The Shared Agenda of Group Committees in Common (CiC)

Transcription

1 Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT) The Shared Agenda of Group Committees in Common (CiC) Monday, 22 nd May 2017 at 10:00am Humphrey Booth Lecture Theatre, Mayo Building, Salford Royal, Stott Lane, SALFORD M6 8HD AGENDA: Part 1 1. Nurses Day Film 2. Chairman s Opening Remarks Chairman 3. Apologies for Absence Chairman 4. Declarations of Interest All 5. Minutes of Previous Meeting (Part 1) - Meeting held on 24 th April CEO Report, including Chief Executive Interim High-level Performance Metrics 7. PAT Improvement Plan Chief Delivery 8. PAT Transition Report Chief Delivery 9. Health Innovation Manchester Mrs Rowena Burns - Presentation at meeting 10. Salford: The Digital City - Presentation on the strategy and Chief Strategy and development of Salford City Digital Strategy Organisational Development 11. Opening Position : Chief Executive Board Assurance Frameworks/Corporate Risk Registers 11.1 SRFT 11.2 PAT 12. Directors: Standards of Business Conduct Report Group Secretary /17 Annual Report & Accounts including Group Secretary Quality Report and Annual Self Declarations 14. Group Staff Engagement Chief Strategy and Organisational Development

2 15. SRFT: SCAPE Panel Report Chief Nursing 16. Consort Bank Account Chief Finance 17. Reports from Standing Committees: 17.1 Group Audit Committee Vice-Chairman - meeting held on 28 th April Group Executive Committees: Risk and Assurance Committee - meeting held on 15 th May 2017 Chief Executive 17.3 Joint Research and Development Committee Chief Medical - meeting held on 27 th March Sealed Documents Group Secretary 19. Any other business (Part 1) 20. Date and Time of the Next Meeting: Monday, 26 th June 2017 from 10am Venue: Humphrey Booth Lecture Theatre, Level 1, Mayo Building, Salford Royal NHS Foundation Trust. Resolution: To exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be prejudicial to public interest, by reason of the confidential nature of business. The press and public are requested to leave at this point.

3 Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust Shared Minutes of Group Committees in Common - DRAFT Meeting held in Public Monday, 24 th April 2017 Humphrey Booth Lecture Theatre, 1 st Floor Mayo Building, Salford Royal. Part 1 Held in Public Monday 24 th April 2017 Humphrey Booth Lecture Theatre, Mayo Building, Salford Royal. Present: Mr Jim Potter, Chairman Sir David Dalton, Group Chief Executive Mrs Jude Adams, Group Chief Delivery Mr Chris Brookes, Group Chief Medical Mrs Diane Brown, Senior Independent Director Mrs Rowena Burns, Non-Executive Director Mr Damien Finn, Chief North Manchester Care Organisation Mrs Elaine Inglesby-Burke CBE, Group Chief Nursing Mr Raj Jain, Group Chief Strategy and Organisational Development Mrs Chris Mayer CBE, Non-Executive Director Mr Ian Moston, Group Chief Finance Dr Chris Reilly, Non-Executive Director Dr Hamish Stedman, Non-Executive Director Mr James Sumner, Chief Salford Care Organisation Mr Steve Taylor, Chief Bury & Rochdale Care Organisation Mr John Willis CBE, Vice-Chairman Mrs Jane Burns, Director of Corporate Services and Group Secretary Mrs Rebecca McCarthy, Deputy Trust Secretary Observing: Mr Andrew Lynn, Head of Communications, PAT Mrs Karen Doyle, Associate Director of Communications, SRFT Mr Stuart Logan, Assurance Framework Manager, SRFT Apologies for Absence: Mrs Donna McLaughlin, Chief Oldham Care Organisation

4 No. Item Action Welcome The Chairman welcomed everyone present to the first meeting of the Group Committees in Common and confirmed this was a shared meeting of committees established by the Boards of Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust. The Chairman confirmed that Group Committees in Common had delegated powers to consider and make decisions about operational and strategic matters relating to both Trusts. The Chairman stated that the agenda, papers and presentations from the public part of the meeting would be available via the Salford Royal and Pennine websites. He added that the meeting would have two parts: Part 1 Open to members of the public Part 2 Private session for the review of confidential matters. The Chairman informed the Group Committees in Common that the Boards of Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust would continue to meet three times a year to in May, September and December, on the same day and immediately following the meeting of Group Committees in Common. 1. Patient Story The Group Committees in Common listened to a Patient Story read by the Group Chief Nursing. Opening Matters 3. Apologies for Absence The Group Committees in Common accepted apologies for absence as recorded above. 4. Declarations of Interest The Chairman requested that s declared any actual or potential conflict of interest relevant to their role as a member of the Group Committees in Common and in particular to any matter being discussed at the meeting. There were no interests declared. 5. Minutes of Previous SRFT and PAT Boards a) Salford Royal NHS Foundation Trust The Chairman confirmed that Part 1 of the Board of Directors meeting held on 27 th March 2017 had been open to members of the public. The draft minutes recorded of that session were presented to the Group Committees in Common for information. b) Pennine Acute Hospitals NHS Trust The Chairman confirmed that Part 1 of the Board of Directors meeting held on 30 th March 2017 had been open to members of the public. The draft minutes recorded of that session were presented to the Group Committees in Common

5 No. Item Action for information. The Vice-Chairman highlighted a correction to Minute 24/17, to be recored as achieved its CIP target for 2016/17. The Vice-Chairman referred to Minute 25.17; he expressed his view that achieving the planned agency costs in would be a significant challenge, and a matter that the Group Committees in Common should focus attention. The Senior Independent Director referred to Minute 29/17; she commented that she had emphasised the importance of prioritising the priority actions and ensuring that performance management was effective which would in itself improve staff engagement. The Senior Independent Director requested inclusion of this discussion within the final minutes. 6. Matters Arising No matters arising. 7. CEO Report including the SRFT and PAT Integrated Board Performance Dashboard The Group Chief Executive confirmed that the reports were presented to the first meeting of the Group Committee in Common in the familiar format from both SRFT and PAT. 7.1 Year-end Financial Positions - SRFT and PAT The Group Chief Executive reported that the year-end financial position for SRFT was significantly better than planned and that these positions were expected to improve further with additional reward STF funding from NHS Improvement (NHSI) to be notified on the 24th April. He confirmed that the year-end position for SRFT was a surplus of 0.5m; against a planned deficit of 4.3m and that the year-end position for PAT was a deficit of 3.9m; against a planned deficit of 15.9m. The Group Chief Executive commended the leadership at both organisations in attaining the financial positions. The Group Chief Executive reported that the planned Use of Resources ratings had been achieved for SRFT and PAT; 2 and 3 respectively. 7.4 Key Performance Indicators SRFT A&E 4 hour Standard (95% Standard) The Group Chief Executive confirmed that the A&E 4 hour standard had not been achieved (84.7%, March 17). He commented that an improvement in this position was anticipated in line with the implementation of additional bed capacity and development of relationships with care home providers and home care, facilitating a reduction in delayed transfers of care (DToC). In response to the Vice-Chairman querying the timeline for additional bed capacity, the Chief of the Salford Care Organisation confirmed this was planned for the end of May, highlighting that due to staffing implications the additional beds may initially be utilised for escalation. A Non-Executive Director acknowledged that the delayed transfers of care largely affected Salford patients, and sought further information on this matter.

6 No. Item Action The Group Chief Executive confirmed an improving position, highlighting the current position of 3-4% of patients with DToC. He added that the Greater Manchester indicator was less than 3.5%. The Chief of the Salford Care Organisation reiterated the current position, noting that this had reduced by 1-2% within the previous two week period. He confirmed that this position was the result of additional home care hours during April and some reduction in the number of patients admitted. In response to a Non-Executive Director seeking further information regarding the integral role of rostering on this issue, the Chief of the Salford Care Organisation confirmed focussed work was underway, in partnership with the Intensive Support Team to explore different models of support and bed management PAT A&E 4 hour Standard (95% Standard) The Group Chief Executive reported that, although an incrementally improving position, there continued to be difficulties achieving the A&E 4 hour standard. He highlighted that all sites had achieved an improvement on the February position, with the exception of North Manchester which continued to be particularly challenging. The Group Chief Executive expressed his disappointment that there had been 73 reported 12 hour breaches in March, the majority taking place at North Manchester due to an inability to admit to the Acute Assessment Ward. He confirmed the agreed plan to open additional assessment beds from July which was anticipated to reduce the position. The Group Chief Executive added that provisional figures for April to date included 29 breaches (25 at North Manchester and 4 at Royal Oldham Hospital) and that there would remain a key focus on avoiding any 12 hour trolley waits. Noting the number of 12 hour trolley waits to date, the Senior Independent Director queried the target for North Manchester and Oldham specifically, and the timescales to achieve this target. The Group Chief Executive confirmed a declining trajectory, highlighting that almost all occurrences at North Manchester were due to the low number of acute assessment beds. He stated that the ability to open more beds was subject to the move of Orthopaedics to Bury which would not be effective until the end of July. The Group Delivery expressed her view that zero 12 hour trolley waits was not an unrealistic target and reiterated that this should be possible, however only following the aforementioned changes SRFT Infection Control The Group Chief Executive reported that all infection control targets had been achieved PAT Infection Control The Group Chief Executive stated that there had been 58 C-Difficile cases up to end of March 2017, 3 above the year-end target of <55. He confirmed the Group Chief Medical was leading action to address this PAT Single Sex Accommodation Breaches The Group Chief Executive confirmed that PAT had experienced a number of single sex accommodation breaches in year, highlighting that all breaches were as a result of delayed step down from critical care, not men and women sharing the same accommodation in a ward environment Other Key Performance Indicators

7 No. Item Action Further discussion took place as follows: A Non-Executive Director referred to sickness absence performance at SRFT and highlighted the incorrect rating, noting that this should be red. In addition, the Non-Executive Director queried if the Registered Staff Day/Night Time were rated appropriately. The Group Chief Nursing provided contextual information and confirmed that nurse staffing levels standards were set appropriately (80%), and confirmed that the Registered Staff Day Time should be rated as red not amber. The Senior Independent Director referred to PDR performance at PAT; she acknowledged the improved performance from the previous year, yet noted the limited progress since December The Senior Independent Director sought further information regarding the directive to improve performance to divisions within each of the Care Organisations. The Group Chief Strategy and Organisational Development fully acknowledged the comments, cautioning that a disparity between locally and corporately held data had been identified that required resolution. The Chief Executive for the Bury & Rochdale Care Organisation echoed these comments; he confirmed that lengthy discussion had taken place at divisional level, stressing the 90% target and offered that the local position was not reflective of the corporately reported position. A Non-Executive Director recognised the signs of improvement in mortality at PAT and requested further information with respect to the issues contributing to the mortality performance and how they were being addressed. The Group Chief Medical referred to a number of initiatives taking place across PAT with respect to mortality and specifically highlighted the necessity to provide standardised care practice including reliable hand-over between teams and communication of care decisions. He acknowledged the importance of the Group Committees in Common comprehensively reviewing this matter and confirmed that he would provide a report to the Group Committees in Common in due course. A Non-Executive Director referred to the well-versed improvement plans to address urgent care performance at Salford and North Manchester. She commented that performance at the Oldham Care Organisation was also below target and sought further information regarding improvement plans in place in the other Care Organisations. The Group Chief Executive confirmed that plans were in place for each locality including contribution from the respective Care Organisations, Local Authority and Clinical Commissioning Group; and agreed at a Greater Manchester level. He confirmed that a summary for each of locality would be shared. The Group Chief Medical stated that focus had been given to ensuring safe A&E services across all Care Organisations and provided assurance with respect to the safety of A&E services in Oldham. He confirmed that focus would now be given to ensuring timely flow of patients through the department. Group Chief Medical Group Chief Delivery A Non-Executive Director queried if patient outcomes on wards using a higher proportion of agency staff had been measured, perhaps considering agency spend versus length of stay in order to provide assurance that patient care was not being adversely affected. The Group Chief Nursing confirmed that there was a direct line of sight to wards employing higher levels of bank and agency staff, highlighting known wards in the SRFT & PAT organisations. She commented that review of incidents and triangulation with the Nursing

8 No. Item Action Assessment and Accreditation System (NAAS) provided visibility of quality related outcomes at ward level, and that the SRFT Staffing Levels dashboard included bed occupancy and length of stay for each ward. She expressed her view that it was not possible to determine direct cause and effect between use of agency staff and quality of patient care, due to the number of variables, fully acknowledging that the indicators on the SRFT Staffing Levels dashboard may act as a trigger. The Group Chief Strategy and Organisational Development commented that the ratio of contracted and non-contracted staff can be easily identified, and informed the Group Committees in Common that this is more challenging to attribute at Speciality Doctor level. The Group Chief Nursing stressed that staffing issues remained a significant concern for both organisations and referred to the development of a staffing heat-map to clearly identify wards/departments with high use of bank and agency staff. The Group Chief Executive shared his concern regarding wider clinical staffing issues and commented that the Group must remain alert to the monies being spent and the care being received. The Senior Independent Director suggested further discussion at an appropriate time with respect to safe staffing levels/ratios alongside workforce planning. In response to a Non-Executive Director asking to what extent the introduction of Trendcare and the Digital Health and Care Control Centre would allow production of information, the Group Chief Strategy and Organisational Development confirmed that Trendcare and the digitisation programme were providing significant additional information on processes of care. He added the use of applications and development of algorithms that utilise this data in a way that enables improvement in care process is in development and through this, it is expected that care outcomes will improve. 7.5 Pennine Improvement Board The Group Chief Executive confirmed the Pennine Improvement Board met monthly, chaired by Jon Rousse, to review progress against actions identified in the CQC Inspection. He added that focus at April s Improvement Board had been on the fragile urgent care service at North Manchester. The Group Chief Executive informed the Group Committees in Common that NHS Improvement (NHSI) had confirmed investment to support the Improvement Plan and had also offered the further support of an NHSI Improvement Director whose expertise was in organisational development. The Group Chief Executive confirmed that the Trust s CQC Engagement Manager was undertaking a formal visit to North Manchester on 24th April and that it was anticipated an unannounced CQC Inspection would take place in 6-8 weeks. The Group Chief Nursing confirmed that she had spoken to CCGs in the North East sector, including Central and North Manchester, who had confirmed their involvement. The Group Chief Executive confirmed that the North Manchester Strategy Board had been established and met for its inaugural meeting in March. He confirmed the remit of the North Manchester Strategy Board was to determine the vision and service proposition for site, have oversight of estate development, including disposal of surplus land, and allow discussion with staff and the local population. In response to the Vice-Chairman querying the organisations represented on the North Manchester Strategy Board, the Group Chief Executive confirmed, in addition to himself, representation from Manchester City Council, Central Manchester NHS Foundation Trust, Bury CCG, Rochdale Local Authority, Greater Manchester Mental Health NHS Foundation Trust and the Partnership Board. In response to the Chairman

9 No. Item Action querying the timetable for the North Manchester site, the Group Chief Executive confirmed the intention to develop a roadmap, included timescales, in the following three months. 7.6 Strategic Matters Management Agreement The Group Chief Executive confirmed that the Management Agreement to support Pennine Acute Hospitals NHS Trust was in place Development of Integrated Care Organisations (ICO) / Local Care Organisations (LCOs) The Group Chief Executive informed the Group Committees in Common that the Salford ICO team continued to take forward the agreed transformation priorities and were now co-located with Salford Primary Care Together to accelerate implementation. The Senior Independent Director referred to recent discussion at the Council of Governors Strategic Direction Subgroup, and relayed some hesitation from Governors with respect to the neighbourhood approach not providing a standard offering and reliability across neighbourhoods. The Chief of the Salford Care Organisation provided assurance that a standard operating model blueprint would be in place, that could be tailored to meet the specific needs of the neighbourhoods it served. Primary Care Streaming The Group Chief Executive informed the Group Committees in Common that NHS England had invited bids from acute trusts for capital to support the delivery of the national primary care streaming approach. He stated that formal notification had not yet been received, however anecdotally he had been informed that the capital bid submitted for Salford had been successful. In response to the Vice-Chairman seeking information regarding the differences this would make to the current system, the Group Chief Executive confirmed that this development would provide a front facing primary care service for all patients attending A&E unless they required Trauma or Stroke services. In response to a Non-Executive Director querying if this was a proven model to address pressures in A&E, the Group Chief Executive confirmed the Dunstable model had been implemented successfully in other organisations. Greater Manchester Major Trauma Centre The Group Chief Executive reported that implementation of the Trauma Centre continued; highlighting that progress was inhibited by the requirement of additional capacity. He confirmed that the capital proposal for Major trauma and Healthier Together had been supported by the Greater Manchester H&SSC Partnership Board and is awaiting a decision on the allocation of national capital. North West Sector The Group Chief Executive provided an overview of North West Sector developments in: General Surgery Breast Services Paediatric Services Elective Orthopaedics Maternity Services

10 No. Item Action The Chairman queried if an alternative site for the Salford Ante/Post Natal clinics and Midwifery Lead Unit (MLU) had been identified. The Group Chief Executive confirmed a site had been identified, noting that Salford City Council had indicated a three month delay in the site becoming operational. He stated that the Board had, at the March Board Meeting, reaffirmed its position that the 1 st October deadline for transferring the MLU to new accommodation should be adhered to in order to provide access to clinical service capacity. North East Sector The Group Chief Executive provided an overview of North Eest Sector developments in: General Surgery North East Sector Acute Strategy Transformation Proposals Manchester LCO In response to a Non-Executive Director seeking further information regarding the development of Local Care Organisations in the North East sector localities, and querying the scope of Non-Executive Director engagement in the developing proposals, the Group Chief Executive confirmed that work had been initiated to develop a more consistent approach to integrated care and shape proposals within Local Care Organisations. He confirmed that the Oldham model of care was more developed in its thinking at this time. The Group Chief Executive highlighted that as SRFT was proposed as the Lead Provider for the Salford Integrated Care Organisation, this required significant scrutiny and review by the Board of Directors. He confirmed that a separate briefing regarding the development of the Local Care Organisations would be provided at the appropriate time. The Vice-Chairman conveyed encouraging discussion at the Council of Governors Strategic Direction Subgroup as to how the leadership team would develop quality and improve standards in Care Homes. Group Chief Executive The Senior Independent Director asked if consideration had been given as to how and when Divisions would present to the Group Committees in Common, noting the valuable discussions emerging from these presentations. The Group Chief Executive commented that Care Organisations would present to Group Committees in Common as part of the reporting schedule.

