day services; and to standardise and improve the quality, safety and efficiency of patient care. Theme 3 is the programme that the Trust has to date been most closely involved in through the 3 work-streams for standardising acute care; Specialised services. Healthier Together. The development of GM led system-wide clinical redesign priority areas; paediatrics, maternity and obstetrics, respiratory and cardiology, MSK and Orthopaedics, breast, urology, neuro-rehabilitation and vascular.. Transformation theme 4 - Standardising back office and support functions. Exploring opportunities to share ideas, ways of working, buildings, technology, research and development and training across GM in the areas of; Procurement, Hospital pharmacy, Pathology, Radiology and Corporate functions. Transformation theme 5 - Enabling better care. This focuses on working together to deliver the enablers for transformation and integration including Workforce, IM&T, Estates as well as Commissioning and Incentivising reform through payment and contracting GM Cross Cutting Programmes. There are also five cross-cutting programmes that are being led at a GM level to ensure system-wide transformation, but will be delivered within localities. Tameside and Glossop economy has established local multi-agency work-streams to respond to and work alongside these GM led programmes: Mental Health - The Greater Manchester Mental Health and Well-being strategy takes a system wide approach to service delivery, focused on understanding the holistic needs of individuals and their families, within the context of the communities in which they live. The single commissioning function is leading the Tameside and Glossop Mental Health programme with representation from the Trust. Dementia - Development work has taken place to help the wider system understand the Dementia United offer/model. This programme focuses on 4 key outputs; Agreement of a set of GM standards; Locality profiles highlighting variation; a 4

92 proposed implementation model; a financial model, acknowledging that significant potential investment may be required to deliver the priorities of the plan. The Trust is leading the Tameside and Glossop Dementia programme, Led by the Chief Nurse. Learning Disabilities - Greater Manchester was awarded 3m funding to initiate the delivery of a programme to significantly reduce the level of in-patient use and provision for people with a learning disability and/or autism, and replace it with much strengthened community based services. GM s ambition for Learning Disabilities and Autism services is predicated four key objectives: Improving in/out reach intensive support Expansion of community based accommodation 60% reduction in non-secure beds 40% Reduction in the number of commissioned secure beds The Tameside and Glossop work-stream is led by the commissioners with representation and input from the Trust learning disability team. Cancer - The GM cross cutting programme for cancer has three aims: Reducing the number of people dying early from cancer; Transforming cancer services; The establishment of the National Cancer Vanguard, in which Greater Manchester is one of the three partner areas. A GM Cancer Board has been established which integrates representation from people affected by cancer, commissioners and providers of cancer services, public health, primary care and cancer education and research. A GM Cancer Plan has been developed with domains reflecting Taking Charge and Achieving World Class Cancer Outcomes; Prevention; Earlier and better diagnosis; Improved and standardised care; Living with and beyond cancer; Commissioning, provision and accountability; Patient experience; User involvement; Research & Education. Locally the Tameside and Glossop response to the GM cancer plan is a joint programme across the Trust, Commissioners and Public Health. GM Services for Children Review - Alongside Health & Social Care the Greater Manchester Review of Services for Children is a significant priority for the GM devolution agreement and the wider work on reform across Greater Manchester. The review looks at how to make best use of existing resources and transform services to focus on delivering the best outcomes and life chances and drive down variation across the ten boroughs. GM's aim is to develop a financially sustainable plan for services for children in the context of the current and future challenges and opportunities facing Local Authorities and wider public services. A set of proposals have been developed led by a GM Director of Children's Services, for a 'whole system' transformation of services for children, within a framework of locally accountable leadership, delivery and commissioning arrangements. The Tameside and Glossop programme is led by the Commissioners supported by the Trust. 5

93 3. Maturity Assessment of the GM Programme 3.1. The GMH&SCP structure and work programme is complex as it works across 12 CCGs, 14 acute, community and MH Trusts & 1 ambulance Trust, 500 GP Practices and 10 local authorities and is made up of a wide range of projects across the programmes as detailed above Therefore GM is undertaking a Programme Maturity Assessment in February/March 2018 which will ensure that; Assess the current implementation status of all projects / programmes to inform a review of benefits realisation assumptions Inform the GM business planning approach for 18/19 Confirm that GM are not missing the delivery of any key must do s with regard to the transformational delivery areas. Investment agreement ambitions are reflected in locality operating plans to enable robust monitoring Contracts ( activity and finances) are aligned to local and GM ambition Finances are aligned to local and GM ambition supporting 5 year plan The programmes demonstrate progress towards delivering population health outcomes Capacity is identified to support local and GM programmes 3.3. The maturity assessment will review the status of the programme based on six stages of development; 6

