Meeting of the Board of Directors

Transcription

1 Meeting of the Board of Directors Wednesday, 1 February am to 11.35pm Seminar Room, Clinical Education Centre, Southport Hospital Open to Members of the Public An integrated care organisation

2 AGENDA OF THE BOARD OF DIRECTORS Wednesday 1 February 2017 commencing at 9.00am Seminar Room, Clinical Education Centre, Southport Hospital Agenda Part 1 - Open to Members of the Public N o. Agenda Item Page Action By Report Time Duration 001/17 Chair s welcome & note of apologies n/a Note Chair Verbal 9.00am 1 min 002/17 Declaration of Directors Interests concerning agenda items n/a Note Chair Verbal 9.01am 1 min 003/17 Staff Story n/a Note MD Verbal 9.02am 10 mins 004/17 Minutes of the Meeting held on 21 December Approve Chair Y 9.12am 5 mins 005/17 Matters Arising Action List 11 Assure Chair Y 9.17am 20 mins FORMULATING STRATEGY 006/17 Interim Chief Executive s Report 17 Note CEO Y 9.37am 10 mins 007/17 High Level Risk Register 25 Assure DoN Y 9.47am 10 mins ENSURING ACCOUNTABILITY 008/17 Integrated Performance Report 56 Assure COO Y 9.57am 20 mins 009/17 Director of Finance Report 70 Note DoF Y 10.17am 20 mins 010/17 Monthly Nurse Staffing Report 104 Assure DoN Y 10.37am 10 mins COFFEE BREAK am ENSURING ACCOUNTABILITY 011/17 HR Quarterly Report 110 Note HRD Y 11.00am 20 mins BOARD COMMITTEE REPORTS 012/17 Finance, Performance & Investment n/a Assure JN Verbal 11.20am 3 mins 013/17 Quality & Safety 123 Assure AP Y 11.23am 3 mins 014/17 Charitable Funds 131 Approve JN Y 11.26am 3 mins CLOSING BUSINESS 015/17 Any Other Business n/a Note Chair Verbal 11.29am 1 min 016/17 Message from the Board n/a Approve Chair Verbal 11.30am 5 mins 017/17 Date and time of next meeting: Wednesday 1 March 2017, 9.00am Seminar Room, CEC, Southport n/a Note The Board resolves that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest. Page 1 of 143

3 Draft Minutes of the Public Section of the Board of Directors Meeting Held on Wednesday, 21 December 2016 at 9.00am Seminar Room, Clinical Education Centre, Southport Hospital (Subject to the approval of the Board on 1 February 2017) 004/17 Minutes of 21 December 2016 PRESENT Richard Fraser, Chair Jeannette Newman, Non-Executive Director Paul Burns, Non-Executive Director Su Fowler-Johnson, Non-Executive Director* Carol Baxter, Non-Executive Director Iain McInnes, Interim Chief Executive Therese Patten, Chief Operating Officer Sheila Lloyd, Director of Nursing, Midwifery & Governance Rob Gillies, Medical Director Steve Shanahan, Director of Finance IN ATTENDANCE Jane Hindle, Company Secretary Brigette Barton Siddiqui, Assistant Company Secretary (minutes) APOLOGIES Ged Clarke, Non-Executive Director *Indicates Non-Voting Members 146/16 CHAIRMAN S WELCOME AND NOTE OF APOLOGIES Mr Fraser opened the meeting by welcoming everyone, especially Sheila Lloyd who had recently joined the Trust as Director of Nursing, Midwifery and Governance. Apologies were received and accepted from Ged Clarke. 147/16 DECLARATION OF DIRECTORS INTERESTS CONCERNING AGENDA ITEMS No declarations were received in relation to the agenda. 148/16 PATIENT STORY The Board heard from a patient and his son in relation to his care and the support he has received to manage chronic pain. They were accompanied by Dr D Bray Consultant Clinical Health Psychologist. Mr Howard shared with the board how following several diagnostic tests he had not received a conclusive diagnosis and was advised that he would need to manage his pain. He used his prescribed medication to help him cope but this left him feeling sedated. He became angry with the services that couldn t support him further. He also experienced guilt as his son saw him heavily medicated and was concerned to know if he was alright. Following a referral from his GP to the Community Pain Service he was introduced to Dr C Baker and members of the Physiotherapy team. They treated him with acupuncture but also supported him to shift his focus from what he could no longer do to what he could do. His son was an avid Dr Who fan and Mr Howard felt inspired to build him a life-size dalek. He downloaded plans for the model and began focussing on the project as a series of short term goals. This provided an opportunity for positive interaction with his son which he could no longer achieve through activities such as sport. Mr Howard advised the Board that he had served as a Trust volunteer for the last 9 years, sharing his experience with others in similar circumstances. Mr Howard s son commented that through the interaction Page 2 of 143

4 with his father he had learned invaluable practical skills that had led him to choose a career in graphic design. He felt that because of the way his father managed his condition it had not had the negative impact on his life that it might have done. The Chair thanked Mr Howard for sharing his experience and noted that it was harrowing to hear how his life had been changed by his condition. He asked if there was anything about the care that was provided that could be improved. Mr Howard stated that with his condition patient to patient support was crucial as it was easy to feel isolated and that no-one had felt the same. He had found that interaction with others helped suffers to learn coping skills. 004/17 Minutes of 21 December 2016 Dr Bray commented that the service adopted a model of partnership and focused on what really matters to patients as individuals. He also noted that other patients with similar conditions are encouraged to talk to Mr Howard. Mr Howard added that if he is able to help others smile his journey has been worthwhile. The Board: a) noted the patient story. 149/16 MINUTES OF THE MEETING HELD ON 2 NOVEMBER 2016 Subject to the following amendments, the minutes of the meeting held on 2 November 2016 were approved as a true and accurate record of proceedings: Page 4 Item 129/16 should read: Ms Patten reported that the Chief Operating Officers had met the previous day and discussed a joint work plan for the development of middle office services, pathology, radiology and pharmacy. 150/16 MATTERS ARISING ACTION LIST The Board considered the following matters arising in turn: 16/044 IPR - Workforce Indicators A paper would be presented to the Q&S in January. 16/063 IPR - Falls A report had been presented to Q&S in November. A further report would be presented to that committee in January This item was completed and would be removed from the action list. 16/066 Medicines Safety lessons learnt The final MIAA report would not be available until January. This paper would be presented to the Board in February. 16/066 Medicines Safety revised procedure The procedure would be updated to reflect the final MIAA report, which would not be available until January. 077/16 Quality & Safety Review A more in depth business case was required by FP&I. It was recognised that some band 7s were in post, funded from existing vacancies. The remaining post was expected to be funded from the existing budget. 082/16 Seven Day Service Feedback from the survey was still outstanding and would be reported once it was available. 087/16 CQC action plan mandatory training There would be an update at the February Board meeting. 101/16 Medicines Safety This was included in the Board Assurance Escalation Framework. This item was complete and would be removed from the action list. 104/16 Risk Management Strategy This item had been completed and would be removed from the action list. 108/16 Corporate Risk Register Mr McInnes confirmed that this was being update regularly. The next quarterly update would be presented to the February meeting. 111/16 Bi-annual Nurse Staffing Review This item had been completed and would be removed from the action list. 124/16 Patient Story pain management This would be incorporated into the Patient Experience Strategy, which had been due to be presented to Q&S in November, but had been deferred to January to enable the new Director of Nursing, Midwifery and Governance to input into the strategy. 124/16 Patient Story advocacy This would be reviewed by the Q&S committee. Page 3 of 143

5 131/16 IPR Ms Patten advised that the two relevant IT systems were not linked, however a cohort snapshot would be produced for the February meeting, which would give a feel for any trend. 133/16 HR Quarterly Report recruitment This would be presented in the next HR quarterly report at the February Board meeting. 139/16 Complaints Quarterly Report A seasonal trend in complaints could not be established. This item was completed and would be removed from the action list. 142/16 Q&S Maternity Action Plan This item had been completed and would be removed from the action list. With regards to matters arising for future Boards, Mr Shanahan advised that under action 132/16 the SFIs would be reviewed for the March meeting. 004/17 Minutes of 21 December /16 CHAIR S REPORT Mr Fraser took the opportunity to assure the Board that he was committed to taking the Trust forward, to ensure it provided the best possible service to the local population. He commended the staff for working positively through a difficult period and congratulated the Trust for having the most improved A&E performance in the NHS in the North of England. Mr Fraser presented the Chair s report and asked the Board to ratify the use of Emergency Powers to access an uncommitted revenue support loan. The Board was also asked to approve the declarations of interest for Board members. The Board: a) ratified the use of Emergency Powers to access an uncommitted revenue support loan. b) approved the declarations of interest for Board members. 152/16 INTERIM CHIEF EXECUTIVE S REPORT Mr McInnes presented this report and highlighted the following points: 2017/18 and 2018/19 National Tariff Payment System This would have a negative impact on the Trust. The impact had been expected to be neutral, but could have been affected by the coding of outpatients. It was expected that the control total would be adjusted to compensate for this. External auditor appointment Mr McInnes confirmed the Trust had made an appointment. NHS Pension Scheme The cost of the proposed administrative levy would be on a per employee basis. In relation to Improving Clinical Outcomes & Efficiency, Mr Gillies advised that as part of the Getting it Right First Time programme the Orthopaedic Team had been visited by Professor Tim Briggs, who had highlighted where the Trust was an outlier. The staff had felt it had been a collaborative visit. With regards to the Winter Escalation Framework, Ms Patten advised that the new winter escalation framework was being implemented. The Executive team would be 3 rd On Call over the holiday to provide additional support to staff. The Board: a) noted the Interim Chief Executive s report. Page 4 of 143

6 153/16 INTEGRATED PERFORMANCE REPORT The Board s attention was drawn to the exceptions in performance. The following key points were highlighted: PERFORMANCE A&E 4 hour target Ms Patten reported the Trust had achieved 93.7% in November, but was currently 89.6% in December. The Trust was unlikely to achieve the December trajectory, but was still the best performing Trust in the region. Stroke Changes were being made to the stroke pathway at the Trust. It was noted that regionwide changes were planned; the Trust would retain its Stroke Unit, hyper acute needs would be met elsewhere. There would be an update on the new stroke pathway in February ACTION: EXECUTIVE MEDICAL DIRECTOR BY WHEN: FEBRUARY BOARD 004/17 Minutes of 21 December 2016 PRODUCTIVITY Average Length of Stay Ms Patten reported that this was reducing, however there were still a significant number of people who were Medically Fit and Optimised for Discharge (MFOD). One issue was that there was not a single assessment process here, which the Emergency Care Improvement Programme team had seen used effectively in other hospitals. Additionally there was evidence that patient assessments were more accurate when carried out in their normal place of residence, which would require their discharge prior to assessment. It was accepted this would be difficult to achieve, as it was dependant on patients home circumstances/care provider. QUALITY Mortality Mr Gillies reported that the Trust continued to focus on pneumonia and sepsis. Falls Mrs Lloyd reported that a deep dive was in progress and the findings would be presented to Q&S in the New Year. Friends and Family Test - the Trust was not collecting enough feedback. This process was being linked into the Patient Experience Strategy, the draft of which had been sent to the Patient Experience Group. Pressure Sores There would be a thematic review with the CCG on 22 December to address the contract query. A deep dive was needed to understand the issues and establish the best way to report. Never Events Mr Gillies reported there had been a never event in November, in elective orthopaedics. The wrong implant had been used in knee surgery. The mistake had been realised during the surgery and corrected immediately. The patient had not been harmed and had received an apology. The error had been due to human factors and the policy had been changed to ensure this would not re-occur. Mrs Lloyd advised there had been another never event in December, in Dermatology. A patient had attended for the removal of a carcinoma and, after the procedure, advised the team that the wrong lesion had been removed. The Trust was working with the family and an urgent review had taken place; lessons learned were being implemented. The Board recognised the openness of the clinical teams involved. DSSA Breaches Ms Patten reported that the issue was with the Stroke Unit and there was a plan in place to resolve the issue. FINANCE Mr Shanahan advised that this section would be covered in his report. WORKFORCE All indicators were red. Mrs Lloyd advised that a Head of Nursing & Safe Staffing had been recruited to focus on the nursing issues. Mr Burns commented that HR issues were a significant challenge for the Trust and expressed concern that a HR representative was not at the meeting. Mr Fraser asked for a written report from the Interim Director of HR to be circulated with the minutes, providing more information on these indicators. ACTION INTERIM DIRECTOR OF HR BY WHEN: END OF JANUARY 2017 Page 5 of 143

7 The Board: a) took assurance from the areas of compliance b) noted the action being taken to address areas of non-compliance or deteriorating performance. 154/16 DIRECTOR OF FINANCE REPORT The following key points were highlighted: The Month 7 year to date deficit was - 13m. There had been a loss of - 1.2m in October against a planned deficit of - 0.1m. Agency spend was expected to be under 800k at month 8 and could fall to 600k by April 2017, which would help going into the new financial year. The consultancy rate had been reduced to 105 per hour in emergency specialities. Nurse agency staff were being recruited at the capped rates for non-specialist roles, which reflected the positive work done. The cap was being exceeded in A&E, ITU, spinal and theatres. 004/17 Minutes of 21 December 2016 Mr Fraser stated that a collaborative was being created to try to develop an app which could be used to recruit staff directly, thus avoiding the need to use agencies. Opportunities for the Trust would be discussed outside the meeting. Mr Shanahan reported that the Trust was considering piloting a temporary/bank system for medics and it was believed that some Junior Doctors would be interested. This would be established in January CIP Mr Shanahan reported that the CIP was likely to deliver savings of 3.6m for the full year. Work on improving productivity was not taking costs out of the system and Mr Shanahan was not confident that this figure could be improved upon. Cash The Trust had drawn down an uncommitted revenue support loan in October. CQUIN and penalties Mr Shanahan confirmed that the Trust had agreed the local CQUINS, which related to New to Follow Up referrals and Consultant to Consultant referrals. The Trust was still in dispute with the CCG regarding contract penalties. Mrs Fowler-Johnson asked whether the CCGs had shared their recovery plans with the Trust. Mr Shanahan confirmed they had. Ms Patten advised that, the exercise detailed in point (page 48 of 231), regarding consultants programmed activities, was in progress and the outcome would be reported to the next Board meeting. ACTION: CHIEF OPERATING OFFICER BY WHEN: FEBRUARY BOARD The Board: a) noted the Director of Finance s report and the month 7 position. 155/16 BOARD ASSURANCE ESCALATION FRAMEWORK Mrs Lloyd presented this report and advised that the draft framework had been reviewed by Q&S. The framework addressed the assurance gaps from ward to board, as well as clarifying the subcommittee structure. In the Corporate Business Units (CBUs), Heads of Nursing, Operational Leads and Clinical Directors would take joint responsibility for clinical governance issues. The next step would be to develop a high level implementation plan, which would ensure that staff understood the importance of this. The standardisation of agendas and terms of reference were welcomed. Mr Burns commented that this was a very helpful document that provided a change of emphasis, improving the focus on outcomes and contributing to a positive shift in culture. It was agreed the process would require a lot of support to take people through it. There would be a further report to the Board once the framework had been finalised. ACTION: DIRECTOR OF NURSING, MIDWIFERY & GOVERNANCE BY WHEN: APRIL BOARD Mrs Lloyd confirmed the Q&S and FP&I committees would monitor the effectiveness of the framework Page 6 of 143

8 once it had been implemented. The Board: a) noted the Board Assurance Escalation Framework. 156/16 QUALITY AND SAFETY ASSURANCE REPORT Mrs Lloyd presented the Quality and Safety Assurance Report template, advising that this would be owned and delivered by each CBU. To provide corporate assurance, the Business Intelligence Unit would be the independent data source for each report. The reports would feed into the Q&S and FP&I committees, which would escalate issues to Board if necessary. This was a new way of working, but initial responses from staff had been positive. 004/17 Minutes of 21 December 2016 A discussion took place as to whether the Trust would need to review how it would deliver objective 1: provide lifelong, integrated care across the local health economy in light of the outcome of the community tenders. The Board agreed that achieving this would be challenging, but there was a strong commitment to continue to care for patients and deliver integrated care with the new providers. The Board: a) noted the proposed format of the quality and safety assurance reports. 157/16 BOARD ASSURANCE FRAMEWORK Mrs Hindle apologised for the lateness of the revised Board Assurance Framework (BAF) for The key highlights were: There had not been a reduction in the risk scores across all the risks. There had been an increase in the risk score for BAF011 relating to achievement of the control total. A new risk had been added concerning cyber security. Lincolnshire Trust had been hacked in October, resulting in a loss of elective surgery and income. Miss Newman queried the score on BAF001, which did not appear to correlate with the Corporate Risk Register. Mr McInnes advised that STP issues were affecting this; the memorandum of understanding had not been finalised and there was a lack of clarity around sovereignty. It was agreed that more work was needed to clearly link the BAF and the Corporate Risk Register. Mrs Fowler-Johnson commented that the workforce plan/strategy was not captured in the BAF. It was not clear that the right controls were in place to manage the risk. Mr Burns commented that, while he understood the pressures that had contributed to the lateness of this paper, the Board had fallen into the habit of large quantities of papers being very late. The Executive Team needed to think about the discipline and rigor required to provide papers in a timely manner. Mr Fraser agreed, adding that Executives needed to consider how they could provide the information more succinctly, to reduce the workload. The Board: a) noted the content of the report. 158/16 CORPORATE RISK REGISTER Mrs Lloyd presented this report and clarified that the BAF, Corporate Risk Register (CRR) and Board Escalation Assurance Framework would triangulate to effectively manage risks. From January to March 2017 there would be an Interim Deputy Director of Nursing in place to support this process. Miss Newman commented that in relation to the workforce risk 1368, that a noticeable gap in controls was the lack of a robust recruitment strategy, which was not demonstrated. It was agreed that better articulation of the risk was required and also clarity around the gaps in control and the action plans to mitigate risks. Mrs Lloyd would ensure that the CRR provided greater clarity to the Board on the articulation of risks and Page 7 of 143

9 how these would be managed; particularly relating to workforce. The red risks would be reported on in more detail. ACTION: DIRECTOR OF NURSING, MIDWIFERY & GOVERNANCE BY WHEN: FEBRUARY BOARD The Board: a) noted the current corporate risks and noted the additional risks identified. 159/16 MONTHLY NURSE STAFFING REPORT Mrs Lloyd advised that a number of new and additional parameters had been added to the report, supporting the move towards a triangulated approach in reporting safe nurse staffing. The nurse staffing establishment would be overhauling, using collaborative work. The report would continue to be revised as additional parameters were added. 004/17 Minutes of 21 December 2016 The Board: a) took assurance that there are systems in place for monitoring the safety of nurse staffing levels. b) noted the exceptions identified in October. c) noted the on-going work to include additional data in future reporting. 160/16 CHARITABLE FUNDS ACOUNTS Mr Shanahan advised that the accounts were being presented to the Board for approval. The documents had been discussed and scrutinised by the Charitable Funds earlier in December. Miss Newman commented that point 2.1 (page 153 of 231) stated that in 2015/16 more had been spent than had been received. This was positive, as it meant that money was being used as intended by donors. The Board acting as the Corporate Trustee: a) approved the charitable fund 15/16 accounts and annual report. b) approved the wording of the management representation letter. c) authorised the Chief Executive as the Accountable Officer to sign the Statement of Financial Position, the annual report and the management representation letter. d) authorised the Assistant Director of Finance to submit the final signed documentation to the Charity Commission. 161/16 CHARITABLE FUNDS EXPENDITURE REQUEST Mr Shanahan advised that any request to the Fund above 10k required Board approval. This request was for 12k from the Maternity Fund to be spent on the conversion of a room to make better use of the facilities. The Board approved the request. It was agreed that the ceiling for requests that could be approved by the Charitable Funds should be increased. It would be established whether the Standing Orders and Standing Financial Instructions could be revised to increase the limit of requests that could be approved by the Charitable Funds to those not exceeding 20,000. ACTION: COMPANY SECRETARY & DIRECTOR OF FINANCE BY WHEN: MARCH BOARD The Board: a) approved the conversion of an admission room on the Maternity Assessment Unit into an ultrasound room at a cost of 12k funded by Charitable Funds. Page 8 of 143

10 162/16 AUDIT COMMITTEE Mrs Pennell provided a verbal report of the meeting held on 16 November The following key points were highlighted: The Security Management Progress Report would be re-presented in January. Two internal audit reviews had received limited assurance and would be added to the Corporate Risk Register. There had been a paper highlighting a suspension of the Trust s Standing Orders relating to the disciplinary procedures for the recent investigations. The had agreed that the actions taken were in keeping with good governance. The Board: a) noted the verbal update from the meeting held on 16 November /17 Minutes of 21 December /16 FINANCE, PERFORMANCE & INVESTMENT COMMITTEE Miss Newman provide a verbal report of the meeting held on 5 December, highlighting the following key points: The had approved the Winter Plan by , following a discussion in the meeting. The new e-rostering system had been approved, which would impact on the way doctors rotas were planned and have a positive impact on agency costs. The NHSI change to the way capital resources were calculated was discussed and the impact noted. The had been asked to review the in-month spend against the revised financial plan/outturn. This would be possible once the information was available. The Board: a) formally received the minutes from the Finance, Performance & Investment held on 31 October b) noted the verbal update from the meeting held on 5 December /16 QUALITY & SAFETY COMMITTEE Mrs Pennell provided a verbal report of the meeting held on 9 December The key points from the meeting were: The never event that had occurred on 9 December Assurance had been taken from the awards for the A&E department and the Community Cancer Team. The draft Board Assurance Escalation Framework had been reviewed and discussed. The had been update on progress of the CQC 2016 action plan. The had received the final report on the outcome of the Complaints Deep Dive. The Board: a) formally received the minutes from the Quality & Safety held on 26 October b) noted the verbal update from the meeting held on 9 December /16 MESSAGE FROM THE BOARD The following items were agreed for inclusion within Team Brief: Positive performance in Urgent Care emphasising work across the Trust to support this. Financial position. Approval of business case for e-rostering. Shift in openness and candour. Patient Story. Q&S Report. 166/16 ANY OTHER BUSINESS There was no other business to be discussed. Page 9 of 143

11 167/16 DATE, TIME AND VENUE OF THE NEXT MEETING Wednesday 1 February am Seminar Room, Clinical Education Centre, Southport Hospital 004/17 Minutes of 21 December 2016 Page 10 of 143

12 Public Board Matters Arising Action List February 2017 BRAG Status Key Red Significantly delayed and/or of high risk Amber Slightly delayed and/or of low risk Green Progressing on schedule Blue Completed 005/17 Matters Arising Action List DATE AGENDA ITEM LEAD AND TARGET DATE JUL /044 IPR Workforce Indicators IDHR August 2016 ACTION It was agreed that there should be an additional indicator for mandatory training. Mr Jones would take this forward to the Quality and Safety. BRAG STATUS AMBER COMMENTS/UPDATE August 2016: Some issues identified with regard to data accuracy of mandatory training data within OLM module of ESR. Reconfigures training establishment with a view to recruiting new input/analyst. This action was expected to be completed in time for the October Board meeting. October 2016: Paper re Statutory and Mandatory Training received in Sept. Further discussion required around KPI s at SEMT. Outcome will be formally presented to Q&SC in October. November 2016: In progress. The paper will be presented to Q&SC in December. December 2016: This paper has been deferred to January, due to pressures on the Q&S agenda in December. February 2017: Business case presented to Q&S in January and received committee support. Case to be taken forward to FP&I. Page 11 of 143

13 DATE AGENDA ITEM LEAD AND TARGET DATE AUG 2016 AUG 2016 SEPT /066 Medicines Safety 16/066 Medicines Safety 077/16 Quality and Safety Review EMD September 2016 EMD September 2016 DoN/COO October 2016 ACTION Provide a paper that outlines how the Trust knows that lessons learned from medicine incidents are effective. Revise 4.1 of Procedure to ensure that it is clear that nursing staff must retain keys on their person at all times and the current process for handover. Ensure that the governance structure at page 66 was revised to reflect that the Task and Finish Group will report into Drugs & Therapeutic Safety and through to Q&SC. To provide an update on the business case for the Band 7 risk/governance managers for the CBU s. To report back to Board following discussion at October s FP&I committee meeting. BRAG STATUS RED RED GREEN COMMENTS/UPDATE September 2016: Chief Pharmacist to meet senior nursing staff to address procedural change and will also meet with MIAA to discuss auditing of lessons learned week commending 5th September Update to the Board in October October 2016: Following discussion with MIAA draft terms of reference have been developed for an audit that will capture how lessons become embedded. The outcome will be presented to Board in December. December 2016: The field work for the MIAA has been completed by the inspector, but the final report will not be released until early January. This will be presented to the Board in February. February 2017: Deferred to March due to the absence of the Chief Pharmacist. September 2016: No update provided. October 2016: Following discussion with MIAA draft terms of reference have been developed for an audit that will capture the effectiveness of the procedure and handover process. The outcome will be presented to Board in December. December 2016: The field work for the MIAA has been completed by the inspector, but the final report will not be released until early January. This will be presented to the Board in February. February 2017: Deferred to March due to the absence of the Chief Pharmacist. October 2016: The business case would be discussed at the FP&I meeting on 31 October. November 2016: Business case was not approved by FP&I. An alternative solution would be identified and re-presented to FP&I. December 2016: SBAR went to Execs Ms Patten is taking forward the lack of substantive post in urgent care; post looking to identify funding from existing budget. February 2017: Currently funded by a vacant post. The Executive Team will identify alternative funding for the longer term. 005/17 Matters Arising Action List Page 12 of 143