11 No. Item Action 15. Any other business No other business. 16. Date and Time of the Next Meeting The Chairman confirmed that the next meeting would take place on Monday, 22 nd May 2017 from 2pm at Humphrey Booth Lecture Theatre, Mayo Building. Closure of Part 1 of the Group Committees in Common Meeting 17. Exclusion of the Public The Group Committees in Common resolved to exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be inappropriate, by reason of the sensitive and confidential nature of business. Members of the public were requested to leave the meeting room at this point.

12 Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute Hospitals NHS Trust (PAT) Title of Report Standing Financial Instructions Meeting Author Presented by Shared Board Meeting of SRFT & PAT Joe Lever, SRFT Head of Procurement Joe Lever, SRFT Head of Procurement Date 22 nd May 2017 Executive Summary Principal Associated Risks Recommendations This report confirms amendments to the Standing Financial Instructions that govern the Trusts procurement activities. 5. Delivery of Mandatory Standards N/A The SRFT and PAT Boards are asked to approve the below amendments to the Standing Financial Instructions: Adopt Pennine Acute Hospitals NHS Trust (PAT) Quotation/Tender limits for all Care Organisations that the new threshold should be as PAT s i.e. excluding VAT Quotation waivers should be signed off Procurement Director/Chief Procurement and tender waivers signed by either Chief Financial or Director of Finance of Care Organisation s whether it is revenue or capital non-pay. That the Standing Financial Instructions are amended stipulating a more generic term for this such as applicable OJEU threshold for both Foundation Trusts and NHS Trusts. Terminology such as this covers off both values and then wouldn t require amendments every 2 years as thresholds change. Public and/or Patient Involvement (Including equality related impacts) N/A Communication N/A

13 Freedom of Information Please indicate appropriate box below A This document is for full publication X B This document contains FoIA exempt information C This whole document is exempt under the FoIA If you have chosen B above, highlight the information that is to be redacted within the document for subsequent removal. Confirm to the Group Secretary which applicable exemptions apply to the whole document or to highlighted sections. 1. Introduction This report is to make amendments to the current Standing Financial Instructions that govern Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute Hospitals NHS Trusts (PAT) procurement activities; the proposed amendments are set out below. 2. Standing Financial Instructions As part of the integration between SRFT and PAT it was agreed to standardise Standing Financial Instructions (SFI s) for all Care Organisations. There are a number of areas which require amendments in order to ensure the application of the SFI s is possible, practical and appropriate. The proposed amendments below relate to the following: Quotation/Tender limits Approval of Waivers Adjustment to EU Threshold value The previous limits for both organisations were as follows: Quotations/Tender limits SRFT: Up to 10k 2 verbal quotations* 10-25k 3 formal quotations* 25k EU threshold formal tender process* Salford s threshold include VAT PAT: Up to 15k 2 verbal quotations* 15-50k 3 formal quotations* 50k EU threshold formal tender process* PAT s exclude VAT

14 *All of the above aren t mandatory or applicable if there is an appropriate framework agreement that can be utilised and demonstrate value for money. Currently the revised SFI s are in line with SRFT s however given that both organisations are now procuring jointly this will increase the value of orders and contracts as part of joint exercises subsequently this will increase the aggregated value of these contracts. Therefore, adopting PAT s limits for quotation and tender exercises will ensure that practically the procurement team across all care organisations can ensure competitive procurement processes are undertaken within a reasonable timeframe but also demonstrate value for money that will deliver the goods/services that each of the Care Organisations require. When benchmarking these limits with other similar sizes Trusts their tender thresholds are the same as what PAT s were previously. Approval of Waivers Within the revised SFI s it stipulates that only the Chief Financial can sign off quotation and tender waivers related to revenue non-pay expenditure but that the Chief Financial or the Director of Finance for CO s can approve capital waivers for quotation and tender waivers. Previously at Salford quotation and tender waivers are signed off by the Procurement Director and Director of Finance. At PAT the quotation waivers are signed off by the Divisional Managing Director or Clinical Director; tender waivers are signed off by the Director of Finance. The proposed way forward is as follows: Quotation waivers purchases between 15-50k are signed off by the Procurement Director/Chief Procurement or Care Organisation Director of Finance Tender waivers purchases above 50k are signed off by the Chief Finance or Care Organisation Director of Finance The approval of waiver forms for all non-pay related purchases whether revenue or capital should be delegated to the appropriate people as above with no differentiation between revenue and capital. Adjustment to EU Threshold value Within EU law and Public Contract Regulations 2015 this legislation states that public sector organisations are required to market test opportunities within the Official Journal of European Union (OJEU) should they go above a specific financial value. These values are different depending on the type of public sector body, what is being procured (goods, services or works) and are revised every two years. The currently legislation states that the EU threshold limit for FT s is 164,176 which would apply to Salford and non FT s is 106,047 which would apply to Pennine. The revised SFI s state that wavering of quotations & tenders is up to the value EU procurement threshold 164,176 ( 209,000). This isn t applicable to PAT as they aren t a Foundation Trust and they must work to a lower limit of 106, Conclusion In summary, the following recommendations are submitted to the Board of Directors for approval: Adopt PAT Quotation/Tender limits for all Care Organisations that the new threshold should be as Pennine s i.e. excluding VAT

15 Quotation waivers should be signed off Procurement Director/ Chief Procurement and tender waivers signed by either Chief Financial or Director of Finance of CO s whether it is revenue or capital non-pay. That the SFI s are amended stipulating a more generic term for this such as applicable OJEU threshold for both Foundation Trusts and NHS Trusts. Terminology such as this covers off both values and then wouldn t require amendments every 2 years as thresholds change.

16 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Harms Salford HSMR Rolling 12 Month FairfieldHSMR Rolling 12 Month /15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q Rochdale HSMR Rolling 12 Month 40 Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma /15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 North Manchester HSMR Rolling 12 Month Oldham HSMR Rolling 12 Month Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma HSMR - Rolling 12 months Salford Royal Foundation Trust Pennine Acute Hospitals Trust 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q

17 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Harms Salford SHMI Quarterly Fairfield SHMI Quarterly 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 Rochdale SHMI Quarterly 40 Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma 20 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 North Manchester SHMI Quarterly Oldham HSMR Rolling 12 Month Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma SHMI - Quarterly Salford Royal Foundation Trust Pennine Acute Hospitals Trust 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q

18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Harms Salford Safety Thermometer % of All Harms Bury & Rochdale Safety Thermometer % of All Harms 100% 99% 100% 99% 98% 97% 96% 95% 94% 93% 98% 97% 96% 95% 94% 93% 92% 91% 90% 92% 91% 90% Actual Target Actual Target North Manchester Safety Thermometer % of All Harms Oldham Safety Thermometer % of All Harms 100% 99% 98% 100% 99% 98% 97% 96% 95% 94% 93% 92% 91% 90% 97% 96% 95% 94% 93% 92% 91% 90% Actual Target Actual Target Safety Thermometer Salford Royal Foundation Trust Pennine Acute Hospitals Trust Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr % 97.4% 97.3% 98.0% 97.7% 96.8% 97.8% 96.7% 97.8% 98.3% 97.8% 95.8% 97.7% 93.72% 95.7% 94.33% 93.75% 95.4% 95.9% 94.19% 94.66% 94.66% 93.97% 94.85% 94.99% 98.6%

19 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Urgent Care Salford A&E 4 Hour Performance Bury & Rochdale A&E 4 Hour Performance 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Actual Trajectory Actual Trajectory North Manchester A&E 4 Hour Performance Oldham A&E 4 Hour Performance 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Actual Trajectory Actual Trajectory A&E 4 Hour Performance Salford Royal Foundation Trust Pennine Acute Hospitals Trust Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr % 90.2% 94.0% 81.8% 90.1% 92.0% 87.6% 80.2% 83.7% 76.7% 77.3% 84.8% 89.9% 85.8% 86.5% 84.8% 81.6% 87.1% 84.7% 81.6% 79.6% 77.8% 76.7% 78.1% 81.3% 80.9%

20 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Elective Access Salford RTT Open Performance Bury & Rochdale RTT Open Performance 96% 94% 92% 90% 88% 86% 84% 82% 80% 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Actual Target Actual Target North Manchester RTT Open Performance Oldham RTT Open Performance 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Actual Target Actual Target RTT Open Performance Salford Royal Foundation Trust Pennine Acute Hospitals Trust Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr % 93.6% 93.0% 93.0% 92.8% 92.8% 92.9% 92.6% 92.0% 92.7% 92.5% 92.7% 92.4% 94.7% 94.1% 93.3% 92.4% 92.0% 92.1% 92.7% 92.3% 93.1% 92.1% 92.1% 92.2% 92.0%

21 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Elective Access Salford Diagnositc 6 Week Performance Bury & Rochdale Diagnositc 6 Week Performance 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Actual Target Actual Target North Manchester Diagnositc 6 Week Performance Oldham Diagnositc 6 Week Performance 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Actual Target Actual Target 6 Wk Diagnostic Performance Salford Royal Foundation Trust Pennine Acute Hospitals Trust Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr % 99.2% 99.2% 99.3% 99.4% 99.4% 99.4% 99.4% 99.1% 99.2% 99.0% 99.0% 99.1% 95.0% 96.1% 95.8% 91.4% 90.8% 94.6% 99.2% 99.3% 99.0% 99.1% 99.6% 99.4% 99.2%

22 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Cancer Pathways Salford 62 Day Performance Pennine 62 Day Performance 100% 100% 95% 95% 90% 90% 85% 85% 80% 80% 75% 75% 70% 70% 65% 65% 60% 60% National GM Target National GM Target Salford TWW Performance Pennine TWW Performance 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Actual Target Actual Target 62 Day National Salford Royal Foundation Trust Pennine Acute Hospitals Trust 62 Day GM Salford Royal Foundation Trust Pennine Acute Hospitals Trust TWW Salford Royal Foundation Trust Pennine Acute Hospitals Trust Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr % 91.1% 92.4% 90.5% 88.4% 86.0% 97.3% 93.2% 88.9% 89.9% 89.3% 89.8% 86.6% 90.9% 77.8% 83.6% 87.7% 84.2% 81.9% 89.0% 87.6% 85.6% 82.4% 76.1% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr % 89.1% 89.3% 89.2% 87.0% 81.3% 97.3% 90.4% 86.8% 85.0% 88.5% 88.5% 81.6% 85.7% 72.6% 79.7% 83.6% 80.1% 77.9% 85.3% 82.9% 82.2% 74.6% 69.1% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr % 97.1% 96.7% 95.7% 93.0% 96.7% 97.8% 96.4% 96.1% 93.0% 96.9% 92.8% 95.5% 94.9% 94.3% 93.5% 93.5% 94.8% 95.8% 97.3% 93.6% 89.4% 94.8% 93.5%

23 Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT) Title of Report PAT Improvement Plan Meeting Group Committees in Common Author Jayne Downey, Director of Governance Jude Adams, Chief Delivery Presented by Jude Adams, Chief Delivery Elaine Inglesby- Burke, Chief Nursing Date 22 nd May 2017 Executive Summary Principal Associated Risks Recommendations PAT Improvement Plan progress report. Pursuing Quality Improvement to assure safe, reliable and compassionate care Saving Lives, Reducing harm and CQC quality improvements The Group Committees in Common is asked to note the above report and the updates and key risks to the delivery of the CQC and SRFT Diagnostic Improvement plan. Public and/or Patient Involvement (Including equality related impacts) None Communication To be discussed through NES CO Quality Improvement meetings and Team Brief Freedom of Information Please indicate appropriate box below A This document is for full publication x B This document contains FoIA exempt information C This whole document is exempt under the FoIA If you have chosen B above, highlight the information that is to be redacted within the document for subsequent removal. Confirm to the Group Secretary which applicable exemptions apply to the whole document or to highlighted sections. 1.0 Purpose To outline for the Group Committees in Common the progress and key risks in delivering the Pennine Improvement Plan. 2.0 CQC Update Following a scheduled relationship call with the CQC on 18 th May 2017, information was provided regarding the process for the follow up inspection at Pennine Acute Hospitals this year.

24 CQC are now working to their new regulatory framework which is currently understood to be as follows: The period of Purdah currents prevent CQC from publishing any materials relating to hospital inspections. It is therefore unlikely that any request for data relating to a follow up inspection will be requested until after June 12 th. The data request document will be sent to the Trust to commence collation of the information required prior to the inspection. The CQC has a total of 20 weeks from the date the Trust receives this request to complete their inspection process including the follow up announced well-led visit and to publish their report. To conduct an unannounced inspection the CQC framework only allows for 3 core services to be reviewed. Given that the Pennine inspection identified 5 fragile services (including medical specialties) it is unlikely the CQC will visit unannounced. Their current intention is to conduct a planned inspection reviewing 3 hospital sites, the 5 fragile services and potentially surgery at Royal Oldham and Fairfield General. The Trust has 4 weeks to complete the data request document and return it to the CQC CQC will meet with NHSi following receipt of the data to discuss resources for the inspection and decide which services to visit. The information requested and previous information provided by the Trust to such issues as complaints or whistleblowing incidents along with any visits undertaken by the CQC inspectors will assist in determining the services to be visits The announced visit is likely to take place towards the end of August/early September, followed 2 weeks later by the an Announced Well-Led assessment The whole process should be complete by the end of September 2017 but this will be confirmed at a follow up call with the CQC inspectors next week. In preparation for the assessment a weekly senior Executive meeting has been scheduled chaired by the Chief Nurse to discuss progress and review the data submission Weekly improvement plan monitoring meetings are already in place at Corporate and Care Organisation Level led by the Director of Governance and Directors of Nursing An unannounced mock CQC inspection supported by staff from SRFT and the CCG s took place on 17 th May 2017 on each site and within Urgent Care, Medicine and Surgery Regular Senior leadership walk-rounds are taking place to address sections of the improvement plan and Key Lines of Enquiry Engagement sessions are scheduled and have taken place to promote Pride in Pennine 3.0 Overall Improvement Plan Progress Since the previous report further progress has been made towards delivery of the Improvement Plan, with the following ratings applied in month Overview of progress: BRAG Blue Green Amber/Green Amber Amber/Red Red Actions The root causes of current challenges remain constant with workforce availability, capacity requirements and changing culture identified, although progress can been seen in some of these areas. In month further progress has been made across the theme of leadership and strategic relations with the recruitment and commencement of key senior nursing, medical and managerial leaders across all Pennine Care Organisations as we implement the new CO structures.

25 The tender for international recruitment of nursing staff from India has been agreed The Quality Improvement collaborative on deteriorating patients continues to establish innovative tests of change and continued engagement with staff, with the North East Sector Quality Improvement Plan now clearly defined with engagement sessions delivered to promote and engage staff with the plan The NAAS progress continues with a total of 29 first NAAS assessments undertaken, 9 pilot assessments and 4 re-reassessments. The assessment plan has been realigned for completion of all wards by September 2017 due to the number of re-assessments not initially anticipated across the organisation and a key aim to have 50% of all wards at green status by April 2018 The recruitment of 3 Corporate Matrons to the NAAS team will provide support to the implementation of NAAS action plans within each Care Organisation and address themes identified through the assessments Mortality remains a key focus for the Medical teams led by the Chief Medical officer and the new bereavement centres opened on 12 th May A clear trajectory to establish real time complaints responses has been agreed with CCG s by November 2017 Improvement to Data Quality and the PAS cleanse are progressing, albeit behind plan, with the intention of completing the full cleanse and patient validation by the end of June. 4.0 Key Risks Recruitment and workforce availability remains a key risk to the delivery of a number of improvement actions, in particular, sustainability and transformation of Urgent Care delivery plans including patient flow throughout the hospital and timely discharge. However, progress has been made since 1 st April to reduce the number of 12 Trolley waits within the A/E departments and there have been no 12 hour DTA waits for FGH, ROH in May with only 7 to date at NMGH - a reduction from 36 in April. Workforce availability continues to be a key risk but with activities on-going to support recruitment of staff, including overseas recruitment of nursing and medical staff. Alternative nursing workforce models are also being developed to mitigate the risks of sustainably closing the gap on nursing staff numbers. Between 6 April and 17 May, the Trust has made the following appointments: Nursing and Midwifery Band 5 Band 6 Band 7 Midwives Medical & dental Consultants SAS doctors 7 incl 1 locum 5 Ongoing activities include: Emergency Village Band 5 recruitment model for A&E & AMU advertised for North Manchester. Band 5 Medicine & Acute Medicine recruitment campaign has closed and we will be interviewing on 26 May. Scoping B and 5 rotational model between the Stroke Unit s (Fairfield and Salford Royal) including feasibility of including Neuro.

