Board of Directors. Approval Discussion Information Assurance
|
|
- Ferdinand Jackson
- 5 years ago
- Views:
Transcription
1 Report Title: Executive/NED Lead: Report author(s): Previously considered by: Board of Directors Tuesday, 31 October 17 Board Assurance Framework & Corporate Risk Register Ann Alderton, Company Secretary Ann Alderton, Company Secretary Quality and Risk EMC; F&P,POD & QPS Board Assurance Committees Approval Discussion Information Assurance Executive summary Purpose The Board Assurance Framework (BAF) sets out the strategy objectives, identifies risks in relation to each strategic objective along with the controls in place and assurances available on their operation. The BAF can be used to drive the board agenda. The Corporate Risk Register (CRR) is the corporate high level operational risk register used as a tool for managing risks and monitoring actions and plans against them. Used correctly it demonstrates that an effective risk management approach is in operation within the Trust. Status Update since the previous meeting (refer to EMC report) BAF There are risks in the BAF, of which 9 are red, as follows. There have been no changes to the risk scores since the previous report but the narrative has been updated to reflect the most recent assurance activity and to reflect Board Assurance committee discussions, as appropriate: Risk Unless we work with our health and social care partners to understand flow across the system, then we may have inadequate arrangements in place to manage demand (activity) which may impact on the system resilience and internal efficiencies, impacting on delivery of contractual performance [Up from previous report due to deteriorating trajectories] If we do not have in place effective organisational financial management, then we may not be able to fully mitigate the variance and volatility in financial performance against the plan leading to failure to deliver the control total, impact on cash flow and long term sustainability as a going concern [No change] Failure to achieve quality and cost improvements in Pathology leading to suboptimal service and impacting on patient care and relationship with partners [Up from mathematical error] If we do not fully engage our staff on the improvement journey, then they may fail to make a positive contribution to change, which may limit the sustainability of improvements made [No change] If we do not resource our nurse staffing rotas at ward/ department level then we will long term impact on staff resilience and poor retention of staff [No change] If we do not resource our medical staffing rotas at ward/ department level then we will long term impact on staff resilience and poor retention of staff [ No change] If we do not have in place robust processes for the recording of activity, then we may have inaccuracies for clinical use and reporting of activity, which may lead to suboptimal care for our service users due to information gaps regarding patient Risk Score 25
2 diagnosis, care and treatments, tracking of patient pathways and coding inaccuracies [No change] If we do not improve the quality of care to patients sustainably and consistently as a result of gaps in key roles and poor engagement, leadership, capacity and capability, we will fail to provide good care, fail to achieve regulatory compliance and will suffer reputational damage. [No change] If we do not transform through strategy and operational change management then we will lose grip on our long term sustainability [Risk revised down from ] If we do not resource our AHP staffing rotas at ward/ department level then we will long term impact on staff resilience and poor retention of staff [No change] If we do not have in place a suitably qualified and experienced leadership team (across sub board levels, including Divisional and Clinical Delivery Group (CDG) Leadership, then we may fail to deliver the required improvement at pace, with the potential for continued or escalated regulatory enforcement action [No change] If we do not have effective accountability and escalation arrangements, the executive team and the board may be unaware of important risk issues, significant control weaknesses and patient safety concerns in the rest of the organisation. This may lead to failure to act to protect patient safety, failure to learn as an organisation and potential regulatory intervention. [No change] 15 Corporate Risk Register There are risks in the Corporate Risk Register with a current score of and above, of which four are red, as follows: Risk A failure to comply with the National Safety Standards for Invasive Procedures (NatSSIPs) recommendations issued by NHS England in September 15, caused by a lack of engagement and escalation by the Divisions, may result in the Trust being non-compliant with National Guidance, compromise patient safety and negatively impact the Trusts reputation [New] A failure to ensure that sufficient staff are recruited and retained to meet the requirements of increased activity and acuity requirements, caused by inefficient recruitment processes and insufficiently embedded retention schemes, may lead to increased staff sickness related to low staffing levels thereby increasing the vacancy factor and the inability to deliver high quality care [No change] A failure to have sufficient trained staff across the