14 DATE AGENDA ITEM LEAD AND TARGET DATE SEPT 2016 SEPT 2016 SEPT /16 Chair s Report 082/16 Interim Chief Executive s report Seven Day Services 082/16 Modern Slavery Act Chair Oct 2016 CEO Nov 2016 DoF Jan 2017 ACTION The Chair would consider whether there could be a fourth Non-Executive Director on the Audit. The outcome of the survey would be formally reported to the Board in November. There would be a verbal update in October, if the information was available sooner. The outcome of the review of the top 100 suppliers will be reported to FP&I. BRAG STATUS AMBER AMBER GREEN COMMENTS/UPDATE October 2016: Matter under consideration. November 2016: The membership of the Audit will remain unchanged and is quorate. This will be reviewed again in January February 2017: This will be informed by the Effectiveness reviews due in March. November 2016: Submission of the survey had been delayed to the end of October. Awaiting outcome. Update to Board in December. December 2016: Still awaiting feedback. There will be a report to the Board in February. February 2017: Update included in Interim Chief Executive s report. February 2017: Report has been prepared for FP&I meeting on 30 January /17 Matters Arising Action List SEPT 2016 NOV /16 CQC Post Inspection Action Plan 124/16 Patient Story IDHR Nov 2016 DoN Dec 2016 The Trust needed to look at how it delivered mandatory training to urgent care staff and produce a business case for the FP&I. The DoN would produce a paper on pain management, prioritising end of life, for Q&S. This would include: Outcomes of the meeting with Queenscourt, highlighting any resulting changes to practice/policy. Identify the training implications. Review bank and agency recruitment to build in assessment of attitude. AMBER AMBER November 2016: In progress. A paper would be discussed at SEMT before submission to FP&I. December 2016: Business case has been presented as agreed but response still awaited. An interim appointment has however been made of an ESR administrator to help improve data provision and this person has now commenced in post. February 2017: Business case presented to Q&S in January and received committee support. Case to be taken forward to FP&I. December 2016: Dr Groves and the DDoN have discussed pain management. It is a main theme in the Patient and Carer Experience Strategy, which will be presented to Q&S in January The management of bank and agency staff has also been added to the Patient and Carer Experience Strategy. Outcomes will be monitored via the Patient and Carer Experience. February 2017: Patient and Carer Experience Strategy tabled at the patient experience group meeting 10 February for approval prior to sign off at QSC on 22 February. Page 13 of 143

15 DATE AGENDA ITEM LEAD AND TARGET DATE NOV 2016 NOV 2016 NOV 2016 NOV /16 Patient Story 131/16 Integrated Performance Report 133/16 HR Quarterly Report 133/16 HR Quarterly Report DoN Dec 2016 COO Dec 2016 IDHR Feb 2017 COO Feb 2017 ACTION There needed to be a discussion on advocacy and how the Trust could work with family, friends and agencies. DoN would take that forward. Ms Patten would ask the Information Team to establish whether there was any correlation between long stays and incidents of avoidable harm. A report on the outcome of the review of leavers would be presented to the Board in February. Ms Patten would update the Board on the number of A&E nursing posts filled following approval of the business case. BRAG STATUS COMMENTS/UPDATE AMBER December 2016: This will be picked up as part of the carer theme of the Patient And Carer Experience Strategy, which will be presented to Q&S in January February 2017: Patient and Carer Experience Strategy tabled at the patient experience group meeting 10 February for approval prior to sign off at QSC on 22 February. GREEN December 2016: The Information Team cannot provide this information without conducting an audit. A cohort snapshot will be produced for February s Board meeting. February 2017: There will be a verbal update at the meeting. Working with Datix, we have found a method of linking Datix data to Medway data which will allow us to produce a report within the next week. GREEN February 2017: This would be reported on in part 2 of the Board meeting. AMBER February 2017: Band 5 posts 7.80WTE posts approved - currently we are on a rolling programme of advertisement and interviews as carrying vacancies on top of the approved uplift, we have recruited 5.0 WTEs all started in post and 1.0 is starting with us on 6/2/17. Despite this we have a total of WTE band 5 vacancies; we are shortlisting again this week and planning interviews and will continue on a rolling basis. The gaps are currently being filled with a mixture of staff doing extras, NHSP and agency. 005/17 Matters Arising Action List NOV /16 HR Quarterly Report IDHR Dec 2016 Recruitment: IDHR would provide information on the conversion rate from offers made to staff in post. GREEN Band 6 posts Patient safety nurses 5.85WTE posts Successful banding of the patient safety nurses via QA confirmed on 18/01/17, out to advert now and will close this week for shortlisting and then interviews will be planned. December 2016: Will be presented for next quarterly report due in February February 2017: Mr Jones will provide a verbal update to the Board. Page 14 of 143

16 DATE AGENDA ITEM LEAD AND TARGET DATE NOV 2016 DEC 2016 DEC 2016 DEC 2016 DEC 2016 DEC /16 Pneumonia Mortality Update 153/16 Integrated Performance Report - Format 153/16 Integrated Performance Report - Stroke 153/16 Integrated Performance Report Workforce 154/16 Director of Finance Report Medical Staff programmed activities 158/16 Corporate Risk Register EMD Feb 2017 COO Feb 2017 EMD Feb 2017 IDHR Feb 2017 COO Feb 2017 DoN Feb 2017 ACTION Mr Gillies would establish where the reclassified cases sat and ensure that the measures identified in the pneumonia reviews were implemented and reported to Q&S in January Ms Patten would work with the Information Team to develop a summary sheet for the report. Mr Gillies would provide an update on the new stroke pathway at the February Board meeting. Mr Jones would provide a written report providing further information on the workforce indicators, which will be circulated with the Board minutes. To include an analysis of the spike in nursing vacancies in October. Ms Patten would report on the outcome of the exercise to determine the correct level of medical staff programmed activities, highlighting any risks. Mrs Lloyd would ensure that the CRR provided greater clarity to the Board on the articulation of risks and how these would be managed; particularly relating to workforce. The red risks would be reported on in more detail. BRAG STATUS RED AMBER GREEN AMBER GREEN AMBER COMMENTS/UPDATE February 2017: The paper was deferred to February Q&S due to pressures on the January agenda. February 2017: The information team will create a sheet to allow the Execs to complete narrative for the summary sheet and then produce the summary each month. February 2017: Verbal Update on hyper-acute stoke units for Cheshire & Merseyside. February 2017: There would be a verbal update on the current status of the indicators. February 2017: This would be reported on in part 2 of the Board meeting. February 2017: Work ongoing to review the management and escalation of risks within the organisation alongside full implementation of the BAEF For full roll out April /17 Matters Arising Action List Page 15 of 143

17 DATE AGENDA ITEM LEAD AND TARGET DATE NOV /16 Director of Finance Report DoF/CoSec Mar 2017 Matters Arising for Future Boards ACTION Mr Shanahan and Mrs Hindle would review the SFIs. BRAG STATUS DUE MARCH 2017 COMMENTS/UPDATE 005/17 Matters Arising Action List DEC /16 Board Assurance Escalation Framework DoN Apr 2017 Mrs Lloyd would present a further report to the Board once the framework had been finalised. DUE APRIL 2017 DEC /16 Charitable Funds Expenditure Request CoSec/DoF Mar 2017 It would be established whether the Standing Orders and Standing Financial Instructions could be revised to increase the limit of requests that could be approved by the Charitable Funds to requests not exceeding 20,000. DUE MARCH 2017 Page 16 of 143

18 P U B L I C TRUST BOARD 1 February /17 Interim Chief Executive's Report Agenda Item: 006/17 Report Title: Chief Executive Report (Public Section) Lead Director: Iain McInnes Interim Chief Executive Report Author: Iain McInnes Interim Chief Executive Purpose: Note Approve Assure Summary: This report seeks to provide the Trust Board with contextual information about the current challenges facing the NHS, and their impact locally, Recommendation(s): Linked to Strategic Domains: Regulatory Requirement: Presented to Other s: The Board is asked to: a) note progress on the Seven Day Hospitals Self- Assessment Survey b) note and implement the Very Senior Manager (VSM) appointment changes c) accept the invitation to enrol in the National Maternal and Neonatal Safety Health Collaborative Life-long integrated care Excellence in Treatment and Care Best Performance within Resources Develop Staff Organisational Sustainability Supporting the Interim Chief Executive in his role of Accountable Officer Non applicable Page 17 of 143

19 006/17 Interim Chief Executive's Report Southport & Ormskirk Hospital NHS Trust Board Meeting to be held on 1 February 2016 (Public Section) Chief Executive Report Iain McInnes, Interim Chief Executive 1 New safe staffing improvement resources Together with national partners, NHSI are leading the national programme to develop setting-specific safe, sustainable and productive staffing improvement resources to support you to deliver the right staff, with the right skills, in the right place at the right time. Following the publication of the National Quality Board s Safe Sustainable Productive Staffing, NHSI are now seeking views on the first of the setting-specific resources - adult inpatient in acute care and learning disability services. 2 Seven Day Hospitals Self-Assessment Survey - An update from Professor Sir Bruce Keogh, NHS England s National Medical Director, and Dr Kathy McLean, NHS Improvement s Executive Medical Director Thank you for taking part in the latest 7DS self-assessment survey your responses will help us to measure the sector s overall progress against the four priority clinical standards. The survey results and further analysis will also be published shortly on the NHS England website and on the My NHS website. This should help you identify other organisations you feel you might learn from, or work more closely with, to implement the standards in a sustainable way. Here are some important changes to the next survey which will be taking place in spring 2017: we re amending the timing of the survey to provide progress taken from between mid-march to mid-april 2017 with the results being available by 7 June 2017 we re shortening the data collection period to a seven day consecutive period within a four week window (15 March to 12 April) - to allow you enough time to complete this work, we propose increasing the data collation time from three to six weeks Page 18 of 143

20 This timetable will apply to the next 7DS self-assessment survey. Data collection period (one consecutive seven day period within this window) Wednesday 15 March - Wednesday 12 April 2017 Data collection Data submission Analysis time date available 6 weeks 24 May June /17 Interim Chief Executive's Report 3 Very Senior Manager (VSM) update 3.1 Engaging VSM staff on an off-payroll basis HMRC has recently updated its guidance relating to the use of off-payroll interims in board-officer positions. NHSI guidance has now been updated to reflect this, and details can be found on the NHSI website. These guidelines highlight the need to change the way trusts engage some offpayroll interims, and will require immediate action to be taken in some cases. NHSI will work with trusts to minimise any disruption this causes. We have been aware the guidance was coming and the trust has followed good practice in ensuring all interim Board level positions are engaged on payroll or via secondment. 3.2 VSM pay approval process A VSM pay approval process is in place (pending the development of a national VSM pay framework in early 2017) which requires: NHS trusts and FT s to seek approval from NHS Improvement, DH, the Minister of State for Health, and HMT before confirming appointments This process covers: all on-payroll appointments for VSM roles in NHS ambulance and community trusts on-payroll VSM appointments in all other NHS trusts and in all NHS foundation trusts where the annual salary is 142,500 or more as well as new appointments, this includes cases relating to acting up arrangements, promotions/pay rises for individuals already in post and earning above 142,500, and NHS secondments and conversion of off-payroll interims into on-payroll arrangements In the event we seek to recruit to a VSM salary position we must start the pay approval process at the start of the recruitment process so that expectations can be well managed at the outset, acceptable pay ranges/conditions agreed in advance and delays whilst views/ approvals are sought after appointment minimised. There are no recruitments planned. Page 19 of 143

21 4 National Maternal and Neonatal Safety Health Collaborative NHSI are launching a new three-year National Maternal and Neonatal Safety Health Collaborative early this year to enable providers of maternity services to work collaboratively to improve clinical practices and reduce unwarranted clinical variation. 006/17 Interim Chief Executive's Report All providers of maternity services have been contacted to introduce the collaborative, request a range of information about how we intend to participate and ask that we identify local improvement leads to engage with the initiative. Further information will be provided as the collaborative develops. 5 Use of Resources and Well Led Framework NHS Improvement and the Care Quality Commission (CQC) continue to align their approaches to overseeing providers and understanding where support is needed. To help with this, they are consulting on a new use of resources assessment and a new well-led framework. We are invited to share our views by completing the on line survey by 5pm on Tuesday 14 February CQC has also published a consultation on its next phase of regulation and we are encouraged to read this too before responding on use of resources and well-led. 6 NHS Efficiency Map Meeting current demand in better ways making better use of technology and ensuring care is delivered in the best setting and at the right time is how we will meet the long-term sustainability challenge. But it is not all about new models of care. We need to tackle variation in services and eliminate it where it is unwarranted often adding unnecessary cost. And we need to push harder to improve our productivity in both frontline and support services; making full use of Lord Carter s pioneering work in this area. There is already good work underway, but there is also significant scope for improvement. Even the most efficient provider has services that are seriously inefficient. We need to get better at spreading good practice and make the most of existing tools and proven approaches to accelerate our efficiency drive. With this goal in mind, NHS Improvement and the Provider Cost Improvement Group have worked with the HFMA to update the NHS efficiency map. Published recently, it s an easy way for provider finance teams to look for new efficiency ideas and to test whether what they are already doing is effective. The map brings together efficiency guidance, tools and examples to help produce cost improvement plans quick links to information on the Getting it right first Page 20 of 143

22 time programme or Lean-based productive series of specific setting improvement methodologies. It provides links to best practice on how to lead, manage and report on efficiency programmes. And we hope it will become a gateway to help managers find the resources they need to support local improvement drives a living document that is updated regularly with real-life examples where trusts are realising savings. 006/17 Interim Chief Executive's Report 7 Recent A&E workshop and next steps There continues to be a focus on Urgent care and specifically A&E performance and ambulance handover. ECIP continue to support our local health economy; the Chief Operating Officer will update on recent A&E performance at this meeting. Following Jim Mackey s letter of 19 December Broadening our oversight of A&E, over 50 representatives from the sector attended a workshop on 12 January focusing on the practical next steps to help relieve pressure on systems and support performance improvement. Areas covered included taking a more standardised approach to the streaming of patients when they arrive at emergency departments, how support is prioritised for our sickest patients and ensuring there is a consistent and holistic view of providers performance on emergency care. In the letter it was suggested that regional workshops would be held on 27 January. However, thankfully, NHSI has decided not to hold these on that date as they appreciate it s not the best time to be asking key staff to be away from trusts. Over the coming weeks NHSI will work with clinical and sector leads to develop products and support offers for the system, followed by piloting and testing. Iain McInnes Interim Chief Executive 25 January 2017 Page 21 of 143

23 APPENDIX B 006/17 Interim Chief Executive's Report Summary of the Single Oversight Framework 1 Five themes of the Single Oversight Framework (SOF) 1.1 In carrying out their role NHS Improvement will work across five themes: Quality of care (safe, effective, caring, responsive): this will use CQC s most recent assessments of whether a provider s care is safe, effective, caring and responsive, in combination with in-year information where available. NHSI will also include delivery of the four priority standards for 7-day hospital services. Finance and use of resources: this will oversee a provider s financial efficiency and progress in meeting its financial control total, reflecting the approach taken in Strengthening financial performance and accountability NHSI are co-developing this approach with CQC. Operational performance: this will support providers in improving and sustaining performance against NHS Constitution standards and other, including A&E waiting times, referral to treatment times, cancer treatment times, ambulance response times, and access to mental health services. These NHS Constitution standards may relate to one or more facets of quality (i.e. safe, effective, caring and/or responsive). Strategic change: working with system partners this will consider how well providers are delivering the strategic changes set out in the 5 Year Forward View, with a particular focus on their contribution to sustainability and transformation plans (STPs), new care models, and, where relevant, implementation of devolution. Leadership and improvement capability (well-led): building on the joint CQC and NHS Improvement well-led framework, this will develop a shared system view with CQC of what good governance and leadership look like, including the organisations ability to learn and improve. Page 22 of 143

24 1.2 By focusing on these five themes NHSI will support providers to improve to attain and/or maintain a CQC good or outstanding rating. Quality of care, finance and use of resources, and operational performance relate directly to sector outcomes. Strategic change recognises that organisational accountability and system-wide collaboration are mutually supportive. Leadership and improvement capability are crucial in ensuring that providers can deliver sustainable improvement. 006/17 Interim Chief Executive's Report 1.3 These five themes are also reflected in NHS Improvement s 2020 Objectives. The Single Oversight Framework will support the delivery of NHS Improvement s 2020 objectives, including helping more providers achieve CQC good or outstanding 2 Summary of NHSI approach 2.1 NHS Improvement s Single Oversight Framework: provides one framework for overseeing providers, irrespective of their legal form helps NHSI identify potential support needs, by theme, as they emerge allows NHSI to tailor support packages to the specific needs of providers in the context of their local health systems, drawing on expertise from across the sector as well as within NHS Improvement is based on the principle of earned autonomy. 2.2 NHSI will be flexible in how it carries out its role. For example, they may need to respond quickly and proactively to unexpected issues in individual providers or sets of providers, or to national policy changes. They may, therefore, from time to time, adjust the approach set out in the SOF, for example: add/remove some metrics from their oversight of providers increase the frequency of data collection act sooner than the general threshold set in the framework. 3 Segmentation 3.1 NHSI will segment the provider sector according to the scale of issues faced by individual providers. This segmentation will be informed by data Page 23 of 143

25 monitoring and, importantly, judgement based on an understanding of providers circumstances (see Figure 1) below. 3.2 Summary of information required for monitoring 006/17 Interim Chief Executive's Report Iain McInnes Interim Chief Executive 24 th September 2016 Page 24 of 143

26 P U B L I C TRUST BOARD 007/17 High Level Risk Register 1 February 2017 Agenda Item: 007/17 Report Title: High Level Risk Register Lead Director: Shelia Lloyd Director of Nursing, Midwifery & Governance Report Author: Alan Lee Physical Risk Manager Purpose: Note Approve Assure Summary: The High Level Risk Register for February 2017 is attached for review by the Trust Board. Since the previous meeting of the Trust Board, the content of the High Level Risk Register has been reviewed by the Executive Directors of the Trust, with support from the Integrated Governance Team. Recommendation(s): Linked to Strategic Domains: Regulatory Requirement: Presented to Other s: Changes have been made to a number of risks; these are detailed on the attached report. The Board is asked to: a) Note the changes that have been made to the High Level Risk Register during the reporting period. b) Take assurance that there are actions in place to mitigate the risks. Life-long integrated care Excellence in Treatment and Care Best Performance within Resources Develop Staff Organisational Sustainability CQC Standards The report will be presented to the Quality & Safety and Audit s. Page 25 of 143

27 Southport and Ormskirk Hospital NHS Trust High Level Risk Register Report February /17 High Level Risk Register 1. Introduction The High Level Risk Register is maintained by the Executive Directors of the Trust with support from the Integrated Governance Team. Since the last meeting of the Trust Board, all risks that were scheduled for review have been reviewed, by the Executive Directors of the Trust with support from the Integrated Governance team. It is anticipated that the finance risks that are due for review on 31 st January 2017, will have been reviewed on or before this date. In order to strengthen the risk management process, all risks contained in the High Level Risk Register, have been mapped against the Board Assurance Framework (BAF). The content of the BAF has also where possible been mapped against the Corporate Risk Register. 2. Status of Risks The Corporate Risks Register currently consists of 24 risks, these are classed as follows: Number of risks Extreme 9 High 12 Moderate 3 Low 0 All of the risks on the High Level Risk Register have been mapped against the Trust s strategic objectives. Changes 3.1 New Risks The following risks have been added to the High Level Risk Register since the last meeting of the Trust Board: Page 26 of 143

28 Risk Id Amendment 1478 Published Mortality Data 3.2 Amended Risks The following risks have been amended: Risk Id Amendment 1473 Allocated to Dir. of HR. 007/17 High Level Risk Register 1327 Description - Reworded to provide increased clarity regarding nature of risk Description Reworded to reflect nature of risk and impact. Controls Added Trust Recruitment and Selection Policy Added discussions with Southport College, regarding Acorns programme. Added Assistant Director of Nursing Workforce role. Assurances Removed Overseas recruitment campaign Added 2017 to 2019 Work Force Plan submitted to NHS I Description - Reworded to provide increased clarity regarding nature of risk Gaps in Assurance Added Validity of published mortality data Description - Reworded to provide increased clarity regarding nature of risk Assurance Amended completion date for Cultural Review to 28/02/ Description - Reworded to provide increased clarity regarding nature of risk 1439 Actions Added job plans to be agreed by 28/02/ Description Reworded to provide more clarity. 3.3 Closed Risks Since the last meeting the following risk(s) have been closed: Risk ID Reason for Closure 1370 The Research Department is now being managed under an SLA with St Helens and Knowsley Hospitals NHS Trust. There is therefore adequate governance of research activity. Page 27 of 143

29 4 Recommendation The Trust Board is requested to a) note the changes to the content of the High Level Risk Register and b) take assurance from the actions in place to mitigate the risks. 007/17 High Level Risk Register ALAN LEE PHYSICAL RISK MANAGER Page 28 of 143

30 High Level Risk Register Strategic Objective Objective 1 - Provide lifelong, integrated care across the local health economy Link to BAF BAF003 Opened ID ADO/Exec Lead Title 26/09/ Chief Operating Officer Non Achievement of National A&E 4 Hour Performance Target 007/17 High Level Risk Register Description Non-achievement of National A&E 4 hour performance target at Southport : Controls Clinical impact - delay reviewing patients, ambulances queuing, no physical space to see patients. This would result in the potential risk to the safety of patients and poor patient experience Financial - Penalties for non-compliance will be applied resulting in a reduction in income. Trust rating- potential to impact on Trust CQC rating, patient & public perception of the quality of care within the Trust. If the Trust is unable to maintain patient flow, associated CQI targets will not be met and will put increased pressure in A&E due to lack of movement resulting in potential risks to patient safety. Increased financial risk due to inability to manage resources effectively which will lead to an increase in expenditure. Urgent Care improvement plan progressing Operational contingency plan in place Weekend plans introduced to support 1st & 2nd on call senior managers Breach analysis undertaken on daily basis Increase PTWR to 2 per day Daily ward or board round by all consultant physicians, Surgeons Appointment of locum Acute Care physician for 1 year Amendments to A&E Medical staff rota to optimise senior medical cover Potential recruitment of further 2 A&E consultants ongoing Move Bed Managers to a new Manager to ensure they are supported and able to escalate issues quickly Introduce a new bed meeting format Introduce next day discharge sheets to be completed by all wards and discussed at the bed meeting Audit all failed discharges and ask for SBAR so we can learn from them and avoid the Breach analysis m in the future. Management of length of stay for all patients with LOS over 14 days initially Open ambulatory care unit from 1st June to relieve pressure at front door Bed reconfiguration to create addtional capacity within SDGH site ED Nurse paper ED senior mangers meetings Accelerated Flow programme Business Case submitted for to FP&I Comm, in relation to a) Relocation of Urology services 2) Theatre forward waiting area, 3) Surgical Assessment Unit Business case approved for improved A&E staffing Gaps in Controls Unable to recruit to A&E Consultant vacancies (rolling advert out) If the new way of working is not accepted or successful this process would fail Gaps in nursing and junior medical grade vacancies which are difficult to recruit Inability of health economy to support changes - recent closure of nursing homes with impact on MOFD Accelerated Flow Programme - requirement of Board to support urology business case to progress with bed remodeling work Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Possible (3) Major (4) 12 High Risk 12 High Risk 29/11/ /03/2017 Assurance Monitored through Integrated Performance Reports - monthly to Trust Board Performance monitored via PMF Monitoring of Improvement Plan via Urgent Care Operational Group Urgent Care improvement plan reviewed weekly by COO Monthly systems resilience meeting with local health economy which includes review of Urgent Care plans Monthly through Board committees A & E Delivery Board 1 Page 29 of 143 Gaps in Assurance

31 ED Supportive measures Accelerated flow programme Winter Planning Group has been reformed, to focus on work streams for a) Care in hospital, b) Support at home and c) "Bluebell II" Action Plan To prepare a consolidated action plan following the NHSI Executive Improvement Board. Action Plan Due Date 28/02/2017 Action Plan Rating Moderate Progress Made 007/17 High Level Risk Register Page 2 of 27 Page 30 of 143

32 Strategic Objective Objective 1 - Provide lifelong, integrated care across the local health economy Link to BAF BAF001 Opened ID ADO/Exec Lead Title 29/12/ Director of HR Engagement with stakeholders across the health economy Description Controls If the Trust does not actively engage with stakeholders in the Health Economy then models of integrated care will not be delivered for the population of Sefton and West Lancashire. Engagement with providers for community services Engagement strategy Gaps in Controls Engagement Strategy requires approval by the Trust Board 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Possible (3) Major (4) 12 High Risk 8 High Risk 23/01/ /03/2017 Assurance Gaps in Assurance Action Plan Action Plan Due Date Action Plan Rating Page 3 of 27 Page 31 of 143

33 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF002 Opened ID ADO/Exec Lead Title 10/05/ Director of Finance Replacement medical equipment Description If the Trust is unable to allocate sufficient capital resources to replace medical equipment programme, then the quality of patient care may be compromised. Controls Planned asset replacement cycle prioritised over 3 years. Capital Investment Group established and meet up every month. This is led by the Director of Finance. Equipment register (RAM software) NHSI only allowing spending from internally generated sources. Gaps in Controls Planned 3 year medical equipment programme based on the equipment register (RAM) not yet complete. Accelerated patient flow project may impact on 16/17 capital plans 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Likely (4) Major (4) 16 Extreme risk 6 Moderate risk 28/11/ /01/2017 Assurance Capital Investment Group (CIG) monthly meeting Finance, Performance & Investment who receive the minutes from the CIG meeting. Gaps in Assurance Action Plan Introduction of a rolling 3 year replacement programme for medical equipment. This will be monitored through Capital Investment Group Action Plan Due Date 28/02/2017 Action Plan Rating Moderate Progress Made Page 4 of 27 Page 32 of 143