94 3.4. Through the initial assessment GM has identified that there are currently over 300 projects in development across the programme The maturity assessment will help GM define what has already agreed and is funded for 18/19 from GM programmes (through Transformation Funding agreements), which GM programmes are likely to appear in the joint commissioning pipeline for 18/19, and produce a longer options list for 19/20 as well as identifying any projects that need to be brought forwards to meet operating plan requirements GM will be liaising with localities in February to complete the next stages of the assessment which will involve confirmation of maturity stage of locality projects, confirmation of funding and governance arrangements for projects assessed as at stage 4 and 5 (funded and in implementation) and agreement of priorities for schemes at stage Following the completion of the programme maturity assessment GM will formulate a Taking Charge implementation and delivery update. 4. Recommendation The Trust Board is asked to note and discuss the Greater Manchester Transformational programme update and the Tameside and Glossop arrangements to respond to the developing work plan of these programmes. The Trust Board is asked to note the proposed plans for a GM programme maturity assessment for planning of References/Further Reading Taking Charge of our Health and Social Care in Greater Manchester [online] Taking Charge Implementation and Delivery Plan [online] STP-3-Implementation-Delivery-Narrative-FINAL pdf 7

95 6. Appendices Appendix One GM Programme and Alignment to National and Local Strategy 8

96 9

97 Agenda Item 18 KEY ISSUES AND ASSURANCE REPORT Charitable Funds Committee February, 2018 The Committee draws the following matters to the Trustee s attention- Issue Committee Update Assurance received Action Timescale Charitable Funds position The funds position remained broadly constant, with 11.8k received and 27.4k expended on beneficiaries. The Committee was assured that there is a commitment to use the funds for the beneficiaries, not simply continue to hold them Guide on what can and cannot be supported through Charitable Funds to be produced Policy on gift acceptance/ fundraising activities to be produced May 18 May 18 Investment approach The Committee reviewed options for investment of funds Having regard to the appropriate approach for a charity, the Committee agreed to continue investment in banking facilities rather than stockmarket investments Review position in six months October 18 Risk Register The Committee reviewed a register of identified risks for the charitable funds Overall, the risks identified were appropriate and reflected the identified areas of risk Request to add risk regarding internal fundraising methods to register May 18 Grant procedures Committee approved procedures for applications to the Everyone Matters Fund (General Fund) Committee noted that it would be necessary to have clarity on priorities to judge applications against Consider priorities for charitable funding May 18 Future Charitable Strategy Committee received presentation from recent workshop event and staff survey Committee welcomed enthusiasm for involvement, and the various ways forward identified Continue work to develop strategy and determine best approach, including approval of plans for marketing budget spend. May 18 Assurance gained includes the Committee receiving evidence that: i. The extent of the issue has been quantified; ii. The impact is included in all internal and external reporting iii. There are processes in place to learn from the occurrence, and measures have been put into place to prevent them happening again

98 TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 22 nd February, 2018 Agenda Item Title 19a Minutes of the Finance & Performance Committee held on 18 th January 2018 Sponsoring Executive Director Claire Yarwood - Director of Finance Author (s) Purpose Claire Yarwood - Director of Finance To inform the Board of the discussions held by the Finance & Performance Committee at its meeting in January Previously considered by Not previously considered Executive Summary : The attached reflect the minutes of the Finance and Performance Committee which met in January Related Trust Objectives Risk Assurance risk impacted upon Legal implications/regulatory requirements Financial Implications Has a quality impact assessment been undertaken? How does this report affect Sustainability? 5 Develop a strategic plan to secure clinical and financial sustainability for the Trust in conjunction with the Trust s strategic partners and key stakeholders 7 to deliver against local and national frameworks in order to meet all the requirements of the Trust s operating licence and the commissioners requirements. 723 Failure to meet, deliver Trust s financial plan In breach of Licence None No Review financial sustainability of organisation Action required by the Board The Board is asked to note the minutes from the Finance & Performance Committee. 1

99 FINANCE AND PERFORMANCE COMMITTEE Agenda item 2 Date of Meeting: 18 th January 2018 Time: 2.00 pm Location: Board Room, Silver Springs Present Position Initial Mr M Taylor Non-Executive Director (Chair) MT Mrs J McCall Trust Chair JMc Mrs C Yarwood Director of Finance CY Ms C Elliott Non-Executive Director CE Mrs A Dray Non-Executive Director AD Ms S Bridgen Non-Executive Director SB In attendance Ms A Bromley Director of Human Resources AB Mrs P Cavanagh Director of Operations TC Mr D Warhurst Associate Director of Finance DW Mr S Parsons Trust Board Secretary SP Ms S Holroyd Associate Director of Finance SH Additional attendees Item No Description Action 01/2018 Apologies Mrs K James, Mrs W Brelsford (Governor), Ms J McShane, Mr P Nuttall 02/2018 Minutes of the previous meeting 21 st December 2017 Minutes of the meeting were approved as an accurate record once the agreed minor amendments have been made. 124/2017 Sentence amended to read: A similar exercise is to be undertaken to show improvements overall in the health economy beds as a result of transformation, twenty spot beds have been closed. Matters Arising 2

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