organisation to provide physical intervention (restraint) caused by an insufficient number of staff trained may lead to potential patient harm if intervention is performed incorrectly or not delivered as required in a timely manner [New] A failure to ensure the safe management of cellular pathology specimens from source through to delivery to the lab, caused by a lack of standardised process of management across the trust, may lead to potential risk to patient safety [No change] A failure to have a robust system for identifying and updating policies/procedural documents requiring review in a timely manner may cause staff to act on inaccurate information resulting in potential regulatory and contractual sanctions [No change] A failure to not fully comply with Health and Safety (Sharps Instruments in Health Care) Regulations 13 caused by failing to trial sharps safety devices in all areas of the Trust and in particular theatres and children s wards, not complying with environmental legislation when disposing of sharps boxes not assembled or signed correctly and staff members failing to comply with good practice and training may lead to non-compliance resulting in HSE enforcement notices and financial loss and 2 Risk Score 15
3 injuries occurring due to poor disposal of sharps and poor practice by staff members [No change] A failure to ensure that the Trust maintains a rolling programme for medical equipment replacement, including those at high risk of failure such as the interventional radiology equipment, caused by financial constraints and an ineffective equipment management system, may lead to staff using equipment that is no longer fit for purpose and increases the risk to patient safety. This in turn will impact upon the Trust s compliance against external regulatory requirements, which may lead to regulatory action [Reviewed risk reduced] A failure to consistently sustain the end of life care for all caused by a lack of mandatory face-to-face training for clinical staff determined by the End of Life Education Strategy may lead to poor patient experience, lack of advanced care planning and lack of ability to discharge patients rapidly to their preferred place of care [Reviewed and re-worded] A failure to ensure that robust governance processes are in place to provide assurance of risk mitigation, patient safety improvements, learning from incidents, complains and claims, including the delivery of policies and procedures that meet national best practice, caused by insufficient scrutiny and review of existing practice due to insufficient frameworks and guidance in place, may lead to the Trust being non-compliant with CQC Fundamental Standard and 17 [No change] A failure to ensure that staff are supported in the raising of concerns within the Trust, caused by colleagues lacking confidence that concerns will be answered and acted upon in a robust and timely fashion, may lead to on-going whistleblowing cases being made externally to the organisation. This may subsequently lead to a sustained increase risk profile and increased scrutiny, with potential sanctions placed upon the Trust against the failure to comply with Health and Social Care Act regulation [No change] A failure to ensure that learning from incidents and serious incidents is embedded consistently across the Trust caused by immature developed governance within the Divisions, may lead to a reactive response to patient safety concerns, a failure to ensure systems and processes are in place to prevent recurrence, thereby increasing the risk of patient harm occurring [No change] A failure to provide service contract for the existing decontamination machines (provided by Cantel) caused by the end of life of the current machines and the inability to provide a service contract for the machine whilst transitioning between old to new contracts as part of the new decontamination facility. This could Gastro, GI services, ENT and Urology [Reviewed and risk reduced] Layer Marney Ward A failure to provide safe and effective care caused by poor leadership and critical nursing staff shortages may lead to avoidable serious incidents, poor patient experience, increased distress to relatives and increased complaints in additional to a poor staff experience leading to a high attrition rate and difficulty in recruiting substantive nursing staff [New risk] Pharmacy Building a failure to ensure that the Pharmacy building is of a suitable standard to prepare medicines for injection by aseptic methods, caused by insufficient planning and identification of the extent of building degradation with associated financial constraints when action has been required, may lead to the Trust losing MHRA accreditation and license to manufacture, which will subsequently lead to disruption in patient care delivery, subsequent financial penalties and a negative reputational impact on the Trust being able to deliver comprehensive medication services [New risk] A failure to ensure that both NICE guidance and quality standards are reviewed, responded to, actioned and evidenced, caused by historical backlogs of NICE guidance inactivity, competing priorities and a lack of rigour in ensuring such action 3