34 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF007 Opened ID ADO/Exec Lead Title 22/09/ Chief Operating Officer BED OCCUPANCY > 93% SDGH Description Controls If bed occupancy remains in excess of 93%, then the Trust's capacity to meet the demand for its services may compromise patient experience and safe care. Bed Management policy Daily escalation meetings ED escalation policy in place NWAS escalation policy in place Full to capacity and flow protocol in place Bed escalation policy in place Weekly special measures meeting with ED team to manage top risks Roll out of SAFER bundles programme Event planning e.g. winter AFP to increase non elective capacity by 22 beds ESCIT Urgent Care pathway review to be carried out commencing 07/11/16 To review the format of the daily urgent care huddles. Regular communication with commissioners regarding discharge delays. Gaps in Controls Clearly identified escalation beds Medical staffing establishment out of hours 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Likely (4) Major (4) 16 Extreme risk 8 High Risk 03/01/ /02/2017 Assurance Daily analysis and retrospective daily view Delivery Board meeting with local health economy which includes review of Urgent Care plans Urgent Care improvement plan reviewed at weekly ED meeting with COO Overview by F&I & Trust Board Reviewed at PMF on a quarterly basis Performance comparison between peer Trusts Gaps in Assurance Nil identified Action Plan To be merged with Winter planning programme. Action Plan Due Date 28/02/2017 Action Plan Rating Actions Almost Completed Page 5 of 27 Page 33 of 143

35 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF010 Opened ID ADO/Exec Lead Title 22/09/ Director of HR Not able to recruit - reliance on agency staff and the impact on quality and finance Description Controls As the Trust is not able to recruit to all of the vacant posts and has to rely on the use of agency staff, there is an impact on the on the quality of care delivered to the Trust's patients. Introduction of a nationally capped rate for agency for both medical and nursing staff Policies and processes around bank/agency staff usage Development of a nurse bank in conjunction with existing NHSP bank supply Edge Hill additional cohort for training nurses Executive oversight at weekly meetings Monthly review at FP & I Monthly review at Board Monthly review at PMFs Individual authorisation of requests above cap for agency staff Strategic Alliances with other health care providers International recruitment ( Medical staff ongoing and qualified nursing) Targeted advertising campaign for qualified nursing staff (HEI) Workforce planning methodology agreed Succession planning methodology agreed Planned recruitment campaigns agreed NHSP cohorts for HCA recruitment Recruitment and Selection Policy Assistant Director of Nursing role leads on Nurse recruitment Discussions with Southport College regarding "Acorns" project for Nurse development Gaps in Controls Draft HR Strategy requires approval Further work to be commenced around more robust workforce planning, engaging service managers. Continuing staff groups that are difficult to recruit to requiring different solutions 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Likely (4) Major (4) 16 Extreme risk 9 High Risk 23/01/ /02/2017 Assurance Monitoring of fill rates of bank and agency staff through weekly ED meetings Monitoring of fill rates through monthly Trust Board Shared arrangements with other Trusts for Consultant posts Agency Spend Review Undertaken. Project Co-Coordinator appointed for 6 months to progress actions Monitoring of Recruitment Action Plan through quarterly HR Report to Trust Board Workforce Plan submitted to HE England as approved by the Medical Director. Ongoing targeted advertising campaigns. Trust HR Governance provided with information on Workforce Plan Nurse recruitment campaigns in Higher Education institutes. DON working with NHSP Joint appointments for Senior Consultant with St Helens & Knowsley Hospital NHS Trust, Liverpool Heart & Chest Exit interview process review carried out, with action plan as a result Workforce Plan submitted to NHSI Gaps in Assurance Status of workforce plan Action Plan Action Plan Due Date Action Plan Rating Page 6 of 27 Page 34 of 143

36 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF003 Opened ID ADO/Exec Lead Title 26/09/ Director of Nursing & Quality CQC Registration Description Controls If the Trust fails to respond to the CQC report in relation to areas of non-compliance identified in the 2016 inspection report, then there will be a risk to the Trust's registration and reputation. Trust governance structures review of gaps in controls Support from an external consultant to formulate action plans for each CBU, arising from report of inspection in April Action plans reviewed and agreed by Executive Team Gaps in Controls Embedding the structure and holding to account 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Likely (4) Major (4) 16 Extreme risk 4 Moderate risk 03/01/ /02/2017 Assurance Q&S Dashboard / balanced scorecard monthly to Q&S PMF structures CQC Board report monthly Monthly review of CQC action plan Monthly relationship meeting with CQC External review of services (CQC, NHSI, NHSE) Divisional Governance meetings Assurance on the effective implementation of CBU action plans to be received by Quality & Safety Gaps in Assurance Action Plan All CBU s receiving support from external consultant in formulation of action plans arising from CQC report. Action Plan Due Date 31/03/2017 Action Plan Rating Actions Almost Completed Page 7 of 27 Page 35 of 143

37 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF003 Opened ID ADO/Exec Lead Title 06/01/ Director of Finance DH/2014/003 Testing of fire & smoke dampers and integrity of fire stopping Description Controls Testing of fire/smoke dampers and inspection of fire stopping could lead to a contravention of Article 17 of the Regulatory Reform Order 2005 therefore placing patients, visitors and staff at risk in the event of a fire. All smoke/fire dampers across the Trust tested and operation around 1200 with around 60 with access issues, consulting engineer appointed to prepare specification to address any potential issues with these 60 Trust wide survey & inspection of all fire/smoke dampers completed Basic floor plans issued to service provider to enable commencement of works Inventory now in possession of Trust for dampers. Fire separation surveys now complete and remedials included on 2016/2017 Capital Plan Phased implementation of door repairs ongoing with all phases to complete 2016/2017 (SDGH ),ODGH currently planned for 2017/2018 Gaps in Controls Limited formal maintenance programme in place for all smoke/fire dampers, actuators, controls, fire stopping etc in place Lack of information relating to all inaccessible dampers etc have been identified and awaiting consulting engineer specification/ tender No access to Trust fire risk assessments Implement a control system to ensure the integrity of all fire stopping is re-instated during and following construction/installation works i.e. PTW, inclusion in tender specification FM drawings library inadequate and unable to locate detailed information re damper locations, number of etc Insufficent staffing/funding with Maintenance budget to carry out surveys/inspection regimes in house. Potential for lack of suitable access to a number of Dampers particularly at high level Capital dept. to issue complete set of ''''as fitted ventilation drawings to service provider to enable detailed survey to progress 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Possible (3) Major (4) 12 High Risk 5 Moderate risk 07/12/ /02/2017 Assurance Regulatory Reform Order 2005 Building regulations - Approved Document B HTM 05: fire code - Fire Safety in the NHS HTM 03-01: Specialsied ventilation in healthcare premises (Parts A&B) Phase 2 of Fire doors remedials now commenced at SDGH,surveys of fire doors now complete at ODGH and compartmention works currently out to tender with a return date of end of July 2016 Meeting with AG, NA, SS, IB & AL. Discussed all areas of alert and action plan to be formulated. Surveys now complete to possible 60 problematic fire dampers, specifications in production with completion of works due 1st December at latest Tenders sent out and received back early September,only one tender returned at exorbitant price. Being sent out to tender by 23/9/16 for return in 3 weeks time to another 3 contractors Tender now awarded with prestart meeting held w/c 28/11/2016 Gaps in Assurance Action Plan 1. Commission external specialist to carry out survey of all dampers and fire stopping 2. Implement inspection/maintenance regime as per guidance via external specialist 3. Obtain funding to carry out 1&2 from DOF 4. Ensure compliance is met from Voice and Data services/capital works with regard to maintaining integrity of fire stopping during construction/installations 5. Capital dept. to ensure access to all ventilation/construction drawings is readily available Action Plan Due Date 31/03/2017 Action Plan Rating Actions Almost Completed Page 8 of 27 Page 36 of 143

38 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF003 Opened ID ADO/Exec Lead Title 11/01/ Executive Medical Director Published Mortality Data Description As a result of various processes, carried out by NHS Digital, to extrapolate data regarding deaths in the Trust, it has become apparent that a number of cases have not been included in the Trust's published mortality data. This means that the published data for is around 15% lower that activity recorded in the Trust. This creates a risk that the Trust cannot be assured regarding the quality of care delivered to patients, there is also a reputational risk to the Trust. There are at least 5 other Trusts affected by this problem. 007/17 High Level Risk Register Controls Process introduced to ensure that data fields for the following match - Date of Death, discharge date & episode end date Records of observed deaths checked with audit, to ensure that mortality reviews completed Investigation of data processing being carried out by service provider Service provider altering scripts for data processing, to prevent anomaly in dates. Incident being investigated by NHS Digital Matter escalated to CCG Accountable Officers, NHSI & NHS Digital Gaps in Controls Refreshing of data used to generate mortality indicators by Dr Foster, this will occur in February 2016 Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Possible (3) Major (4) 12 High Risk 12 High Risk 25/01/ /02/2017 Assurance Confirmation requested from NHS Digital regarding, future changes to Trust data Gaps in Assurance Reports from NHSI regarding the data cleansing checks that have been completed regarding Trust deaths. Action Plan To ensure that all submitted data is refreshed during February 2017 data submission. To complete mortality reviews for all unreported deaths To carry out a dead dive into specialist SMR's To request details of other Trust affected by data processing problems. Action Plan Due Date 28/02/ /03/ /03/ /01/2017 Action Plan Rating Little or No Progress Made Moderate Progress Made Moderate Progress Made Actions Almost Completed Page 9 of 27 Page 37 of 143

39 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF003 Opened ID ADO/Exec Lead Title 26/09/ Director of Nursing & Quality Safeguarding - adequacy of infra-structure Description Controls If the Trust does not put sufficient safeguarding structures in place then the risk of a safeguarding incident in both child or adult services will be increased. Contract KPI's will not be met. Named Nurse Safeguarding Adults in post from /5 Specialist Nurse posts commence February One offer on hold following HR process and one further post to go out to recruitment when agreement of wider Trust structure Review of safeguarding structure undertaken Overview by Safeguarding Team of datix incidents Access to supervision 9-5 Mon - Fri for instant advice Gaps in Controls Vacant posts in safeguarding team structure 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Unlikely (2) Catastrophic (5) 10 High Risk 5 Moderate risk 10/01/ /02/2017 Assurance Monitoring through safeguarding committee and safety assurance committee Oversight provided to Sefton CCG Contract KPI's monitored quarterly Support for SONAS by safeguarding team and issues addressed as required Gaps in Assurance Action Plan Business case put to Executive and agreed. Posts out to recruitment. Exception report to be provided to Quality and Safety regarding progress of training following intensive drive in September 2016 to have staff complete training. Figures available from Training Dept. early October. Action Plan Due Date 30/01/ /12/2016 Action Plan Rating Completed Completed Page 10 of 27 Page 38 of 143

40 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF003 Opened ID ADO/Exec Lead Title 26/09/ Executive Medical Director Sepsis mortality performance Description Controls Potential for avoidable harm and avoidable deaths due to the lack of standardisation of care and application of pathways. One diagnosis group currently highlighted as having a statistically above expected mortality: pneumonia. Exposure of Trust to reputational risk if not corrected. Mortality review of task and finish groups Mortality review process embedded in CBU's Gaps in Controls Lack of standardised pneumonia pathway application 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Unlikely (2) Catastrophic (5) 10 High Risk 5 Moderate risk 25/01/ /02/2017 Assurance Sepsis group relaunched Mortality surveillance group Mortality update reviewed quarterly at Quality and Safety committee HSMR below 100 SHMI as expected Pneumonia update report presented to Trust Board in October 2016 Gaps in Assurance Pneumonia coding performance AqUA report shows Trust 16/22 of peer group in recording comorbidities. Validity of published mortality data Action Plan Sepsis group to focus on pneumonia Identify clinical lead to take Sepsis Task and Finish Group forward. Continued close collaboration between clinical staff and coding teams To provide focused training regarding pneumonia for junior doctors. To introduce pneumonia risk rating score to the patient clerking pro forma. To repeat clinical audits that have been carried out regarding management of pneumonia. Action Plan Due Date 31/10/ /10/ /11/ /11/ /11/ /02/2017 Action Plan Rating Completed Completed Completed Completed Completed Actions Almost Completed Page 11 of 27 Page 39 of 143

41 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF005 Opened ID ADO/Exec Lead Title 30/06/ Executive Medical Director Failure to deliver on the IMT Strategy may impact on the Trust Operationally, Strategically and its affect it's Sustainability Description Failure to deliver on the IMT strategy will impact the Trust in relation to clinical care (information and process support), sustainability (mobile working, alliance collaboration) and political implications - lack of Digital Maturity progress may have financial implications from CCG(s). Failure to successfully deliver on the IMT strategy will also negatively impact Benefits Realisation. Controls Causes that contribute to the risk are: Lack of staffing resources Lack of financial resources Lack of clinical/ end user adoption Failure to realise benefits Inadequate underlying IT infrastructure (i.e. datacenters) Lack of wider health economy strategy alignment/ changes of direction Disaster recovery plan Zerto protection Trust approved IMT Strategy Supporting annual business plan Agreed funding / Capital investment plan Alignment to the ilinks Information Sharing Framework (S&F CCG) Alignment to the LPRES programme (West Lancs CCG) Implementation of Structure EPR (Medway and clinical modules) Implementation of Community EPR (EMISWeb) Implementation of electronic case note (Evolve EDMS) Alignment to the Alliance IMT strategy Gaps in Controls Lack of benefits realisation resources impacts on assessment of embedment of strategy Revision of annual capital funding to support Trust sustainability Unknown budget / financial profile over 5 year period (to cover strategy) 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Possible (3) Moderate (3) 9 High Risk 4 Moderate risk 03/01/ /02/2017 Assurance IMT Programme Board IT Community Programme Board FP&I ilinks Clinical Informatics Advisory Group (CIAG) (S&F CCG) LPRES Programme Board (West Lancs CCG) Alliance IMT Programme Board NHS England Digital Maturity Assessment Capital Investment Group Reporting (on financial position/ budgets) Gaps in Assurance Action Plan The core Microsoft network is based on 2003 servers which are out of support and linked to Datix risk ID 1189, Windows 2003 is no longer supported. It will also support the Strategy under enabling theme as the updated microsoft network will support enabling features. This will provide additional compute and memory capacity. Without investment for extra server capacity the Trust may experience service outages. This is linked to Risk id 1251, lack of funding for capacity management. Following external risk assessment, the anticipated remedial work costs total 130,000 to address the key risks within the data centre. Alternatively the cost of a new facility is approximately 250,000 plus network and suitable location to re house. Remedial works to be carried out while a longer term solution is established. Additional RF pager are required to ensure that clinical communication is not compromised. Linked to risk Action Plan Due Date 31/05/ /09/ /11/ /07/ /02/ /03/ /03/ /03/ /03/ /03/ /03/2017 Action Plan Rating Completed Completed Little or No Progress Made Completed Moderate Progress Made Little or No Progress Made Completed Completed Page 12 of 27 Page 40 of 143

42 Cardiac Arrest Communication failure due to ASCOM. To provide IT systems monitoring to ensure that system performance can be monitored and any malfunctions. Permanent staff that are paid from capital. Historical arrangement and recommended to be paid via revenue. Member of staff appointed. Deployment of Vital PAC is a key strategic objective. Users training is essential to support deployment. 20 days of training to be provided by Informatics Merseyside. Associated cost of role out of Vital PAC. Provision of a contingency to allow for the replacement of devices when required. To implement the EMIS Web system for community, providing an electronic record. To complete the roll out of Evolve, including the purchase of tablets, additional IT equipment, staff costs to maintain Evolve. To carry out all essential cabling works to replace cabling and cabinets that are at the end of their lives. Support the digital maturity agenda by developing additional interfaces between the core Medway EPR and Vital PAC/Pathology & Somerset Cancer registry. Replacement of an ageing MDT video conferencing system. A local health economy led approach involving Southport & Ormskirk and will enhance wider collaboration between providers. Implement the order comes module within Medway to address a gap in digital maturity and improve quality, information and stream line the requesting process. IM strategy action plan to be added 31/03/ /03/ /03/ /02/ /03/ /09/2016 Moderate Progress Made Actions Almost Completed Completed Moderate Progress Made Little or No Progress Made Moderate Progress Made Little or No Progress Made Little or No Progress Made Completed 007/17 High Level Risk Register Page 13 of 27 Page 41 of 143

43 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF003 Opened ID ADO/Exec Lead Title 26/09/ Director of Nursing & Quality Deprivation of Liberty Safeguards (DOLS) Description Controls If assessments and authorisation are not undertaken in a timely manner then patients are at increased safeguarding risk and the organisation fails in its duty in terms of DOLS legislation. All DOLS to be submitted onto Datix for monitoring and analysis purposes DOLs training in place Safeguarding team monitoring DOLS on daily basis Authorisation raised as an issue at Sefton local Safeguarding board Attendance by Safeguarding Team at regional sub groups and local sub groups regarding best practice Gaps in Controls Training levels not achieved Local authority backlog 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Possible (3) Moderate (3) 9 High Risk 6 Moderate risk 10/01/ /02/2017 Assurance Centrally held records for DOLS are held on Datix DOLS legislation is discussed at all adult safeguarding committees. CCGs aware All DOLs referrals are electronic and can be tracked Safe inbox for DOLS authorisations Gaps in Assurance Action Plan All ward / area staff are made aware that applications should only be ed: Notified via Trust news Updated information in ward MCA and DoLS folders. Standard operating procedure for DoLS applications to be put in place. Progress of applications and Local authority feedback is monitored centrally: Database to be placed in shared drive with restricted access for interested persons to access live data on DoLS applications. Database to be managed and maintained by nominated persons within safeguarding team. SOP to be developed to identify roles with DoLS monitoring process. All forms related to DoLS application to be stored centrally attached to DoLS DATIX records To continue promoting e-reader to meet planned trajectory. To ensure new clinical staff are aware to complete of e-reader. Feedback to CBU s on issues and training figures through the Trust Safeguarding Steering group. Care Plan 160 updated to reflect process Issues and guidance feedback through Trust Safeguarding Steering Group. E-reader to be updated with process. MCA and DoLS policy to be updated. To be included in SOP. Trust information leaflet to include detail regarding this process. DOLs action plan to be added to the risk Action Plan Due Date 01/11/ /11/ /02/ /11/ /10/2016 Action Plan Rating Completed Completed Completed Completed Completed Page 14 of 27 Page 42 of 143

44 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF003 Opened ID ADO/Exec Lead Title 26/09/ Executive Medical Director Sub-standard case note recording Description Controls If the standard of case note recording is not sufficiently high then there is the possibility of increased clinical risk to patients and reputational risk to the Trust SONAS assurance structures Routine audit from Clinical Audit team Roll out plan for electronic patient record Gaps in Controls Lack of full electronic patient record Human factors 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Unlikely (2) Major (4) 8 High Risk 4 Moderate risk 11/02/ /03/2017 Assurance Clinical Audit routine audit Roll out of EPR EPR role out monitored by IM&T Board Gaps in Assurance Action Plan Evolve (ENT) Electronic Cases note in ENT EMISWeb Community Phase 1 "Migrate off ipm Implement EMISWeb" Interfaces VitalPAC 3.1 Upgrade Major release upgrade VitalPAC rollout to HDU and CCU VitalPAC available in critical care units VitalPAC Nutrition module Rollout of Nutrition module VitalPAC AKI/IPCM module Rollout of AKI/IPCM module VitalPAC indwelling devices module. Rollout of indwelling device module VitalPAC Closing the loop module Rollout of closing the loop module VitalPAC VTE module Rollout of VTE module Skelmersdale Walk-In Centre (EPR Medway Rollout) "Migrate off ipm - Implement Medway EPR" VitalPAC rollout to A&E VitalPAC in use within A&E Medway V4 Upgrade "Major release upgrade Required for OCRR" Evolve (Dermatology) Electronic Cases note in Dermatology Evolve 3.6 Upgrade "Major release upgrade - Required for Mobile App" Action Plan Due Date 29/04/ /07/ /03/ /05/ /09/ /09/ /03/ /03/ /03/ /03/ /06/ /09/ /03/ /02/ /09/ /03/ /11/ /03/ /03/ /03/ /03/ /08/ /10/2017 Action Plan Rating Completed Completed Actions Almost Completed Completed Completed Completed Little or No Progress Made Little or No Progress Made Little or No Progress Made Little or No Progress Made Completed Little or No Progress Made Actions Almost Completed Actions Almost Completed Completed Actions Almost Completed Completed Actions Almost Completed Little or No Progress Made Little or No Progress Made Moderate Progress Made Page 15 of 27 Page 43 of 143

45 VitalPAC Business Intelligence "Deployment of new VitalPAC BI Early adopter - Improved intelligence" EMISWeb MCAS/MSK Evolve Mobile App Deployment of ipad App across Trust ipads Whiteboards EMISWeb Community Phase 2 "Optimise Workflow Implement Mobile Working". "Medway Order Communications and Results Reporting (OCRR) Phase 1: Results Reporting" "Implement Results Reporting for Pathology and Radiology into Medway Decommission Review system" "Medway Order Communications and Results Reporting (OCRR) Phase 2: Electronic Requesting" Implement electronic requesting for Pathology and Radiology tests EPR Action plan to be added Moderate Progress Made Little or No Progress Made 007/17 High Level Risk Register Page 16 of 27 Page 44 of 143

46 Strategic Objective Objective 2 - Ensure excellence in treatment and care Link to BAF BAF003 Opened ID ADO/Exec Lead Title 03/01/ Executive Medical Director Medisec System has limited assurance (MIAA audit) Description MIAA audit identified number of risks/issues with system: 1) - Server Security - (IT) - Out of date server, lack of patches, folder security. 2) - Application Security (CBU) - user account admin, audit of access 3) - Database Access - (IT) - poor model of database security. 4) - Governance - (CBU) - lack of clear system owner 5) - Business Continuity (CBU) - lack of clear BC plan - linked to point /17 High Level Risk Register IT will progress risks associated with IT owners. Addressing these will improve assurance level. Controls Replacement of legacy Windows 2003 Server with new 2008 supported server Review and implementation of tighter folder security permissions Modification of Database security model to industry recommended model Assignment of information asset owner (CBU) Review of administration processes (Information asset owner) Review of system access audit processes (Information asset owner) Develop clear business continuity plan (CBU) Gaps in Controls No clear CBU ownership / Information Asset Owner Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Unlikely (2) Moderate (3) 6 Moderate risk 2 Low risk 25/01/ /03/2017 Assurance IMT Programme Board. - Review of IMT Risk Register MIAA review of audit plan progress Audit Medical Director CBU Meeting - Review of risks Gaps in Assurance Action Plan Address high security risk by replacing old Windows 2003 server with a fully patched Windows 2008 server and tighten the data folder permissions Change the SQL database login security model from mixed mode to domain authentication. This results in tighter and more transparent system security rather than all users accessing via a single SQL system role. Action Plan Due Date 30/12/ /02/2017 Action Plan Rating Completed Little or No Progress Made Page 17 of 27 Page 45 of 143

47 Strategic Objective Objective 4 - Empower and develop staff to achieve their objectives Link to BAF BAF008 Opened ID ADO/Exec Lead Title 22/09/ Director of HR Culture and Engagement of staff Description Controls If the culture and morale of staff is not at a satisfactory level then the Trust's ability to achieve its strategic objectives and the delivery of services to patients may be compromised. Leadership Master Classes Annual Pride Awards Workforce Strategy Junior Doctors Survey Engagement and Culture Strategy Equality and Diversity Working Group New post created for support of records system, recruitment process is ongoing. Gaps in Controls Uncertainty of CEO post 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Likely (4) Major (4) 16 Extreme risk 6 Moderate risk 23/01/ /02/2017 Assurance Quarterly HRD report to Trust Board Result of Staff Attitude Survey Coaching in the workplace Values based recruitment based on guidance from NHS England PDR Process which includes Trust values Charter for Staff and Managers Review of culture in the Trust, being carried out by external adviser. HR Director agreed extension of project, report is expected in February Gaps in Assurance Nil Identified Action Plan Cultural Review as commissioned by the Board Action Plan Due Date 28/02/2017 Action Plan Rating Moderate Progress Made Page 18 of 27 Page 46 of 143

48 Strategic Objective Objective 4 - Empower and develop staff to achieve their objectives Link to BAF BAF008 Opened ID ADO/Exec Lead Title 22/09/ Director of HR Mandatory and Job Specific Training Compliance Description Level of mandatory and job specific training not at required level of 90% Controls All mandatory training records are updated by the Training Admin Team (ODGH) before reports are pulled (5th of each month) Mandatory training records are accurate as at the date of the reports being pulled New reporting mechanism developed in conjunction with the Performance team - new RAG rated reports produced and reports published by 2nd week of each month New reports published on the intranet for all staff to access and to encourage ownership Ongoing reporting anomalies are to be reviewed on an ongoing basis Additional resource deployed to link between local record keeping and corporate Risk Levels Likelihood Consequence Risk Rating (Current) Gaps in Controls Ongoing anomalies in the data stored on OLM and that produced in the reports Workforce structures to be monitored continually for new starters and leavers and new job profiles Limited workforce administration / expertise for a large organisation Manager and self-serve via OLM/ESR would improve compliance monitoring Alignment of workforce structures Variety of training delivery modes impacted by finance Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Possible (3) Moderate (3) 9 High Risk 6 Moderate risk 23/01/ /02/ /17 High Level Risk Register Assurance Action Plan Performance being monitored through Trust Board monthly The PERS 43 Induction & Mandatory Training Policy MIAA Audit June/July 2016 Managers are accountable for mandatory training as per Mandatory Training policy Review through quarterly PMF process To ensure effective governance arrangements are in place and escalation of issues is managed effectively ESR Administrator to develop current RAG reports to remove anomalies and ensure data accuracy. To develop RAG reports for all job specific training To develop communication methods which inform staff of all training requirements and their role and responsibilities To further expand the training needs analysis to cover job specific mandatory training i.e. DoLS, MCA, medicines management, IV drugs, venepuncture, ANTT etc To develop the induction processes identified in the revised policy and embed them in the E&T team daily/monthly work programme To adopt & implement the RoSTA assessment system from HENW to monitor student & junior doctors mandatory training To ensure that all processes have a SOP accessible to relevant staff in the department To increase capacity and skill mix within the training department to fully staff the service To improve manager s effectiveness in the management of mandatory training To allow for 24 hour access to mandatory training online for staff to remain compliant To review with SME s a backfill process to ensure business continuity Increase access to training i.e., implement elearning options for 24 hour access to reduce DNA s SME s to offer bespoke courses in situ for heard to reach groups / consider evening sessions To work with Cheshire & Merseyside streamlining project to deliver pre-hire mandatory training, reduce time to hire, & reduce repetitive mandatory training through IAT management. To develop a new suite of training reports which allow for training planning and compliance To add the training action plan Gaps in Assurance Action Plan Due Date 01/10/ /10/ /09/ /03/ /03/ /03/ /03/ /03/ /02/ /09/ /03/ /03/ /03/ /11/ /10/2016 Lack of resource to produce reports Continued use of e readers Action Plan Rating Completed Completed Completed Moderate Progress Made Moderate Progress Made Moderate Progress Made Actions Almost Completed Actions Almost Completed Moderate Progress Made Moderate Progress Made Moderate Progress Made Moderate Progress Made Little or No Progress Made Completed Completed Page 19 of 27 Page 47 of 143