26 A business case has been drafted with regards to an International Recruitment campaign for nurses. The plan is to recruit 100 nurses. As part of the influential campaign, the 5th was sent to 13,759 consultants in the first week of May. The 6th will be sent in June. Open day/career days have been planned at each Care Organisation for June and July A number of consultant posts are also currently being advertised. 5.0 Fragile Services 5.1 Urgent Care and Acute Medicine Work continues across all sites to run test of change and deliver against agreed improvement actions. Estates work has been completed on the FGH site to support the development of the Emergency Village and accommodate plans to enhance ambulatory care numbers. The transfer of the Integrated Discharge Team from the local authority is now complete and plans are underway to review the opportunity to move to a 7 day model. North Manchester has seen a significant improvement in ambulance handover times for those over 60 minutes following improved systems and processes. Flow throughout the site has improved as demonstrated by reduction in medical outliers and breaches. Successful test of change has been completed for the new primary care front end model with further test scheduled for June. The planned expansion for AMU beds is on track currently with posts out to advert and discussion on-going with UHSM regarding support for Acute Physicians. Work at Royal Oldham is focusing on all clinical and managerial teams owning their own problems with support to fix the problems and embedding the new escalation policy. The new system for electronically capturing all medically optimised patients is being piloted and working well. There are some positive signs of improvements with the new lead for the Integrated Discharge Team and posts are out to advert for the ambulatory care unit expansion. All Care Organisations met their April 4 hour standard trajectories and are on track for May with improvement across other urgent care measures, however there remain some long waiters on the NMGH site and continued focus on hour waiters needs constant attention. 5.2 Maternity Care and Paediatrics Following a scheduled relationship meeting with our CQC relationship managers on 24 th April 2017 a positive visit to the North Manchester Maternity and Paediatric units was undertaken. Two of the CQC staff were in attendance at the last inspection in 2016 and following discussions with staff and senior managers felt that progress against the maternity and Paediatric plans had been made with very obvious progress identified regarding staff engagement, staffing levels and care delivery. A further visit to The Royal Oldham units was undertaken on 10 th May 2017 with again positive feedback against the plan identified with comments that the units felt much different than during the inspection. The inspection team did identify further work to be undertaken on the paediatric pathways at Royal Oldham. The next relationship meeting will be at the end of June and it is anticipated that visits will be made to urgent care units and critical care 5.3 Critical Care Recruitment remain ongoing with successful recruitment to nursing posts, only 9 WTE vacancies remaining across NMGH and TROH with continued recruitment strategies in place. A critical care network visit was

27 undertaken during April and the review recognised the work being undertaken to address the issues, formal feedback is awaited. 6.0 Care Organisation Delivery Plans The Pennine Acute improvement plan has now been disaggregated into the Care Organisations with responsibility for delivery delegated to the Senior Leadership teams. The local Improvement plans have been reviewed to ensure the plans reflect local risks to delivery and actions required and assurances to date. All of the Must and Should requirements identified by the CQC have been reviewed by each Division and included within the Care Organisation s Improvement plans. A central meeting to discuss progress, risks and barriers to implementation has been established fortnightly and local fortnightly meetings have been arranged by each Care Organisation to monitor progress, identify risks and provide assurance Five key organisational issues have been identified against the must and should do s. these were discussed at the Executive Quality and Patient Experience Committee in May and include: Information Governance Sepsis training and competency Environment in particular Critical Care areas Medicines Management Medical Devices-Maintenance, Training and PAT testing

28 Summary of the CQC and SRFT Diagnostic Improvement Plan BLUE GREEN AMBER/GREEN AMBER AMBER/RED RED Milestone successfully achieved Successful delivery of the project is on track and seems highly likely to remain so, and there are no major outstanding issues that appear to threaten delivery significantly. Successful delivery appears probable however constant attention will be needed to ensure risks do not materialise into issues threatening delivery. Successful delivery appears feasible but significant issues already exist requiring management attention. These appear resolvable at this stage and if addressed promptly, should not cause the project to overrun. Successful delivery is in doubt with major risks or issues apparent in a number of key areas. Urgent action is needed to ensure these are addressed, and to determine whether resolution is feasible. Successful delivery appears to be unachievable. There are major issues on project definition, with project delivery and its associated benefits appearing highly unlikely, which at this stage do not appear to be resolvable. Version Version 6.8 Date 12/05/17

29 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS What and why we need to improve During February 2016 the CQC inspected services at PAHT. On 1 st March 2016 Ms. Ann Ford, Head of Hospitals Inspection CQC, wrote to confirm immediate patient safety concerns that had been discovered as a result of the inspection. The concerns thatt required decisive immediate actions to stabilise services and assure patient safety weree across 4 main service areas Maternity, Children, Urgent Care and Critical Care. In April, following the interim appointment of Sir David Dalton as CEO, a team of senior health executives, supplemented by external support constructed and conducted a diagnostic review of the causes of risk to patient safety and care sustainability y. The diagnostic focus was to identify areas for improvement that impacted on patient safety. It was not a full investigation into all aspects of operations of the trust. Nor was it a full due diligence of the trust. The diagnostic was informed by the immediate concerns raised by the CQC. The key areas for improvement identified in addition to the fragile services were: Patientt safety, harm and outcomes Systems of assurance and governance arrangements Operational management and data quality Workforce capacity and capability Leadership and external relations a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

30 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS The CQC report has now been published (August 2016). The CQCC identified 777 Must Dos and 144 Should Dos to ensure sustainable improvement to care delivered across the Pennine Trust services. The full report corroborates the findings of SRFT s diagnostic. The full CQC report has established evidence that PAHT, overall, is rated Inadequate. All of the CQCC must dos and should dos have been mapped across to the themes for improvement identified in the SRFT Diagnostic. This improvement plan sets out the immediate (first 9 months) improvement actions this is to ensuree we are getting the basics right, stabilising services and creating the right conditions upon which we can continue to improve and ultimately transform care delivery across Pennine. Our quality improvement strategy Saving Lives, Improving Lives, aims to go beyond the immediate concerns raised by the CQC report, we will engage our staff in a quality improvement strategy that will result in our services to be rated good or outstanding by regulators, that our staff would rate as a good place to work and a good place for their relatives to be cared for. Who is responsible? NHS Improvement (NHSi), in conjunction with GM Health & Social Care Partnership (coordinating the response of Bury, Oldham, HMR and North Manchester CCGs), invited Salford Royal NHS Foundation Trust (SRFT), to provide interim leadership support to PAHT from 1st April 2016 the Chair, Mr. Jim Potter and the CEO, Sir David Dalton, were appointed to interim positions of Chair and CEO of PAHT. a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

31 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS The Trust Chief Executive Sir David Dalton is ultimately responsible for implementing the actions in this document, the Trust executive team will provide the leadership to ensure we identify the right improvement actions that will tackle some of the long standing issuess the Trust has faced and create the right conditions to deliver the changes required. Our site leadership teams, divisional triumvirates and clinical leaders across the Trust will be key to delivering the actions that will ensure service sustainability and transformation. The high level deliverables articulated in this plan are underpinned by weekly improvement actions that clinical and management teams have developed and own. These weekly actions and evidence of delivery will be managed via an integration management office; teams will be supported to deliver changes at scale and pace with access to the SRFT standard operating model. The GM Improvement Board will bring together parts of the local health and care economies to ensuree there is a shared understanding and collective commitment to the delivery of the improvement plan, including resources that need to be made available to enable the changes to happen. It is evident that the Trust has many thousands of staff trying to deliver good standards of care to patients. However, we need to create a culture of continuous improvement supported by robust governance and accountability arrangements from Board to ward whichh ensures leaders are focused on the key risks to the delivery of excellent care. a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

32 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS How will we measure our improvement? Measurement of our improvements will be fundamental to ensuring sustainability and the reliability of our care. We will develop a high level assurance dashboard against our key themes that measures our progress. We need to ensure that our improvement actions and activities are translating to improvement in outcomes for patients using a small number of key performance indicators. We will assure our improvement plan through our Trust board and Executive assurance committees How will we communicate progress? Internal Communication to staff within the Trust will utilise the full range of existing communication channels and our new leadership arrangements to listen, update and engage staff in the delivery of the improvement plan. We will utilise a weekly message circulated to all staff, site notice boards; monthly face to face Team Talk sessions led by an Executive Director; regular briefings with the staff side representatives and direct engagement sessions between the Executive team and senior managers with a particular focus on meeting with the Clinical Directors. Briefing of key issues through the line management structure; use of dedicated pages on the Trust intranet and articles on our improvement journey will feature in the monthly Pennine News magazine. Any matters which require immediate communicati on will be sent through an all user . a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

33 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS There are multiple routes for staff to feed back comments including the dedicated address; raising issuess at face to face sessions with their line managers or at Team Talk sessions; contributing through the staff engagement programme; if necessary using the Speak in Confidence system to raise matters anonymously directly with senior managers. Working in partnership with the multi agency and integrated delivery of all internal and external communications including staff, patients, families and carers, commissioners, GPs; communications group we will: Ensure the clear, consistent Ensure the public/patients are informed and reassured that services are safe; Ensure that all key partners and stakeholderss are kept up to date and informed about developments, decisions and any service changes that are required and their impact; Ensure all related media enquiries are co ordinated and managed effectively, to ensure clear and consistent messages and to ensure media coverage is accurate; Work together to manage and protect the reputation of the NHS and social care in Greater Manchester and the services provided across the local healthcare economy; Ensure any subsequent operational or servicee changes are communicated effectively across PAT and the local healthcare system to staff, GPs, the public and externally. a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

34 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Improvement Theme Summary of actions required Agreed timescale Assurance and external support RAG Status Executive and Operational Leadership Revised deadline if required BAF Urgent Care Establish clear leadership for the urgent care services and EDs in line with site based leadership model External GM Improvement Board CCGs GM providers New Clinical Director appointments made May 17. Two management and Nursing gaps at NMGH remain AMBER GREEN Chris Brookes Chief Medical June for Division Improving fragile services Ensure adequate stabilisation of consultant and middle grade cover in ED at NMGH to meet the agreed service model requirements Internal Care Board and Quality Assurance Committee Middle grades continue to be covered by locums AMBER for review Revised Assess the options for the Urgent Care service model for North Manchester Assessment complete decision on options to be considered as part of HT Implementation. AMBER a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

35 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Have in place a nursing, ENP, ANP workforce to meet the demand of patients across EDs Have in place a nursing, ANP, AHP workforce to meet the demand of patients across AMU s Nursing workforce model approved, Nursing gaps resolved. Strategic case submitted for ANPs successful in securing 10 ANPs to commence September AMBER As above AMBER Chief Nurse Revised date Develop and deliver primary care offer within ED at NMGH (including streaming) Develop integrated ambulatory pathways and frailty model at NMG New Primary Care front end model outlined and tests of change completed awaiting final sign off and workforce solution. Revised date for full implementation AMBER Model agreed, capital bid against NHSi funding submitted outcome awaited later this month. Frailty offer will be included within phase 2 of the AMU expansion Chief Medical Chief Delivery AMBER a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update Chief Medical

36 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Ensure best practice patient pathways within the ED and time to assessment, treatment and transfers are well understood and delivered in order to manage risks to patient safety and improve care Trust & ECIST pathway review & recommendations determined. Improvement actions underway with weekly tests of change. Workforce & bed capacity remains key risk. AMBER Ensure the pathways/escalation response for medical, surgical and paediatrics and the speciality services capacity to respond to urgent and emergency care is developed in place Speciality solution not yet reliable. Escalation not embedded. 12 hour DTAs still occurring at NMGH but improved AMBER RED Chief Delivery Have in place an extended crisis response service for North Manchester, 8am 10pm, 7 days COMPLETED Go live Feb 17 a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

37 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Maternity Care Put in place the senior management and clinical leadership to develop and drive forward the maternity improvement plan Have in place robust workforce plans and available staff to deliver maternity services, including medical, nursing and support posts. Establish comprehensive risk and governance arrangements which includes learning from incidents, complaints, auditing practice and improving incident and risk management systems and processes. Embed learning culture External GM Improvement Board CCGs CMFT/RBH Internal Care Board and Quality Assurance Committee a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update Delivered but with addition of new Clinical directorr appointment to ROH in line with new CO structures Additional Midwives recruited to commence in post Sept. Current births per midwife NMGH 1: :22 TROH 1:25 2 nd Phase. Obstetrician s recruitment plan agreed for 11 substantive Consultant posts 6 TROH and 5NMGH. GREEN Systems and processess in place. COMPLETED Chief Nurse/ Chief Medical Chief Nurse/Chief Medical Phase appoints In post Ongoingg

38 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Ensure all staff are trained and developed specific to their job roles Indicators all improving with positive feedback from CQC Training programmes in place Appraisals 88% Mandatory Training 84% CTG 87% GREEN Ongoingg Ensure the engagement of all staff in the improvement plan, developing a culture of continuous quality improvement Continuous engagement on going GREEN Ongoingg Paediatric Care Ensure adequate numbers of trained paediatric nurses are in place to meet the demand and ensure safe care Develop and deliver on the new model to stabilise paediatric urgent care for FGH External GM Improvement Board CCGs CMFT/RBH Internal Care Board and Quality Assurance Committee a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update Recruitment underway to increasee bed capacity. Staffing ratio currently 1:5 but to be maintained reliably. HDU beds reliably staffed Total 20 beds open each site on average per day with flexibility as required AMBER Pathway to be auditedd in May COMPLETED Chief Nurse Chief Delivery Chief Nurse

39 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Ensure all staff are trained and competent to manage the critically ill child and have in place a 24hr/7 day rota for APLS/PLS trained staff. Ensure the capacity to treat and care for children requiring elective treatment is in place sustainably Rota to be audited in may COMPLETED Down to 14 weeks waits review with NHSI re: opening wait lists AMBER Chief Delivery Develop and deliver on the new models of care to receive, assess and treat paediatrics at all sites Hr unit in place at NMGH. Gaps in workforce cap/demand at ROH AMBER/GREEN Chief Delivery officer Critical Care Ensure sufficient consultant and middle grade cover to the HDU at ROH Ensure that the required nursing/ahp workforce across the critical care units is determined and in place External GM Improvement Board CCGs CMFT/RBH Internal Care Board and Quality Assurance Committee a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update HDU 150 Hrs. cover delivered. Substantive gaps remain covered by locum Consultants. AMBER Good response to recent recruitment advert, 9 WTE vacancies remain across TROH & NMGH continued recruitment process in Chris Brookes Chief Chief Nurse

40 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS place AMBER Determine the requirements for critical care outreach and safe response at night and weekends Develop and Ignite our QI Strategy Develop PAHT QI strategy External GM Improvement Board CCGs Review post QI patient Deteriorating COMPLETED Chief Nurse Improving Quality Engagement and launch of Strategy with CO staff Improving Safety QI Collaborative on deteriorating patients and managing sepsis Engagement of staff Internal Care Board and Quality Assurance Committee Engagement sessions commenced within CO GREEN COMPLETED Chief nurse/chief Medical ongoing Development of QI faculty COMPLETED Commence collaborative COMPLETED a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

41 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Test of change being undertaken and QI learning being embedded Commenced GREEN Develop change package and scale up and spread Improving Safety 90 day improvement cycles for pressure ulcers, falls, CAUTI Have in place reliablee data (Mar Jun17) Internal Care Board and Quality Assurance Committee To be develop following completion of collaborative Pressure Ulcer data improving, falls data correct, CAUTI reviewed and reliable data with no red flags AMBER/GREEN Chief Nurse/Chief Medical Develop ward improvement goals Falls improvement plans in place. Dashboard in development AMBER GREEN Improving Safety Internal 90 day improvement cycle Care Board and reducing hospital (Oct Dec) Quality Assurance acquired C.Diff Committee a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update Chief Medical Dec Feb

42 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Have in place reliablee data COMPLETED local action plans developed Develop ward improvement goals and plans COMPLETED Mar 17 Review and improve the Trust antibiotic polices and antimicrobial stewardship AMS programme is in progress including: ward audit, Meropenem review, ITU ward round, haematology ward round, T7 consultant/micro joint ward round, MEU ward and Paeds ward round at TROH. 90 days Improvement Plan on the treatment and diagnosis of UTI and the monthly 50 patients review. AMBER Review and improve hand hygiene practices Limited assurance re: Consultant engagement with hand hygiene processes 90 day improvement test of change for patient hand hygienee has now been a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

43 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS expanded to 5 wards. Increasee in sinks within ward areas during upprogramme grade Red/yellow/green card programme to support hand hygiene compliance continues and was seen as good practice by NHSI Continued audit programme of spotby IPN team with feedback to Nursing and Clinical teams checks AMBER Improving Safety Implement NAAS System to ensure core nursing standards are met Mobilise team and engage senior nurse leaders in NAAS model Internal Care Board and Quality Assurance Committee COMPLETED Chief Nurse Undertake desktop assessment COMPLETED Identify data collections methods and priority areas (pilot wards) COMPLETED a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

44 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Baseline assessment of all priority wards and improvement plans developed COMPLETED Completion of all wards On track for revised date for all wards assessed due to number of reassessments AMBER/GREEN % of all wards to achieve Green status Improving Safety Implement patient support system Deploy a support system to support vulnerable patients and families Improving Effectiveness Reducing mortality Commence Complete Internal Care Board and Quality Assurance Committee External GM Improvement Board CCGs COMPLETED Chief Nurse Chief Medical Outline methodology Internal COMPLETED Care Board and Quality Assurance a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

45 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Undertake Trust wide mortality review Committee COMPLETED Determine CO/Service level improvement actions using review data and Dr Foster intelligence Ensure reliable system for M&M reviews and learning from avoidable factors On Track for revised date AMBER Trust wide process is gaining momentum. Engagement with key local specialities led by CMO and Director Patient Safety revised date AMBER GREEN Improving patient experience Improving End of Life Care Undertake a baselinee assessment of bereavement care Work with wards and departments to agree the plan External GM Improvement Board CCGs Internal Care Board and Quality Assurance Committee COMPLETED COMPLETED Elaine Inglesby Directors and Burke Site Nurse Medical Directors a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