4 has been taken, may lead to treatments not being reviewed in line with national best practice, staff being unclear as to what action is required to comply with requirements and patients not being provided with the most appropriate treatments for their conditions [Reviewed risk reduced] Action Required of the Board of Directors The Trust Board is asked to note the BAF and Corporate Risk Register risks listed above, the current status of both documents and future developments. Board Committees are encouraged to update their assurance maps with the above risks so as to ensure that their forward plans are reflective of the principal strategic risks and main operational risks to the Trust Link to Strategic Objectives (SO) SO1 SO2 SO3 Acting in the best interests of every patient every day Supporting our Workforce to look after every patient, every day Achieving financial sustainability and organisational resilience To deliver care in the right place at the right time in line with national best practice To ensure a positive patient experience at every contact by providing safe, effective, kind and compassionate care To achieve sustainable quality improvements in the delivery of care To deliver a positive patient-centred culture of great care for patients To engage, support and develop staff to achieve their potential To train and support all staff to take personal responsibility and accountability for their actions and the actions of others to drive organisational success To develop constructive relationships with partner organisations to deliver sustainable and effective care for patients To deliver consistently and sustainably against national and local priorities To maximise value for money in delivering healthcare in our locality Please tick Risk Implications for the Trust (including any clinical and financial consequences) Trust Risk Appetite If we do not have effective risk management arrangements, we may fail to predict, plan and prepare for potential threats to the organisation s objectives and this may jeopardise their delivery Compliance: The Board has a cautious risk appetite when it comes to compliance and regulatory issues, especially in relation to delivery of safe, high quality care. It will only challenge them if there is strong evidence or argument to do so Legal and regulatory implications (including links to CQC outcomes, Monitor, inspections, audits, etc) Financial Implications Risk Management is part of the Well-led Framework for assessing Boards of Directors There are no financial implications 4
5 Equality and Diversity There are no E&D implications 5
Please indicate: For Decision For Information For Discussion X Executive Summary Summary
Governing Body 22 March 2017 Details Part 1 X Part 2 Agenda Item No. 10 Title of Paper: Board Member: Author: Presenter: PAHT Quality Improvement Plan Catherine Jackson, Executive Nurse Catherine Jackson,
More informationPresentation to the Care Quality Commission. Dr. Lucy Moore, CEO 15 September 2015
Presentation to the Care Quality Commission Dr. Lucy Moore, CEO 15 September 2015 Our Improvement Journey- Key Messages We have Board, Executive and Divisional leadership teams now in place with serious
More informationStrategic Risk Report 4 July 2016
Strategic Report 4 July 20 Haringey CCG Register Introduction The Strategic Report (historically known as the Board Assurance Framework) evidences Haringey Clinical Group s control over the delivery of
More informationStrategic Risk Report 12 September 2016
Strategic Report September 20 Haringey CCG Register Introduction The Strategic Report (historically known as the Board Assurance Framework) evidences Haringey Clinical Commissioning Group s control over
More informationNHS Herts Valleys Clinical Commissioning Group Board Meeting 14 April 2016
NHS Herts Valleys Clinical Commissioning Group Board Meeting 14 April 2016 Title 2015/16 Annual Report and Accounts proposed approval process Agenda Item: 13 Purpose (tick one only) Decision or Approval
More informationNovember NHS Rushcliffe CCG Assurance Framework
November 2015 NHS Rushcliffe CCG Assurance Framework ASSURANCE FRAMEWORK SUMMARY No. Lead & Sub Committee Date placed on Assurance Framework narrative Residual rating score L I rating in 19 March 2015
More informationStrategic Risk Report 1 March 2018
Strategic Report 1 March 2018 Haringey CCG Register Introduction The Strategic Report (historically known as the Board Assurance Framework) evidences Haringey Clinical Commissioning Group s control over
More informationRisk Register Summary Analysis Report
1. Corporate Risk Register High risks There are 11 risks currently categorised as High, i.e. scoring 15 or more using the risk grading matrix set out in appendix 1. 1. 1819 Risk of poor patient experience
More informationNorthumberland, Tyne and Wear NHS Foundation Trust. Board of Directors Meeting
Agenda item 7 iv) Northumberland, Tyne and Wear NHS Foundation Trust Meeting Date: 22 February 2017 Board of Directors Meeting Title and Author of Paper: Safer Staffing Quarter 3 Report (October December,
More informationEAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST
EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS MEETING DATE: 29 JANUARY 2015 SUBJECT: REPORT FROM: PURPOSE: CQC ACTION PLAN CHAIR OF IMPROVEMENT PLAN DELIVERY BOARD Discussion
More informationTHE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST. Board Paper - Cover Sheet