49 Strategic Objective Objective 5 - Maintain organisational sustainability Link to BAF BAF011 Opened ID ADO/Exec Lead Title 09/05/ Director of Finance Achievement of deficit control total 2016/17 Description Controls The Trust faces significant challenges to deliver its 16/17 deficit control total of 6.6m. The figure assumes that the Trust will receive 6.1m from the sustainability and transformation fund (S&T) and that a CIP of 6.4m will be delivered. Contract meetings with Commissioners Monthly management accounts Monthly Performance Management Framework (PMF) meetings Corporate governance - scheme of reservation and delegation re authorisation levels SBS finance system - access and authorisation controls Procurement frameworks to ensure value for money Cost Improvement Programme (CIP) controlled through the Transformation Gaps in Controls Agency control total (annual spend of 7.22m) not met. Lack of a robust recruitment strategy CIP reporting at Clinical Business Unit level in year. 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Assurance Almost Certain (5) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Major (4) 20 Extreme risk 12 High Risk 28/11/ /01/2017 Divisional Finance Managers meet with budget holders every month to go through budget statements. CIP governance at Finance, Performance & Investment Controls reviewed by Mersey Internal Audit Agency (MIAA) on a regular basis. KPMG provide true and fair opinion on the accounts. Gaps in Assurance Southport & Formby CCG in financial recovery. Action Plan To formulate action plan as a result of NHSI Financial investigation of the Trust. Action Plan Due Date 31/12/2016 Action Plan Rating Moderate Progress Made Page 20 of 27 Page 48 of 143

50 Strategic Objective Objective 5 - Maintain organisational sustainability Link to BAF BAF007 Opened ID ADO/Exec Lead Title 10/05/ Director of Finance Returning to financial balance by 2021 Description Controls There is no 5 year plan at this stage which shows the Trust returning to financial balance by 2021 (timescale in line with the 5 year forward view. We now have a long term financial model and a fully costed estate solution from the Deloitte sustainability report. Trust is part of the Cheshire & Mersey STP and a member of the Alliance local delivery system (LDS) Implementing the 5 year forward view locally. Gaps in Controls We need to feed the STP/LDS assumption into our LTFM 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Likely (4) Major (4) 16 Extreme risk 6 Moderate risk 28/11/ /01/2017 Assurance Monthly report to Trust Board re STP and Alliance Transformation Work with the Alliance LDS and the Cheshire & Mersey STP Gaps in Assurance No agreed clinical model for reconfiguration of services within the STP. Action Plan Submission of Trust 2 year operational plans by 23/12/16. Submission of STP plan. Action Plan Due Date 23/12/ /10/2016 Action Plan Rating Moderate Progress Made Completed Page 21 of 27 Page 49 of 143

51 Strategic Objective Objective 5 - Maintain organisational sustainability Link to BAF BAF010 Opened ID ADO/Exec Lead Title 11/11/ Executive Medical Director Financial pressure from medical staff job planning Description Inception of modern job planning for consultants and SAS doctors, produces a potential on going risk to the Trust, with the additional risk of back pay. Aggregate increased PA's, for consultants is 27. SAS job planning on going scheduled to complete November 2016, may increase financial pressure. Controls Review of job plans by COO, EMD & DoF during December 2016, aligned to business planning. Gaps in Controls 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Likely (4) Major (4) 16 Extreme risk 6 Moderate risk 25/01/ /02/2016 Assurance To be monitored through existing business management processes, with reports to PMF, EMT & FP&I Gaps in Assurance Action Plan Job plans to be agreed by 28/02/2017 Action Plan Due Date 28/02/2017 Action Plan Rating Actions Almost Completed Page 22 of 27 Page 50 of 143

52 Strategic Objective Objective 5 - Maintain organisational sustainability Link to BAF BAF011 Opened ID ADO/Exec Lead Title 10/05/ Director of Finance Reliance on external cash support Description Controls As the Trust continues to run with a deficit, there is insufficient cash to support current liabilities. The Trust is reliant on external cash support from the Department of Health via interest bearing loans. Three main CCGs - Southport & Formby, West Lancashire and South Sefton pay contract invoices on 1st working day of the month. Daily cashbooks received and weekly forecasts used to ensure we don't go overdrawn. Debt levels monitored constantly with the aim to have greater than 90 day debt under 5% of total debt. Financial controls on income/expenditure and capital Thirteen week rolling cash flow forecast sent to NHS Improvement (NHSI) every month. Interim revolving working capital facility (IRWCF) in place up to m. Access to further term loans available from Department of Health but subject to approval. We have accessed further loans since fully utilising the m. Gaps in Controls Trust does not meet Sustainability & Transformation condition so can't access 6.1m. 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Assurance Almost Certain (5) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Moderate (3) 15 Extreme risk 6 Moderate risk 28/11/ /01/2017 Monthly monitoring with DH and NHSI Finance, Performance & Investment review. Gaps in Assurance Action Plan Receiving guidance from NHSI on external cash. Now submitting loan requests on a monthly basis. Action Plan Due Date 31/03/2017 Action Plan Rating Completed Page 23 of 27 Page 51 of 143

53 Strategic Objective Objective 5 - Maintain organisational sustainability Link to BAF BAF011 Opened ID ADO/Exec Lead Title 06/12/ Therese Patten Job Planning- Medics Description Job plans are not matched to activity and salary Paper based system - Lack of transparency and difficult to monitor Financial impact - over or underpayment of salary, unknown overspend on divisional medical budgets Recruitment and retention - reputation 007/17 High Level Risk Register Controls Job plans for all medical staff are under review Gaps in Controls Lack of electronic system to monitor activity against job plan Salary to job plan does not match - over,under payment Medical staff working out of date job plans Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Possible (3) Major (4) 12 High Risk 4 Moderate risk 25/01/ /02/2017 Assurance Revalidation process Gaps in Assurance Action Plan Implementation of HealthMedics Optima ejob Plan Action Plan Due Date 28/02/2017 Action Plan Rating Moderate Progress Made Page 24 of 27 Page 52 of 143

54 Strategic Objective Objective 5 - Maintain organisational sustainability Link to BAF BAF011 Opened ID ADO/Exec Lead Title 16/12/ Executive Medical Director Medical and Dental Rota Management Description Controls If the Trust does not provide a consistent approach to roistering across the organisation, increase visibility, ensure patient safety and improve service delivery. There is a risk of failure to comply with 2016 Doctors contract requirements, financial penalties related to re validation, safe working breaches & no reduction in agency cost. Implementation of HealthMedics system Medical staffing workforce team redesign Review of agency usage Gaps in Controls Transition to 2016 Doctor contract has not commenced No standardisation of recording and monitoring of additional hours worked and annual & study leave. Trust does not have complete visibility of compliant prospective rotas to match to pay. The Trust does not have an electronic system for exception reporting, to be overseen by guardian of safe working. The Trust does not have resilience on mapping service delivery against establishment. Minimal reduction in medical agency costs, vacancies filled with locums via agency. 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Possible (3) Major (4) 12 High Risk 4 Moderate risk 25/01/ /02/2017 Assurance Implementation and monitoring of erota-compliant Junior Doctor Rotas Implementation and monitoring of MedicOnline Implementation and monitoring of MedicOnDuty Implementation and monitoring of eexception reporting, Guardian of SafeWorking Implementation and monitoring of Activity Manager Gaps in Assurance Action Plan Action Plan Due Date Action Plan Rating Page 25 of 27 Page 53 of 143

55 Strategic Objective Objective 5 - Maintain organisational sustainability Link to BAF BAF009 Opened ID ADO/Exec Lead Title 26/01/ Chief Executive Continuity of Organisational memory Description Controls Due to interim Executive appointments, there is a risk to the continuity of the organisational memory, uncertainty about the future direction and management of change within the organisation and risk of reputational damage. Interim Exec team in place Keeping key stakeholders informed Board-level ownership of key risks and mitigation Substantive Chief Operating Officer commences Substantive Director of Nursing commences Alternative arrangements for Director of HR cover being considered Gaps in Controls CEO coverage continues to be interim 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Unlikely (2) Moderate (3) 6 Moderate risk 6 Moderate risk 28/10/ /02/2017 Assurance Board oversight Gaps in Assurance Action Plan Options update on Director of HR arrangements to November Board Action Plan Due Date 09/11/2016 Action Plan Rating Completed Page 26 of 27 Page 54 of 143

56 Strategic Objective Objective 5 - Maintain organisational sustainability Link to BAF BAF011 Opened ID ADO/Exec Lead Title 26/09/ Executive Medical Director Lack of accuracy of Clinical Coding of pneumonia diagnosis in the health records Description Controls Inadequate recording of clinical diagnosis, complications and co morbidities and / or procedure by clinicians. This can lead to a higher HSMR rate from inaccurate or incomplete clinical coding, increasing the risk of insufficient income and reputational damage to Trust. Mortality review process of deceased patients embedded in CBU's External audits of coding activity and accuracy e.g. PbR, Dr Foster 2014 commissioned report Internal accuracy audits undertaken within the Trust with MIAA overview Gaps in Controls Review of all patients coding Lack of standardised SOP for coding in casenotes lack of sufficient coders to develop specialty relationships Assurance gaps to be discussed at mortality surveillance group 007/17 High Level Risk Register Risk Levels Likelihood Consequence Risk Rating (Current) Risk Level (Current) Risk Rating (Target) Risk Level (Target) Date of Last Review Date of Next Review Unlikely (2) Moderate (3) 6 Moderate risk 2 Low risk 11/11/ /02/2017 Assurance PbR audit on accuracy Quarterly Monitoring of Mortality action plan at Quality and Safety monthly monitoring at Mortality Surveillance Group Use of Dr Foster (mortality ) data re clinical performance Ongoing review of coding for pneumonia identifying good standards Paper regarding pneumonia progress, presented to Trust Board in October 2016 Gaps in Assurance Action Plan Establish a clinical lead for task and finish group Establish and implement appropriate pathways of care for pneumonia. Audit of pneumonia pathway compliance Establish a task and finish group which addresses pneumonia. Action Plan Due Date 31/10/ /11/ /01/ /10/2016 Action Plan Rating Completed Moderate Progress Made Completed Completed Page 27 of 27 Page 55 of 143

57 Integrated Board Report. Reporting on December data. RAG Ratings by Section 008/17 Integrated Performance Report Strategic Objective 1: Embed An Integrated Care Model Across The Local Health Economy Strategic Objective 2: Ensure Excellence In Treatment And Care Strategic Objective 3: Deliver Performance, Within Resources, Comparable With The Best The NHS Can Offer Strategic Objective 4: Empower And Develop Staff To Achieve Their Objectives Strategic Objective 5: Maintain Organisational Sustainability 0% 20% 40% 60% 80% 100% Page 56 of 143

58 Board Report - December 2016 Strategic Objective 1: Embed An Integrated Care Model Across The Local Health Economy (Page 1 of 1) Indicator Name Description Narrative Responsible Month Trend 008/17 Integrated Performance Report No associated Indicators N/A Page 57 of 143

59 Board Report - December 2016 Strategic Objective 2: Ensure Excellence In Treatment And Care (Page 1 of 5) Indicator Name Description Narrative Accident & Emergency Ambulance Handovers >15 Mins Number of patients spending more than 4 hours in a A&E department from arrival to discharge, transfer or admission. 95% target. Good performance is higher. Bar = Last Financial Year, Line = This Financial Year All handovers between ambulance and A&E staff to occur within 15 minutes. This measure looks at all handover delays over 30 minutes and one hour. Threshold 0 > 30mins. Bar = Last Financial Year Line = This Financial Year Unfortunately the Trust did not achieve the trajectory set out with NHSI. Performance for December 2016 was 90.6%. Across the month there was a 3% increase in overall ED attendances (compared to December 2015). Within this, there was a 9.4% increase in majors category ED attendances and a 6% increase in patients brought in by ambulance, putting significant pressure on the department. December saw the closure of 24 beds on the Southport site (from 14 December), which saw some operational difficulties. Across the Christmas period, the Trust's performance against the 4-hour standard was noted to be the best in the northwest and in the top 10 performers nationally. January saw the opening of 'Bluebell 2', which creates capacity for 22 beds, in addition to a Discharge Lounge, in order to support flow on the Southport site. In line with the pressures experienced across December, achievement of this target remains a significant challenge. However, performance for December was a signficant improvement compared to December The additional investment in nursing staff to support triage in ED is utilised to ensure that patients arriving by ambulance are triaged in a timely manner to enable the team to be able to 'pull' the most sick patients into cubicles to commence treatment, which can result in delays to the 'less sick' ambulance patients when there is restricted flow within the department. Regular observations and intentional rounding is completed to ensure that patient safety is paramount. Responsible Quality & Safety Quality & Safety Month Trend 008/17 Integrated Performance Report TIA (Transient ischaemic attack) Proportion of patients diagnosed with a TIA Treated within 24 hours. Threshold 60%. Good performance is higher. Bar = Last Financial Year Line = This Financial Year During December there were 3 reportable TIA's, two of which were breaches, seen outside the 24 hour period. One patient had symptoms seven days prior to referral. Finance, Performance & Investment Stroke 90% ward stay Proportion of stroke patients who have 90% of their hospital stay on a dedicated stroke ward. Threshold 80%. Good performance is higher. Indicator may change as a result of delayed validation. Bar = Last Financial Year Line = This Financial Year Performance against this target continues to be a significant challenge. The stroke team continue to 'pull' any patients requiring a stroke bed from ED wherever possible. Nonstroke patients on the ward are identified daily and moved out in the event of a patient on an acute ward requiring a Finance, stroke bed. As previously reported, the configuration of bays Performance on the current stroke unit template do create some difficulties & Investment in meeting male/female demand. The stroke team continue to provide care to patients requiring their input who cannot be accommodated on the stroke unit. Discussions are ongoing regarding the future of stroke at executive level and also at stroke clinical lead level. Page 58 of 143

60 Board Report - December 2016 Strategic Objective 2: Ensure Excellence In Treatment And Care (Page 2 of 5) Indicator Name Description Narrative SHMI (Summary Hospital-level Mortality Indicator) Summary Hospital-level Mortality Indicator (SHMI) is the standardised mortality both in hospital and within 30 days of discharge. Source = Dr. Foster. Please note: This indicator is reported quarterly and is 6 months behind due to when Dr Foster publish the data. Good performance is 100 or less. Alert to Trust Board Members sent on 11th January Verbal update and formal paper by Executive Medical Director of issue logged on Corporate Risk Register, presented to Q&S on 18th January Matter escalated to Trust Board. Responsible Quality & Safety Month Trend 008/17 Integrated Performance Report HSMR (Hospital Standardised Mortality Ratio) Bar = Last Financial Year Line = This Financial Year The ratio of the observed number of in-hospital deaths with a Hospital Standardised Mortality Ratio (HSMR) diagnosis to the expected number of deaths, multiplied by 100. At Trust level, good performance is 100 or less. Source = Dr. Foster. Please note: This indicator is reported monthly and is 3 months behind due to when Dr Foster publish the data. Alert to Trust Board Members sent on 11th January Verbal update and formal paper by Executive Medical Director of issue logged on Corporate Risk Register, presented to Q&S on 18th January Matter escalated to Trust Board. Quality & Safety Bar = Last Financial Year, Line = This Financial Year Green = Previous Value, Blue = Corrected Value C-Diff Number of Clostridium difficile (C. diff) infections for patients aged 2 or more on the date the specimen was taken. Trust target 36 for the year. Good performance is fewer than 36 for the year. Bar = Last Financial Year Line = This Financial Year The Trust target for C-Diff is to have no more than 36 attributable cases in fiscal year , this averages out as 3 cases per month, hence April to December we should of had no more than 27 cases. Actual total cases in this time period are 15 and the Trust has successfully appealed 6, hence the Trust is well below trajectory with 9 attributable cases YTD. Quality & Safety MRSA The number of Methicillin Resistant Staphylococcus Aureus (MRSA) test samples that were positive. The threshold is 0. There is a zero tolerance for MRSA bacteraemia. In August the Trust had one case; this is the only case so far for the year, with zero cases in the 3rd quarter. Quality & Safety Bar = Last Financial Year Line = This Financial Year Page 59 of 143

61 Board Report - December 2016 Strategic Objective 2: Ensure Excellence In Treatment And Care (Page 3 of 5) Indicator Name Description Narrative Responsible Month Trend 008/17 Integrated Performance Report VTE (Venous thromboembolism) VTE risk assessment: all inpatient Service Users undergoing risk assessment for VTE. Threshold 95%. Good performance is higher. Bar = Last Financial Year Line = This Financial Year VTE Assessment target acheived in December and in every month in 2016/17. Quality & Safety Falls The number of falls within the hospital per 1,000 bed days. Threshold: 4.5 per 1000 bed days. Good performance is lower. Bar = Last Financial Year The Introduction of the falls alarms, robust assessment documentation and falls risk identification supports close monitoring of falls management by the Trust. Moving forward, enhanced reporting through Q&S Divisional reports and the completion of RCA's in Datix will enable a clearer perspective on the risk factors and maintain the focus on those factors that are important in the analysis and prevention of a fall event. Quality & Safety Friends and Family Test Friends and Family Test. The proportion of patients that would recommend the Trust to their friends and family. Threshold: 94%. Good performance is higher. Bar = Last Financial Year Line = This Financial Year The feedback from patients across the organisation is generally low, with some areas doing markedly better then others. The implementation of the Patient and Carers Experience Strategy , with a pledge to - ' increase the profile of Patient and Carer Experience and collect patient opinion in a more robust manner' will review the FFT process, work with our service users to develop and implement a more robust and acccesible system to increase feedback and ensure systems and processes are in place to act on feedback driving change. Quality & Safety Hospital Pressure Sores Number of reported Trust acquired pressure sores graded between 2 and 4. Threshold: 28. Collaborative goal: Elimination of grade 3 and 4 pressure ulcers plus 25% reduction overall. Bar = Last Financial Year Line = This Financial Year Every reported incident is investigated, lessons learned are cascaded down to staff at ward level. Overarching action plan in place to cover common themes as requested by CCG's, and training for staff continues on a monthly basis. Investigations result in either avoidable, unavoidable or not due to pressure, therefore data can fluctuate accordingly, for example, at least 3 incidents from December have been rejected as pressure ulcers as on investigation, they were found to be moisture lesions or trauma wounds.projects this year include a focus on heel pressure ulcer prevention. Quality & Safety Page 60 of 143

62 Board Report - December 2016 Strategic Objective 2: Ensure Excellence In Treatment And Care (Page 4 of 5) Indicator Name Description Narrative Responsible Month Trend 008/17 Integrated Performance Report Community Pressure Sores Collaborative goal: Elimination of Grade 3 and 4 pressure ulcers plus 30% reducton overall. Bar = Last Financial Year Line = This Financial Year Every reported incident is investigated, lessons learned are cascaded down to staff at ward level. Overarching action plan in place to cover common themes as requested by CCG's, and training for staff continues on a monthly basis. Investigations result in either avoidable, unavoidable or not due to pressure, therefore data can fluctuate accordingly, for example, at least 3 incidents from December have been rejected as pressure ulcers as on investigation, they were found to be moisture lesions or trauma wounds.projects this year include a focus on heel pressure ulcer prevention. Quality & Safety Harm Free Safety Thermometer - Percentage of Patients With Harm Free Care. Threshold 98%. Higher is better. Bar = Last Financial Year Line = This Financial Year The last 4 months has seen the organisation achieve over 98% which is positive. Quality & Safety Never Events Never Events - A particular type of serious incident that is wholly preventable and has the potential to cause serious patient harm or death. Bar = Last Financial Year Line = This Financial Year There were no Never Events during the month of December. In November 2016, a patient underwent a total knee replacement where an incorrect implant was inserted into the femur. This was recognized immediately by a Consultant Orthopaedic Surgeon. The Consultant involved sought a second opinion immediately and proceeded to remove the implant and replace it with the correct implant. The Duty of Candour requirements were complied with. Quality & Safety Safe Staffing The ratio between the proposed number of nursing staff to ensure a safe staffing level and the actual number of nurses working those shifts. Threshold: 95%. Bar = Last Financial Year Line = This Financial Year The Organisation consistantly acheives over 95%. The newly appointed Assistant Director of Nursing for Workforce is working with the Heads of Nursing to review and implement a Workforce Strategy by April Quality & Safety Page 61 of 143

63 Board Report - December 2016 Strategic Objective 2: Ensure Excellence In Treatment And Care (Page 5 of 5) Indicator Name Description Narrative DSSA (Delivering Same Sex Accommodation) Breaches - Trust This indicator monitors the Trust's part in the NHS commitment to eliminate mixed sex accommodation. Each patient breaches each 24 hours. Bar = Last Financial Year Line = This Financial Year 4 breaches all on Critical Care where HDU and CCU are mixed bays. Whilst the patients are requiring L2 and L3 care being in a mixed sex area is acceptable. Once they are made wardable they become a breach. In July 2016 the decisison was made to trial for 3 months flexible use of side room 1 for CCU & side room 7 & 8 for ICU patients who are potentially hitting the 24 hr mixed breach. Process cascaded to all staff, process is being closely monitored. DSSA breaches continue due to ICU occupied up to 7 beds consistently throughout Oct, Nov, Dec, (only 5 beds funded), unable to utilise flexi bed system. 24 hour delayed discharges continue due to hospital bed flow. Responsible Quality & Safety Month Trend 008/17 Integrated Performance Report Page 62 of 143

64 Board Report - December 2016 Strategic Objective 3: Deliver Performance, Within Resources, Comparable With The Best The NHS Can Offer (Page 1 of 4) Indicator Name Description Narrative Responsible Month Trend 008/17 Integrated Performance Report 14 day GP referral to Outpatients Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer. Target 93%. Good performance is higher. Bar = Last Financial Year Line = This Financial Year Target met - of the patients who breach these are mainly patient choice - ie declined, DNA and or cancellations - work ongoing with CCG's to esnure that GP's advise patients of the reasons for referrals and the timescales they will be seen. Finance, Performance & Investment 31 day treatment Percentage of patients receiving first definitive treatment within one month (31 days) of a cancer diagnosis (measured from 'date of decision to treat'). Target 96%. Good performance is higher. Bar = Last Financial Year Line = This Financial Year Target met. Finance, Performance & Investment 62 day GP referral to treatment Percentage of Patients receiving first definitive treatment for cancer within two months (62 days) of urgent GP referral for suspected cancer. Target 85%. Good performance is higher. Bar = Last Financial Year Line = This Financial Year In November there were 10.5 breaches out of 45 treatments. Radiology capacity and turnaround times are still a concern and continue to impact on patient pathways for all tumour sites. Radioloy have outsourced some routine work to free up capacity. Escalation processes in place. Capacity in Dermatology and ENT has been noted to be a risk due to Consultant vacancies and lost capacity. Finance, Performance & Investment 62 day pathway view All Trust Boards should have sight of tumour specific performance against the 62 day GP referral to treatment. Target 85%. Good performance is higher. Bar = Last Financial Year Line = This Financial Year There were 10.5 breaches in November with 3 relating to Colorectal, 2.5 to Urology and 2 in Haematology. Other areas Finance, with breaches include Gynaecology, Head & Neck, Lung, Performance Skin and Upper GI. 3 breaches were down to & Investment Diagnostic/OPD capacity, 2.5 breaches were due to complex pathways and 1.5 were clinically appropriate. Page 63 of 143

65 Board Report - December 2016 Strategic Objective 3: Deliver Performance, Within Resources, Comparable With The Best The NHS Can Offer (Page 2 of 4) Indicator Name Description Narrative Responsible Month Trend 008/17 Integrated Performance Report Referrals Number of referrals received into the Trust. This will include referrals from GPs, other hospitals and internal referrals. Bar = Last Financial Year Line = This Financial Year Decrease in overall referrals since October by 763. Some activity will have been lost due to the Christmas/New Year period. Ophthalmology referrals are still which is as a results of loss marketshare and patients being referred to other local Trusts or Private Providers. ENT is also down against plan but this will be due to the fact the service has been down 2 doctors and activity levels will return to normal from February. As noted previously, Dermatology has seen an increase in referrals which may be the result of other units being closed to new referrals. Finance, Performance & Investment First Appointments The number of patients seen in a first appointment including where the patient is seen in an outpatient clinic and has a procedure undertaken. Bar = Last Financial Year Line = This Financial Year First appointments are down against plan by 1,614 Trust wide and in month has also seen a decrease of 458. The average wait is 7.5 weeks. Finance, Performance & Investment Daycase/Inpatient The total number of patients treated as either a day case or an elective inpatient in month. Bar = Last Financial Year Line = This Financial Year Daycase/Inpatient procedures are down against plan by 1,345 but we have seen a decrease in December which follows the same trend as December Finance, Performance & Investment Waiting list size The number of patients currently waiting. Bar = Last Financial Year Line = This Financial Year Total RTT Waiting List size has decreased to 10,152. Finance, Performance & Investment Page 64 of 143