46 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Roll out the Royals Alliance bereavement model COMPLETED Improving patient experience Implement what matters most to me Commence Complete Project not yet started Chief Nurse Undertake baseline assessment of Patient Experiencee and determine other key improvement actions Associate Director Patient Experience in post full review FFT undertakenn Task and Finish group established GREEN Develop QI Collaborative on last 1000 days and PJ Paralysis Commence June 17 Ensure safe medicines management Develop plans derived from core standards and audits COMPLETED Chief Medical a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

47 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Deliver on improvements to: CD/RD checks Fridge ambient temps Crossing out/ /signatories Revisee Medicines Safety Group Complete MIAA audit actions On going Duthie audits in place and results provided to Care Organisations. Key Nursing and Pharmacy links to be identified to progress change process in all care organisations AMBER RED Review of ToR and Chair underway AMBER RED Plans in place to address actions AMBER RED a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

48 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Improving Risk and Governance Implement new riskss and governance arrangement across the Trust Undertake comprehensive assessment of governance arrangements and develop work plan focussing initially on 4 priority areas: complaints, claims, serious incidents and coroners inquests External GM Improvement Board CCGs Internal Care Board Executive Risk Assurance Committee Assessment and early improvement actions determined COMPLETED. Month on month improvements continue Complaints backlog trajectory agreed real time response to be in place by November 17 GREEN Chief Nurse Implement new risk and governance framework COMPLETED Put in place new Board Assurance Framework COMPLETED Ensure risk and governance arrangements during Transition to new CO and once new CO are established remain robust New Transition Board established. Clear project plan AMBER GREEN a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

49 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Roll out risk training for all staff COMPLETED for phase 1. Phase 2 training to be delivered for new Divisional leaders once established Implement new Datix system Commence July Not yet commenced On Target goes live June across all sites GREEN Review all safeguarding Deliver on level 3 children s safeguarding training to agreed standard External GM Improvement Board CCGs Local Authorities At 75% against 80% standard and 22% increasee in head count. Key risk areas being targeted AMBER Chief Nurse Ongoingg Undertake gap analysis for MCA DOLs and deliver on agreed action plan Internal Care Board and Executive Quality Assurance Committee Plan in place. Education packs developed and target areas linked to NAAS AMBER/GREEN Ongoingg a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

50 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Improving Operations and Performance Ensure improvement to patient flow Implement SAFER model across all wards Improving reliability of SAFER Ensure flow/bed requirements are driven by agreed clinical pathways of care, are modelled and delivered External GM Improvement Board CCGs Local Authorities Community providers Internal Care Board and Executive Operations and Performance Committee COMPLETE Re launch and improve reliability AMBER RED AMU/ambulatory pathways modelled. GREEN Agreements with Commissioners AMBER/RED Chief Delivery Revised date Have in place robust systems and processes for the management and escalation of patient flow acrosss the acute sites to ensure patients are care for in the right place Trust escalation systems revised to include OPEL. COMPLETE Beddays are reducing. Put in place and deliver against agreed standards which ensure medically optimised patients are Needs agreed timeliness standards across NES AMBER a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

51 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS transferred safely and appropriately Ensure data quality systems and processes are robust to deliver on operational performance Reduce PAS open registrations by completing data cleanse exercise and put in place systems and process for access control Createe business intelligent patient tracking list and tools to support operational staff in managing stages of treatment for patients External GM Improvement Board CCGs Internal Care Board and Executive Operations and Performance Committee Final validation process underway AMBER GREEN Final validation underway AMBER GREEN Chief Delivery Ensure all identified staff groups have access to and are trained and assessed on referral to treatment rules and PAS functionality Core systems trainers appointed. Training on going GREEN Ongoingg Ensure booking and scheduling Draft KPIs developed and functions and resources are in clinical and operational a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

52 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS place to meet the standards required and are structured to support operational delivery and the best patient experience. Put in place systems and processes to ensure clinical input into validation of ED breaches and non breaches Ensure ED symphonyy system is utilised and optimised in patient tracking and clinical pathway management policies/processes under review. Cross group improvement plan developed AMBER COMPLETED Continued delays with technical solution AMBER Ensure ED patient tracker roles are developed and supported acrosss all EDs Undertake self assessment against audit commission standards on DQ, develop action plans to address gaps COMPLETED Reviewing DQ kite marking for all corporate data and actions plans TBD based on level of risk AMBER ongoing a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

53 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Workforce and safe staffing Undertake baseline safe staffing review of nursing Assess all wards and departments against Salford Nursing Standards commencing with high risks areas External GM Improvement Board CCGs COMPLETED Chief Nurse Agreee and develop workforce plan to address shortfalls Internal Care Board and Executive Quality Assurance Committee Priority areas identified. In year funding agreed. Mitigating workforce plans under review and on going More than 300 additional Nurses recruited AMBER RED Ongoing Have in place systems and processes to report and close workforce gaps to achieve safe reliable staffing (90% standard) Fill rates achieved with reliancee on temporary staff due to recruitment challenges AMBER RED Ongoing a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

54 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Undertake baseline safe staffing assessment for medical staff Understand vacancies against funded establishment Assess fragile services against national standards and clinical service need. Develop plans for resolution of gaps External GM Improvement Board CCGs, GMTU Internal Care Board and Executive Workforce Assurance Committee COMPLETED Assessment COMPLETE Agreed initial investment 12.5 WTE Consultants across the three CO s to support general internal medicine COMPLETED Chief Medical Close all critical medical workforce gaps on sustainable base Progress on stabilisation. Sustainable solution at risk timescale and cost Overseas recruitment underway RED a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

55 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Implement new model for recruitment Identify hard to recruit groups Outline model and strategy for recruitment for fragile services COMPLETED COMPLETED plan revised following exec discussion Deliver on staff Happy Health Here programme Promote and improve the health, wellbeing and engagement of the workforce Improve availability of the workforce and reduce reliance on temporary staffing External GM Improvement Board CCGs Internal Care Board and Executive Workforce Assurance Committee Sickness absence currently above targett at 5.10% ( March 17) improved on 15/16 Engagement strategy developed for board approval on 22/5/17 AMBER Vacancy rate 6.46% against standard of 6% %. High reliance remains on temporary posts.ir35 poses additional risk Temporary staffing spend AMBER/RED Chief of Strategy and Organisational Development On going On going a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

56 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Develop new PDR offer and ensure staff have opportunity to engage in performance development discussions New offer developed. COMPLETED Meet 90% PDR standard Ensure all staff have access to and complete mandatory training Meet 90% standard Currently at 76% against 90% standard. DQ issues reported and being addressed. Improved on 15/16 position AMBER Current performance marginally below target at 88% against 90% standard AMBER GREEN On going On going Improving Leadership and strategic relations Development of Group Transition from interim executive Chair and CEO arrangement to permanent solution External NHSi, NHSE, GM Improvement Board CCGs COMPLETED Chief Executive Finalise group structure and governance arrangements COMPLETED a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

57 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Implement Site Leadership model Agreee model and for site leadership and management of services External GM Improvement Board CCGs COMPLETED Jon Lenney Executive Director of HR &OD Recruit to site leadership teams Develop site improvement plans and accountability framework Commence Conclude Internal Care Board and Executive Workforce Assurance Committee COMPLETED COMPLETED Develop and deliver on clinical leadership programmes Design, commission and deliver joint clinical leadership programmes with Chief Nurse, PAHT MD and Salford Head of Leadership (post TFL programme) Design Delivery commence OD strategy in development. QI Leadership programme developed and delivery by AQUA commences June. To be done in conjunction with all senior leaders. AMBER GREEN Chief of Strategy and Organisational Development a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

58 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Develop and deliver a range of leadership workshops for nonclinical leaders with SRFT Head of Leadership and Executive Sponsor(s) Develop Delivery commence QI programme see above. Steve Head days continue in 2 nd Phase for all stafff GREEN a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

59 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Requirements to support improvement action Timescale for implementation Owner Progress against timescale Revised deadline if required Agreement of management contract with SRFT Financial settlement agreed to support improvement plans and delivery on LTFM in 16/17 and projections for 17/18 Agreed specification and plans from commissioners on model of care for primary care front end Engagement with and support from CCGs and LA to deliver on site and locality clinical service strategies Engagement and contribution to system wide UC improvement & safety workshop led respectively by ECIP and Charles Vincent Review of clinical quality and performance arrangements with commissioners to ensure robust assurance and safety systems in place Establishment of IMO to manage integration and co ordinate improvement activities/synerg ies with SRFT Support from GM transformationn unit and GM providers to develop and contribute where appropriate to new models of care for frail services Raj Jain Damien Finn/CCGs CCGs CCG/LAs CCG/LAs and PAHT CCGs and PAHT Jude Adams GMTU Completee Completee Requires finalisation in all localities Joint Transformation Board in place. LCO plans in various stages of development Commenced Contributions to CQC inspections by Commissioners In place In place Requires revised deadline a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

60 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS SALFORD STANDARD OPERATING MODEL a) Summary of the CQC and SRFT Diagnostic Improvement Plan May Update

61 Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT) Title of Report PAT Transition Plan Highlight Report Meeting Group Committees in Common Author Usman Aziz, Analyst Corporate Strategy Gavin Barclay, Assistant Chief Executive Presented by Jude Adams, Chief Delivery Date 22 nd May 2017 Executive Summary Principal Associated Risks Recommendations This paper provides an update to the Group CiC on the progress with the PAT Transition Plan to the September 2017 deadline. Contributes to the delivery of services at scale across the Group footprint. Delivery of new Care Organisations across the PAT footprint will help address many of the risks on the Board Assurance Framework. To consider and note progress, identifying any further actions or information required. Public and/or Patient Involvement (Including equality related impacts) NA Communication. Regular communication of key issues in Team Talk weekly message and on Trust Intranet. Freedom of Information Please indicate appropriate box below A This document is for full publication X B This document contains FoIA exempt information C This whole document is exempt under the FoIA If you have chosen B above, highlight the information that is to be redacted within the document for subsequent removal. Confirm to the Group Secretary which applicable exemptions apply to the whole document or to highlighted sections.

62 AG PAT Transition Team Summary Report Created by GB & UA Date Completed Period Covered Project Commentary This project will facilitate the transition of The Pennine Acute Hospitals NHS Trust into three Care Organisations. Milestones completed & key progress / updates Good progress with establishing Care Organisation interim governance arrangements CO Management Team meetings and Performance, Risk, and Assurance Groups (PRAGs) in place. Transition and Future State charts attached. Divisional & Directorate managers appointed, and arrangements in place to address vacant posts. Draft s completed. Draft CO BAFs to be submitted to PAT EARC in June. Draft Statement of Assurance & draft Single Oversight Framework presented on 10 May by Chief Delivery. Business Partners allocated from Corporate Support to provide interim support. clinical income & activity plans agreed and attributed to COs. Stage 1 income & expenditure opening control totals signed off and agreed with COMTs. RTT, Cancer, and Diagnostics targets being disaggregated for CO Performance Data. Key focus on CIP at Transition Group meeting on 17 May. Milestones missed or delayed Development of Corporate Support section of project plan delayed but plans in place to address and now reported through Group Transition Group. Relevant sections of Group data plan to be incorporated into PAT Transition Plan as Conditions Precedent; dependent on completion of the data plan. Development of a detailed CIP plan. Next Steps Progress all appointments (complete interviews and place staff in post) (from May to September). New management structure charts to be uploaded to Trust Intranet and updated regularly (by end of May). Realign other Corporate Functions (by end of June). Submit draft s and draft CO BAFs to May CiC. Develop Divisional & Directorate risk registers across all COs (from May to September). Develop Divisional s (by end of June). Development of a detailed CIP plan (by end of May). Work to continue with Draper and Dash to provide metrics at CO and Divisional levels (from May to September).

63 Current Management Arrangements During Transition as at 18/05/17 Bury & Rochdale CO Elaine Inglesby- Burke Chief Nursing David Dalton Chief Executive Chris Brookes Ian Moston Raj Jain Jude Adams Chief Medical Oldham CO Group Chief Finance North Manchester CO Chief Strategy & Organisational Development Chief Delivery Jude Adams Chief Delivery Damien Finn Matt Makin Jayne Downey Penninewide functions Director of Finance Medical Director 3 x Deputy Med Directors Medical Education Director of Governance Associate Director Elective Access Paul Downes Chris Brookes Director of Patient Safety Director of Infection Prevention & Control (Groupwide) Jack Sharp Director of Strategy (Groupwide) Medicine FGH+RI I+C FGH, RI, ROH Medicine ROH W&C Medicine NMGH I+C NMGH Surgery (PAT wide) Clinical Support (PAT wide) Elective Access (PAT wide) Lindsay McCluskie Director of Estates & Facilities (Group-wide)

64 North Manchester Care Organisation 17 th May 2017 COMT: Matt Makin Stephanie Gibson Simon Featherstone Damien Finn Medical Director Managing Director Director of Nursing Chief / Director of Finance Standard text: in post Italics: appointed but not yet in post NM Division of Integrated Medicine Anton Sinniah Mike Griffiths Paul Tipping Divisional Clinical Director Divisional Managing Director Acting Divisional Director of Nursing *NM Women s & Children s Division (hosted at Oldham CO) Andrew Baldwin Leah Robins Richard Bulman Division of Surgery Divisional Clinical Director Divisional Managing Director (1 st June) Divisional Director of Nursing Emergency & Urgent Care Directorate Vacant Directorate Manager (interim coming in) Vacant Clinical Director Vacant Assistant Director of Nursing Vacant Clinical Lead A&E Vacant Clinical Lead AMU General & Specialist Medicine Directorate Joanna O Hagan Directorate Manager Vacant Clinical Director ID Vacant Clinical Director Medicine Michelle Connaughton Assistant Director of Nursing Vacant Clinical Lead Respiratory Integrated & Community Care Directorate Emma Flynn Directorate Manager Vacant Clinical Director Alex Barker Assistant Director of Nursing Paediatrics & Neonates Directorate Jenny Brown** Obstetrics and Gynaecology Directorate Directorate Manager (will also cover Obstetrics & Gynae) Vacant Clinical Lead Paediatrics Vacant Clinical Lead Neonates *Matron level nursing support Vacant Clinical Director *Matron level nursing support *Formal reporting to Oldham CO with links to NM CO for site specific issues. **Bury services included until transfer to CMFT. Specialist Surgery Directorate Vacant Directorate Manager (seeking interim) Vacant Clinical Director Urology Vacant Clinical Director Breast Vacant Clinical Director OMFS Sean Jackson Assistant Director of Nursing Gastroenterology Directorate Hosted at Oldham CO General Surgery / Colorectral Surgery Directorate In transition to Oldham CO Clinical Support Services Directorate Emily Hoyle Directorate Manager Vacant Clinical Director Theatres, Anaesthesia & Pre-op Tammy Sutcliffe (interim) Clinical Director Critical Care & HDU* Vacant Assistant Director of Nursing Elective Orthopaedics Hosted at Bury / Rochdale CO *TS to manage CC across PAT until Sept., reporting to Oldham CO.