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Board Paper - Cover Sheet Date 19 th December 2017 Lead Director Report Title Nursing & Midwifery Staffing Three- Monthly Summary Nursing & Patient
More informationPathology Quality Review : Outcomes and Update
Pathology Quality Review : Outcomes and Update Dr Ian Barnes UK NEQAS (H) 17 th Annual Meeting National Motorcycle Museum Tuesday 14 th October, 2014 The Review Launched January 28 th, 2014. (england.pathqareview@nhs.net)
More informationPolicy Register No: Status: Public NURSING STAFFING SHORTFALL ESCALATION POLICY. NICE Guidelines July 2014 CQC Fundamental Standards: 17
NURSING STAFFING SHORTFALL ESCALATION POLICY Policy Register No: 09114 Status: Public Developed in response to: National Quality Board Recommendations2013 NICE Guidelines July 2014 CQC Fundamental Standards:
More informationNorfolk and Suffolk NHS Foundation Trust mental health services in Norfolk
Norfolk Health Overview and Scrutiny Committee 7 December 2017 Item no 6 Norfolk and Suffolk NHS Foundation Trust mental health services in Norfolk Suggested approach by Maureen Orr, Democratic Support
More information: Geraint Davies, Director of Commercial Services
Report to : Trust Board of Directors Date of Report: 15/05/2015 Agenda Item: 0/15 Date of Meeting : 28 May 2015 Subject Report from Purpose : Report on Corporate Risk Register : Geraint Davies, Director
More informationReport to the Board of Directors 2015/16
Attachment 9 Report to the Board of Directors 2015/16 Date of meeting 18 Subject Report of Prepared by Seven Day Services Medical Director Ashling Rivá, Project Manager Previously considered by Transformation
More informationImprove, Inspire, Innovate Quality Improvement Plan
Improve, Inspire, Innovate Quality Improvement Plan 1 QIP Final version 20170706 Contents Background & Summary Page 3 Who is Responsible? Page 4 How will we communicate our progress to you? Page 4 Chair
More informationEXECUTIVE SUMMARY REPORT TO THE BOARD OF DIRECTORS HELD ON 22 MAY Anne Gibbs, Director of Strategy & Planning
EXECUTIVE SUMMARY D REPORT TO THE BOARD OF DIRECTORS HELD ON 22 MAY 2018 Subject Supporting TEG Member Author Status 1 A review of progress against Corporate Objectives 2017/18 and planned Corporate Objectives
More informationTrust Board Meeting: Wednesday 13 May 2015 TB
Trust Board Meeting: Wednesday 13 May 2015 Title Update on Quality Governance Framework Status History For information, discussion and decision This paper has been presented to Quality Committee in April
More informationStatus: Information Discussion Assurance Approval. Claire Gorzanski, Head of Clinical Effectiveness
Report to: Trust Board Agenda item: Date of Meeting: 2 October 2017 SFT3934 Report Title: Annual quality governance report 2016-2017 Status: Information Discussion Assurance Approval X Prepared by: Executive
More informationQuality Assurance Committee Annual Report April 2017 March 2018
Quality Assurance Committee Annual Report April 2017 March 2018 Quality Assurance Committee Annual Report April 2017 March 2018 1. Introduction The role of the quality assurance committee is to provide
More informationRTT Assurance Paper. 1. Introduction. 2. Background. 3. Waiting List Management for Elective Care. a. Planning
RTT Assurance Paper 1. Introduction The purpose of this paper is to provide assurance to Trust Board in relation to the robust management of waiting lists and timely delivery of elective patient care within
More informationDocument Details Title
Document Details Title Quality and Equalities Impact Assessment (QEIA) Process Guidance Trust Ref No 2046-45852 Local Ref (optional) Main points the document This document explains the process for QEIA,
More informationRQIA Provider Guidance Nursing Homes
RQIA Provider Guidance 2016-17 Nursing Homes www.r qia.org.uk A s s u r a n c e, C h a l l e n g e a n d I m p r o v e m e n t i n H e a l t h a n d S o c i a l C a r e What we do The Regulation and Quality
More informationThe Care Values Framework
The Care Values Framework 2017-2020 1 States of Guernsey An electronic version of the framework can be found at gov.gg/carevaluesframework Contents Foreword from the Chief Secretary Page 05 Chief Nurse
More informationWhy do we need this project? What is Mouth Care Matters? Why Does it Matter? Mary. Oral Health Champion Volunteers. August 2018
This month, I am pleased to inform you about this important project, Mouth Care Matters, and am proud to support the Dental Service within the MaxilloFacial Department as the Executive Lead on this. 1
More informationVisit to Hull & East Yorkshire Hospitals NHS Trust
Yorkshire and the Humber regional review 2014 15 Visit to Hull & East Yorkshire Hospitals NHS Trust This visit is part of a regional review and uses a risk-based approach. For more information on this
More informationTHE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST. Board Paper - Cover Sheet
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Board Paper - Cover Sheet Date September 2017 Lead Director Report Title Nursing & Midwifery Staffing Three- Monthly Summary Nursing & Patient Services
More informationT Organisational Risk Register
Foundation Trust Board of Directors 29 March 2017 T Organisational Register Situation At each meeting the Board receives the summary Organisational Register (ORR) highlighting any risk changes and updates
More informationWe are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.
Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Liverpool Heart & Chest Hospital NHS Foundation Trust Thomas
More informationStrategic KPI Report Performance to December 2017
Strategic KPI Report Performance to December 2017 Trust Board 25 th January 2018 Strategic KPI summary SROs: All Directors Objective KPI SRO Target Apr May Jun Jul Aug Sep Oct Nov Success Is Deliver A
More informationESHT Our ambition to be outstanding by 2020
ESHT 2020 Our ambition to be outstanding by 2020 June 2018 1 Contents Page 3 Page 4 Page 6 Page 8 Background 2017/18 progress Vision, values and objectives CQC ratings Page 10 What we will have achieved
More informationIntegrated Performance Committee Assurance Reports, January 2016 and December 2015 Crishni Waring, Chair, IPC Committee
EPB53/825 Title of Report: Prepared By: Sponsor: Action Required: Integrated Performance Committee Assurance Reports, January 2016 and December 2015 Crishni Waring, Chair, IPC Committee Gale Hart, Director
More informationDate of publication:june Date of inspection visit:18 March 2014
Jubilee House Quality Report Medina Road, Portsmouth PO63NH Tel: 02392324034 Date of publication:june 2014 www.solent.nhs.uk Date of inspection visit:18 March 2014 This report describes our judgement of
More informationAgenda Item number: 9.1. Maggie Bayley, Director of Nursing and Quality
Board meeting date: 15 December, 2011 Agenda Item number: 9.1 Enclosure: 6 Title Quality report Accountable Director: Authors(name & title): Maggie Bayley, Director of Nursing and Quality Maggie Bayley,
More informationNHS GRAMPIAN. Grampian Clinical Strategy - Planned Care
NHS GRAMPIAN Grampian Clinical Strategy - Planned Care Board Meeting 03/08/17 Open Session Item 8 1. Actions Recommended In October 2016 the Grampian NHS Board approved the Grampian Clinical Strategy which
More informationQUALITY COMMITTEE. Terms of Reference
QUALITY COMMITTEE Terms of Reference CONSTITUTION 1. The Board of Directors approved the establishment of the Quality Committee (known as the Committee in these terms of reference) for the purpose of:
More informationBoard of Directors Meeting 6 April Agenda item 31/16
Board of Directors Meeting 6 April 2016 Agenda item 31/16 Title Sponsoring Director Author Purpose Executive Summary: Recruitment Update Mary Foulkes, Director of OD and HR Niki Butler, Interim Resourcing
More informationQuality & Safety Sub-Committee
Quality & Safety Sub-Committee Agenda Item QS/029/16 Date: 17/03/2016 Report Title FOIA Exemption Prepared by Presented by Action required Supporting Executive Director Safer Staffing No Exemption Janet
More informationSafe Staffing: The New Zealand Public Health Sector Experience
Safe Staffing: The New Zealand Public Health Sector Experience Jane Lawless February 2014 The NICE Safe Staffing Advisory committee has been given a number of primary tasks: The SSAC will advise NICE on
More informationImprovement and assessment framework for children and young people s health services
Improvement and assessment framework for children and young people s health services To support challenged children and young people s health services achieve a good or outstanding CQC rating February
More informationReviewing and Assessing Service Redesign and/or Change Proposals
Reviewing and Assessing Service Redesign and/or Change Proposals RCN guidance CLINICAL PROFESSIONAL RESOURCE Acknowledgements Helen Donovan, RCN Professional Lead for Public Health Nursing David Dipple,
More informationAssociate Director of Patient Safety and Quality on behalf of the Director of Nursing and Clinical Governance
APPENDIX 5 BOARD OF DIRECTORS 18 JUNE 2014 Report to: Report from: Subject: Board of Directors Associate Director of Patient Safety and Quality on behalf of the Director of Nursing and Clinical Governance
More informationBusiness Case Authorisation Cover Sheet
Business Case Authorisation Cover Sheet Section A Business Case Details Business Case Title: Directorate: Division: Sponsor Name Consultant in Anaesthesia and Pain Medicine Medicine and Rehabilitation
More informationQUALITY IMPROVEMENT PLAN 2017
QUALITY IMPROVEMENT PLAN 2017 Contents Introduction 3 Trust Profile 4 Single Item Quality Surveillance Group meeting 5 CQC Report Findings 2017 6 Trust Board Response 8 Developing a Culture of Continuous
More informationQUALITY STRATEGY
NHS Nene and NHS Corby Clinical Commissioning Groups QUALITY STRATEGY 2017-2021 Approved: By the Joint Quality Committee on 11 April 2017 Ratified: By the NHS Corby Clinical Commissioning Group on 25 April
More informationA fresh start for registration. Improving how we register providers of all health and adult social care services
A fresh start for registration Improving how we register providers of all health and adult social care services The Care Quality Commission is the independent regulator of health and adult social care
More informationItem E1 - Bart s Health Quality Indicators
Item E1 - Bart s Health Quality Indicators 1.0 Purpose 1.1 The purpose of this report is to provide the CCG Board with an update on quality matters across pertaining to our main local Provider organisations.
More informationQuality and Safety Improvement Strategy
Quality and Safety Improvement Strategy 2016-2021 Page 1 of 20 1. Purpose of this Strategy Patient safety and quality of care are at the heart of the NHS agenda. Treating and caring for people in a safe
More informationThe new CQC approach to hospital inspection. Ann Ford Head of Hospital Inspection (North West) June 2014
The new CQC approach to hospital inspection Ann Ford Head of Hospital Inspection (North West) June 2014 1 Our purpose and role Our purpose We make sure health and social care services provide people with
More informationGOVERNING BOARD. Governing Board Assurance Framework. Date of Meeting 16 March 2016 Agenda Item No 6. Title
GOVERNNG BOARD Date of Meeting 16 March 2016 Agenda tem No 6 Title Governing Board Assurance Framework Governing Board members reviewed the GBAF s and process at a development session on 10 February 2016.
More informationSHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY BOARD OF DIRECTORS 17 MAY Kirsten Major, Deputy Chief Executive
SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY BOARD OF DIRECTORS 17 MAY 2017 Subject: Corporate Strategy 2017-2020 and Corporate Objectives for 2017/18. Supporting TEG Member: Authors:
More informationEMPLOYEE HEALTH AND WELLBEING STRATEGY
EMPLOYEE HEALTH AND WELLBEING STRATEGY 2015-2018 Our community, we care, you matter... Document prepared by: Head of HR Services Version Number: Review Date: September 2018 Employee Health and Wellbeing
More informationAintree University Hospital NHS Foundation Trust Corporate Strategy
Aintree University Hospital NHS Foundation Trust Corporate Strategy 2015 2020 Aintree University Hospital NHS Foundation Trust 1 SECTION ONE: BACKGROUND AND CONTEXT 1 Introduction Aintree University Hospital
More informationDelivering Improvement in Practice
v Delivering Improvement in Practice NHS Providers Governance Conference 7 July 2016 Sir Mike Aaronson Chairman, Frimley Health NHS Foundation Trust 2006-2016 Frimley Health FT Comprises: Frimley Park
More informationTRUST BOARD SEPTEMBER Surgical Services Reconfiguration
def Agenda item: 8 (i) TRUST BOARD SEPTEMBER 2011 Surgical Services Reconfiguration PURPOSE: PREVIOUSLY CONSIDERED BY: To provide the Trust Board with an update on plans to reconfigure the Trust s surgical
More informationFT Keogh Plans. Medway NHS Foundation Trust
FT Keogh Plans Medway NHS Foundation Trust July 2014 KEY Delivered On Track to deliver Some issues narrative disclosure Not on track to deliver Medway - Our improvement plan & our progress What are we
More informationQuality Strategy
Quality Strategy 2017-2020 Contents 05 Foreword 06 Introduction 06 Equality & Diversity 07 Context for this Strategy 08 Definition of Quality 10 Quality Objectives 10 Strategic Quality Objectives 16 Quality
More informationQuality and Safety Strategy
Quality and Safety Strategy 2017-2020 Vision statement ESHT combines community and hospital services to provide safe, compassionate, and high quality care to improve the health and wellbeing of the people
More information1st Class Care Solutions Limited Support Service
1st Class Care Solutions Limited Support Service Ramsey House Fairbairn Place Livingston EH54 6TN Telephone: 01506 412698 Type of inspection: Unannounced Inspection completed on: 20 February 2017 Service
More informationHow CQC monitors, inspects and regulates NHS GP practices
How CQC monitors, inspects and regulates NHS GP practices March 2018 Updates to this guidance since October 2017: NEW annual provider information collection (for practices rated as good and outstanding)
More informationConsultant Radiographers Education and CPD 2013
Consultant Radiographers Education and CPD 2013 Consultant Radiographers Education and Continuing Professional Development Background Although consultant radiographer posts are relatively new to the National
More informationis asked to NOTE the update provided on fragile services.
Recommendation DECISION NOTE (select) Reporting to: The Trust Board is asked to NOTE the update provided on fragile services. Trust Board Date Thursday 27 th July 2017 Paper Title Brief Description Services
More informationEAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST
EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 7 AUGUST 2015 SUBJECT: REPORT FROM: PURPOSE: CHIEF EXECUTIVE S REPORT CHIEF EXECUTIVE Decision CONTEXT / REVIEW HISTORY
More informationRISK MANAGEMENT EXPERT SUPPORT TO MANAGE RISK AND IMPROVE PATIENT SAFETY
RISK MANAGEMENT EXPERT SUPPORT TO MANAGE RISK AND IMPROVE PATIENT SAFETY medicalprotection.org +44 (0)113 241 0359 or +44 (0)113 241 0624 RISK MANAGEMENT EXPERT SUPPORT TO MANAGE RISK AND IMPROVE PATIENT
More informationNHSi June 2016)and integrated business plan completed (submitted to TDA in February 2014) NHSi Plan submitted 2016.