66 Board Report - December 2016 Strategic Objective 3: Deliver Performance, Within Resources, Comparable With The Best The NHS Can Offer (Page 3 of 4) Indicator Name Description Narrative Responsible Month Trend 008/17 Integrated Performance Report Diagnostic waits The number of patients waiting 6 weeks or more for a diagnostic test expressed as a percentage of all patients waiting. Threshold 1%. Good performance is lower. Bar = Last Financial Year Line = This Financial Year We are breaching the Diagnostic Target at 1.86%. Majority of breaches relate to Scopes where there are capacity pressures. Lost sessions due to bank holidays in December and staff sickness meant that some lists would not be available for backfill. No longer using "YOUR WORLD" to backfill sessions has also resulted in sessions being taken out where these can not be filled internally. Finance, Performance & Investment Referral to treatment: on-going Percentage of patients on an incomplete pathway with a current wait experience of 18 weeks or longer. Threshold 92%. Good performance is higher. Bar = Last Financial Year Line = This Financial Year Trust Performance did not meet the 92% threshold for December. Bed issues and staffing shortages have effected the elective activity on both sites. Both the Outpatient & Inpatient CIP Projects have been tasked to review productivity but in the short term all areas have been asked to put on extra activity where possible to bring the number of backlog patients down and to improve Trust performance. The Trust is still booking in chronological order to ensure the longest waiters patients are seen. Main areas of concern are Endocrinology (74%), Respiratory (87.4%), ENT (83.2%), T&O (88.7%) and Dermatology (87%). Dermatology has been adversely affected by the closure of other departments to New Referrals and there is an SAS Doctor vacancy which is being advertised; T&O has lost daycase/inpatient activity due to the bed pressures over the Christmas/New Year Period; ENT has been 2 doctors down (1 left August and 1 left November) and we have been awaiting Aintree to fill the positions. Both doctors will be in post from Feb 17 and activity levels will return to normal. Quality & Safety Average Length of Stay The average length of stay for all patients across the Trust. Lower is better. Bar = Last Financial Year Line = This Financial Year The length of stay (LoS) workstream (as part of the Urgent Care Reducing the Pressure programme) continues to meet. Although the overall length of stay across the site increased in December, the emphasis remains on an MDT approach to reducing LoS. The LoS meeting has now extended its scope to include non-elective patients across Planned and Urgent Care with a LoS over 6 days; this had previously focussed on 14 days. Finance, Performance & Investment Bed days post MOFD (Medically Optimised for Discharge) Number of beddays used for inpatients who have passed their medically optimised for discharge date. It is taken as a snapshot on the last working day of the month. Lower is better. Bar = Last Financial Year Line = This Financial Year There is an MDT Medically Fit meeting held weekly with CCG in attendance. This has helped to start to address a full system approach to managing patient flow, clearly understanding where some of the barriers to onward transfers are. There has been a concerted effort to ensure that all patients are clearly identified as MOFD on Medway to enable accurate reporting. There are still data discrepancies due to differing levels of ward clerks across the wards, ongoing nurse staffing levels and high agency usage. Finance, Performance & Investment Page 65 of 143

67 Board Report - December 2016 Strategic Objective 3: Deliver Performance, Within Resources, Comparable With The Best The NHS Can Offer (Page 4 of 4) Indicator Name Description Narrative Responsible Month Trend 008/17 Integrated Performance Report DNA (Did Not Attend) rate The proportion of patients of all those offered appointments or treatment dates that do not give notice of non-attendance irrespective of how short that notice is. Lower is better. Bar = Last Financial Year Line = This Financial Year DNA's had reduced in October to 5.8% but has increased again to 6.4% and may be attribtued to the Christmas/New Year period and increased numbers of patients being unwell. Finance, Performance & Investment New:Follow Up The Trust's overall ratio between new outpatient appointments and follow-up outpatient appointments. Threshold: monitor. Bar = Last Financial Year Line = This Financial Year New: FU has continued to decrease and is being reviewed Trust wide as part of the Outpatient Project. Finance, Performance & Investment Page 66 of 143

68 Board Report - December 2016 Strategic Objective 4: Empower And Develop Staff To Achieve Their Objectives (Page 1 of 1) Indicator Name Description Narrative Responsible Month Trend 008/17 Integrated Performance Report WTE (Whole time equivalents) in post The number of WTE staff with substantive and fixed-term contracts employed directly by the Trust. Bar = Last Financial Year Line = This Financial Year The situation on staff in post remains largely stable despite attempts to improve recruitment. The issue is high on the agenda for both HRD and our two Clinical Executives. Finance, Performance & Investment Sickness rate The proportion of the expected WTE in month, including agency and bank staff who were unavailable for work. Threshold: 4.75%. Lower is better. Bar = Last Financial Year Line = This Financial Year The sickness levels continue to be disappointing and Finance, challenging. The usual winter bugs have had an impact and it Performance is still anticipated that the devolvement of absence & Investment management and a different approach to absence monitoring will bring an improvement over quarter 4. Nursing vacancies Number of nursing vacancies in month. Bar = Last Financial Year Line = This Financial Year The situation with regard to nursing vacancies has been explored in all previous Board meetings. The Director of Nursing has however now appointed an Assistant Director with specific responsibility around workforce and she will be working on this issue over coming months and will liaise as appropriate with the HR department. Finance, Performance & Investment Training The percentage of staff with an upto date Mandatory Training. Threshold: Year to Date 90%. Bar = Last Financial Year Line = This Financial Year There has previously been an issue with regard to data accuracy but the Head of Education & Training now has a new post-holder in situ and we have already seem some benefits from the new appointment. A business case to improve education and training infrastructure went to the January meeting of the Q&S committee and received its support. The trust does need to make some improvements to staffing in this area of HR in order to give proper leadership and direction to this problem. Finance, Performance & Investment Page 67 of 143

69 Board Report - December 2016 Strategic Objective 5: Maintain Organisational Sustainability (Page 1 of 2) Indicator Name Description Narrative Responsible Month Trend 008/17 Integrated Performance Report Spend against capital plan Actual spend against the capital budget plan for the year. Green = Actual, Blue = Budget Bar = Last Financial Year, Line = This Financial Year Although capital spend is 1.8m behind the cumulative plan at the end of December (actual spend 3.9m verses budget of 5.7m) an extensive review of committed, undelivered and forecast spend shows that the Trust will achieve its year end target spend of 6.7m. Finance, Performance & Investment Income & Expenditure This indicator looks at the relationship between Trust income and Trust expenditure at monthly intervals. Green = Expenditure, Blue = Income Bar = Last Financial Year, Line = This Financial Year The Trust incurred a deficit of 1.3m against a planned breakeven in December. The year to date (YTD) position is a deficit of 15.6m against a planned deficit of 5.1m. Stripping out the Sustainability & Transformation Fund (STF m) means that the Trust is 5.92m overspent against this plan. Of this 1.332m relates to a shortfall of income (excluding STF). The Trust is also 4.55m overspent against expenditure budgets. Finance, Performance & Investment Agency Spend The Total spend on agency staff compared to previous year. Bar = Last Financial Year, Line = This Financial Year Green = Trajectory, Blue = Actual Whilst there was decrease in agency spending in November compared to October and a rise in December, the overall trend is still downward. However, the average (over the last 5 months) monthly expenditure remains under 0.9m which represents progress against the levels experienced over the last 12 months. With the roll out of e-rostering and other workforce initiatives the Trust is aiming to reduce the agency spend down to the monthly target of 0.6m as soon as possible. There continue to be difficulties adhering to the national cap and, where this is not possible, the Trust strives to keep below rates agreed with neighbouring Trusts across the Cheshire & Merseyside area. Finance, Performance & Investment Establishment vs Actual Number of WTE posts that are required to staff the Trust against the actual number of post employed substantively. Green = Funded, Blue = Contract Bar = Last Financial Year, Line = This Financial Year Whilst the Trust vacancy rate fell in November (8.92% compared with 9.18% in October) it rose again in December to The largest challenge is still in the recruitment of nursing & midwifery staff where the vacancy rate is 12.3% in December, compared to12.3% in November and 12.0% in October. Finance, Performance & Investment Page 68 of 143

70 Board Report - December 2016 Strategic Objective 5: Maintain Organisational Sustainability (Page 2 of 2) Indicator Name Description Narrative Responsible Month Trend 008/17 Integrated Performance Report Liquidity Liquidity (days) Liquidity indicates whether the provider can meet its operational cash obligations. Liquidity deteriorated to days in November (was in October) and rallied slightly in December to days. With the change in forecast outturn this has resulted in the original target of -18 days moving to a forecast -23 days. As the Trust continues to be reliant on loan funding, this metric will continue to be flagged as amber. Finance, Performance & Investment CIP (Cost Improvement Programme) delivery Actual delivery in financial terms vs. the plan for delivery over the same period. Bar = Last Financial Year, Line = This Financial Year Green = Plan, Blue = Actual As at the end of Month 9, the actual CIP delivered was 2.7m against the target of 3.6m; Some non recurrent savings have assisted in delivering the actual CIP to date. The Trust is predicting that there will be a 2.3m shortfall against the 6.4m CIP. Clinical productivity schemes have not delivered at the levels originally planned and the shortfall has not been mitigated additional income due to minimal levels of activity growth. Finance, Performance & Investment % Agency Staff The proportion of the employed workforce employed through agencies for the workforce. Reliant on finance system to monitor spend rather than the HR system. Bar = Last Financial Year Line = This Financial Year The Director of Finance continues to lead on this area with support from the Human Resource Department, Director of Nursing and Medical Director. The implementation of e- Finance, rostering for nurses has made great progress and the parallel Performance system for medics commenced in January and it is & Investment anticipated that the roll-out of this system will help to maintain and further enhance the improvements made in the third quarter. Cost of staff sickness In month based on staff sickness records. Bar = Last Financial Year Line = This Financial Year The cost reflects the high levels explained and noted above - the communications team have done some work already on translating costs into stories and these efforts will continue. Finance, Performance & Investment Page 69 of 143

71 P U B L I C TRUST BOARD 009/17 Director of Finance Report 1 February 2017 Agenda 009/17 Report Director of Finance Report Item: Title: Lead Director: Steve Shanahan Director of Finance Report Author: Alison Mercer Senior Assistant Director of Finance Purpose: Note Approve Assure Summary: This report contains the following: Month 9 financial performance; Agency controls-price caps; Cost Improvement Programme (CIP); Cash position; Capital position; Commissioning for Quality and Innovation (CQUINS). Recommendation(s): The is asked to note: Month 9 year to date (YTD) deficit of 15.6m is 10.5m adverse against plan; Sustainability & Transformation Fund (STF) of 4.57m not received YTD due to the YTD financial performance. Therefore 5.93m adverse against plan excluding STF; Trust will not receive the full year STF funding of 6.1m and impact on deficit control total ( 6.6m to 12.7m); Agency spend levels increased in December although continued non-compliance and challenges against the Agency Cap; Cash requirement during 2016/17 increased due to loss of S&T fund but facility in place; Financial risks impacting on achievement of forecast year-end financial position. Linked to Strategic Life-long integrated care Domains: Excellence in Treatment and Care Best Performance within Resources Develop Staff Organisational Sustainability Page 70 of 143

72 Regulatory Requirement: Presented to Other s: Finance, Performance & Investment 009/17 Director of Finance Report Page 71 of 143

73 009/17 Director of Finance Report Director of Finance Report for Trust Board Meeting to be held on 1 February Introduction 1.1 This report provides the Board with the financial position of the Trust for December 2016 (month 9) and the year to date (YTD). 1.2 The report asks the Board to discuss the contents and note the current performance and the implications for the year-end financial position. 1.3 The report will also be presented at the Public Board meeting on 1 February 2017 but with only the key appendices i.e. I&E, Balance sheet, cash and CQUIN. 2 Month 9 Financial Performance/Cumulative position 2.1 The Trust planned for a 2016/17 year-end deficit control total of -6.6m. In order for this to be delivered the following targets must be achieved: Funding of 6.1m from the STF providing associated conditions are delivered; A Cost Improvement Programme (CIP) of 6.4m delivered in year; Both income and expenditure perform to plan. 2.2 The Trust has incurred the following at the end of December: In month - Deficit of - 1.3m against a break even plan in month; YTD - Deficit of m against a plan of - 5.1m; adverse variance of 10.5m. 2.3 The financial statements at the end of this report show the performance against this plan in more detail. Due to the Trust s YTD finance performance the STF has not been received or accrued to date and will not be received in 2016/17. Therefore, in order to understand the underlying financial performance the following table has been provided excluding the impact of the STF on the plan: Page 72 of 143

74 I&E (including R&D) Operating Income Annual Plan 000 Plan 000 Year to Date Actual 000 Variance 000 Plan 000 In Month Actual 000 Variance 000 Commissioning Income 173, , ,422 (1,422) 14,295 14,162 (133) PP, Overseas & RTA 2,311 1,733 1,260 (473) Other Income 13,146 9,862 10, ,050 1, Total Income 188, , ,107 (1,333) 15,538 15,517 (21) 009/17 Director of Finance Report Operating Expenditure Pay (134,508) (101,077) (106,612) (5,536) (10,639) (11,671) (1,032) Non-Pay (57,518) (42,895) (42,050) 845 (4,872) (4,639) 233 Total Expenditure (192,026) (143,972) (148,662) (4,691) (15,511) (16,310) (799) EBITDA (3,248) (2,532) (8,555) (6,023) Non-Operating Expenditure (9,598) (7,273) (7,135) 138 (537) (534) 3 Retained Surplus/(Deficit) (12,846) (9,805) (15,690) (5,885) (510) (1,327) (817) Technical Adjustments (35) 12 5 (7) Break Even Surplus/(Deficit) (12,700) (9,696) (15,616) (5,920) (498) (1,322) (824) 2.4 Income has underachieved in Month 9 by 21k ( 350k in Month 8) and is cumulatively under plan by 1.3m. Commissioning activity planned for December was low in line with previous years. However, elective activity levels have not performed to this lower planned level this has been mitigated by an increase in nonelective work. 2.5 Pay is overspent in Month 9 by 1,032k ( 876k in Month 8). 665k of this relates to underperformance against CIP and reserves ( 645k in Month 8). The original CIP plan included a number of pay schemes that have not come to fruition but have been partially mitigated by non pay schemes. All staff groups have overspent by a combined 367k in December ( 231k in Month 8) but this is split mainly across nursing and medical staff areas. 2.6 Medical staff budgets are overspent by 158k in month ( 188k in Month 8). 100k of this overspend relates to A&E medical staff with consultant rotas extended to 9.30pm as part of winter planning in addition to premium rates for agency consultant staff. 2.7 Non Pay is underspent in month 9 by 233k ( 613k in Month 8). A significant element of this is in relation to the revised forecast year-end financial position which has resulted in a reduction in the dividend payment by 357k per annum. A number of other CIP schemes relating to non pay have also been transacted resulting in a favourable variance of 434k on CIP. 2.8 The initial plan submitted to NHS Improvement at the beginning of the financial year was profiled incorrectly. NHS Improvement has been informed of this error but continue to monitor the Trust s financial performance against this plan. The month Page 73 of 143

75 nine financial position declared to NHS Improvement was a deficit of 15.7m against a plan of 5m ( 9.6m excluding STF). 2.9 In summary, the in-month deficit of 1.3m represents a similar deficit to previous months after the non-recurrent impact of the dividend payment is negated. 3 Sustainability and Transformation Fund (STF) 009/17 Director of Finance Report 3.1 The conditions attached to the STF have previously been shared with Board members. No funding has been accrued in the Month 9 YTD position and the Trust is planning for non-achievement of the full 6.1m at the year-end due to the current financial performance. 4 Agency Controls 4.1 The objective of introducing national price caps was to have a maximum charge of 55% above basic pay for all agency staff by 1 st April All agency workers are now sourced from approved frameworks. The Trust continues to recruit some agency staff outside of the national price caps but most of the shifts that do breach are medical and nursing staff. 4.3 The level of breaches above the national price caps are beginning to reduce. Where it is recognised that the caps cannot be enforced then local price caps have been agreed (with neighbouring Trusts) for medical staff and are being implemented wherever possible; there are restrictions within our current contract which is under the CCS framework, with the revised rates being on the HTE framework. 4.4 The Trust continues to report weekly to NHS Improvement regarding the compliance against the agency rules. The last eight weeks returns are summarised within the appendix to this report. 4.4 NHS Improvement have recently increased the monitoring of agency spend. There continues to be a specific focus on national areas of interest such as A&E, cardiology and radiology. Additionally NHS Improvement have requested details of the highest cost agency spend and those individuals who have been employed for over six months. The CEO is now required to personally sign off certain appointments e.g. where appointments exceeding 120 per hour although there are currently no staff requiring this. 4.5 The Trust has introduced the requirement for a requisition/ purchase order for all non-medical, non-nhsp agency to ensure the rate cap is adhered to wherever possible. All requests for agency staff above the cap must be approved by the Director of Finance. Invoices for agency staff will not be paid without a valid purchase order from January Page 74 of 143

76 5 Nurse Agency 5.1 Agency levels have risen in December although total nurse spend remains relatively static. All acute nurse agency staff is engaged via NHS Professionals (NHSP); therefore all shifts are given to bank as a priority before going out to agency. NHSP attempt to engage agency staff within the capped rates but this is not always possible in some hard to fill areas eg A&E, theatres, Spinal injuries and critical care as explained below. The following table has been provided by NHSP and demonstrates the position for all acute nursing staff: 009/17 Director of Finance Report The following table contains the figures for registered nurses: 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 NHSP Filled Hours Agency Filled Hours Unfilled Hours The following table contains the figures for unregistered nurses: 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 NHSP Filled Hours Agency Filled Hours Unfilled Hours 5.2 The Trust has introduced a new cascade of preferred suppliers who have agreed rates for non-specialist nurses at the April cap rate and all agencies are on the framework. Along with the Trust rolling out a new version of e-rostering to ensure rotas are published at least 6 weeks in advance this has given both NHSP and the compliant agencies more time to fill the required shifts. The Trust does not employ agency staff to fill HCA roles. Page 75 of 143

77 5.3 The Trust has an agreement with Pulse that they will provide nine named individuals with guaranteed shifts in Spinal Injuries (5), A&E (3) and ITU (1). These are paid at the February band 6 rate whether filling a band 5 or band 6 role. This arrangement could be extended to March 2017 and we are looking at extending this arrangement to theatres and Frail Elderly Short Stay (FESS) ward due to concerns around substantive staffing levels. 5.4 The Trust did recruit agency staff through both Pulse and Castlerock at February band 6 rates for hard to fill areas. These rates have been reduced from December for all staff via NHSP in line with the Cheshire & Merseyside (C&M) cluster approach. 009/17 Director of Finance Report 5.4 Nurse agency provided within community areas is mainly provided by one supplier, Randstad. Trust officers have met with Randstad to reduce their rates down to the national price caps which would help deliver a 150k CIP. Randstad initially refused to lower the caps citing market forces. The agency was reported to NHS Improvement and the overseeing framework for a resolution. This has resulted in a 2.00 per hour reduction in rates with a reduction to capped rates next financial year. 6 Medical Agency 6.1 The Trust remains 100% compliant in the use of framework agencies for medical staff. 6.2 The Trust uses Asclepius to recruit agency staff and they secure to recruit staff at the lowest possible rate. However, where caps have to be breached, the Trust strives to negotiate a rate which complies with the C&M cluster agreement. The following rates are the maximum allowed for Emergency specialties: Consultant 105 per hour; 50% for on-call ( 52.50) Registrar per hour SHO 53 per hour Note that some of the above rates are higher than the rates the Trust has been attempting to adhere to (SHO surgery; Registrar 65) An escalation process remains in place for any essential shifts that can only be filled using higher rates which is ultimately signed off by the Director of Finance with support from the Medical Director after considering both cost and the impact on safe patient care. 6.4 Any untoward practices are now being reported to NHS Improvement to discuss with the frameworks. The Trust has been releasing agency staff from posts if they refuse to come down to the C&M caps although a significant number of doctors are complying with the request. Page 76 of 143

78 6.5 The Trust is introducing a new system for providing temporary doctors on the bank. The system, TempRE, operates in a similar way that NHSP does for nursing staff. The use of a shared bank should attract staff to vacancies before using agencies and have a favourable impact on the agency bill. The next step is to agree the rates of pay for bank staff. 7 Other Agency 009/17 Director of Finance Report 7.1 Allied Health Professionals (AHP) agency usage is predominantly in theatres which continue to have high levels of agency. The use of agency to cover administration staff is monitored weekly and is now much reduced with only one employee breaching the cap. An action plan is in place to eradicate agency wherever possible. 7.2 Although good progress is being made in reducing addressing the agency spend within the Trust it remains vital that the Trust can recruit quickly to vacancies wherever possible. 8 CIP 8.1 The 6.4m CIP programme is more heavily weighted to the latter half of the financial year. Savings of 3,620k were planned to Month 9, and the Trust has increased its savings delivery from 1,594k at Month 7 to 2,737k year to date Month 9 ( 883k behind plan). Savings for the full year are currently forecast at 4.2m ( 2.2m behind plan) due mainly to the underachievement on the Workforce Programme, and nonelective activity growth, for which CIP delivery assumed 8% for Southport and Formby to mitigate underperformance in the Clinical Productivity Programme. Underperformance of elective activity is also adversely affecting the CIP forecast (2% elective growth is required in the CIP plan). Replacement schemes using income growth is proving difficult given the actions being taken within the economy by local commissioners. 8.2 The Workforce Programme is under-achieved to the end of Month 9 by 1,509k. Planned reductions in sickness absence have not materialised to date, although the project team is only forecasting a full year financial saving of 38k ( 1m behind plan). The project team has been tasked with re-assessing the forecast financial impact of the sickness reduction project actions. Winter months traditionally show a material increase in rates of sickness, which may put this saving at risk. Savings planned as a result of recruiting into medical and nursing posts has not materialised the planned cash savings, and replacement schemes are required to mitigate this underachievement (forecast 614k behind plan). The implementation of the rostering system has resulted in improved planning of future rotas with resultant savings on agency staff. Efforts to reduce premium rate agency spend have delivered 447k YTD and forecast to deliver 663k. No further savings are expected from the Overseas Recruitment element of the recruitment project, and urgent action is required to mitigate the forecast shortfall of 412k with other recruitment initiatives. Page 77 of 143

79 8.3 Progress on the Clinical Productivity projects has not been to plan, with forecast savings increasing slightly to 1.0m behind plan for the full year. A key risk is underachievement of elective activity, putting at risk plans to deliver a CIP based on 2% elective growth. There is also a risk that the anticipated 8% growth in nonelective activity for Southport and Formby will not materialise based on year to date performance. In pure activity terms, non-elective activity (including A&E) has not increased in the way expected year to date, however non-elective income (including A&E) has exceeded plan. 009/17 Director of Finance Report 8.4 Underachievement in the Clinical Productivity and Workforce programmes has been partly offset by forecast overachievement of 2.1m in the Procurement and Cost Reduction programme. This overachievement is driven mainly by the revised asset lives scheme ( 0.9m recurrent), VAT repayments arising from the Fleming Case and Modular Building ( 0.4m non recurrent), dividend payment reduction 0.4m (recurrent) and a further 0.4m on procurement related savings (recurrent). 9 Cash 9.1 The Trust continues to require cash support as it is trading with a deficit each month. 9.2 A rolling 13 week cash forecast is updated monthly and sent to NHS Improvement on Monday prior to month end and this forms the basis of any cash draw downs in the future month. 9.3 Owing to the Christmas period, NHSI required the Trust to inform them of December s and January s requests in late November. The Trust had a 2.133m loan in December and a further 995,000 in January. 9.4 Performance against the cash targets in November and December were as follows: November 2016 Description Target 000s Actual 000s Comments Opening balance 1,000 Final Oct payment run reduced to reflect 1,538 available cash at the time. Larger than planned VAT recovery ( 350k) Cash inflows 16,054 16,907 plus unplanned receipt from Clatterbridge ( 150k). Payment runs higher than forecast with a Cash outflows (15,769) (17,358) combination of catching up on delayed payments and increased capital spend Closing balance 1,285 1,087 Page 78 of 143

80 December 2016 Description Target Actual Comments 000s 000s Opening balance 1,000 1,087 Cash inflows 18,187 18,837 Two VAT refunds received in month ( 612k) Cash outflows (18,187) (18,603) Closing balance 1,000 1,321 Last payment run was before Christmas so based on funds available on the day. In hindsight more could have been utilised. 009/17 Director of Finance Report 10 Capital 10.1 A revised capital report has been produced to provide assurance to the Board and Finance that the Trust can deliver its capital programme by year end Whilst the Trust has only spent 3.9m at this stage of the financial year, it can be seen that there are high value items out on order, commitments have been given on a number of schemes and future spending has been forecast with the relevant teams. 11 Commissioning for Quality and Innovation payments (CQUINS) 11.1 The Trust has an income of 3.9m within the 2016/17 contract relating to CQUINS. This represents 2.5% of the contract value (except Specialist Commissioning from NHS England which has been reduced to 2%) The CQUIN schemes are shown in the appendices to this report. The local and NHSE CQUINs have been circulated to leads and the requisite data flows checked were appropriate The national CQUINs are non-negotiable. There is a choice to be made regarding CQUIN 1A, the Trust has chosen option B. Trajectories for CQUINs 2a (2.2) and 2b have yet to be agreed with the CCGs The CCG and Trust have agreed baseline data for local CQUINs and CCG s have shared weightings and proposals for partial payment should the target not be reached in full by 31 st March The Trust is currently reviewing these before agreement can be reached and the CQUIN plan can be varied into the contract The CCG and Trust are working together to ensure that a performance monitoring system can be put in place in order to accurately measure achievement against the plan. Page 79 of 143