65 Oldham Care Organisation 17 th May 2017 COMT: Mr Jawad Husain Donna McLaughlin Nicola Firth Carolyn Wood Medical Director Managing Director / Chief Director of Nursing Director of Finance Standard text: in post Italics: appointed but not yet in post Division of Medicine *Women s & Children s Division Division of Surgery Suresh Chandra Nina Parekh (interim) Paul Devlin Divisional Clinical Director Divisional Managing Director (offer made) Divisional Director of Nursing (5 th July) Vacant Deborah Carter Helen Howard Kathryn Krinks Divisional Clinical Director Divisional Managing Director Divisional Director of Nursing & Midwifery Head of Paediatric Nursing Nick Tierney Vacant Sue Anderton Divisional Clinical Director Divisional Managing Director Divisional Director of Nursing Emergency & Urgent Care Directorate Paula Baker Directorate Manager General & Specialist Medicine Directorate Zeph Curwen (covering) Directorate Manager (out to advert) Paediatrics Directorate Obstetrics and Gynaecology Directorate Jane Bryan Directorate Manager** Neonatology Directorate Gastroenterology Directorate (incl Endoscopy) Trustwide Mo Hussein Directorate Manager Orthopaedic Trauma & Vascular Directorate Paula Guoveia Directorate Manager General Surgery / Colorectal Surgery Directorate Trustwide Vacant Directorate Manager Clinical Support Services Directorate Rachel Scott Directorate Manager Vacant Clinical Director Kay Miller Assistant Director of Nursing (8b) Vacant Clinical Lead AMU Vacant Clinical Lead A&E Vacant Clinical Director Medicine Julia Riley Assistant Director of Nursing Vacant Clinical Lead Haematology Vacant Clinical Lead Diabetes and Endocrinology Vacant Clinical Director Paediatrics *Matron level nursing support Vacant Clinical Director Obs & Gynae *Matron level nursing support Vacant Clinical Director Neonatology *Matron level nursing support *Ongoing management responsibility Trustwide until the transfer of services from NM CO to CMFT. **Also covering services at Bury & RI sites following transfer of NMGH services to CMFT. Vacant Clinical Director Vacant Assistant Director of Nursing Vacant Clinical Director Vascular Surgery Layla Alani Assistant Director of Nursing Vacant Clinical Director Trauma Vacant Clinical Director Vacant Assistant Director of Nursing *TS to manage CC across PAT until Sept., reporting to Oldham CO. Vacant Clinical Director Theatres, Anaesthesia & Pre-op Vacant Assistant Director of Nursing Tammy Sutcliffe (interim)* Clinical Director Critical Care & HDU

66 Bury & Rochdale Care Organisation 17 th May 2017 COMT: Dr Shona McCallum Steve Taylor Tyrone Roberts Nicola Tamanis Medical Director Managing Director / Chief Director of Nursing Director of Finance Standard text: in post Italics: appointed but not yet in post Bury Division of Integrated Care HMR Division of Integrated Care Aslam Chougle Divisional Clinical Director Mark Coates Divisional Clinical Director Keeley Gibbons Divisional Managing Director Katie Foster-Greenwood Divisional Managing Director Jill Stott Divisional Director of Nursing (17 th July) Vic Thorne Divisional Director of Nursing Emergency & Urgent Care Directorate General & Specialist Medicine Directorate Elective Orthopaedic & ENT Directorate Gastroenterology Directorate Clinical Support Services HMR Integrated Neighbourhood Teams Directorate HMR Urgent & ITS Directorate Ophthalmology DIrectorate Vacant Directorate Manager (out to advert) Vacant Clinical Director Louise Palmer Assistant Director of Nursing Vacant Clinical Lead AMU Vacant Clinical Lead A&E Tammy Sutcliffe (interim)* Clinical Lead Critical Care Gillian Ivey Directorate Manager Vacant Clinical Director Cardiology Vacant Clinical Director Stroke Vacant Clinical Director Gen. Medicine Tracy Shaw Assistant Director of Nursing *TS to manage CC across PAT until Sept., reporting to Oldham CO. Amy Brierley Directorate Manager Richard Heasley Clinical Director Elective Orthopaedics Shalesh Agarwal Clinical Director ENT Janet Stanton Assistant Director of Nursing Hosted at Oldham CO Sarah WIseley Directorate Manager Simon Drake Clinical Director Theatres, Anaesthesia & Pre-op Vacant Clinical Lead Day Surgery Vacant Assistant Director of Nursing (IVs w/c 15.05) Vacant Directorate Manager (out to advert) Vacant Clinical Director Shirley Fisher Assistant Director of Nursing Zeph Curwen Directorate Manager Vacant Clinical Director Jackie Heatley Assistant Director of Nursing Charlotte Marshall Directorate Manager Vacant Clinical Director Matron

67 Transition PAHT Assurance Committees QI Meeting PRAG (Performance, Risk & Assurance Group) Medical services Surgical services W&C services

68

69 This image cannot currently be displayed. Health Innovation Manchester An Introduction

70 VISION AND PURPOSE

71 Rising costs of health & social care and relatively slow introduction of innovations to address challenges are a major frustration to policy makers and care providers Over the next five years, the Greater Manchester region faces significant public health challenges and is currently performing below national averages against a range of disease and mortality figures 20% Increase in over 65s population between 2011 and % Increase in over 85s population between 2011 and b Funding deficit to the economy by 2021 if no action is taken The obstacles to more rapid implementation of innovations Fragmented and slow decision making Structures which do not assist collaboration and coordination Lengthy and uncertain routes to adoption excellent initiatives in one locality are not shared across the system Industry find multiplicity of orgs/initiatives confusing and add to risk 3

72 The devolved NHS for GM has enabled the formation of an Academic Health Science System allowing for the acceleration of clinical research into clinical practice HInM s vision is to transform the health and wellbeing of the people of Greater Manchester by accelerating the introduction of innovation in our health and social care services. The Unique offering of Greater Manchester GMHSCP Delegated financial control Coordinated Academic & Industry System 2.8 million citizens Integrated Health Providers (primary, secondary, mental & social care) 4

73 Health Innovation Manchester brings together academic & clinical assets with industry innovators to create shorter &more certain pathways to adoption at scale HInM, an Academic Health Science System (AHSS) is an integrated healthcare delivery system covering every stage of the translational pathway from discovery science through to health services commissioning & real world evaluation The Translation Continuum via a GM Academic Health Science System Assessment & Validation Proof of Concept 2.8 million citizens Evaluation in Practice Health Innovation Manchester Discovery Science Commissioning & Adoption 5

74 As an AHSS, HInM is well placed to enhance GMs position and showcase our capabilities by aligning to local, regional and national initiatives and strategies HInM s strategic priorities align with and support not only the GM wide Digital Strategy but also feed into the national Accelerated Access Review and the Life Sciences Industrial Strategy highlighting GM s as an exemplar site Inward investment for clinical trials & regional data hubs Support for the practical and specialist skill shortages Streamlining mechanisms for identifying and prioritising innovations Working to accelerate approvals, adoption & evaluation of technologies Integration of data records across GM for health and for social care Build GM wide informatics capacity Provide a single voice for GM as we engage in national debate 6

75 PROGRESS TO DATE

76 Health Innovation Manchester s development and progress has strengthened since summer 2016 and delivery of the Business Plan is now underway September 2015 HInM launched Launched in late 2015 as a virtual organisation without dedicated resource Summer 2016 Review of HInM Steering Group formalised as a Board and Executive Chair appointed Initiated discussions on merging AHSC and AHSN within a single HInM brand and governance structure. Developing Business Plan with core HInM leads and relevant senior input from across the H&SC system February 2017 Business Plan completed HInM Business Plan signed off by Board with agreement that there was a clear delivery plan, and that this should begin immediately. Business Plan delivery commences Delivery of key immediate tasks within the Business Plan begins Coalescing the AHSC and AHSN into one, combined team with a supporting transition plan Developing KPIs for HInM; recruitment to urgent positions; and launching the innovation pathway and calls for innovations.

77 Health Innovation Manchester is focused on delivering three strategic priorities, quick wins and a digital health pipeline to build momentum 1. Informatics Establishing a GM population wide informatics capability as a vital tool to improve patient outcomes and access to innovations/trials. DataWell implementation is central to this. 2. Clinical Research Excellence Extend our strong research and clinical trials expertise, and strengthen our infrastructure and processes to create a one stop shop for industry wanting to access the GM H&SC system and our 2.8m population. Quick wins Selecting and using a number of existing initiatives to establish and test the innovation pathway and its supporting processes. Strategic priorities 3. Precision Medicine Leverage existing strengths in Precision Medicine, and building on data analytics capabilities, to redesign clinical pathways in the treatment of chronic diseases. Digital health pipeline Develop a specific GM digital and MedTech health brand to attract investment, drive business growth, and support innovation and clinical adoption. 9

78 Accelerating the delivery and adoption of identified quick wins across the health and social care system will help to test and refine the innovation pathway Quick Wins will be selected for their significant impact not only in improved patient outcomes but also for their potential cost reduction to the health & social care system leading to positive impact in local economic activity Quick Win Categories Primary Care Secondary Care Mental Health Social Care Population Health Expansion of this initial list, targeting innovations that span across primary care, mental health, social care and wider population health, will be priorities in the launch of the innovation pathway and calls for innovation 10

79 Active, relevant and consistent engagement with all partners and stakeholders across the health and social care system will be vital to delivering innovation in support of the Health & Social Care Partnership s shared goals HEALTH & SOCIAL CARE SYSTEM Local Authorities x 10 Health Innovation Manchester SMEs: Local small and medium enterprises INDUSTRY & BUSINESS PARTNERS GPs and primary care Strategic Clinical Networks ACADEMIC & RESEARCH PARTNERS Clinical Commissioning Groups x 12 Acute & community trusts 11

80 The Innovation Pathway: providing structure, organisation and a systematic approach to translation and adoption through the H&SC system Adoption and diffusion will be delivered through the Joint Commissioning and Provider Federation Boards, H&SC stakeholders engagement, project management, economics and evaluation support Core Programmes* Specific Digital & E Health Calls Horizon Scanning General Industry Inquiries & Engagement Proposed innovations through different channels Lessons learned and NHS specific needs feedback Innovation into local health economy Innovation Inflow & Screening Qualification & Impact Assessment Implementation, Adoption and diffusion Evaluation Lessons learned Core Themes* Informatics, Clinical Research Excellence, Precision Medicine 12

81 NEXT STEPS

82 Key activities until summer 2017 will be to establish the HInM one team, secure resourcing, progress quick wins, and launch the HInM innovation pathway Key delivery milestones March 2017 June 2017 Sept 2017 HInM shadow leadership team created and operational Innovation pathway open for business Begin formal AHSN and AHSC transition to HInM Establish Industry Advisory Board Implementation of quick wins Annual business planning cycle begins Publish communications on updates and progress, promote business plan and engage widely with GM stakeholders Support implementation of Datawell and associated accelerator projects Submit full 3 year funding application (GM TF) 14

83 Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT) Title of Report Opening Board Assurance Framework/Corporate Risk Register : 1. Salford Royal NHS Foundation Trust (Appendix A) 2. Pennine Acute Hospitals NHS Trust (Appendix B) Meeting Author Presented by Group Committees in Common Jane Burns, Director of Corporate Services Stuart Logan, Assurance Framework Manager Sir David Dalton, Chief Executive Date 22 nd May 2017 Executive Summary In December 2016, both Salford Royal NHS Foundation Trust and Pennine Acute Hospital Trust submitted their operational plans to NHS Improvement for the year. The two opening Board Assurance Frameworks presented today provide assurance to the Group Risk and Assurance Committee that both statutory bodies have in place the required infrastructure to ensure the achievement of the Trusts principle objectives through successful identification and mitigation of risks associated with the delivery of the operational plans. The opening BAFs have been produced in conjunction with both Group Executive and Care Organisation Directors with updates provided by the Directors and their teams. In producing the opening BAFs the following has been undertaken: A review of the risk scores to ensure that they are reflective of the current level of risk A review of the controls in place and the assurances offered to ensure that these are reflective of the current arrangements and are operating effectively. Where there is an action plan in place to reduce the risk, the breadth of action being undertaken. Both Board Assurance Frameworks are fully aligned to the Operational Plans that were submitted to NHS Improvement in December 2016 and incorporate strategic risks which were identified as part of the planning process and operational risks that have been identified locally. The opening BAFs for SRFT and PAT will form a starting point in the development of a Group Assurance Framework and Care Organisation Assurance Frameworks, development of which will progress over the coming months. A first draft of Care the Organisation Board Assurance Frameworks were presented to May s meeting of the Group Risk and Assurance Committee to provide an update on the work undertaken so far. Oversight of the two statutory organisation BAFs will be overseen by Group Risk and Assurance Committee on a quarterly basis. Once fully developed, it is anticipated that the Group Assurance Framework and Care Organisation Assurance Frameworks will also be overseen by Group Risk and Assurance Committee on a quarterly basis Points of clarity PAT BAF At the Pennine Executive Risk and Assurance Committee held on Monday 15 th May, the committee approved the Pennine Board Assurance Framework subject to amendments. The committee asked that the Director of Corporate Governance support a further review and refinement of the Pennine Board Assurance Framework to ensure that the opening position accurately reflected the current risk profile at Pennine Acute Hospitals Trust. The committee should note that this exercise was completed prior to Group CIC with approval of the final document provided directly by the Group Executives who have confirmed an accurate position. There are three objectives within the Pennine which will be fully risk assessed against in 1

84 line with ongoing work as follows: 3.5 Membership and Election: This objective is yet to be risk assessed in light of the developing Shadow Group Council of Governors, and the importance of Group-wide membership and governor engagement. A risk assessment is underway and will be included from the beginning of Q Undergraduate and Post Graduate Education: Establishment of the Salford Royal/Pennine Group structure following the agreement of the management contract - A group medical office is being established to oversee Education across both organisations. A key component of this work will be description of key risks to delivery. As such a definitive risk register will be incorporated within the Board Assurance Framework from Q2 onwards 6.5 Corporate Social Responsibility and Public Health Strategy: This objective will be reviewed in the context of the Corporate Social Responsibility standards with a completed risk assessment included from the beginning of Q2. Risk Profile The highest scoring risks at12 and above are provided below for SRFT and in Appendix B for PAT: Salford Royal NHS Foundation Trust: Principal Associate d Risks Recomme ndations Risk Score Risk Name Page no. 13 Non Elective Capacity Clinical Staffing Levels Number of qualified radiographers Delivering Better Lower Cost Vascular intervention 8 12 Neuro Rehabilitation Pathways Paediatric Provision and Support Increased number of trauma admissions Capital requirements for Major Trauma and Healthier 35 Together 12 Transformation Funding Activity and Income Levels Capacity Plans for increasing demand Compliance with the capped agency rate Operational estate capacity 54 The Group Committees in Common is asked to review and approve the opening position Board Assurance Frameworks. Public and/or Patient Involvement (Including equality related impacts) N/A Communication N/A Freedom of Information: This document is for full publication Appendix A 2

85 Salford Royal NHS Foundation Trust and 2018/19 Operational Plan Strategic Theme 1. Pursuing Quality Improvement to become the safest, highest quality care organisation Priority 1.1 Save and Improve lives through reliable and safe care 1.2 Delivering personalised care 2. Deliver Financial Plans 2.1 Drive efficiency and sustain financial performance, reducing costs by 51m over and 2018/19 3. Supporting high performance and improvement 4. Improving care and services through Integration & Collaboration 3.1 Deliver the Workforce Strategy 3.2 Support and develop our people to deliver Safe, clean & personal care 3.3 Improve Engagement with and the Well Being of our People 3.4 Implement the Membership Development Strategy 4.1 Work with partners across the Salford Locality to transform community based care and upgrade population health 4.2 Work with partners to reconfigure services across the NW Sector 4.3 Work with partners across GM to reconfigure and develop specialist services 4.4 Develop the Health Group improving services through standardisation at scale in association with Pennine Acute 5. Delivery of Mandatory Standards 5.1 Clinical and Quality Standards 5.2 Financial Standards 5.3 IM&T Standards 5.4 Access Standards 5.5 Workforce Standards 5.6 Buildings and facilities Standards 6. Implement Enabling Strategies 6.1 Research and Development Strategy 6.2 Under and Post Graduate Education 6.3 Hospital and Estates Redevelopment 6.4 IM&T and Innovation Strategy 6.5 Corporate Social Responsibility and Public Health Strategy Key to Board Assurance Framework and Corporate Risk Register 3

86 Risks are stated in the IF.THEN format Likelihood scores are defined as: 1 = rare - do not expect this to happen 2 = unlikely - most probably will not happen 3 = occasionally - 50:50 chance of occurring 4 = likely - most probably will happen 5 = almost certain - confident that this will happen. Impact scores are defined as: 1 = almost non - no obvious harm* 2 = minor - no permanent harm (recovery within month)* 3 = moderate - semi-permanent harm (recovery takes longer than 1 month but no more than 1 year) and/or adverse publicity for the Trust. * 4 = major - permanent harm not resulting in death or severe disability to a person or persons and/or start of a national investigation into the Trust and/or disruption of key Trust services which significantly hinder the Trust in meeting its responsibilities.* 5 = catastrophic - death or permanent severe disability to a person or persons and/or significant loss of reputation for the Trust and/or loss of key Trust services which prevent the Trust meeting its responsibilities.* Control scores are defined as: 1 = risk is fully under control 2 = risk is adequately controlled 3 = action to control risk adequately has started and appears effective 4 = action to control risk is agreed but no action started or not yet effective 5 = no actions to control risk identified. Risk tolerance levels: 3 5 = minor risk which is adequately managed and may be retained if further control limits the capacity to control higher ranking risks. 6-9 = moderate risk which must be reported and managed locally by the departmental, directorate or group manager/lead clinician = significant serious risk which must be reported to the Executive Assurance and Risk Committee (EARC) = Significant serious risk to the Trust which must be reported to and managed through the Board of Directors via EARC. 4

87 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Nursing Supported By: Chief Medical Principal Risks and Significant Operational Risks Principal Risk IF the Quality Improvement Strategy is not delivered, THEN the Trust may fail to save and improve lives through reliable and safe care. Risk Lead: Chief Nursing Risk Number: 2268 Likelihood Impact Key Control established 3 3 QI Directorate resources. Established QI Strategy ( ) QI Project Leads assigned. Divisional responsibility for quality. Standardised mortality review process across the organisation. All recommendations from Internal Audit Mortality Framework Review completed. Key Gaps in Controls Mortality review process continues to be refined. Control Assurance Gaps in assurance Action plan summary 2 Monthly Corporate None Implement new mortality Quality and People review process and Experience methodology proposed by the Committee reports Royal College of Physicians. to Salford EARC, Group Risk and Assurance Committee and Group Committees in Common. QI Dashboard presented quarterly to Group Committees in Common. Closing Position 2016/17 Opening Position 8 8 5

88 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Finance Principal Risks and Significant Operational Risks Principal Risk IF the impact of the Better Care at Lower Cost Programme is not appropriately assessed THEN reliable and safe care may be adversely affected. Risk Lead: Chief Finance Risk Number: 2270 Likelihood Impact Key Control established 2 4 Governance system for the programme includes Quality Impact Assessment of any proposed schemes and cost reductions to ensure impact is understood across the organisation. Audit control of Programme commissioned by the board through Mersey Internal Audit. Quality concerns escalated to Productivity Improvement Board. Key Gaps in Controls Mersey Internal Audit recommendation regarding Quality Impact Assessment identified. Control Assurance Gaps in assurance Action plan summary 3 Work stream None See key controls. Steering Group QPID (PMO) Governance arrangements management regarding Quality Impact arrangements. Assessment to be updated. Overall Programme Governance. External audit. Process being established to record review and approval by Medical and Nurse director on the PIDs. Closing Position 2016/17 Opening Position 9 9 6