1604 Executive 18/06/2014 1603 Executive 18/06/2014 Finance - Fin. Management 1491 Responsiveness 29/08/2013 ED - Adult Involvement of Service Users 11//2017 Failure to maintain Emergency Department performance
More informationHealth and Safety Strategy
NHS Newcastle Gateshead Clinical Commissioning Group Health and Safety Strategy Document Status Equality Impact Assessment Document Ratified/Approved By Final No impact Quality, Safety and Risk Committee
More informationRTT Recovery Planning and Trajectory Development: A Cambridge Tale
RTT Recovery Planning and Trajectory Development: A Cambridge Tale Linda Clarke Head of Operational Performance Addenbrooke s Hospital I Rosie Hospital Apr 2014 May 2014 Jun 2014 Jul 2014 Aug 2014 Sep
More informationReport of the Care Quality Commission. May 2017
Report of the Care Quality Commission May 2017 1. Purpose 1.1 The purpose of this report is to formally confirm the findings of the Care Quality Commission (CQC) following its inspection in October 2016;
More informationNHS GP practices and GP out-of-hours services
How CQC regulates: NHS GP practices and GP out-of-hours services Appendices to the provider handbook March 2015 Contents Appendix A: Population group definitions... 3 Older people... 3 People with long-term
More informationAvon and Wiltshire Mental Health Partnership NHS Trust
Avon and Wiltshire Mental Health Partnership NHS Trust Community-based mental health services for adults of working age Quality Report Head Office, Jenner House Langley Park Chippenham Wiltshire SN15 1GG
More informationLearning from Deaths Policy. This policy applies Trust wide
Learning from Deaths Policy This policy applies Trust wide Document control page Name of policy Learning from Deaths Policy Names of linked Learning from Deaths Procedure procedures Accountable Medical
More informationQuality Improvement Plan June 2017
Quality Improvement Plan June 2017 Contents Page Contents Page Foreward 3 Trust Profile 4 Partnership and Collaborative Working 5 Working with Partners 6 Quality Summit 6 On-going Dialogue 6 Summit Commitments
More informationStewart Mason, Emergency Planning and Resilience Officer Tom Jones, Clinical Programme Manager
Paper 8 Recommendation DECISION NOTE Reporting to: The Trust Board is asked to RECEIVE and APPROVE the Emergency Department Service Continuity Plan (Princess Royal Hospital site). Trust Board Date Thursday
More informationFlat 5 Oronsay Court Support Service
Flat 5 Oronsay Court Support Service Oronsay Court Portree IV519TL Telephone: 01478 613110 Type of inspection: Unannounced Inspection completed on: 28 September 2016 Service provided by: NHS Highland Service
More informationAction required: To agree the process by which Governors will meet with the inspection team.
Airedale NHS Foundation Trust Council of Governors: 28 th January 2016 Title: CQC Inspection Briefing Author: Jane Downes, Company Secretary As you will be aware, the Care Quality Commission ( CQC ) have
More informationStaff Story Trainee Nursing Associate
Staff Story Trainee Nursing Associate Meeting Board of Directors Date 18 September 2018 Agenda item 23 Lead Director Paula Simpson, Director of Nursing & Quality Improvement Author(s) Anna Simpson, IG
More informationYORKSHIRE AMBULANCE SERVICE NHS TRUST Quality Improvement Action Plan 23/05/1017 FINAL. Deputy/ Associate Director. Executive Director TRUST WIDE
YORKSHIRE AMBULANCE SERVICE NHS TRUST Quality Improvement Action Plan 23/05/1017 FINAL CQC findings TRUST WIDE 1.1 1.2 Ensure that at all times there are qualified experienced staff (including Staff communication
More informationNHS Nursing & Midwifery Strategy
Colchester Hospital University NHS Foundation Trust NHS Nursing & Midwifery Strategy 2015-2018 Foreword Caring with Pride is our three-year Nursing & Midwifery Strategy for Colchester Hospital University
More informationMain body of report Integrating health and care services in Norfolk and Waveney
Item 18.73a ii Norfolk and Waveney Sustainability and Transformation Plan Update for governing bodies and trust boards September 2018 Purpose of report The purpose of this paper is to update members of
More informationNot considered by the Executive Team
Agenda Item: 2.1 MENTAL HEALTH & LEARNING DISABILITIES COMMITTEE Date of Meeting: Oct 2016 Subject : Approved and Presented by: Prepared by: Other s and meetings considered at: Considered by Executive
More informationYour guide to the CQC Fundamental Standards
Your guide to the CQC Fundamental Standards RDaSH Introduction In order to get to the heart of people s experiences of care and support, the focus of the Care Quality Commission (CQC) Regulatory Framework
More informationMonthly Nurse Safer Staffing Report May 2018
Monthly Nurse Safer Staffing Report May 2018 Trust Board June 2018 Dr Shelley Dolan Chief Nurse /Chief Operating Officer 1 Monthly Nursing Report Introduction Following the investigation into Mid Staffordshire
More informationRISK MANAGEMENT STRATEGY
RISK MANAGEMENT STRATEGY Version Number 6.1 Version Date February 2018 Policy Owner Chief Executive Author Trust Risk and Patient Safety Manager First approval or date last reviewed The Risk Management
More informationPerformance and Delivery/ Chief Nurse
Governing Body 26th May 2017 Quality and Performance Report 22nd May 2017 Author: Other contributors: Executive Lead Audience Eileen Clark - Acting Director of Clinical Performance and Delivery/ Chief
More informationQuality Strategy (Refreshed March 2015)
Quality Strategy 2012-2017 (Refreshed March 2015) 1 Table of Contents 1. Executive Summary... 3 2. Drivers for improvement... 4 2.1 The Trust s ambition - vision and mission... 4 2.2 Corporate Strategy...