81 12 Contract penalties As the Trust signed up to the STF there are two contract penalties that can be applied to the contract. Sleeping accommodation breaches and MRSA have incurred 20,750 in fines up to the end of October Under the terms of the contract this will need to be reinvested by the CCG and discussions are taking place to utilise the funds to reconfigure the ward environment. 009/17 Director of Finance Report 13 Financial Risks 13.1 A number of risks were highlighted in the 2016/17 plan. In addition, other financial risks will arise as the financial year progresses. This section will identify those risks so that the committee has sight of them and can seek assurance on how they are being managed CIP The 2016/17 plan requires a CIP of 6.4m, of which 1.8m (28%) has been profiled in the first seven months. The remaining 4.6m (72%) is profiled broadly evenly from November onwards ( 0.9 per month). Current projections indicate a shortfall of 2.2m on the programme. This will be managed at Transformation committee as well as FP&I committee CQUIN, Penalties and contract queries The 2016/17 plan did not have any provision for income loss associated with either contract penalties or CQUIN deductions. The main contract penalties (ambulance handovers, cancer, A&E 4 hour wait) should not be deducted as the Trust has signed up to the STF. Any underperformance on CQUIN resulting in the withdrawal of the payment will have an adverse impact on income. The Month 9 position includes a 1.0m reduction in income against CQUIN risk and the coding audit that was instigated by NHS West Lancashire CCG. There is a further risk of a 1.7m relating to the non-achievement of some of the local CQUIN schemes and coding audit STF Fund The 2016/17 plan assumed the STF would be paid in full ( 6.1m). The Trust s revised forecast year-end financial position will not include any STF funding Budget performance The Trust is already 6.8m overspent against plan at month 6 YTD ( 3.3m against the plan excluding STF). Activity is not at planned levels and income could be further affected by outstanding issues from 2015/6 such as the coding audit initiated by West Lancashire CCG and the final value of CQUIN payments. Pay budgets remain under pressure even though the run rate has shown signs of improvement. Page 80 of 143

82 Medical Staff programmed activities (PA s) An exercise is being undertaken to determine the correct level of PA s for consultant staff. Early indications suggest that this will be a cost pressure in 2016/17 and could be backdated to 2015/16. There is also a risk that extra PA s may be required for Specialist and Associated Specialty (SAS) doctors. Once a robust figure is know this will be built into the financial projection. 009/17 Director of Finance Report Capital Cash The capital plan is closely monitored on a monthly basis by the capital investment Group (CIG). The urology move capital element of the Accelerated Flow Project has now been actioned and funded from re-assessing all 2016/17 schemes. Main risks then for 2016/17 is that the capital contingency budget has been heavily utilised recently and therefore there is little flexibility now to cope with any urgent requests. Whist short term cash support via DH loans will enable the Trust to meet its current liabilities, the medium/long term solutions have not yet been confirmed. 14 Recommendations 14.1 The Board are asked to discuss the contents of the report and in particular: The Month 9 year to date (YTD) deficit of 15.7m is 10.5m adverse against plan; Sustainability & Transformation Fund (STF) of 4.57m not received due to the the Trusts financial performance. Therefore 5.9m adverse variance from plan excluding STF; Full year S&T funding of 6.1m will not be received and impact on deficit control total ( 6.6m to 12.7m); Agency spend has increased due to the increased number of vacancies, however, note the progress against the Agency Cap; Cash requirement during 2016/17 has increased due to loss of S&T fund and budgetary pressures but facility in place; The financial risks impacting on achievement of deficit control total; The Month 9 financial performance has not impacted on the forecast yearend financial position agreed by the Board at the meeting on 21 December Public Sector Equality Duty Southport & Ormskirk Hospital NHS Trust has a duty under the Equality Act 2010 to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations between people from different groups. The Page 81 of 143

83 Act protects against discrimination on grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, gender and sexual orientation. We have thought about how the issues dealt with in this paper might affect protected groups. We believe the paper will not have any adverse impact upon these groups and that the Trust has fulfilled its duty under the Act. 009/17 Director of Finance Report Exempt information None of this report is exempt from publication under the Freedom of Information Act Steve Shanahan, Director of Finance Alison Mercer, Senior Assistant Director of Finance 23 January 2017 Page 82 of 143

84 Statement of Comprehensive Income (Income & Expenditure Account) I&E (including R&D) Operating Income Annual Plan 000 Plan 000 Year to Date Actual 000 Variance 000 Plan 000 Commissioning Income 179, , ,422 (5,997) 14,803 14,162 (641) In month down by 184k excl STF; YTD down by 1.4m excl STF - see supporting information by point of delivery further in the appendices In Month Actual 000 Variance /17 Director of Finance Report PP, Overseas & RTA 2,311 1,733 1,260 (473) All YTD adverse variance due to RTA income underperformance Other Income 13,146 9,862 10, ,050 1, A one off VAT repayment ( 300k)was received in September and CIP benefits represent the majority of the favourable YTD variance. Total Income 194, , ,107 (5,907) 16,046 15,517 (529) Operating Expenditure Pay (134,508) (101,077) (106,612) (5,536) (10,639) (11,671) (1,032) 0.7m CIP and reserves; 0.3m pay overspend Non-Pay (57,519) (42,895) (42,050) 845 (4,872) (4,639) 233 Over acheivement of non-pay CIP 1.2m year to date. Total Expenditure (192,027) (143,972) (148,662) (4,691) (15,511) (16,310) (799) EBITDA 2,852 2,043 (8,555) (10,598) 535 (793) (1,328) Non-Operating Expenditure (9,598) (7,273) (7,135) 138 (537) (534) 3 Retained Surplus/(Deficit) (6,746) (5,230) (15,690) (10,460) (2) (1,327) (1,325) Technical Adjustments (35) 12 5 (7) Break Even Surplus/(Deficit) (6,600) (5,121) (15,616) (10,495) 10 (1,322) (1,332) Memorandum STF adjustment (6,100) (4,575) 0 4,575 (508) Break Even Surplus/(Deficit) (12,700) (9,696) (15,616) (5,920) (498) (1,322) (824) * The budget profile in the ledger differs from the profile in the Trust FIMS submission. This is explained further in the Director of Finance report. I&E Page 1 Page 83 of 143

85 Pay Expenditure Analysis by Staff Group Staff Group Staff Type Annual 2016/ / / /17 Plan 000 Plan 000 Actual 000 Year to Date Variance 000 Actual 000 Plan 000 In Month Actual 000 Variance 000 Consultants Substantive 15,615 11,943 11, ,288 1,306 1, Bank Agency ,624 (1,076) 1, (199) Total 16,217 12,492 13,169 (678) 12,591 1,324 1,481 (157) Other Medical staff Substantive 16,313 12,345 11, ,699 1,358 1, Bank Agency 1, ,648 (716) 2, (107) Total 17,503 13,277 13,340 (63) 12,908 1,444 1,444 (1) Nurses & Midwives Substantive 57,365 43,088 38,515 4,573 36,438 4,745 4, Bank ,111 (2,672) 1, (284) Agency ,217 (4,087) 3, (422) Total 58,116 43,657 45,843 (2,186) 41,752 4,794 4,984 (190) Scientific, Technical Substantive 18,847 13,873 13, ,476 1,543 1, &Theraputic Bank (133) (11) Agency (510) (58) Total 18,856 13,882 13,975 (93) 13,295 1,543 1,556 (13) Other Staff Substantive 26,652 19,680 19, ,585 2,173 2, Bank (313) (34) Agency (412) (16) Total 27,145 20,151 20,286 (134) 19,603 2,181 2,186 (5) Reserves 1, CIP (4,815) (2,478) 0 (2,478) 0 (686) 0 (686) Total (3,328) (2,382) 0 (2,382) -90 (646) 19 (665) Total Substantive 131,463 98,547 94,164 4,384 89,396 10,479 10, Bank ,608 (3,118) 2, (329) Agency 2,369 2,039 8,840 (6,801) 8, (803) Total 134, , ,612 (5,536) 100,059 10,639 11,671 (1,032) Substantive Consultant expenditure is low in month due to a reduction in waiting list initiative payments. The variance relates to A&E, general medicine and Women and Children. The nursing expenditure has increased in month,with bank fill reducing and agency increasing in December. Work continues to reduce agency and fill vacant posts. Agency costs have reduced significantly as substantive appointments have been made to a number of key posts. 009/17 Director of Finance Report Pay Page 2 Page 84 of 143

86 Pay Expenditure Analysis by Staff Group Staff Group Staff Type Plan WTE Contract WTE In Month 2016/17 Worked WTE Variance WTE Consultants Substantive Bank Agency (8) Total Other Medical staff Substantive Bank Agency (14) Total Nurses & Midwives Substantive 1,523 1,348 1, Bank (101) Agency (75) Total 1,537 1,363 1, There are currently 7.6 WTE consultant vacancies There are 26 WTE contrated vacancies in other medical staff indecember, an increase of 7 from October. The Trust currently has WTE nursing vacancies WTE registered and WTE unregistered nursing staff, an increase from October and slight reduction from November. 009/17 Director of Finance Report Scientific, Technical Substantive &Theraputic Bank (6) Agency (11) Total Scientific and theraputic staff have 36.51WTE vacancies a reductionfrom October of 2.34 WTE. Other Staff Substantive Bank (25) Agency (6) Total There are WTE vacancies on all other staff currently being covered by a combination of overtime, bank and agency. Total Substantive 3,315 3,008 3, Bank (132) Agency (114) Total 3,329 3,027 3, The Trust has an overall vacancy factor of 9.22% in December. Pay wte Page 3 Page 85 of 143

87 Staff Group Staff Type 2015/ /2017 Month 9 Month 10 Month 11 Month 12 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Actual 000 Actual 000 Actual 000 Actual 000 Actual 000 Consultants Substantive 1,255 1,190 1,163 1,389 1,177 1,300 1,281 1,298 1,254 1,225 1,416 1,328 1,265 Bank Agency Total 1,415 1,288 1,391 1,545 1,303 1,457 1,532 1,483 1,440 1,314 1,608 1,550 1,481 Actual 000 Actual 000 Actual 000 Actual 000 Actual 000 Actual 000 Actual 000 Actual /17 Director of Finance Report Other Medical staff Substantive 1,242 1,100 1,129 1,242 1,238 1,242 1,283 1,245 1,337 1,342 1,341 1,411 1,251 Bank Agency Total 1,515 1,431 1,374 1,443 1,436 1,470 1,508 1,467 1,501 1,502 1,495 1,513 1,444 Nurses & Midwives Substantive 4,109 4,124 4,243 4,206 4,388 4,280 4,360 4,259 4,251 4,247 4,209 4,261 4,229 Bank Agency Total 4,733 4,718 4,932 5,344 5,394 5,115 5,254 5,094 5,055 4,969 4,983 4,964 4,984 Scientific, Technical Substantive 1,395 1,388 1,421 1,416 1,479 1,462 1,478 1,488 1,503 1,481 1,470 1,475 1,487 &Theraputic Bank Agency Total 1,508 1,460 1,494 1,473 1,535 1,517 1,578 1,554 1,566 1,548 1,550 1,566 1,556 Other Staff Substantive 2,082 2,051 2,219 2,046 2,113 2,075 2,148 2,111 2,141 2,120 2,118 2,151 2,146 Bank Agency Total 2,285 2,204 2,390 2,256 2,297 2,301 2,324 2,275 2,301 2,239 2,208 2,171 2,205 Total Pay Substantive 10,083 9,853 10,175 10,299 10,395 10,359 10,550 10,401 10,486 10,416 10,554 10,626 10,378 Bank Agency 1, ,139 1,288 1,221 1,121 1,260 1, Total 11,456 11,101 11,581 12,062 11,965 11,860 12,196 11,873 11,864 11,572 11,845 11,764 11,671 Non-Pay Supplies & Services Clinical Supplies & Services General Establishment Expenses Premises & Fixed Plant Miscellaneous Services From Other NHS Bodies Non Operating Expenditure Total Total Expenditure 1,946 2,017 1,712 1,976 2,000 2,003 2,026 2,012 1,822 1,980 1,939 2,036 2, ,010 1,000 1,043 1,018 1,033 1,026 1,050 1,022 1,169 1, , ,313 5,408 5,051 4,952 5,567 5,581 5,607 5,634 5,310 5,766 5,127 5,448 5,171 16,769 16,509 16,632 17,014 17,532 17,441 17,803 17,507 17,174 17,338 16,972 17,212 16,842 Run Rate Page 4 Page 86 of 143

88 WTE by month for 2016/17 Appendix 2 (Worked) 2015/ /2017 Month 9 Month 10 Month 11 Month 12 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 009/17 Director of Finance Report Staff Group Staff Type WTE WTE WTE WTE WTE WTE WTE WTE WTE WTE WTE WTE WTE Consultants Substantive Bank Agency Total Other Medical staff Substantive Bank Agency Total Nurses & Midwives Substantive 1,330 1,320 1,364 1,373 1,365 1,339 1,331 1,340 1,329 1,326 1,331 1,326 1,336 Bank Agency Total 1,480 1,489 1,520 1,588 1,573 1,558 1,546 1,552 1,536 1,514 1,525 1,527 1,527 Scientific, Technical Substantive &Theraputic Bank Agency Total Other Staff Substantive Bank Agency Total Total Pay Substantive 2,969 2,949 3,010 3,028 3,008 2,975 2,978 2,980 3,008 2,991 2,998 2,998 3,004 Bank Agency Total 3,196 3,200 3,249 3,328 3,306 3,281 3,278 3,264 3,289 3,261 3,268 3,267 3,266 Runrate WTE Page 5 Page 87 of 143

89 Bank and Agency Spend 009/17 Director of Finance Report The Trust has spent a total of 1.29m on bank and agency staff in December. The average monthly spend on bank has increased from 279k in 2015/16 to 401k this financial year, the majority of which is in nursing. The average monthly spend on agency has reduced from 978k in 2015/16 to 982k this year. Bank spend has increased from approx 2.3% to 3.6%, while agency has risen from 6.4% to 7.8% since The Trust has been set a 7.2m agency spend target for the year. This is equivalent to a 38% reduction against the 2015/16 spend of 11.7m. Agency spend was 914k in December, an increase from October. The Trust has planned to achieve the control total based on the blue profile in the graph.performance to December means the 7.2m target for the year will not be met. The aim is to achieve the 0.6m monthly run rate as soon as possible. Bank & Agency Page 6 Page 88 of 143

90 Non-Pay Expenditure Annual 2016/ / /16 Plan 000 Plan 000 Actual 000 Year to Date Variance 000 Actual 000 Plan 000 In Month Actual 000 Variance /17 Director of Finance Report Supplies & Services Clinical 23,782 17,871 17, ,948 1,871 2,011 (140) Supplies & Services General 2,328 1,741 1,753 (12) 1, (32) Establishment Expenses 3,596 2,725 2,838 (113) 3, (16) Premises & Fixed Plant 11,909 8,745 9,301 (556) 8, ,004 (9) Miscellaneous 4,852 3,639 3,674 (35) 3, Services From Other NHS Bodies 8,665 6,542 6,655 (113) 6, (57) Total non-pay excluding reserves/cip 55,132 41,263 42,050 (787) 41,798 4,390 4,639 (249) Reserves CIP 1,602 1, , Total Reserves/CIP 2,387 1, , Total non-pay 57,519 42,895 42, ,798 4,872 4, Supplies & Services Clinical - 140k overspend is due to an increase in drugs 44k and medical and surgical supplies 96k Supplies & Services General has incresed catering provisions 16k, printing 11k and disposable linen 7k The benefit on reserves is due to the number of reserves not utilised in line with the original plan e.g. contingency and some business cases that have not yet been implemented due to difficulties in recruiting staff. The benefit on CIP schemes is due to a reduction in depreciation from an increase in asset life and a reduction of dividend payments. Non-pay Page 7 Page 89 of 143

91 Non-EBITDA Income and Expenditure Non EBITDA items Non-operating items Annual 2016/ / /16 Plan 000 Plan 000 Actual 000 Year to Date Variance 000 Actual 000 Plan 000 In Month Actual 000 Variance 000 Profit/(Loss) on disposals 0 0 Depreciation (5,795) (4,422) (4,279) 143 (4,690) (458) (454) 4 Investment Revenue (4) (1) Interest payable (2,086) (1,564) (1,564) 0 (1,005) (174) (174) 0 PDC Dividend (1,742) (1,306) (1,307) (1) (1,887) Total Non-Op. items (9,598) (7,273) (7,135) 138 (7,563) (537) (534) 3 009/17 Director of Finance Report Technical adjustments IFRIC 12/ Donated Asset Adjustment (35) (7) Total for Technical Adjustments (35) (7) Overall Impact on Break Even (9,452) (7,164) (7,061) 103 (7,438) (525) (529) 4 Non-Operating Items refers to items of income or expenditure that are not regarded as being directly associated with the day-to-day running costs of the Trust and are included in the Statement of omprehensive Income. Non EBITDA Page 8 Page 90 of 143

92 Income Analysis Income Year to Date In Month Annual Plan Plan Actual Variance Plan Actual Variance '000 '000 '000 '000 '000 '000 '000 Operating Income Commissioning Income 179, , ,422 (5,997) 14,803 14,162 (641) PP, Overseas & RTA 2,311 1,733 1,260 (473) Other Income 13,146 9,862 10, ,050 1, Total Income 194, , ,107 (5,908) 16,046 15,517 (529) 009/17 Director of Finance Report Analysis - PP, Overseas, RTA Year to Date In Month Annual Plan Plan Actual Variance Plan Actual Variance '000 '000 '000 '000 '000 '000 '000 PP, Overseas, RTA Private Patients (20) 6 3 (3) Overseas Patients RTA Income 2,229 1,672 1,213 (459) Total Income 2,311 1,733 1,260 (473) Other Income Year to Date In Month Annual Plan Plan Actual Variance Plan Actual Variance '000 '000 '000 '000 '000 '000 '000 Other Income Training & Education 5,701 4,296 4, (3) Income Generation 2,569 1,926 2, Services to Other Bodies (23) (3) R&D (0) Other Income & Charges 4,428 3,334 3, Total Income 13,146 9,862 10, ,050 1, Income Page 9 Page 91 of 143

93 Commissioning Income - Analysis of Activity and Activity-Related Income Activity YTD Plan Activity - Year-to-Date YTD Actual YTD Diff. YTD Diff % Plan '000 Income - Year-to-Date Actual '000 Diff. '000 Diff % Accident and Emergency 53,345 55,519 2, % 6,316 6, % Elective 20,802 19,731 (1,071) -5.15% 16,776 15,666 (1,110) -6.62% Non-Elective 19,579 20, % 31,160 31, % Out-Patients 141, ,349 (4,982) -3.53% 18,169 17,204 (965) -5.31% Diagnostic Imaging 14,441 12,852 (1,589) % 1,189 1,065 (124) % Maternity Pathway 3,320 3,005 (315) -9.49% 2,911 2,837 (74) -2.55% A higher financial variance indicates an increase in the acuity of patients attending A&E. In month elective activity 127k down against plan, YTD under performance due to loss of beds to cope with emergency demand combined with staffing problems within theatres. Orthopaedics continues to be the main specialty affecting the inderperformance. General medicine activity up as well as T&O. Significant over performance in first 3 quarters over and above marginal rate baseline which has been set at 14/15 outturn priced at 16/17 tariff. 111k YTD deduction reflected within the penalties line below. It is noticeable how the unit price for emergency admissions has increased against the plan reflecting the higher acuity patients being admitted. Finances down proportionately more than activity as a result of significant under performance in respect of outpatient procedures. 009/17 Director of Finance Report Excess Bed Days 1,721 1, % Delays in discharge relating to a relatively low number of patients many with significant social care needs in addition to complex medical conditions has led to increased LOS triggering excess beds days over and above plan. AQP % Under performance in respect of Podiatry, which relates to coding issues associated with move to EMIS, these have now been rectified. This is off-set by over performance in MSK and Physio and Audiology. GPAU % Significant over performance as a result of changes to the urgent care pathway introduced earlier in the year. Urgent Care Ormskirk 1,736 1,563 (173) -9.98% ex West Lancashire Health Partnership activity lower than planned. Direct Access Radiology 985 1, % Direct Access Pathology 2,375 2,147 (228) -9.59% Further investigation being under taken to understand under performance observed in first 6 months. Spinal 6,855 7, % Increase observed in inpatient activity in year. Chemotherapy % Activity dropped in 15/16 but has recovered in 16/17, drop last year partly due to national shortage of BCG. HIV (7) -6.27% Other Activity (including NCA's) 50,690 46,287 (4,402) 4.57m S&T fund not received as not achieved financial plan Q1 and Q2. Offset by an increase in NCA income. Total before Pass Through 142, ,516 (5,152) -3.61% Drugs & Devices (Pass Through) 3,345 3, % Total with Pass Through 146, ,107 (4,908) 0.60% Activity-Related (Non-Specific) 0 Penalties & Denials - (1,000) (1,000) Marginal Rate Emergency Threshold (MRET) 111k; Forecast penalties of 889k YTD (CQUIN 2015/16 and 2016/17; Coding audit; contract penalties for sleeping accommodation breaches) Total Commissioning Income 146, ,107 (5,908) 0.60% Clinical Inc Page 10 Page 92 of 143

94 009/17 Director of Finance Report Plan vs Actual In Month Year to date PbR Activity Activity Activity Finance Activity Finance Plan Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Plan unit '000s price Nos. Nos. Nos. % '000s '000s '000s % Nos. Nos. Nos. % '000s '000s '000s % A&E Attendances - ALL 113,802 10, ,460 9, % (31) (3%) 84,921 84,157 (764) (1%) 8,052 8, % Elective - (IP_DC) 27,884 22, ,175 1,962 (213) (10%) 1,754 1,611 (143) (8%) 20,802 19,457 (1,345) (6%) 16,776 15,666 (1,110) (7%) Non Elective - (NEL_NELST_NELSD) 22,891 35,586 1,555 2,032 2,015 (17) (1%) 3,145 3, % 17,247 17,072 (175) (1%) 26,802 27, % Non Elective - (ALL) 25,939 41,282 1,592 2,273 2,248 (25) (1%) 3,595 3, % 19,579 19,241 (338) (2%) 31,160 31, % Outpatients - (FIRST) 39,250 5, ,062 2,604 (458) (15%) (65) (14%) 29,281 27,667 (1,614) (6%) 4,457 4,199 (258) (6%) Outpatients - (FOLLOW UP) 99,449 9, ,757 6,592 (1,165) (15%) (114) (16%) 74,189 71,677 (2,512) (3%) 7,011 6,705 (307) (4%) Outpatients - (INC PROCS) 189,452 24, ,777 12,738 (2,039) (14%) 1,900 1,603 (297) (16%) 141, ,349 (4,982) (4%) 18,169 17,204 (965) (5%) Maternity Pathways 4,450 3, (31) (9%) (21) (7%) 3,320 3,005 (315) (9%) 2,911 2,837 (74) (3%) For Financial Purposes Only Elective Total (incl XBDs) 28,562 22, ,228 2,134 (94) (4%) 1,766 1,649 (116) (7%) 21,308 20,105 (1,203) (6%) 16,888 15,808 (1,080) (6%) Non Elective Total (incl XBDs) 35,757 43,416 1,214 3,133 2,830 (303) (10%) 3,781 3, % 26,978 27, % 32,769 33, % PbR Activity Daycase 24,717 14, ,928 1,736 (192) (10%) 1,119 1,031 (89) (8%) 18,439 17,142 (1,297) (7%) 10,703 9,707 (996) (9%) Elective 3,167 8,141 2, (21) (9%) (54) (9%) 2,363 2,315 (48) (2%) 6,073 5,959 (114) (2%) Elective excess bed days % % % % Non-Elective Emergency 18,663 32,398 1,736 1,642 1, % 2,851 3, % 14,054 14, % 24,396 25, % Non-Elective short stay 2,556 1, (48) (20%) (28) (17%) 1,945 1,873 (72) (4%) 1,392 1,320 (72) (5%) Non Elective IP (Same Day) 1,672 1, (27) (18%) (25) (20%) 1,249 1,107 (142) (11%) 1, (103) (10%) Non-Elective Non-emergency 3,048 5,696 1, (8) (3%) (23) (5%) 2,331 2,169 (162) (7%) 4,358 4,099 (258) (6%) Non Elective IP (Non Emerg - Same Day Non-Elective Emergency excess bed days 9,336 1, (277) (34%) (59) (34%) 7,030 8, % 1,492 1, % Non-Elective Non-emergency excess beddays (1) (3%) (1) (4%) (56) (15%) (17) (15%) Out-patient FA - Single Professional 35,242 5, ,749 2,456 (293) (11%) (43) (10%) 26,291 26, % 4,012 3,986 (26) (1%) Out-patient FA - Multi Professional 4, (165) (53%) (22) (46%) 2,990 1,281 (1,709) (57%) (232) (52%) Out-patient FU - Single Professional 90,348 8, ,047 6,150 (897) (13%) (92) (14%) 67,400 68, % 6,320 6,319 (1) (0%) Out-patient FU - Multi Professional 9, (268) (38%) (22) (31%) 6,789 3,344 (3,445) (51%) (306) (44%) Outpatient Procedures 50,752 8, ,959 3,542 (417) (11%) (118) (17%) 37,861 37,005 (856) (2%) 6,701 6,300 (400) (6%) Out-patient - Unbundled Diagnostic Imaging 19,358 1, ,510 1,264 (246) (16%) (18) (15%) 14,441 12,852 (1,589) (11%) 1,189 1,065 (124) (10%) A&E Attendances - 24Hr ConsLed 71,700 8, ,951 6, % (7) (1%) 53,345 55,519 2,174 4% 6,316 6, % A&E Attendances - Minor Injuries 42,103 2, ,509 3,096 (413) (12%) (24) (13%) 31,577 28,638 (2,939) (9%) 1,736 1,562 (174) (10%) Maternity Pathways - AnteNatal 2,534 3,384 1, (3) (1%) (14) (5%) 1,890 1,872 (18) (1%) 2,524 2, % Maternity Pathways - PostNatal 1, (28) (19%) (7) (17%) 1,430 1,133 (297) (21%) (75) (19%) Total ,454 28,744 (2,710) (9%) 8,773 8,434 (339) (4%) 292, ,047 (8,252) (3%) 79,978 78,691 (1,287) (2%) There is an element of uncoded activity each month which is given an average financial value thereis 6.5% uncoded activity in December 2016 Page 93 of 143