89 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Medical Principal Risks and Significant Operational Risks Principal Risk IF systems and processes operating within the Trust s theatres that ensure patient safety are not effective THEN patient care may be compromised. Risk Lead: Chief Medical Likelihood Impact Key Control established Steps to Safer Surgery fully implemented. Continuous qualitative audit of 5 Steps to Safer Surgery Amalgamation of the two units Level 1 /Level 3 CD/Senior manager appointments completed. Audit of NATSIPS Key Gaps in Controls Debrief from Emergency Surgery Control Assurance Gaps in assurance Action plan summary 3 Outcome of stated None Continuous audit of 5 steps to Audits. safer surgery. Theatre A&P Group reporting, to MD fortnightly. Monthly report to Divisional Ops Committee. Biannual Divisional Report to Board includes Cancelled Operations/Theatre Utilisation Theatre Collaborative to be introduced for Safer Surgery. Monthly review at O&P Governance Committee Closing Position 2016/17 Opening Position Risk Number: 2274 Theatre Safety questionnaire completed. Monthly report to Ops Board 7

90 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Medical Principal Risks and Significant Operational Risks Principal Risk IF there is no provision for vascular intervention on site THEN patients are at increased risk of delays which may lead to higher rates of mortality and morbidity. (In particular this is in relation to GI bleeds or bleeds as a result of renal biopsy. SRFT does not have vascular services on site, but is still required to provide vascular radiology support) Risk Lead: Chief Medical Risk Number: 2275 Likelihood Impact Key Control established 3 5 Monday session provided by Consultant Radiologist from CMFT who covers emergency vascular intervention. Neuro vascular support offered for cases during normal working hours. Trauma collaborative provides cover for vascular intervention for trauma cases. Highly skilled neuro vascular radiologists are well versed in NEURO embolization techniques. In life threatening emergency cases would be able to provide emergency assistance. An SLA has been drafted by the SRFT Trauma Implementation Board which describes the provision of vascular intervention by CMFT for SRFT for trauma. Further consideration is being given to extending this SLA to non trauma related vascular intervention 52 weeks per year and in emergencies. Key Gaps in Controls Expert vascular intervention is only available on a Monday. Other days during the week are covered by skilled neurovascular radiologists; however they do not practice in GI/renal techniques on a daily basis. No cover provided outside of normal working hours. Neurovascular provision covers patients who are fit for transfer only and would not support patients who are too unwell to transfer Control Assurance Gaps in assurance Action plan summary 4 Incident There are changes monitoring. planned around vascular Divisional intervention across Governance Review GM, progress with of incidents as support for SRFT is occur. Meetings unlikely until this occur monthly. has been resolved No easy method of auditing number of patients on whom vascular intervention would have been beneficial and the subsequent delay. The risk has been escalated to CEO s in both organisations which has opened up channels for further discussion. CMFT are still in discussions around non trauma related vascular radiology at SRFT. Final word required from Ian Lurcock and Jane Eddlestone at CMFT and a response has been chased SLA produced to cover trauma agreed SLA for non trauma outstanding and awaits feedback 6.5 PA's suggested to be paid for this cover but CMFT have failed to recruit into vacant positions to support this service The actions below have been taken from the Scope of GM Radiology Paper as produced by the Healthier Together Chief Medical Advisor and Team dated 24/6/2016: 1) Understanding of North East Sector VIR work July ) Separation of emergency Closing Position 2016/17 Opening Position

91 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation Principal Risks and Significant Operational Risks Likelihood Impact Key Control established Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary and elective VIR lists (3 sectors) September ) Determination of core and complex VIR competencies and agreement of what is appropriate to be delivered at sites due to complexity August ) Agreement of staffing model and rotas to cover the North East sector for VIR September ) Implementation of a GM wide 24/7 service with 2 rotas operating across GM August 2017 tbc Closing Position 2016/17 Opening Position 9

92 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Medical Principal Risks and Significant Operational Risks Principal Risk IF there is no provision for nonvascular intervention on site THEN patients are at increased risk of delays leading to higher rates of mortality and morbidity. (In particular, this is in relation to abdominal and pelvic drainages and nephrostomy insertions. Recent examples of delayed intervention leading to poor outcomes for our patients. Risk associated with insufficient Radiologist and Nursing support.) Risk Lead: Chief Medical isk Number: 2276 Likelihood Impact Key Control established 3 4 SOP has been produced which describes the process to facilitate access to out of hours interventional support. This describes the following: Consultant Radiologists can provide a range of out of hours interventions and are rota d on a 1 in 11 basis for DIAGNOSTIC work. Highly skilled interventional radiologists offer ad hoc support when required. Nursing support is provided in emergency circumstances by the referring ward/dept. Agreement has been reached with CMFT to provide NVI support in the event of SRFT not being able to provide in house. Key Gaps in Controls Not all Consultants can provide all interventions due to competency issues in specialist techniques. 6 Consultants have interventional skills, 2 have full range of skills required to provide an on call service. Interventional rota cannot be established on a 1 in 6 basis. On sessions when interventional trained Consultants are not available, service provision is offered on a best endeavours basis by the 6 Consultants trained in intervention. There is no radiology nursing support to ensure that the staff and patient are supported during the procedures currently offered. This means that any interventions Control Assurance Gaps in assurance Action plan summary No KPI's exist related to CMFT response times for intervention 3 Incident monitoring. Incidents highlighting deficiencies in the SOP are flagged at Directorate and Divisional Level Ongoing discussions as part of a task and finish group which reports to the GM HT Radiology Clinical Advisory Group which aims to scope NVI provision across GM. Review of nursing hours to include weekend cover is underway and will provide 7/7 cover with nursing team The actions below have been taken from the Scope of GM Radiology Paper as produced by the Healthier Together Chief Medical Advisor and Team dated 24/6/ Radiology standards agreed and signed off July Consensus of core, intermediate and advanced/complex nonvascular IR competencies July A baseline assessment and gap analysis against the standards (reporting and nonvascular IR core competencies August Design of sector service Closing Position 2016/17 Opening Position

93 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation Principal Risks and Significant Operational Risks Likelihood Impact Key Control established Key Gaps in Controls are higher risk out of hours than in hours. Staff accompanying the patient are often unfamiliar with the radiological interventional environment or unavailable. There is no guarantee that intervention will be supported by Consultant Radiologists who are not on call for the respective session. Action plan is reliant on having sufficient people to participate in the two rota s (diagnostic & intervention). At present we have insufficient personnel to participate. Control Assurance Gaps in assurance Action plan summary models to meet HT requirements November Delivery of sector models for non vascular intervention April 2017 Closing Position 2016/17 Opening Position 11

94 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Medical Principal Risks and Significant Operational Risks Principal Risk IF the Trust fails to comply with the standards outlined in Core Standards for Intensive Care Units which ensure high quality standards of care THEN this may adversely impact on the Trust s plans to with regard to Major Trauma and Healthier Together. Likelihood Impact Key Control established 2 4 Core Standards Review Group (CSRG) established KPIs monitored via national body (ICNARC) Options appraisal with respect to compliance completed. Key Gaps in Controls Lack of progress highlighted by GM CCN Peer Review Control Assurance Gaps in assurance Action plan summary 3 Report through the Medical Director led task and CSS&TM Divisional finish group to review options Operations Board appraisal and select most and Divisional appropriate action and oversee Governance Board. implementation. The above to be reported to Clinical Effectiveness Committee. Closing Position 2016/ Opening Position Risk Lead: Chief Medical Risk Number:

95 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Medical Principal Risks and Significant Operational Risks Principal Risk IF the issues of fragmentation, lack of coordination, lack of standard framework for clinical practice, and delays to securing complex packages of care for neurorehabilitation are not resolved across Greater Manchester, THEN the upstream backlog in terms of pressure in acute care capacity and hence cost will continue to be carried by Salford Royal Likelihood Impact Key Control established Key Gaps in Controls 4 4 Absence of common rehab standards across the total pathway. Patients held in inappropriate settings. Tracheostomy and challenging behaviour patients are difficult to place outside of SRFT. No lead provider to coordinate and manage flow of patients. Time limited pathway required from referral to authorisation for packages of care. Control Assurance Gaps in assurance Action plan summary 4 ODN for As part of Trauma Programme Rehabilitation of Care SRFT would see itself agreeing GM becoming the lead provider for service model and neurorehabilitation in Greater specification. Manchester which would assist in facilitating standards of care across the rehab pathway and co ordination of care and patient flow. Closing Position 2016/17 Opening Position Risk Lead: Chief Medical Risk Number:

96 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Strategy and Organisational Development Principal Risks and Significant Operational Risks Principal Risk IF established Trust wide clinical staffing levels cannot be achieved, THEN the Trust will remain heavily reliant on noncontracted staff which may in turn compromise patient care and service delivery. Risk Lead: Chief Strategy and Organisational Development Risk Number: 2271 Likelihood Impact Key Control established 4 5 Trust Workforce Strategy. Divisional Workforce Plans developed. Range of interventions in place to retain nursing staff. Established medical staffing processes. Internal bank of locum doctors. Quality assurance processes in place for external locum doctors. All ward managers to be in a supervisory role. All shift coordinators to act in a supervisory capacity. All ward areas to review funded establishments twice yearly using a recognised acuity and dependency tool. Divisional review and full analysis of staffing recruitment gap. Specialling Change Package developed. Key Gaps in Controls National shortage of training grade, middle grade and some consultant medical staff, in particular in A&E, Radiology, Stroke, Blood Transfusion Service and Histopath. National shortage of commissioned nurse training places, resulting in national shortage of Registered Nurses. SRFT s limited control of deanery rotations. Appropriate workload and responsibility for medical trainees. Effective supervision and learning arrangements for nonconsultants nontraining staff and nursing staff Ability to recruit to established nursing posts. Control Assurance Gaps in assurance Action plan summary 4 Divisional None governance arrangements including monthly clinical staffing report by Divisional HR Manager to Divisional Ops Board. Safe Staffing included in Integrated Performance Dashboard reported monthly to Salford Management Board and Group Committees in Common. Monthly Workforce Strategy Board, reporting quarterly to QPE Governance Committee. Development of formalised Recruitment Strategy and Retention interventions with targets set for Monthly Workforce Strategy Board in place and focussing on effectively addressing this risk. Focus on delivery of divisional workforce strategies. Working with Universities to ensure the Salford Royal job offer is fully understood and we recruit as many newly qualified nurses as possible. Full implementation of Trendcare in progress. Fair and equitable bank rates for all general wards. Closing Position 2016/17 Opening Position

97 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation Principal Risks and Significant Operational Risks Likelihood Impact Key Control established International nursing recruitment programme contract revised. Key Gaps in Controls Ability to respond to short term nurse staffing pressures. Control Assurance Gaps in assurance Action plan summary improved recruitment and retention rates. Closing Position 2016/17 Opening Position Trendcare care capacity system rolled out across the Trust. Internal nurse transfer scheme established Senior Nurse seconded in to support Recruitment and retention. Recruitment and Retention Strategy being revised. Oversee recruits requiring 12 months experience, access to and requirements to pass an OSCE. Limited control in utilisation of NHSP to fill registered nursing shifts. Utilisation of Trendcare to match nursing activity to acuity and dependency. Divisional workforce plan agreed 15

98 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Medical Principal Risks and Significant Operational Risks Principal Risk IF there is not sufficient paediatric provision & support onsite THEN paediatrics are at increased risk of harm & may lead to increased mortality and morbidity. Likelihood Impact Key Control established 4 4 Anaesthetic Team respond to any paediatric emergency, alongside A&E team. SOP being developed specifically to address management of paediatrics (0 3). Key Gaps in Controls Maintenance of skills remains difficult as workload not sufficient. Likelihood of risk may increase with new trauma centre. Maintain the lack of paediatric experience. Trust was scheduled to accept paediatric trauma from April Control Assurance Gaps in assurance Action plan summary 4 Report through the Clinical Effectiveness Divisional Committee to oversee the Governance following actions. Committee and Divisional Service review as part of NW Assurance and Risk sector plans. Committee. SOP being developed. Meetings planned with NWAS. Closing Position 2016/17 Opening Position (In particular SRFT is a designated Paediatric Trauma Unit and as such will receive Paediatric Trauma and Paediatric emergencies. These will require anaesthetic support from the consultant anaesthetists at SRFT and potentially emergency surgery should there be life threatening trauma. Further detail included in Datix) The current level of neither minor elective paediatric activity nor the MEPA FC is not an adequate control to support Paediatric Trauma. Risk Lead: Chief Medical Risk Number:

99 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Delivery Principal Risks and Significant Operational Risks Principal Risk IF the number of trauma admissions continues to increase THEN there will be a delay to patients accessing theatre/surgery within an appropriate clinical time period therefore patient outcomes maybe be adversely affected. Risk Lead: Chief Delivery Risk Number: 2254 Likelihood Impact Key Control established 4 5 Weekly review of patients waiting and the length of wait within sub specialties Additional theatre lists planned to reduce length of wait Elective cases cancelled and replaced by trauma where possible, although the ability to do this frequently has reduced following all Orthopaedic elective work being off site at Trafford Control Closing Position 2016/17 Key Gaps in Controls Assurance Gaps in assurance Action plan summary Increased demand 3 Report through the Action plan underway Divisional Governance Committee and Divisional Assurance and Risk Committee. Opening Position 17

100 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Strategy and Organisational Development Principal Risks and Significant Operational Risks Principal Risk IF there are insufficient suitably qualified doctors and radiographers to report images in a timely manner THEN it increases the risk of delayed diagnosis resulting in higher morbidity and mortality with resultant increased cost and potential damage to Trust reputation. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 5 5 Images can be prioritised for reporting if there is clinical concern. Plain film work is being outsourced. Reporting radiographer is in training. WLI offered for MR and CT backlogs. Home work stations implemented. Payment per scan implemented for Junior Doctors. Job planning to ensure that reporting capacity is accurately documented and includes allowance for cross cover as necessary. Robust dashboard now developed which provides live position Key Gaps in Controls Insufficient number of Radiologists and Radiographers to satisfy the demand for reporting. Reporting sessions may be missed due to cover for other commitments e.g MDTs, reporting for other Trusts Consultants do not wish to take additional WLI Job plans need updating (including radiographers) Timely reporting to Emergency Department Control Assurance Gaps in assurance Action plan summary 3 Compliance with Update job plans following turnaround times completion of capacity and monitored at demand calculation. weekly Divisional Access and MSK Radiologist appointments Performance and being considered. monthly to Divisional Governance Committee Closing Position 2016/17 Opening Position Risk Number: 1850 Specialty Doctor recruited 18

101 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.1 Save and Improve lives through reliable and safe care : Chief Delivery Principal Risks and Significant Operational Risks Principal Risk IF the Trust s Business Continuity systems, plans and processes are not robust, THEN the continuity of critical patient services when faced with major disruption from identified local risks e.g. severe weather, IT failure, fuel shortage, industrial action, may be affected whilst steps are taken to reinstate disrupted services. Likelihood Impact Key Control established 2 4 Service Continuity Policy and Strategy developed, including alignment with Emergency and Major Incident Planning. Major Incident Plans in place. Key Gaps in Controls Bespoke Business Continuity plans require further development. IM&T Inability to test the continuity plans of high profile systems due to the lack of planned downtime. Control Assurance Gaps in assurance Action plan summary 4 Service Continuity Policy and Strategy developed and reviewed by appropriate Corporate Governance Committee. Annual review via Resilience Group and Operations and Performance. Merge Emergency Planning, Major Incident and Business Continuity functions. To expand the remit of the current Resilience Group to include Business Continuity Each division to have a named Business Continuity/Emergency Planning lead. Bespoke Business Continuity Plans to be developed on a priority basis with first consideration given to business critical functions such as IM&T, Estates, Support Services such as Pharmacy, Pathology, Radiology. Closing Position 2016/17 Opening Position Risk Lead: Chief Delivery Risk Number:

102 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 1. Pursuing Quality Improvement to become the safest, highest quality care organisation 1.2 Delivering personalised care : Chief Nursing Principal Risks and Significant Operational Risks Principal Risk IF the Trust fails to understand and act upon the explicit expectations of patients THEN the Trust will not meet the specific and personal needs of its patients. Risk Lead: Chief Nursing Risk Number: 2278 Likelihood Impact Key Control established 2 3 Real time Patient Feedback, including community and outpatients patient experience. Senior Nurse Clinical Walk Abouts, Matron Rounds. NAAS, CAAS, OPAAS, PALS, Complaints. National Survey results, Draft NICE guidelines reviewed against trust actions. Friends and Family results monitored, including inpatients, community services and outpatient areas. FFT / patient experience survey results disseminated and monitored by own teams to ensure patients are listened to and improvements made at a local level. Patient Experience Strategy Patient, Family and Carer Experience Quality Improvement Collaborative continues. Local tests of change continue. Key Gaps in Controls Variation in reported patient experience across the organisation. Control Assurance Gaps in assurance Action plan summary 3 Six monthly Patient None Experience Report Quality and People Experience Committee. Including results of all stated key controls. Six monthly combined Patient Experience/Respon siveness/adverse Events Report to Board of Directors. Mersey Internal Audit Agency (MIAA) Patient Experience audit. Focus on review of current systems and processes on the management, monitoring, reporting and communicating the Trust s work on patient experience, and information on how patients/family/carer feedback and concerns are raised and acted upon. Report to be finalised. Patient, Family and Carer Experience Collaborative ongoing. Divisions reviewing their own patient experience you said we did and completing tests of changes to improve practice. There will be a Learning Session where the Divisions will come together to share their tests of change held later in Real time patient feedback to wards and departments from FFT, including text commentary. Individual wards, teams and departments are being held to account for actions against comments and improvements via Divisional Governance Committees. Closing Position 2016/ Opening Position 20