More informationReview of Terms of Reference of Quality Assurance Committee
Review of Terms of Reference of Quality Assurance Committee Governing Body meeting 3 May 2018 H Author(s) Sponsor Director Purpose of Paper Sue Laing, Corporate Services Risk and Governance Manager Mandy
More informationLink to Relevant CQC Domain: Safe Effective Caring Responsive Well Led
Enclosure H Safe Staffing Trust Board Item: 12 Date 29 th November 2017 Enclosure: H Purpose of the Report: This report provides the Trust Board with an update on progress with meeting the safe staffing
More informationOverall rating for this location. Quality Report. Ratings. Overall summary. Are services safe? Are services effective? Are services responsive?
John Munroe Hospital Rudyard Quality Report Horton Road Rudyard Leek Staffordshire ST13 8RU ST13 8RU Tel:01538 306244 Website:www.johnmunroehospital.co.uk Date of inspection visit: 11th January 2016 Date
More informationDELIVERING THE LONDON QUALITY STANDARDS AND 7 DAY SERVICES
Enclosure I DELIVERING THE LONDON QUALITY STANDARDS AND 7 DAY SERVICES Trust Board Meeting Item: 13 Date: 25 th May 2016 Purpose of the Report: Enclosure: I To update the Board on the Trust s current performance
More informationInternal Audit. Cardiac Perfusion Services. August 2015
August 2015 Report Assessment A A R A This report has been prepared solely for internal use as part of NHS Lothian s internal audit service. No part of this report should be made available, quoted or copied
More informationBASINGSTOKE AND NORTH HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST
BASINGSTOKE AND NORTH HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST SUMMARY This policy provides guidance for providing safe maintenance procedures for assets and buildings owned by the Trust. 1 BASINGSTOKE
More informationTitle Open and Honest Staffing Report April 2016
Title Open and Honest Staffing Report April 2016 File location WILJ2102 Meeting Board of Directors Date 25 th May 2016 Executive Summary This paper provides a stocktake on the position of South Tyneside
More informationRBCH Actions to meet CQC Essential Standards
RBCH Actions to meet CQC Essential Standards REGULATION 17 How the regulation was not being met Patients, their relatives, and staff told us about incidents where people had not been treated with dignity
More information21 March NHS Providers ON THE DAY BRIEFING Page 1
21 March 2018 NHS Providers ON THE DAY BRIEFING Page 1 2016-17 (Revised) 2017-18 (Revised) 2018-19 2019-20 (Indicative budget) 2020-21 (Indicative budget) Total revenue budget ( m) 106,528 110,002 114,269
More information2017/ /19. Summary Operational Plan
2017/18 2018/19 Summary Operational Plan Introduction This is the summary Operational Plan for Central Manchester University Hospitals NHS Foundation Trust (CMFT) for 2017/18 2018/19. It sets out how we
More informationMORTALITY REVIEW POLICY
MORTALITY REVIEW POLICY Version 1.3 Version Date July 2017 Policy Owner Medical Director Author Associate Director of Patient Safety & Quality First approval or date last reviewed July 2017 Staff/Groups
More informationEXECUTIVE MEDICAL DIRECTOR JOB DESCRIPTION. Medical Education Leads Clinical Directors (professional leadership) Director of Clinical Audit
EXECUTIVE MEDICAL DIRECTOR JOB DESCRIPTION Job Title: Accountable to: Responsible for: Executive Medical Director Chief Executive Director of Research & Development Medical Education Leads Clinical Directors
More informationQuality Improvement Scorecard February 2017
Mortality: HSMR Nat Performance continued to improve into Q3 2016/17. NB: Each month is a 12 month rolling value. I.e. Mar-16 reports the monthly average of Apr-15 to Mar-16. Mortality: HSMR (weekday)
More informationJoint Chief Nurse and Medical Director s Report Susan Aitkenhead, Chief Nurse
TRUST BOARD IN PUBLIC REPORT TITLE: Date: 28 March 2013 Agenda Item: 2.4 Joint Chief Nurse and Medical Director s Report Susan Aitkenhead, Chief Nurse EXECUTIVE SPONSOR: Dr. Des Holden, Medical Director
More information