95 Analysis by programme Month 09 YTD Plan 000 Month 09 YTD Actual 000 Month 09 YTD Variance 000 Annual Plan 000 Month 09 FOT 000 Month 09 FOT variance 000 Clinical Productivity (575) 1, (1,044) CIP011 Theatre productivity (218) (385) CIP012 Outpatient productivity (90) (168) CIP016 Gen Med and subspecialties (301) (646) CIP026 AE Recipe book CIP028 NEL Growth CIP032 Paediatric medication review CIP043 Ward 15a Workforce & Agency 2, (1,509) 3, (2,530) CIP004 HR Nurse recruitment (incl. overseas) (244) (412) CIP007 Medical staff - appointments (370) (504) CIP008 Agency rate caps and authorisation (157) 1, (545) CIP009 Reduction of sickness cost (738) 1, (1,069) CIP020 Implement TempRE and reduce stafflow rate CIP024 Rota management - Medical CIP025 Workforce systems - Nursing Procurement & cost reductions 284 1,884 1, ,662 2,168 CIP001 Procurement workplan CIP002 Procurement - Ambulance contract CIP003 Managed service contract 30 0 (30) CIP005 Income from overseas visitors 15 0 (15) CIP006 Finance - Saving on pathology contract CIP027 Productivity gains (Back office, corp, admin) CIP039 Women's and Children's JDI CIP040 Procurement and cost reduction JDI 0 1,361 1, ,792 1,792 CIP042 Community non rec Abandoned schemes (398) (793) CIP015 Gen Surg and subspecialties (171) (341) CIP018 Community productivity review.xlsm 9 0 (9) 18 0 (18) CIP601 Pre-procedure elective bed days 3 0 (3) 6 0 (6) CIP602 Pre-procedure non-elective bed days 87 0 (87) (173) CIP603 Reducing length of stay 40 0 (40) 79 0 (79) CIP604 Abandoned schemes 29 0 (29) 58 0 (58) CIP605 Other skill mix review 60 0 (60) (117) Grand Total 3,620 2,737 (883) 6,395 4,197 (2,198) CIP performance is 0.9m behind plan year to date Month 9. Forecast savings for the full year are 4.2m ( 2.2m behind plan). This represents an improvement of 0.5m over the previous month's forecast, which is explained as follows: m CIP040 - PDC dividend recalculation CIP043 - Ward 15a CIP Facilities Npower benefit & electric van CIP040 - Corporate employers costs CIP006 - Recalculate pathology contract saving CIP012 - Outpatent productivity CIP009 - Reduction of sickness cost (0.013) CIP007 - Medical staff appointments (0.019) CIP020 - Implement TempRE and reduce stafflow rate (0.020) Total Clinical Productivity The programme is underachieved at the end of Month 9 by 0.6m, forecast outturn is 1m behind plan. In month 9, CIP relating to the closure of ward 15a has been recognised. From M10, the in-month target for this programme is 252k per month, with current forcast against that target 96k per month (shortfall 156k per month). The main drivers behind the CIP recognised in the FOT within this programme are: 1) CIP011 - Reduction in waiting list payments through utilising middle grade doctors to backfill consultant annual leave in orthopaedics 50k; Members of the orthopaedic team undertaking an additional case per full day list 105k; Urology consultant undertaking additional cases per list 18k 2) CIP012 - Reduction in outpatient DNA's 169k; Other 10k 3) CIP016 - Cardiology reduction in WLI payments 48k 4) CIP032 - Paediatric medication review 11k 5) CIP043 - Closure of ward 15a 145k Non elective income (including A&E) continues to perform ahead of plan ( 1.015m YTD before NEL marginal rate deduction, excess bed days and maternity) due to a more complex casemix, rather than due to demographic growth, and for this reason NEL overperformance has not been recognised in the CIP as shown opposite (CIP028). Workforce and Agency The programme is underachieved at the end of Month 9 by 1.5m, forecast outturn is 2.5m behind plan. The Sickness reduction project is forecasting 230k less than the previous month. The project team has been tasked to re-assess the financial impact that the project will have by year end, based on the recent efforts in targeted areas e.g. Spinal Injuries. Procurement and Cost Reductions The programme has overachieved year to date M9 by 1.6m, forecast outturn is 2.2m ahead of plan. This is mainly due to the "Just do it" projects within CIP040 (summarised below) 1) Asset lives 909k 2) Fleming repayment ZR catering 264k 3) VAT reclaim - modular building 2 103k 4) Continence rebate 63k 5) Veolia rebate 50k 6) Saving on Dr Foster contract 16k 7) Urology products 10k 8) PDC dividend recalculation 357k 9) Facilities NPower benefit & electric van 12k 10) Corporate employers costs 8k The procurement workplan has also over delivered by 113k YTD and 165k FOT. The Managed Service project is planned to progress to contract sign- off in January. Year to date and forecast figures will be updated pending contract sign-off. Abandoned schemes No projects have been abandoned in December. 009/17 Director of Finance Report CIP Page 12 Page 94 of 143

96 Statement of Financial Position (Balance Sheet) Opening balance Closing balance Movement Mvt in month 01/04/ /12/2016 '000s '000s '000s '000s NON CURRENT ASSETS Property plant and equipment/intangibles 118, ,485 (393) 150 Other assets 1,102 1, TOTAL NON CURRENT ASSETS 119, ,954 (26) 265 CURRENT ASSETS Inventories 2,286 2, Trade and other receivables 6,590 5,986 (604) (341) Cash and cash equivalents 1,022 1, Non current assets held for sale TOTAL CURRENT ASSETS 9,898 9, CURRENT LIABILITIES Trade and other payables (16,886) (19,760) (2,874) 333 Provisions (192) (93) 99 0 Borrowings (1,507) (1,499) 8 0 DH Capital loan (400) (400) 0 0 TOTAL CURRENT LIABILITIES (18,985) (21,751) (2,767) 333 NET CURRENT ASSETS/(LIABILITIES) (9,087) (11,777) (2,691) 487 TOTAL ASSETS LESS CURRENT LIABILITIES 110, ,177 (2,717) 752 NON CURRENT LIABILITIES Trade and other payables Provisions (359) (399) (40) 0 Borrowings (incl working cap facility) (19,331) (33,372) (14,041) (2,133) PFI/Finance lease liabilities (17,159) (16,098) 1, DH Capital loan (2,200) (1,800) TOTAL NON CURRENT LIABILITIES (39,049) (51,670) (12,620) (2,078) TOTAL ASSETS EMPLOYED 71,844 56,507 (15,337) (1,326) FINANCED BY TAXPAYERS EQUITY Public Dividend Capital 95,852 96, Retained earnings (28,781) (44,468) (15,687) (1,326) Revaluation reserve 4,773 4, TOTAL TAXPAYERS EQUITY 71,844 56,507 (15,337) (1,326) In month material movements are as follows: The Trust borrowed 2.133m in December, this has subsequently explained both the increase in borrowings and the slight increase at the month end for the cash balance. This increase in available money saw an improvement in trade and other payables, and an increase in inventories, property plant and equipment and other assets. In month adverse movement on retained earnings has fallen slightly due to a recalculation of the 3.5% dividend payable on net assets to the Department of Health. 009/17 Director of Finance Report SOFP Page 13 Page 95 of 143

97 Analysis of Accounts Receivable (Debtors) Analysis of Accounts Payable (Creditors) 6,000,000 9,000, /17 Director of Finance Report 5,000,000 8,000,000 7,000,000 4,000,000 6,000,000 3,000,000 5,000,000 4,000,000 2,000,000 3,000,000 1,000,000 2,000,000 1,000,000 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2013/ / / / / / / /17 Better payment practice code performance This month NHS Non-NHS Total Total Year to date Dec-16 '000s '000s '000s % Better Payment Practice Code Value 0-30 days overdue , % Number 000s days % Non NHS days % Total bills paid in the year 32,341 45,928 In excess of 90 days , % Total bills paid within target 17,333 20,433 All Debtors 2,114 1,187 3, % Percentage of bills paid within target 53.6% 44.5% NHS Last month NHS Non-NHS Total Total Total bills paid in the year 1,311 12,566 '000s '000s '000s % Total bills paid within target 536 3, days overdue 1, , % Percentage of bills paid within target 40.9% 30.3% days % Total days % Total bills paid in the year 33,652 58,494 In excess of 90 days , % Total bills paid within target 17,869 24,237 All Debtors 2, , % Percentage of bills paid within target 53.1% 41.4% Dbs and crs Page 14 Page 96 of 143

98 Statement of cash flows Cash Flows from Operating Activities Year to Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 date '000s '000s '000s '000s '000s '000s '000s '000s '000s '000s Operating Surplus/(Deficit) (787) (1,466) (2,995) (1,591) (1,653) (1,184) (877) (1,027) (1,247) (12,827) Depreciation and Amortisation ,279 Interest Paid (79) (42) (73) (49) (50) (374) (456) (49) (50) (1,222) Dividend paid (522) (522) (Increase) in Inventories (19) (12) 40 (7) (4) 59 (108) (69) (261) (381) (Increase) in Trade and Other Receivables (757) (1,353) 1, ,247 (45) (333) Increase in Trade and Other Payables 928 1,218 (180) (127) (546) (721) (192) 2,019 The Trust held enough cash to cover 2.5 days of operating expenditure at the end of Decemberr 2016 (Novemberr = 2 days). Increase in Provisions 19 (19) (23) (27) 9 (33) (17) (5) 30 (66) Net Cash Inflow/(Outflow) from Operating Activities (160) (1,140) (1,624) (1,176) (436) (2,270) (758) 122 (1,109) (8,551) Month end cash balances held in the last 2 years 009/17 Director of Finance Report Cash Flows from Investing Activities Interest Received (Payments) for Fixed Assets (151) (171) (454) (299) (1,101) (351) (427) (456) (796) (4,206) Receipts from disposal of fixed assets Rental Revenue 13 (13) Net Cash Inflow/(Outflow) from Investing Activities (149) (169) (452) (284) (1,112) (336) (426) (455) (778) (4,161) Cash Flows from Financing Activities Public dividend capital received Public dividend capital repaid Loans received from DH 1, ,111 2,400 2,374 1,556 1, ,133 14,041 Loans repaid to DH Principal repayment of DH capital loan (200) (200) 0 0 (400) Capital element of Finance Leases & PFI (12) (13) (141) (13) (13) (12) (646) (118) (12) (980) Net Cash Inflow/(Outflow) from Financing Activities ,970 2,387 2,361 1, (118) 2,121 13, Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/ / /17 NET INCREASE/(DECREASE) IN CASH 601 (447) (106) (1,062) (210) (451) Cash - Beginning of the Period 1,022 1,623 1,176 1,070 1,997 2,810 1,748 1,538 1,087 1,022 Cash - End of the Period 1,623 1,176 1,070 1,997 2,810 1,748 1,538 1,087 1,321 1,321 Cashflows Page 15 Page 97 of 143

99 Cash flow forecast Cash Flows from Operating Activities Actual Actual Actual Actual Actual Actual Actual Actual Actual Plan Plan Plan Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Total '000s '000s '000s '000s '000s '000s '000s '000s '000s '000s '000s '000s '000s Operating Surplus/(Deficit) (787) (1,466) (2,995) (1,591) (1,653) (1,184) (877) (1,027) (1,247) (1,350) (1,350) (1,348) (16,875) Depreciation and Amortisation ,638 Interest Paid (79) (42) (73) (49) (50) (374) (456) (49) (50) (170) (319) (445) (2,156) Dividend paid (522) (761) (1,283) (Increase) in Inventories (19) (12) 40 (7) (4) 59 (108) (69) (261) (Increase) in Trade and Other Receivables (757) (1,353) 1, ,247 (45) (333) (500) (747) (910) Increase in Trade and Other Payables 928 1,218 (180) (127) (546) (721) (192) ,375 Increase in Provisions 19 (19) (23) (27) 9 (33) (17) (5) 30 (9) (9) (7) (91) Net Cash Inflow/(Outflow) from Operating Activities (160) (1,140) (1,624) (1,176) (436) (2,270) (758) 122 (1,109) (714) (1,456) (2,581) (13,302) 009/17 Director of Finance Report Cash Flows from Investing Activities Interest Received (Payments) for Fixed Assets (151) (171) (454) (299) (1,101) (351) (427) (456) (796) (500) (592) (650) (5,948) Receipts from disposal of fixed assets Rental Revenue 13 (13) Net Cash Inflow/(Outflow) from Investing Activities (149) (169) (452) (284) (1,112) (336) (426) (455) (778) (498) (587) (646) (5,892) Cash Flows from Financing Activities 0 Public dividend capital received Public dividend capital repaid 0 0 Loans received from DH 1, ,111 2,400 2,374 1,556 1,470 2, ,400 3,325 20,761 Loans repaid to DH 0 0 Principal repayment of DH capital loan (200) (200) (400) Capital element of Finance Leases & PFI (12) (13) (141) (13) (13) (12) (646) (118) (12) (104) (281) (174) (1,539) Net Cash Inflow/(Outflow) from Financing Activities ,970 2,387 2,361 1, (118) 2, ,119 3,151 19,172 NET INCREASE/(DECREASE) IN CASH 601 (447) (106) (1,062) (210) (451) 234 (321) 76 (76) (22) Cash - Beginning of the Period 1,022 1,623 1,176 1,070 1,997 2,810 1,748 1,538 1,087 1,321 1,000 1,076 1,022 Cash - End of the Period 1,623 1,176 1,070 1,997 2,810 1,748 1,538 1,087 1,321 1,000 1,076 1,000 1,000 Cashflow forecast Page 16 Page 98 of 143

100 Capital Programme Gross capital spend Mth 9 YTD Actual Ordered not received Committed Estimated future spend Total forecast 000's 000's 000's 000's '000s 009/17 Director of Finance Report Electronic Patient Record (EPR) IT ,101 Community PAS Allocate Rostering Software Lift refurbishments SDGH Capital Team CERT Team Fire precautions - dampers and compartmentation Fire Alarms - ODGH Fire Doors Risk schemes Vehicles A&E Side Entrance Air tube system Aseptic Suite UPS Theatre Medical Equipment 16/17 1, ,261 Contingency Donated assets GE radiology equipment Urology move Theatre Forward wait 0 Telephony Bedhead lighting Gross Capital Spend 3, ,705 6,547 Available capital resources 6,667 Remaining capital resources 120 Capital expenditure has been calculated and presented in a different way to provide assurance to the and to the Board that the Trust will come in on plan. In addition, this information will feed into the Capital Investment Group to aid decision-making on utilising the remaining capital contingency monies. Key Ordered not received - the purchase order has gone to the supplier but the goods had not arrived by the end of Dec-16. Committed - either a letter of intent has gone out or the Capital Investment Group has made a purchase decision but no official purchase order has yet gone out. Estimated future spend - based on discussions with the relevant Project Managers. Capital Page 17 Page 99 of 143

101 CQUIN Performance with Trajectories CQUIN National CQUIN's 1. NHS Staff Health and Wellbeing Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Qtr. 4 / YTD Target 009/17 Director of Finance Report 1a Staff Health and well being: Introduce Health & Wellbeing Initiatives, Option B Performance Health and well-being plan submitted No report required No report required Initiatives implemented and evidence of staff take up - Target: see text per qtr. 1b Staff Health and well being: Healthy food for NHS Staff, visitors and patients Performance Data submitted via UNIFY No report required No report required Four outcomes delivered - Target: see text per qtr. 1c Staff Health and well being: Improving the uptake of flu vaccinations for front line staff Performance Data collection starts in Sept '16 0.0% Trajectory % 0.0% 25.0% 50.0% 75.0% 75.0% 75.0% - Q4: 75% 2A. Identification of Sepsis in Emergency Department: 2.1 Sepsis Screening, screening - Emergency Dept. Performance 67.6% 77.5% 78.8% 58.9% 57.1% 60.0% Trajectory 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% Per Qtr.: 90% 2.2 Sepsis Screening Antibiotic Administration within 1 hr and Sepsis Antibiotic 3 Day Review. - Emergency Dept. Performance 58.3% 66.7% 50.0% 87.9% 81.8% 70.0% Trajectory 50.0% 50.0% 50.0% 60.0% 60.0% 60.0% 70.0% 70.0% 70.0% 80.0% 80.0% 80.0% 70.0% Local target tbc 1617 CQUIN Page 18 Page 100 of 143

102 2B. Identification of Sepsis in Acute In-Patients Settings 2.1 Sepsis Screening, screening - Acute Inpatient 2.2 Sepsis Screening Antibiotic Administration within 1 hr and Sepsis Antibiotic 3 Day Review. - Emergency Dept. Performance 50.0% 57.1% 100.0% 40.0% n/a 100.0% Trajectory 50.0% 50.0% 50.0% 65.0% 65.0% 65.0% 75.0% 75.0% 75.0% 90.0% 90.0% 90.0% 70.0% 3A. Antimicrobial Resistance and Antimicrobial Stewardship reduction in antibiotic consumption Performance 100.0% 80.0% n/a 100.0% n/a n/a Trajectory 50.0% 50.0% 50.0% 65.0% 65.0% 65.0% 75.0% 75.0% 75.0% 90.0% 90.0% 90.0% 70.0% Q4: 90% Local target tbc 009/17 Director of Finance Report 3.1 Reduce antibiotic consumption per 1000 admissions - Antibiotic consumption > 1% Performance Trajectory Submission of historical consumption data Awaiting agreement on baseline year >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction - Q4: >=1% reduction on (baseline year TBC) 3.2 Reduce antibiotic consumption per 1000 admissions - Carbapenem > 1% Performance Trajectory Submission of historical consumption data Awaiting agreement on baseline year >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction - Q4: >=1% reduction on (baseline year TBC) 3.3 Reduce antibiotic consumption per 1000 admissions - Piperacillintazobactam > 1% Performance Trajectory Submission of historical consumption data Awaiting agreement on baseline year >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction >=1% reduction - Q4: >=1% reduction on (baseline year TBC) 3B. Antimicrobial Resistance and Antimicrobial Stewardship empiric review of antibiotic prescriptions 3.1 Antimicrobial Resistance and Stewardship: Empiric review of cases in sample Performance Trajectory 82.0% 93.0% 25.0% 50.0% 75.0% 90.0% - Qtr. 1 = 25% Qtr. 2 = 50% Qtr. 3 = 75% Qtr. 4 = 90% 1617 CQUIN Page 19 Page 101 of 143

103 Local CQUIN's 5. Living with and Beyond Cancer 5a Holistic needs assessment and care plan 5a Cancer treatment summaries 6. Maternity Performance Baseline current delivery by tumour type Develop protocol for measurement and reporting Trajectory Delivery against local target Performance Baseline current delivery by Develop protocol for measurement and Delivery against Trajectory local target 009/17 Director of Finance Report 6a Peri Natal Mental Health Improvement Performance Complete audit with recommendations Agree improvement plan with commissioners, identify milestones and Progress quality and performance report Final progress quality and performance report - Target: see text per qtr. 6b Breastfeeding Improvement Performance Complete audit with recommendations Agree improvement plan with commissioners, identify milestones and Progress quality and performance report Final progress quality and performance report - Target: see text per qtr. 6c NHS Maternity Safety Thermometer Performance Complete survey Complete survey Complete survey Complete survey - Target: see text per qtr. 6d Normality of Childbirth Performance Agree set of metrics and baseline Performance report Progress against performance Progress against performance - Target: see text per qtr. 7. Activity & Performance 7a Zero Length of Stay Performance Trajectory 6mth scheme to be delivered from 1st October 2016 Locally agreed target 7b Consultant to Consultant Performance Trajectory 6mth scheme to be delivered from 1st October 2016 Locally agreed target 7c Reduce the follow up ratio within the CCG's top over performing specialties Performance Trajectory 6mth scheme to be delivered from 1st October 2016 Locally agreed target 1617 CQUIN Page 20 Page 102 of 143

104 Nursing Control w/c 07/11/16 w/c 14/11/16 w/c 21/11/16 w/c 28/11/16 w/c 05/12/16 w/c 12/12/16 w/c 19/12/16 w/c 26/12/16 All framework, wage & price cap Both wage and price cap Wage cap only Framework only Price cap only /17 Director of Finance Report Medical Control w/c 07/11/16 w/c 14/11/16 w/c 21/11/16 w/c 28/11/16 w/c 05/12/16 w/c 12/12/16 w/c 19/12/16 w/c 26/12/16 Both Price & wage cap Wage cap only Other agency Staff group w/c 07/11/16 w/c 14/11/16 w/c 21/11/16 w/c 28/11/16 w/c 05/12/16 w/c 12/12/16 w/c 19/12/16 w/c 26/12/16 Healthcare assistant and other support Scientific, Therapeutic & Technical (AHPs) Administration & estates agency Page 21 Page 103 of 143

105 P U B L I C TRUST BOARD 1 February /17 Monthly Nurse Staffing Report Agenda Item: 010/17 Report Title: Monthly Nurse Staffing Paper Lead Director: Sheila Lloyd Director of Nursing, Midwifery & Governance Report Author: Carol Fowler Assistant Director of Nursing and Midwifery (Workforce) Purpose: Note Approve Assure Summary: In July 2016 the National Quality Board (NQB) released further guidance on nurse staffing to enhance and build on the previous work that was recommend in 2013, including the 1:8 ratio of nurse to patient. Recommendations were made that all nurse staffing should be based on a triangulated approach with the main principles being: Right Care doing the right thing, in the right setting, at the right time. Minimising avoidable harm a relentless focus on quality. Maximising the value of available resources. Reducing waste across the system (Carter Report 2016). This approach would provide analysis of the safety of staffing levels based on patient s needs, acuity and risks that is monitored from ward to board. This moves the emphasis away from the 1:8 ratio and determines further parameters that should be reviewed together to provide an overarching understanding of the impact of staffing levels on care. The attached report highlights the Trust overall reports a RAG rating = RED Page 104 of 143

106 Planned Care = RED Urgent Care = RED Women and Children s = Amber Community and Continued Care = Amber Ward/Department areas and parameters equating to Red Flags are reflected in the overall dashboard and recommends future monitoring and action planning to determine what is required for improvement. 010/17 Monthly Nurse Staffing Report It should also be noted that the report is a work in progress that will change over the coming months as further parameters are added to take forward from April Recommendation(s): Linked to Strategic Domains: Regulatory Requirement: Presented to Other s: The Board is asked to: a) note the compliance with expected staffing levels during the month of April and b) be assured that mitigating actions are taken when staffing falls below what is expected and be assured that no harm events have been linked to staffing levels. Life-long integrated care Excellence in Treatment and Care Best Performance within Resources Develop Staff Organisational Sustainability National Quality Report 2016 Carter Review 2016 Care Quality Commission Safe, Caring, Responsive, Effective and Well Led Page 105 of 143

107 Background Nurse Staffing Paper Data - December 2016 In July 2016 the National Quality Board (NQB) released further guidance on nurse staffing to enhance and build on the previous work that was recommend in 2013, including the 1:8 ratio of nurse to patient. Recommendations were made that all nurse staffing should be based on a triangulated approach with the main principles being: 010/17 Monthly Nurse Staffing Report Right Care doing the right thing, in the right setting, at the right time. Minimising avoidable harm a relentless focus on quality. Maximising the value of available resources. Reducing waste across the system (Carter Report 2016). This approach would provide analysis of the safety of staffing levels based on patient s needs, acuity and risks that is monitored from ward to board. This moves the emphasis away from the 1:8 ratio and determines further parameters that should be reviewed together to provide an overarching understanding of the impact of staffing levels on care. For noting Care hours per patient day (CHPPD) Currently monitored by a manual process, however this is now available in SafeCare (Safe staffing tool) linked to live rosters for all areas implemented to date. Future reporting will be reflective of this from February For noting further discussion has concluded a revised Red, Amber, Green (RAG) rating to support the triangulation of flagging of reported harms versus resources versus care given and is reflected below in Table 1. Table 1 supports proposed actions against Rag rated scores against current 20 parameters. TABLE 1 10 or more RED or 15 or more Ambers ratings out of the 20 measurements reports at RED 1-9 RED or 1-14 Ambers out of the 20 measurements reports at Amber No Red or Amber Overall RED UNSAFE staffing, urgent review required and actions taken to address identified issues. Escalation to DoN required Overall AMBER Staffing requires close monitoring to ensure identified issues do not increase. Overall GREEN Safe staffing Page 106 of 143

108 Table 2 -Executive summary for Safe staffing escalation in December TABLE 2 Trust overall 12 RED 2 AMBER Urgent Care Overall 12 RED 4 AMBER Planned Care 10 RED 3 AMBER Women and Children s 5 RED 6 AMBER Community and Continued Care 6 RED 3 AMBER 010/17 Monthly Nurse Staffing Report As with previous months, there remains high bank and agency usage to assure safe staffing is maintained. Key areas of high usage to note: 15B has utilised 67.73% trained agency and bank staff to ensure they meet staffing requirements. FESS reports 53.19% trained bank/agency usage. Matrons continue to assess staffing levels at Trust Capacity Escalation meetings and staff moved to provide cover to the shortfalls. The new and additional parameters added to this report, supports a move towards a triangulated approach in reporting nurse staffing and patient safety and experience. Next Steps Further work will be undertaken to ensure all NQB and Carter recommendations are captured and reported. The safe staffing report to board will be reviewed by the new Director of Nursing, Midwifery and Governance ready for the 1 st April Carol Fowler Assistant Director of Nursing and Midwifery (Workforce) Page 107 of 143

109 Overall Rating Realtime Staffing CHPPD % Temp Staffing of Nursing in post - Registered % Temp Staffing of Nursing in post - Non Registered Nursing Vacancies Staffing related Incidents Medication - Missed Doses Post Fall # Neck of Femurs Falls Pressure Sores Bed Occupancy VTE Risk Assessments * Total Relating to clinical treatment Relating to attitude FFT - % recommended Sickness - Registered Sickness - Non Registered % of Obs that were late Mandatory Training - Registered Mandatory Training - Non- Registered Staffing Incidents Harms Complaints FFT Sickness VitalPac Training Dec-16 Trust 97.82% % 19.08% (17) % 97.86% 46 (22) % 6.49% 8.45% 17.46% 72.89% 73.02% Urgent Care 98.09% % 32.71% 91 (96) 12 (9) 2 (2) 0 40 (40) 7 (7) 91.18% 97.02% 23 (17) 9 (7) 9 (6) 86.08% 6.75% 11.83% 18.98% 73.90% 70.27% 7A 94.06% % 75.00% % % % 13.92% 18.13% 30.23% 61.21% 53.41% 7B % % 62.22% % % % 5.76% 9.45% 12.02% 72.95% 84.85% Stroke Unit 95.35% % 38.37% % 97.67% % 3.90% 2.40% 10.91% 67.61% 66.67% FESS 96.61% % 17.43% % 88.24% % 18.35% 0.77% 10.10% 75.21% 79.87% EAU 96.94% % 26.38% % 97.71% % 10.73% 1.76% 37.20% 74.79% 72.73% SSU % % 39.58% % % % 0.75% 1.96% 15.05% 75.35% 73.64% 11B 95.83% % 73.15% % 93.33% % 3.18% 35.42% 7.73% 71.59% 53.54% 14B 95.56% % 18.24% % 96.97% % 1.49% 9.63% 7.03% 45.99% 38.79% A&E 94.59% N/A 25.92% 6.87% N/A N/A % 10.83% 3.46% N/A 76.88% 83.52% Obs % % 19.66% % 92.25% % 1.67% 12.69% 39.34% 74.31% 63.64% Rehab % % 45.69% % % % 6.78% 26.94% 14.14% 90.07% 88.31% Critical Care 96.57% % 12.01% % % N/A 5.96% 4.34% 25.04% 84.48% 85.45% Women & Childrens 96.66% % 1.30% -4 (-4) 4 (3) % 95.50% 3 (2) % 5.47% 6.34% 18.62% 77.34% 78.49% E Ward % % 4.06% % 94.33% % 0.43% 15.20% 18.62% 92.38% 93.94% Maternity 95.10% % 1.52% % 96.43% % 4.52% 2.91% N/A 65.08% 65.22% NNU 93.73% % 0.00% % N/A N/A 11.82% 3.57% N/A 96.27% 96.00% Childrens Ward 98.77% % 0.00% % N/A % 9.39% 1.11% N/A 88.13% 85.71% Childrens A&E 99.61% N/A 5.13% 2.12% N/A N/A % 9.29% 2.19% N/A 87.66% 91.67% PAB 97.58% N/A 0.00% 0.00% % N/A N/A 0.00% 0.00% N/A 63.64% N/A Planned Care 98.18% % 16.45% 70 (54) 6 (5) (13) 6 (5) 81.97% 99.31% 13 (3) 9 (3) 2 (0) 95.29% 8.15% 6.07% 14.47% 66.44% 72.41% PIU 89.93% % 85.00% % 99.29% % 23.59% 0.00% 11.48% 53.72% 56.82% 14A % % 32.51% % % % 9.81% 6.73% 17.30% 56.13% 63.64% 15A 84.65% % 38.46% % % N/A 2.85% 12.63% 14.55% 61.36% 63.64% 15B % % 54.55% % % % 2.05% 16.39% 13.84% 60.91% 69.42% Spinal Unit 92.86% % 6.80% % 97.73% % 0.92% 1.41% 14.01% 65.97% 68.76% G Ward % % 5.69% % 99.39% % 1.09% 0.00% 15.64% 75.00% 75.00% Treatment Centre N/A N/A 0.00% 0.00% N/A 99.22% % 4.62% 12.21% N/A 71.38% 74.83% Theatre N/A N/A 19.43% 0.00% N/A N/A N/A 18.58% N/A N/A 59.65% N/A Radiology N/A N/A 0.00% 0.00% N/A N/A N/A 0.00% N/A N/A 63.64% N/A Community & Continued Care 96.49% N/A N/A N/A (3) N/A 4 (0) 38 (36) N/A N/A 3 (0) 1 0 N/A 4.74% 6.65% N/A 73.36% 75.70% Burscough D/Ns 95.24% N/A N/A N/A N/A 0 1 N/A N/A N/A 25.89% 0.00% N/A 70.91% 81.82% Hillside D/Ns 97.73% N/A N/A N/A N/A 0 5 N/A N/A N/A 0.89% 0.00% N/A 63.64% 72.73% Hants Lane D/Ns 97.27% N/A N/A N/A N/A 0 10 N/A N/A N/A 6.13% 42.86% N/A 65.45% 45.45% Sandy Lane D/Ns % N/A N/A N/A N/A 0 2 N/A N/A N/A 1.00% 3.86% N/A 59.50% 54.55% Tarleton D/Ns 97.90% N/A N/A N/A N/A 0 3 N/A N/A N/A 1.09% 0.00% N/A 80.28% % Ainsdale D/Ns 94.47% N/A N/A N/A N/A 0 2 N/A N/A N/A 3.69% 0.00% N/A 65.73% 81.82% Churchtown D/Ns 94.01% N/A N/A N/A N/A 0 6 N/A N/A N/A 3.74% 55.56% N/A 67.95% 90.91% Curzon Road D/Ns 96.39% N/A N/A N/A N/A 0 5 N/A N/A N/A 0.53% 0.00% N/A 76.30% 57.14% Formby D/Ns N/A N/A N/A N/A N/A 0 2 N/A N/A N/A 2.30% 0.00% N/A 67.53% 81.82% NB. All Trust & CBU totals relate to all wards and departments within these groups. The numbers in brackets relate to the total of the areas shown in this report. * Figures subject to change Red <90% N/A 15%> 15%> 5> 1> 1> 1> 1> 1> 93%> <94% N/A 1> 1> <80% 7%> 7%> 15%> <80% <80% Amber 90-95% N/A 10-15% 10-15% % 94%-95% N/A % 4-7% 4-7% 10-15% 80-89% 80-89% Green 95%> N/A <10% <10% <85% 95%> N/A %> <4% <4% <10% 90%> 90%> 010/17 Monthly Nurse Staffing Report Page 108 of 143

110 Locations not above Falls Staffing Related Incid Community Urgent Care 1 x Audiology 1 x Bed Management 1 x Adult Therapies 1 x ECG 1 x Physiotherapy 1 x Not attributable to 1 x CERT Women & Childrens 1 x Outpatients Pressure Sores Planned Care Planned Care 1 x MFU 1 x Fracture Clinic HR Community 2 x Medical Staffing 1 x Community Matrons 2 x Unassigned 010/17 Monthly Nurse Staffing Report Complaints Urgent Care 5 x Outpatients 1 x Skelmersdale WIC Women & Childrens 1 x Outpatients Planned Care 4 x Outpatients 2 x Dermatology 1 x Cancer Services 1 x Eye Clinic 1 x MFU 1 x Orthopaedic Outpatients Community 1 x CERT 1 x Physio 1 x Discharge Planning Page 109 of 143

111 P U B L I C TRUST BOARD 011/17 HR Quarterly Report 1 February 2017 Agenda Item: 011/17 Report Title: Quarterly Report from the Director of HR & Communications Lead Director: Richard Jones Interim Director of HR & Communications Report Author: Richard Jones Interim Director of HR & Communications Purpose: Note Approve Assure Summary: Represents a quarterly report on key HR activity since the last report that was submitted to the November 2016 Trust Board. Recommendation(s): Linked to Strategic Domains: Regulatory Requirement: Presented to Other s: The Trust Board is asked to note this report. Life-long integrated care Excellence in Treatment and Care Best Performance within Resources Develop Staff Organisational Sustainability N/A N/A Page 110 of 143

112 Q u a r t e r l y R e p o r t f r o m t h e D i r e c t o r o f H R & C o m m u n i c a t i o n s J a n u a r y /17 HR Quarterly Report 1. INTRODUCTION This report is for the third quarter of 2016/17. The Board is aware of the busy context in which the departments from HR and Communications have continued to work. Moreover in the 3 quarters so far of the financial year there has been no continuity at Director level there having been 3 post-holders in this key role over the 9 month period. Nonetheless there continues to be progress being made in many areas, albeit with significant challenges in other areas although in respect of recruitment in particular, this context is shared by most of the other English NHS organisations. The following report highlights key work activity and notes lack of required progress, particularly with regard to mandatory training and sickness absence. 2. RECRUITMENT ACTIVITY This report repeats the message previously stated to the Board of difficulties that Southport and Ormskirk NHS Trust faces in recruiting qualified clinical staff to fulfil our required staffing establishment and recruitment continues to be very challenging in the UK for all NHS trusts. A consequence of this on-going challenge is the continuing need to fill posts on a temporary basis by using bank, agency and/or locum staff. This has been an on-going issue for the previous 24 months and whilst vacancies are not the sole reason for this usage, they constitute the principle reason and as such there is a financial cost to be met which is covered later in this report and elsewhere in the Board agenda. The position with regard to the recruitment of non-clinical and non-management posts continues to be much more positive. Previous quarterly reports have identified that clearly in terms of the labour supply and demand equation, the supply of suitably qualified staff is of a regional, national or even international dimension, whereas in respect of non-clinical and non- Page 111 of 143

113 management posts the labour supply tends to be more local (although for more senior and specialist posts the supply again tends to be regional). 2.1 NURSING & HCA VACANCIES Current nursing and HCA vacancy data provided by the Recruitment department around vacancies that they are currently working on. The Trust currently has the following number of vacancies as at 23 rd January Division WTE Community and Continued Care Division 8.4 Planned Care Division Urgent Care Division Women and Children s CBU 3.64 Grand Total /17 HR Quarterly Report This vacancy figure is based upon vacancies that are actively being recruited to, they are either, Awaiting to go out to advert, Advertised, Longlisting, Shortlisting or Interviews are being held or to be scheduled. These figures do not include successful recruitment campaigns where offers of employment have been made to fill outstanding vacancies and candidates are undergoing their pre-employment checks. 2.2 MEDICAL STAFFING TEAM At previous updates this year the Board has been kept up to date with difficulties that have been experienced in relation to the medical staffing team. In particular since the departure of the Medical Staffing Manager in the summer of last year the team has struggled and this had a negative impact in respect of the teams work schedule and effectiveness. The position has been constantly monitored over the last quarter and attempts have been made to improve the situation. At the current time it does seem that the situation within the team has improved and recent discussions with the British Medical Association has recognised this development. There has been an impact in terms of the new contract for doctors and this is covered in the next paragraph. Moving forward there are plans which could see working more closely with colleagues in other Trusts and looking to build on the possibilities that emerge for the team from e-rostering. 2.3 NEW JUNIOR DOCTOR/TRAINEE CONTRACT The Board will recall that the issue of a new junior doctor contract gained a very high profile with the media and public last year and that there was real concern regarding Page 112 of 143

114 the industrial action taken by this group. Subsequently the secretary of state and employers decided that it was necessary to impose the new contract but employers were given some local discretion around implementation. Locally whilst executives were very supportive of the need for a new approach, there was caution expressed, particularly with regard to some of the external aspects that needed to be in place to ensure imposition was not challenged. In the autumn of last year therefore, having regard to these external measures (such as exception reporting and e-rostering) and having regard to on-going difficulties with medical staffing team, it was decided to delay implementation somewhat at this Trust. Thus whilst nationally many Trusts have already implemented the new contract for F1 juniors, this Trust is doing so from the next intake in April of this year. Similarly currently it is the intention to phase in F2 doctors from the August intake albeit most other Trusts may have used the new contract for their F2 s from April. 011/17 HR Quarterly Report The rationale for this decision is to try and ensure that the new arrangements are a success from day 1, rather than having to respond to difficulties that could be faced if the new contract is used too quickly. As has been reported above, the situation in medical staffing has improved and the Trust has started to implement an e-rostering project for medical staff and both of these on-going improvements should ensure a smooth transition into the new employment arrangement for this important group of staff. In terms of cost of implementation, the NHS England view is that the new arrangements once implemented will be mostly cost neutral but we do feel that there will be some cost, particularly with regard to the transitional pay protection elements of the national agreement and this will be the subject of on-going review by finance colleagues. 2.4 PROGRESS ON MEDICAL VACANCIES (CONSULTANT POSTS) The below table explains the position with regard to Consultant and SAS doctor recruitment. In respect of junior doctor/trainees, we continue to be able to attract staff albeit due to a national shortage of trainees in some posts, gaps in rotas do remain. This situation is however replicated in other neighbouring Trusts. As a consequence of gaps in rota s and shortages in some areas it continues to be the practice to utilise locum staff where required. The financial aspect of this issue is covered elsewhere in board reporting. It is anticipated however that with the rollout of e-rostering for medical staff over coming months, that this will give corporate management a better tool to allow for assurance and oversight of this key issue. Page 113 of 143

115 Consultants 14 Locum Consultants 4 Specialty doctor level 11 Approved Appointment 1 3. AGENCY CAP EFFECT 011/17 HR Quarterly Report The Board has been previously advised about that Agency Cap rates were introduced in November 2015 and February 2016 in accordance with NHSI/Monitor s requirements and were further reduced with effect from 1 st April This has resulted in a significantly increased workload for the Trust as each individual booking over the rate cap needs to be approved by a member of the Executive team. The impact of the agency and locum doctors spend has had a huge detrimental impact on the Trust s deficit reduction plan as is reported elsewhere in Board reports. The Director of Finance takes the lead role on trying to address this but is assisted by the Medical Director and other members of the Executive team. Whilst overall the costs of bank and agency cover for the Trust has reduced significantly from the early part of this financial year, the position with regard to medical staff has not seen the same reductions as nursing. This therefore remains a key area for improvement and as has been noted already in this report, the roll-out of e-rostering is crucial not just in terms of safe working for juniors but in respect of the intelligence it should bring thereby increasing our ability to manage locum usage. 4 WORKFORCE KPIs 4.1 EMPLOYEE RELATIONS: Table 1: Employee Relations Cases 31 st Dec 30 th Sept 31 st Jul 31 st May 29 th Feb 31 st Dec Disciplinary MHPS Grievance Dignity at Work T O T A L Exclusions Page 114 of 143

116 Community & Continued Care Estates/ Facilities Planned Care Urgent Care Women s & Children s Other Total Restricted Duties Employment Tribunal claims Please note the figures detailed in terms of caseload do not include senior management investigations. Table 2: Employee Relations Cases CBU Breakdown 29th February /17 HR Quarterly Report Employee Relations Cases Exclusions (Medical Staff) Restricted duties (Medical Staff) Exclusions (Non-Medical Staff) Restricted duties (Non- Medical Staff) STAFF SURVEY 2016 Publication of 2016 Staff Survey results Draft benchmark reports sent to organisations: w/c 20 February 2017 Embargo lifted: Tuesday 7 March 2017 Full results published: Tuesday 7 March 2017 The Board will wish to note the above key dates and that a full review of the results can be considered at the next board with an action plan prepared for April. Page 115 of 143

117 6 CULTURAL REVIEW The Board will recall that the Trust commissioned a cultural review to be undertaken by Professor Surinder Sharma from the University of Leicester. The review commenced in August 2016 and it was hoped a report of findings would have been available in January Professor Sharma has requested further information which will be submitted over the coming days with a view to the report being available perhaps in February. 7 TRAINING & DEVELOPMENT UPDATE 011/17 HR Quarterly Report 7.1 MEDICAL EDUCATION Following the Health Education North West (HENW) monitoring visit in April 2016, the Trust was issued a formal notification of four patient safety issues which required immediate action. Since the Director of Medical Education (DME) developed and returned the Trust action plan to HENW, the action plan has been returned by HENW with further actions requesting increased clarification. In the meantime, the DME and Medical Education Manager (MEM) have met with the HENW s Postgraduate Dean to seek guidance on the level of detail HENW are looking for. In light of this, HENW have requested a site visit on the 7 th March 2017 with a specific agenda see below: Overview of education and training governance (DME or Medical Director) including Board level of involvement and local quality control processes. Trust response to the action plan following the monitoring visit March 2016 Supervision of paediatric trainees Patient safety comments (NTS 2016) and staffing: A&E Ormskirk; medicine The DME and MEM have a site visit booked to attend Blackpool at HENW s proposal, to better understand and learn from an exemplar site. 7.2 EDUCATION & TRAINING GOVERNANCE ARRANGEMENTS Governance arrangements for education & training have tightened over the last six months with the previous Chair, the Director of Medical Education, being replaced by the Executive Director of HR & Communications due to the wider nature of the Trust s educational agendas. Below is the current reporting structure: Page 116 of 143

118 Medical Education Trust Education Education Governance Group The Trust Education is the formal venue where the following Trust agendas (see below) are presented and discussed. The Trust Education will escalate any issues via the HR Operational, the Quality & Safety or others as appropriate. 011/17 HR Quarterly Report Undergraduate Medical Education Library & Knowledge Services Organisational Development Training Needs Analysis Learning & Development Agreement (HENW) Postgraduate Medical Education Mandatory & Job Specific Training Undergraduate Nurse Education i.e. PEF s / Mentorship Educational Estates & Facilities Management Training Administration (ESR/OLM) Continuing Professional Development (CPD) Leadership & Management Development Postgraduate Nurse Education i.e. Preceptorship, Revalidation Communications & marketing Events management Simulation Clinical Skills Training On boarding processes i.e. Induction Corporate & Local Apprenticeships, vocational development AHP s, Midwifery, HCS development 7.3 APPRENTICESHIP LEVY The Task & Finish Group met on the 16 th January 2017 to discuss how to maximise the apprenticeship levy for 2017/18.The group focussed the discussion on answering the following questions: i. How can we maximise the apprenticeship levy to reduce our vacancies thereby reducing agency usage; and how we can develop our people, improve staff motivation and increase retention of key roles? ii. Which of our existing staff groups should be the focus for 2017/18? The group agreed that the Trust s main priority for 2017/18 should be the recruitment of HCAs and qualified nurses. Based on budgeted establishment it is understood currently the Trust has around 40 x HCA vacancies (bands 2-4) and around 100 x qualified nurse vacancies (bands 5-8b). The group also agreed that the focus for 2017/18 would be bands 1-4 posts in the first instance, until the higher and degree apprenticeships are fully established. Apprenticeships to support succession planning were also discussed, the Head of Education & Training is sourcing the relevant apprenticeships starting this year with a specific interest in leadership & management apprenticeships. Page 117 of 143

119 The action plan includes: Mapping of HCA vacancies and identify suitable wards/departments for recruitment to apprenticeships Fast track the work with Southport College and University of Cumbria to launch a local school of nursing by September 2017 grow your own nurses. Introduce new Nursing Associate role (March 2017) Undertake 2017/18 training needs analysis (Feb 2017) to inform this year s registrations for apprenticeships from the current workforce Continue to work with departments to better understand how we can use the levy to support succession planning Review the leadership & management apprenticeship offer as a Trust standard for future progression Launch the Think Apprenticeships communication campaign 011/17 HR Quarterly Report The next Task & Finish Group will meet in March TRAINING NEEDS ANALYSIS An organisational training needs analysis will be circulated in early February 2017 with a view to inform this year s programmes of bespoke leadership and management development, apprenticeships, CPD spend for clinical staff bands 5-8, and general courses i.e. IT training, first aid etc. In previous years response rates have been extremely poor and the TNA has served purely to take an annual snapshot. Senior managers are asked to encourage their CBU s to respond in number to provide a better informed spend for next year s training budget. Due to such tight budgets, the TNA is only for information and does not guarantee approval of funding. 7.5 APPRAISALS & WORKSHOPS A revised Performance Appraisal and PDR Policy was signed off at JNC (January 2017), minor amendments are being made before the policy is published. A programme of ManagersNet appraisal/pdr workshops will commence in February 2017 in line with the publication of the policy, with a focus on quality conversations rather than simply process. The appraisal workshops will roll out at the same time as ESR Manager Self-Serve workshops delivered to train managers to use ESR effectively to manage real time data for both appraisal recording and mandatory training. 7.6 MANDATORY TRAINING Following the MIAA Audit in June 2016, the Trust now has an action plan which is governed on a quarterly basis through the Quality & Safety (Q&S). A business case for an increase in establishment to the training department was Page 118 of 143

120 submitted to finance (Dec 2016). It was agreed at the January Q&S that a short paper be presented at February s Finance, Performance and Investment (FP&I) outlining the key roles within the business case for an immediate decision by the members. Below is an overview of % compliance for core mandatory training. Table 1 shows % compliance overall Trust and CBU level. The data was pulled on 4th January 2017 and is based on a rolling 12 month period from 1st January to 31st December 2016 on staff employed by the Trust. Exceptions include: long term sickness and maternity leave. Overall Trust compliance has increased by 0.6% from 75.93% as at 30th Nov to 76.53% as at 31st Dec Table 1 011/17 HR Quarterly Report 7.7 Overall % by CBU (Dec 2016) % Trust Capital & Facilities Community & Continued Care Corporate (12 people) 35.5 Executive Management (1 person) Finance Human Resources 90 Medical Director Nursing & Midwifery Planned Care Service Improvement (5 people) Urgent Care Women s & Children s TRAINING BUDGETS It is anticipated that HENW funded CPD SLA and cash allocations for clinical staff bands 5-8 will continue on a year on year downward trend. The Trust received 47, (cash) and 94, (SLA) for the financial year 2016/17; this was a reduction of 83,000 from the previous year (2015/16). With the arrival of the apprenticeship levy the focus of Further Education & Higher Education Colleges is to map their curricula to higher national apprenticeships to follow the funding. To maximise the spending of the apprenticeship levy, the Trust will work closely with its local colleges and universities to ensure that national and local developments are closely monitored and implemented as appropriate. 7.8 TRIUMVIRATE LEADERSHIP DEVELOPMENT To support the development and a successful implementation of the Trust s triumvirate leadership model, a programme of bespoke facilitated workshops, team coaching and individual support will be developed to ensure that the triumvirate model is fully embedded to maximise its success in delivering CBU and organisational Page 119 of 143

121 objectives. Focus in phase one will be on agreeing ways of working, aligning personal and professional accountability & responsibility, developing effective reporting lines and governance, building relationships and establishing inter-cbu communications. 8 EQUALITY AND HUMAN RIGHTS As has been reported previously, a key area for future improvement for the Trust is within the function of equality and human rights. The Trust does have an Equality & Diversity and some basic statutory requirements for the Trust are in place but within the next 12 months a re-launch will take place following the publication of the culture review noted earlier. The action plans will emerge from both the culture review and staff survey will incorporate a revised approach to Equality & Diversity. This will of course dovetail with other work necessary around patient experience. 011/17 HR Quarterly Report 9 SEASONAL INFLUENZA STAKEHOLDER REPORT It is pleasing to report that according to the above report for Cheshire & Merseyside, Southport & Ormskirk was the 6 th (out of 22) most successful Trust in terms of take up by staff of the flu jab. In 2016 we achieved 76.8% uptake which was slightly down from the 79% achieved in This is a very credit worthy performance by our Health and Wellbeing department. 10. PRIDE AWARDS 2017 The Board is aware of the Pride Awards held each year which is in the form of an awards dinner and presentation for: The Trust to recognise the excellence of its staff and teams; Staff to recognise the achievements of one another; Patients to recognise staff who have given outstanding care. This year following discussion with staff side it has been decided to make the following changes: i) Ticket cost for attendance at dinner to be reduced to 5 (from 30/20 in previous years) ii) Awarding committee membership to increase from Executive Team to include Clinical CBUs, Volunteer and staff representatives. The timetable for Pride Awards starts in February 2017 with the Awards dinner being held at the Floral Hall, Southport in June. 11 COMMUNICATIONS AND MARKETING Page 120 of 143

122 15 press releases issued 11 press statements issued 45 media inquiries 18 issues of Trust News delivering 213 news items 120 print media items published 113 Trust tweets on Twitter; 193 retweets 011/17 HR Quarterly Report There was significant media attention on the Trust during Q3. Particular interest was created by the dismissal of two senior Trust officers; the publication of the CQC report; the inquest into the death of a Trust patient; and the loss of the Southport and Formby adult community services tender bid. We continue to receive media interest around the STP proposals, issues related to the dismissal of the Trust officers and winter pressures. Negative print media coverage over the quarter was balanced by pushing positive stories about the Trust. The Communications team developed an A&E leaflet with the support of Dr David Snow, Assistant Medical Director for Emergency Care, which aims to reduce complaints by explaining the triage process, signposts alternatives to attending A&E and shows how patients can help the Trust recover health care costs. Other trusts including the Royal Liverpool and Aintree are now looking to develop their own leaflet on the back of this work. Further work is planned to improve information for patients in A&E. Page 121 of 143