103 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 2. Delivering Financial Plans Principal Risks 2.1 Drive efficiency and sustain financial performance, reducing costs by 51m over and 2018/19 : Chief Delivery Principal Risk IF systems and processes operating within the Trust s theatres that ensure efficient and effective theatre utilisation do not deliver an optimum service THEN theatre productivity may be adversely affected. Likelihood Impact Key Control established 2 4 Theatre efficiency task group established Divisional MD led. A&P Theatres implemented. Balance scorecard in use. Amalgamation of the two units Level 1/Level 3. CD/Senior Manager appointments completed implementation. Auditing of theatre activity/productivity, including underruns, overruns and theatre utilisation. Key Gaps in Controls Effective utilisation measurement not in place. Control Assurance 3 Theatre A&P Group reporting, to MD fortnightly. Monthly report to Ops Board. Biannual Divisional Report to Board includes Cancelled Operations/Theatre Utilisation/ Gaps in assurance None Action plan summary Further BCLC schemes to be implemented: Managed service in theatres Single use items Improved theatre tray packaging Closing Position 2016/ Opening Position Risk Lead: Chief Delivery Revised theatre utilisation measurement tool in place Audit of NATSIPS 2.1 Drive efficiency and sustain financial performance, reducing costs by 51m over and 2018/19 : Chief Finance Risk Number: 2467 Principal Risk IF the Trust fails to deliver Better Care at Lower Cost target of 28.7m in THEN the Trust may not achieve the forecast outturn financial position for. Risk Lead: Chief Finance Risk Number: Productivity Improvement Board (PIB) chaired by Executive Director to proactively manage programme. None identified at present 21 4 Monthly PIB Terms of Reference approved by Board of Directors. Monthly BCLC Report to Board. PIB to report and manage risks (10 and above) through EARC Work streams continue to develop for

104 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 2. Delivering Financial Plans Principal Risks 2.1 Drive efficiency and sustain financial performance, reducing costs by 51m over and 2018/19 : Chief Finance Principal Risk IF the Trust breaches the agency spend cap THEN this will adversely affect the Trust s Single Oversight Framework financial risk score and determination of potential regulatory action. Likelihood Impact Key Control established 5 2 Workforce plans; weekly joint review by Divisional MDs; Recruitment plans in place to reduce premium spend; Central temporary staffing team and robust approval processes. Key Gaps in Controls Locum spend data is not fully completed by Divisions re RAG rated action plans to reduce spend. Bookings within SHSC Division currently do not all go through Central Team. Control Assurance 4 Monthly Report to Corporate Finance, Information & Capital Committee Monthly Finance Report to Board Gaps in assurance Action plan summary Action plan agreed with SHSC re all bookings through Central Team. Director of OD and Chief Medical met with counterparts at CMFT in February 17 to reach agreement on compliance. Closing Position 2016/17 Opening Position Risk Lead: Chief Finance Risk Number:

105 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 3.Supporting high performance and improvement within the workforce Principal Risks 3.1. Deliver the Workforce strategy : Chief Strategy and Organisational Development Principal Risk IF the Trust fails to have an effectively delivered workforce strategy THEN workforce transformation may be inhibited and clinical and financial benefits may not be realised. Risk Lead: Chief Strategy and Organisational Development Risk Number: 2652 Likelihood Impact Key Control established 3 4 Trust level Workforce Strategy approved by Board Divisional workforce plans in place Productivity benchmark agreed as aim for all divisions. Temporary staffing team established in HR. Additional team members for recruitment team appointed Recruitment and Retention role established to focus on nursing recruitment Contracted with NHSP doctors (all staff groups now with NHSP) MD s sign off all above cap shifts for locums Weekly review of agency spend with MD s Key Gaps in Controls Lack of GM/ national position on locum cap feeding over spend. Training numbers determined by HENW Control Assurance 4 Quarterly report to Group Committees in Common/ Salford EARC/ Salford Quality and People Experience Governance Committee. Monthly Workforce Strategy Board. Weekly recruitment meeting. Gaps in assurance Action plan summary Divisional workforce plan agreed and now delivery is monitored at monthly Workforce Strategy Board. Continued focus on agency cap reductions and movement of agency to NHSP. Closing Position 2016/17 Opening Position Weekly review of nursing recruitment with Director of Nursing and HR Workforce Dashboard received monthly at Workforce Strategy Board and Divisional Meetings. 23

106 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 3.Supporting high performance and improvement within the workforce Principal Risks 3.2 Support and develop our people to deliver Safe, clean & personal care : Chief Strategy and Organisational Development Principal Risk IF the Trust fails to apply its Values and Contribution Framework in a consistent and sustainable way THEN the move to a performance culture will not be achieved. (Current objective: 95% for incremental cycle) Risk Lead: Chief Strategy and Organisational Development Risk Number: 2280 Likelihood Impact Key Control established 3 3 Corporate templates & guides fully available. Continued staff involvement. Awareness and feedback sessions with directorate teams taking place. Training programme completed for all leaders and ongoing for new leaders. Cultural values based Induction Programme. Electronic tracking site established. Talent / performance management plans in place. Core objectives agreed for all nursing colleagues. Key Gaps in Controls Robust plans for high and low performerstalent management and performance management to improve Control Assurance 3 Annual NHS Staff Survey engagement score. Monthly tracking of compliance included in Board Integrated Performance Dashboard. Quarterly F&FT report to Corporate Quality and People Experience Governance Committee. Monthly update reports to Appraisers and Head of Department. Gaps in assurance None Action plan summary Training programme ongoing for all reviewees Focus on departments with low compliance and report on these to Operations and Performance Corporate Governance Committee and Workforce Strategy Board. Sanctions to be introduced for leaders with consistently low compliance Closing Position 2016/ Opening Position 24

107 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 3.Supporting high performance and improvement within the workforce Principal Risks 3.3 Improve Engagement with and the Well Being of our People : Chief Strategy and Organisational Development Principal Risk IF the Trust does not continue to achieve high levels of satisfaction in the national staff survey, THEN the known correlation with high quality patient care and the Trust s reputation as an employer may be compromised. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 4 3 Quarterly staff FFT on satisfaction and harm. Five key focus areas: Bullying and harassment Trust wide staff communication Speaking up Improving support from managers Health and well being. Refreshed communications and engagement strategy established. Key Gaps in Controls Review of internal surveys not robust enough. Need to be reviewed at DARCs/ Ops Board and Workforce Strategy Board. Need to publish quarterly Staff FFT results. Leaders to have objectives for re Staff Engagement. Control Assurance 3 Comprehensive Staff Survey Report to Quality and People Experience Governance Committee, Group Committees in Common and Council of Governors. Quarterly Staff FFT Survey results. Gaps in assurance None Action plan summary Implementation of revised Communications and Engagement Strategy. Process to establish robust review of internal surveys quarterly reporting regimes to be established to Board. Publish quarterly Staff FFT results. Closing Position 2016/17 Opening Position Risk Number:

108 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 3.Supporting high performance and improvement within the workforce Principal Risks 3.3 Improve Engagement with and the Well Being of our People : Chief Strategy and Organisational Development Principal Risk IF the Trust fails to implement an effective Health and Well being Strategy for staff THEN sickness levels may not improve and there may be adverse impact on productivity. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 3 3 Health and Well being steering group established with monthly meeting. Progress reviewed at Workforce Strategy Board Proactive and reactive improvement proposals in place. EAP Service in place. Return to work interviews being monitored. Fast track service for staff Implemented. Employee Assistance Programme in place Key Gaps in Controls 50% compliance in return to work interviewsfurther controls to be established Coherent strategy required for enabling staff to return to work in alternative areas. Control Assurance 3 Progress report to monthly Workforce Strategy Board. Progress reviewed of Health and Well Being initiatives Absence % reviewed at Trust and staff group/ department level Report to Quality and People Experience Committee. Gaps in assurance None Action plan summary External Wellbeing Charter assessment completed in May 17, feedback awaited. Absence reviewed at monthly workforce strategy meeting. Closing Position 2016/ Opening Position Risk Number:

109 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 3.Supporting high performance and improvement within the workforce Principal Risks 3.4 Implement the Membership Development Strategy : Chief Strategy and Organisational Development Principal Risk IF engagement is not effective, during, with members, patients and the public THEN the Trust will miss opportunity to gather comments and feedback on SRFT s services and plans from SRFT s members, patients and the public Risk Lead: Chief Strategy and Organisational Development Risk Number: 2309 Likelihood Impact Key Control established 2 2 Robust Membership & Public Engagement Strategy and comprehensive Membership and Public Engagement Plan in place. Trust wide engagement activities and Governor Led Engagement Plan included within the Membership and Public Engagement Plan. Fully functioning Membership and Engagement section of intranet. Fully functioning Patient and Public Experience Register, allowing central record of patient and public involvement in service improvement. Control Key Gaps in Controls Assurance None 2 Monitored on quarterly basis by CoG via Engagement Subgroup. Annual Report to Quality and People Experience Governance Committee. Gaps in assurance None Action plan summary Continue to populate Patient and Public Experience Register. Engage with PAT Membership department to develop engagement with members, patients and public served by PAT communities. Low Risk: Risk continues to be adequately maanaged Closing Position 2016/ Opening Position 27

110 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.1 Work with partners across the Salford Locality to transform community based care and upgrade population health : Chief Strategy and Organisational Development Principal Risk IF ICO transformation plans are not developed and implemented THEN the scale of budgetary and demand pressures in the system may adversely affect the delivery of the Locality Plan. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 3 4 Commissioners will lead Transformation planning through the Service and Financial Plan, with detailed proposals co designed through the Advisory Board for Integrated Care. The Service and Financial Plan is currently being developed for the adult population. It will unify commissioning intentions for the services within the pooled budget. Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary 4 Reports to Group Committees in Common, Locality Leadership Group, ICO Programme Board and Executive Strategic Programme Board. The ICO Programme Board will monitor the ICO implementation, including the linked development of system wide transformation plans and efficiency savings. Commissioners will continue to lead transformation plans through the new Integrated Care System Governance arrangements. Phase 3 of the Service and Financial Plan was endorsed by the Integrated Care Joint Committee (ICJC) in October 2016 and provides the framework for system transformation. More detailed plans, at a work stream level, have been drafted and are now being shared with commissioners for ongoing development through the Integrated Care Advisory Board. Closing Position 2016/17 Opening Position Risk Number: 2740 As part of the ICO 100 Day report, concerns have been raised by ICO staff in relation to capacity to integrate governance systems and deliver transformation. Action plans against these areas are being closely monitored at the ICO Programme Board. 28

111 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.1 Work with partners across the Salford Locality to transform community based care and upgrade population health : Chief Strategy and Organisational Development Principal Risk IF ICO efficiency plans are not developed and implemented THEN budgetary and demand pressures in the system may adversely affect SRFT service quality and sustainability. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 3 4 In parallel with transformation planning, and in accordance with the Commissioner to ICO Risk Share Agreement, SRFT will produce a plan to deliver the agreed 2% Adult Social Care efficiencies in. The plan is to be agreed with Commissioners for implementation in. Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary 4 Reports to Group Committees in Common, Locality Leadership Group, ICO Programme Board and Executive Strategic Programme Board. The ICO Programme Board will monitor the ICO implementation, including the development of ICO efficiency savings. Initial plans to deliver 2% ICO efficiencies in have been drafted and are being shared with Commissioners for further development. The SHSC will lead on the delivery of the plan following its agreement. Closing Position 2016/17 Opening Position Risk Number:

112 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.1 Work with partners across the Salford Locality to transform community based care and upgrade population health : Chief Strategy and Organisational Development Principal Risk IF agreement can t be reached to bring together General Practice and the ICO arrangements THEN plans to deliver a preventative population health approach through a neighbourhood model are unlikely to be delivered and improved outcomes for the adult population are unlikely to be achieved. Likelihood Impact Key Control established 3 4 Work is continuing with partners to agree the vision and steps required to move towards an Accountable Care Model. The scope of the model is still to be finalised, discussions are that it would have a whole population (all ages) responsibility, with a focus on health, care and wellbeing. The development of the Accountable Care model will be supported by a single GP Provider Body in Salford. Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary 3 Monthly report to Executive Strategic Programmes Board, ICO Programme Board and Salford Leadership Group. Externally facilitated programme of support commenced for senior leaders to develop shared vision and work programme. Work is ongoing to agree the vision and next steps to move towards an Accountable Care model, supported by the newly established GP provider federation Salford Primary Care Together in Salford to facilitate federated working at a neighbourhood level. The business case for SPECT staffing and location has now been approved, and options for colocation and joint appointments are being explored with the ICO leadership team. Closing Position 2016/17 Opening Position Risk Lead: Chief Strategy and Organisational Development Risk Number:

113 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.1 Work with partners across the Salford Locality to transform community based care and upgrade population health : Chief Strategy and Organisational Development Principal Risk IF SRFT fails to deliver the GMMH subcontract for Salford Mental Health Services THEN SRFT would be in breach of commissioning arrangements and may experience adverse impact on performance, reputation with commissioners. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 3 4 Managed via ACS Provider Board assurance processes/joint contract meetings with Salford CCG and exception report to Group Risk and Assurance Committee. Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary GMMH to submit Risk Registers. 2 Monthly progress report to ACS Provider Board Assurance Process GMMH to submit risk register and monthly performance reports to ACS Provider Board. Performance Reports ongoing. Development of system wide risk register for ACS. Development of supply chain arrangements. Closing Position 2016/ Opening Position Risk Number:

114 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.2 Work with partners to reconfigure services across the NW Sector : Chief Strategy and Organisational Development Principal Risk IF partners within the north west sector are unable to agree a clinical model for the sector to implement the Healthier Together recommendations and agree the development of single service models for sector response for Healthier Together and other sector services THEN these may not be sustainable/meet the required standards for the future. Likelihood Impact Key Control established 2 4 NW Sector Project Board and Leadership Group. Range of sector based partnership agreements in place, formalised through a North West Sector Partnership Board with representation from 3 CCGs and 3 FTs, underpinned by new Memorandum of Agreement (MoA) of the North West Sector Partnership. Clinical model signed off by GM as part of the Stage 2b assurance process. Key Gaps in Controls Finalisation of mobilisation plans contingent upon capital approval Control Assurance Gaps in assurance Action plan summary 3 Monthly progress None Further development of HT report to mobilisation plans and Executive establishment of Shared Services Strategic Board. Programmes Board. NW Sector Progress reports to GM Theme 3 Team & GM H&SC Board Closing Position 2016/ Opening Position Risk Lead: Chief Strategy and Organisational Development Risk Number:

115 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.2 Work with partners to reconfigure services across the NW Sector : Chief Strategy and Organisational Development Principal Risk IF the reconfiguration of acute services within GM is not sufficiently coordinated and cognisant of codependent services THEN this may adversely impact on other services and compound problems associated with capacity and transfers of care. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 4 3 SRFT teams are engaged in programmes of work across a range a services and this work is coordinated through a number of internal and external governance boards including; GM Provider Federation Board GM Cancer Board GM OG Implementation Board established NW Sector Partnership Board NW Sector Alliance Board NW Sector Task and Finish Group Specialty Group supporting GM Theme 3 work streams Executive Strategic Programme Board SRFT HT Implementation Board Key Gaps in Controls Discussions ongoing with commissioner and partners regarding the strategic direction. Control Assurance Gaps in assurance Action plan summary None 3 Monthly HT Implementation Board, Progress report to Executive Strategic Programmes Board and onwards to Strategy & Investment Committee. GM Theme 3 and NW Sector review programme currently underway and SRFT actions coordinated through the Internal HT Programme Board. Closing Position 2016/17 Opening Position

116 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.3 Work with partners across GM to reconfigure and develop specialist services : Chief Strategy and Organisational Development Principal Risk IF the Trust fails to deliver the required standards to be a principal receiving site as a Major Trauma Centre, achieve the required improvement in patient outcomes and within the designated financial tariff, THEN the reputation of SRFT may be compromised. Risk Lead: Chief Strategy and Organisational Development Risk Number: 2287 Likelihood Impact Key Control established 3 4 Internal action plans and implementation of trauma standards. Surgery & Neuro Division leading implementation and monitoring standards. Collaboration across GM economy. Interim IRU beds agreed. Key Gaps in Controls Finalising the required shared service arrangements, through effective partnership working with other key GM Trusts. Agreement on necessary Capital plans with Commissioners Control Assurance Gaps in assurance Action plan summary 3 Developed None Pan Greater Manchester Project performance Plan agreed and taken forward. dashboard, reviewed weekly Internal SRFT project plan via Major Trauma established to deliver Working Group. requirements for principal Major Trauma receiving site provision. Implementation Board overseeing development. Report to Corporate Finance, Information & Capital Governance Committee. Monthly progress report to Executive Strategic Programmes Board and onwards to Strategy & Investment Committee Closing Position 2016/17 Opening Position

117 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.3 Work with partners across GM to reconfigure and develop specialist services : Chief Strategy and Organisational Development Principal Risk IF the Trust fails to secure agreement around capital requirement for Major Trauma and Healthier Together in a timely manner THEN there is a significant risk to the implementation timetable for these important strategic developments Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 3 4 MT and NWS HT capital requirements identified, supported by commissioners. Submission made to the Treasury, as part of GM capital requirements. Effective engagement with the GM Health & Social Care Partnership and with commissioners. Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary 5 Report to Development of Major Trauma Executive Finance, and Healthier Together Information & mobilisation plans, pending capital Capital approval. Committee. Monthly progress report to Executive Strategic Programmes Board and onwards to Strategy & Investment Committee Closing Position 2016/17 Opening Position Risk Number:

118 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.4 Develop the Health Group improving services through standardisation at scale in association with Pennine Acute : Chief Strategy and Organisational Development Principal Risk IF SRFT is unsuccessful in securing capital to develop the Standard Operating Model THEN Group will not have its improvement proposition. Speed at which funding sources respond may mean reduced speed to development. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 3 4 Continue to engage GM Devo & National Develop alternate funding strategy including options in developing business case.. Key Gaps in Controls Devolution of transformation funding has created slowdown distribution particularly for Acute Care Collaboration. Control Assurance Gaps in assurance Action plan summary 3 Monthly progress report to Executive Strategic Programmes Board. Detailed review of key elements at Strategy and Investment Committee Group Programme Board Regular report to Group Committees in Common Group Committees in Common to determine reporting mechanisms. Stakeholder engagement to test alternate funding strategy. Target funding through Control Centre via GM Transformation fund. Further funding through Centre of Global Digital Excellence. Closing Position 2016/17 Opening Position Risk Number:

119 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.4 Develop the Health Group improving services through standardisation at scale in association with Pennine Acute : Chief Strategy and Organisational Development Principal Risk IF SRFT is in unable to secure the right senior management/ talent to implement Group projects THEN there is a risk that new members may have reduced benefit from Group thus reducing chances of further growth. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 3 4 Recruitment plan and investment. Progress made identifying talent and senior management internal and external to SRFT. Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary 3 Monthly progress BOD to determine reporting report to mechanisms. Executive Strategic Programmes Board. Detailed review of key elements at Strategy and Investment Committee Group Programme Board Regular report to Group Committees in Common Recruitment of senior management to support group. Talent identification with Group members. Closing Position 2016/17 Opening Position Risk Number:

120 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.4 Develop the Health Group improving services through standardisation at scale in association with Pennine Acute : Chief Finance Principal Risk IF the Trust does not have operational capacity to deliver the needs of potential commercial contracts THEN the income opportunities will not be reached. Risk Lead: Chief Finance Likelihood Impact Key Control established 3 4 Each commercial opportunity will be developed with divisional leads; capacity constraints will be identified, if it is possible to mitigate then the commercial opportunity will proceed, if not then it will not be pursued. Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary 1 Business case Active commercial portfolio. review via Executive Finance, Clear risk/reward prioritisation of Information and projects with a view on wider Capital work. Governance Committee. Executive Strategic Programmes Board. Strategy and Investment Committee. Closing Position 2016/ Opening Position Risk Number: 2657 Regular report to Group CIC 38

121 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 4. Improving care and services through Integration & Collaboration 2016/17 Principal Risks 4.4 Develop the Health Group improving services through standardisation at scale in association with Pennine Acute : Chief Strategy and Organisational Development Principal Risk IF the Trust fails to secure the appropriate transformation funding for PAHT THEN SRFT will withdraw its offer to incorporate PAHT in the SRFT Group. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 4 4 Develop and execute stakeholder engagement plan. Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary 4 Group Programme SRFT to prepare exit strategy in Board. preparedness of system failure. Regular report to BoD. Further submission to GM HSCP for additional transformation funding. Ongoing talks with national bodies. Closing Position 2016/17 Opening Position Risk Number:

122 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 5. Delivery of Mandatory Standards Principal Risks 5.1 Clinical & Quality Standards : Chief Nursing Principal Risk IF the Trust is judged as failing to comply with the CQC s standards for the quality and safety of services, THEN patient care may be compromised and the Trust may be considered as in breach of its Licence. Risk Lead: Chief Nursing Risk Number: 2288 Likelihood Impact Key Control established 2 5 EARC approved Trust wide compliance assessment programme. Complemented by Risk Register process, NAAS, CAAS and OPAAS. Internal CQC Corporate Assurance Visits Regular report to QPE, CEC with escalation reports to EARC as appropriate Key Gaps in Controls Further development of existing controls to reflect current CQC inspection standards. Control Assurance 2 Overarching Division specific annual assurance report and corporate annual assurance report to EARC. Assurance reports to Audit Committee 5* per year Audit Committee reviews MIAA Independent review Gaps in assurance Action plan summary Comprehensive action plan active to ensure lesson learning for all weaknesses perceived by CQC. EARC monitoring progress of action plan. Mock CQC took place December Report presented to QPE in February 2017 and action plan approved by EQE in April. Immediate actions taken following the internal review where improvements were identified and needed locally. Closing Position 2016/ Opening Position Exec Review Department Service review. Successful outcome to full CQC inspection January

123 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 5. Delivery of Mandatory Standards Principal Risks 5.1 Clinical & Quality Standards : Chief Delivery 5.1 Clinical & Quality Standards : Chief Medical Principal Risk IF CQUIN and KPI targets are not achieved THEN there will be a financial implication to the Trust Risk Lead: Chief Delivery Risk Number: 2289 Principal Risk IF the Trust fails to have appropriate measures in place for the prevention of C difficile THEN both patient experience and outcome and organisational reputation may be jeopardised. Risk Lead: Chief Medical Risk Number: 2290 Likelihood Impact Key Control established 3 4 Performance Report & individual measures managed & monitored via Operations and Performance Corporate Governance Committee and EARC. Monthly meeting with commissioners to monitor compliance. Readmissions T&F group underway which is reporting to Operations and Performance Corporate Governance Committee. 2 5 Policies in place to ensure measures are implemented to prevent Clostridium difficile including Clostridium difficile Policy, Mandatory Training Policy, and Antimicrobial Guidance. Performance monitored via High Impact intervention audits, Antibiotic audits, Infection control audits and environmental cleanliness audits. Monthly reporting on performance against Divisional Clostridium difficile acquisition reduction targets. Control Key Gaps in Controls Assurance None 3 Monthly review via Operations and Performance Corporate Governance Committee and EARC None 2 Monthly reports to Clinical Effectiveness Committee and Group CIC on Clostridium difficile performance against national target. Clinical Effectiveness and Divisional monthly reports on Antimicrobial prescribing compliance. Closing Position 2016/17 Opening Position Gaps in assurance Action plan summary None See controls None Trust Clostridium difficile action plan in place and includes: guidance to limit the use of Proton Pump Inhibitors has now been implemented as PPIs are associated with increased risk of Clostridium difficile. guidelines have been implemented on use of probiotics for patients aged >65 and on antimicrobial treatment has commenced

124 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 5. Delivery of Mandatory Standards Principal Risks 5.2 Financial Standards : Chief Finance Principal Risk IF the planned activity and income levels are not achieved and/or expenditure controls are exceeded leading to a NHSI Use of Resources Rating lower than planned in, THEN this will increase regulatory investigation and intervention. Likelihood Impact Key Control established 4 5 Financial Plan forecast to be achieved and exceeded. Draft Financial Plan submitted 24 th November 2016 and final plan on 23 rd December Contracts with commissioners agreed. Control Key Gaps in Controls Assurance Divisional contracts to be agreed. 3 Monthly Corporate Finance, Information and Capital Governance Committee Audit Committee Financial Review Monthly Board of Director Financial Review Gaps in assurance Action plan summary None Financial Plan for approved by Board of Directors December Closing Position 2016/17 Opening Position Risk Lead: Chief Finance Risk Number:

125 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 5. Delivery of Mandatory Standards Principal Risks 5.3 IM&T Standards : Chief Strategy and Organisational Development Principal Risk IF increasing levels of SPAM and malware into the Trust continue, increasing the risk to cyber security THEN normal business functions may be compromised which would impact on patient service delivery. Risk Lead: Chief Strategy and Organisational Development Risk Number: 2436 Likelihood Impact Key Control established 4 4 NHS SPAM filtering SRFT Virus Protection Web filtering Cyber Essentials Certification Retainer for NCC Group for Incident Recovery Team Education programme for staff Warnings of cyber security attacks on NHS from Government Key Gaps in Controls No intrusion detection No internal SPAM filtering Reduced staff understanding of the risks involved due to the increase in frequency and malevolence of malware attacks No forensics process to deal with a catastrophic attack Systems in place for previous level of threat and not the current heightened risk Control Assurance 2 Detection of malware and reporting by staff. Internal forensics process monitored via established Security Board. Onward exception report to Executive Finance, Information and Capital Governance Committee. Internal audit by MIAA Cyber Essentials Certification Virus attacks have occurred but been managed Penetration Test results. Gaps in assurance Action plan summary Intrusion detection system purchased. Requires calibration to provide optimal support. SPAM filtering now operational. Requires calibration to provide optimal support. Develop further advanced forensics and incident response with an external company. Development of an internal Technical Security resource. Start a system of ethical, targeted SPAM, monitor. Awaiting report Trust response and develop an education programme. Penetration test to agree effectiveness. Closing Position 2016/17 Opening Position

126 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 5. Delivery of Mandatory Standards Principal Risks 5.4 Access Standards : Chief Delivery Principal Risk IF demand for emergency admission exceeds non elective capacity or specialist teams/diagnostic services do not respond in a timely manner THEN more than 5% of patients will wait longer than four hours in A&E, and elective flow and patient care may be compromised. Likelihood Impact Key Control established 5 4 Daily breach analysis, Emergency Village escalation plans in place. Robust deflection programme in place. Urgent Care Programme Board for Salford economy in place. Key Gaps in Controls Delayed transfers of care to Trafford out of SRFT immediate control. Issues with Home Care market in GM. Revised Urgent Care Action Plan required to address above. Unable to recruit to planned establishment due to recruitment difficulties. Control Assurance 4 SITREPS and EARC Report. Monitored and reported at Operations and Performance, Urgent, Emergency Care Board and EARC. Gaps in assurance None Action plan summary Please see Clinical Staffing Risk. Revising Urgent Care Action Plan Review of escalation / divert processes across Greater Manchester in progress. Closing Position 2016/17 Opening Position Risk Lead: Chief Delivery Risk Number:

127 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 5. Delivery of Mandatory Standards Principal Risks 5.4 Access Standards : Chief Delivery Principal Risk IF specialities do not have robust capacity plans in place to meet demand / increasing demand and standardised systems in place to effectively manage the open/incomplete referral to treatment time standard THEN more than 8% of patients will not receive their treatment within 18 weeks. Likelihood Impact Key Control established 5 4 Systems in place within each Division to monitor and validate waiting lists, and track demand and capacity plans. Weekly Access and Performance Meetings. Agreed capacity modelling tool in place for elective work streams. Pan organisational weekly/fortnightly Access and Performance Capacity review. Key Gaps in Controls Monitoring systems require standardisation across the three clinical Divisions. Control Assurance 3 Corporate Operations and Performance Governance Committee EARC and Board Gaps in assurance None Action plan summary Task and Finish Group ongoing to review the systems and processes in place to ensure standardisation across the organisation and systemize patient activity recording processes. Revised Recovery Plan in place. Closing Position 2016/17 Opening Position Risk Lead: Chief Delivery Risk Number:

128 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 5. Delivery of Mandatory Standards Principal Risks 5.4 Access Standards : Chief Delivery 5.4 Access Standards : Chief Delivery Principal Risk IF capacity plans are not sufficiently robust, THEN the 14 day cancer standard may not be met. Risk Lead: Chief Delivery Risk Number: 2295 Principal Risk IF capacity plans are not sufficiently robust, THEN the 62 day cancer standard may not be met. Risk Lead: Chief Delivery Risk Number: 2428 Likelihood Impact Key Control established 2 3 Systems in place to monitor waiting times. Cancer tracking and escalation systems in place. 4 2 Systems in place to monitor waiting times. Cancer tracking and escalation systems in place. Key Gaps in Controls Assurance Fluctuations in demand across GM. 2 Cancer Performance Implementation Meeting (CPIM). Cancer Tracking Access and Performance. Corporate Operations and Performance Governance Committee. EARC Referrals and transfers dependent on 3 Cancer other providers. GM Access policy not Performance yet signed off. Implementation Meeting (CPIM). Cancer Tracking Access and Performance. Corporate Operations and Performance Governance Committee. EARC Control Closing Position 2016/17 Gaps in assurance Action plan summary None 7 7 None Active management and validation. Support sign off of GM Access Policy Opening Position

129 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 5. Delivery of Mandatory Standards Principal Risks 5.4 Access Standards : Chief Delivery Principal Risk IF capacity plans are not sufficiently robust, THEN the diagnostic standard may not be met. Risk Lead: Chief Delivery Likelihood Impact Key Control established 3 2 Systems in place to monitor and deal with escalating waiting times. Capacity and demand plans in place. Key Gaps in Controls Capacity problems in Cancer MDT's to received more work Control Assurance 3 Access and Performance Corporate Operations and Performance Governance Committee EARC Gaps in assurance None Action plan summary Ongoing monitoring via Corporate Operations and Performance Governance Committee Risk assess potential impact to services in Radiology, CRI, Pathology Closing Position 2016/ Opening Position 5.5 Workforce Standards : Chief Strategy and Organisational Development Risk Number: 2299 Principal Risk IF the Trust does not comply with the capped agency rates (from Nov 16) and cannot provide adequate explanation for breaches, THEN this may adversely affect the Trust s Single Oversight Framework rating 5 3 Workforce plans; weekly joint review by Divisional MDs; Recruitment plans in place to reduce premium spend; Central temporary staffing team and robust approval processes Unable to reach agreed position with local Trusts to comply with capped rates in key areas. 4 Monthly Report to Corporate Finance, Information & Capital Committee Monthly Finance Report to Board Dir of OD and Med Director to meet with counterparts at CMFT to reach agreement on compliance Risk Lead: Chief Strategy and Organisational Development Risk Number:

130 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 5. Delivery of Mandatory Standards Principal Risks 5.6 Building & Facilities Standards : Chief Strategy and Organisational Development Principal Risk IF fire compartmentation is not in place THEN there is an increased risk due to none compliant fire stopping throughout PFI buildings, fire and smoke can rapidly spread causing reduced time for evacuation, putting lives at risk. Increased building damage, damage to Trust reputation and increased likelihood of prohibition notice being served on the hospital. Likelihood Impact Key Control established 2 4 Hospital Fire team fully briefed Increased Security patrols Increased environmental checks Communications to Staff. Revised evacuation plans. Completed remedial work. Key Gaps in Controls Control Assurance 2 Fire Authority Inspection. Report to Health & Safety Committee and onward to Corporate Quality and People Governance Committee. Gaps in assurance Action plan summary All fire stoppings works completed in PFI Buildings Hope Building and Mayo Building Closing Position 2016/17 Opening Position 8 8 Risk Lead: Chief Strategy and Organisational Development Risk Number:

131 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 6. Enabling Strategies 2016/17 Principal Risks 6.1 Research & Development Strategy : Chief Medical Principal Risk IF cost of R & D activity is not equal to income THEN a sustainable, credible and high quality research and development function may not be possible. Risk Lead: Chief Medical Risk Number: 2300 Likelihood Impact Key Control established 3 4 Review /rationalise of activities and costs to support the research and development function including the allocation of Research PAs. Identification of core infrastructure need to support strategy. Assessment of research outputs. Restructuring and job redesign within the R&D Directorate to ensure that the support available is optimal to meet the changing research environment. Initiatives to support effective research cost identification and recovery for the Trust relating to Research. Identification of areas of investment to support and increase funding from the NIHR. Exploration of strategic partnerships with Industry and others to increase income, activity and ability to deliver activity. Exploration of the viability of income generation activities. Key Gaps in Controls Potential impact of Greater Manchester Research Hub requires clarity. Uncertainty about how we will be working with Salford CCG and other GM NHS partners. Control Closing Position 2016/17 Assurance Gaps in assurance Action plan summary 3 Financial position None See controls reviewed by Joint R & D Steering Committees (This committee will become R&D Cabinet), R&D Management Meeting, Education and Research Assurance Committee Review, MAHSC involvement. Opening Position 49

132 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 6. Enabling Strategies 2016/17 Principal Risks 6.1 Research & Development Strategy : Chief Medical Principal Risk IF the Trust fails to effectively implement arrangements for the delivery of the R&D Strategy for Salford Royal, as the NHS & HEI partner landscape changes THEN R&D objectives may not be met. Likelihood Impact Key Control established 3 3 SRFT Board continually reviewing proposed NHS changes and identifying required action. Education and Research Exec Governance Committee oversees management of this risk. Revised R&D Strategy presented and approved by Board. Key Gaps in Controls Potential effects on the delivery of the R&D Strategy to be identified & solutions agreed. Uncertainties associated with changes planned at a local (changes within MAHSC) regional and national level. Control Assurance Gaps in assurance Action plan summary 3 R and D steering None Regular review and Committee (this engagement within committee will become partnerships. R&D Cabinet) and R&D Management Meeting review on regular basis. Active engagement within partnerships Closing Position 9 9 Opening Position Risk Lead: Chief Medical Risk Number:

133 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 6. Enabling Strategies 2016/17 Principal Risks 6.1 Research & Development Strategy : Chief Medical Principal Risk IF the Trust fails to redevelop and reappoint, in a timely manner, the R&D senior management team THEN there will be a lack of effective leadership to ensure delivery of the service, fulfilment of our role within MAHSC & implementation of strategy. Likelihood Impact Key Control established 3 4 Key senior appointments have now been made R&D Chair, Principal Clinical Research Lead, 2 x Senior Clinical Research Leads and a Director of R&D operations are in place. Key Gaps in Controls Uncertainty regarding when discussions will be concluded preventing progression of appointments Control Assurance Gaps in assurance Action plan summary 2 Review by R & D A restructure of the Steering Committee. service is ongoing and Regular discussion with the development of a Senior Management joint R&D management Team and support service that will provide support to both SRFT and Pennine Acute is underway. Closing Position 9 9 Opening Position Risk Lead: Chief Medical Risk Number:

134 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 6. Enabling Strategies 2016/17 Principal Risks 6.2 Under & Post Graduate Education : Chief Medical Principal Risk UGME: IF specific time is not protected in consultant job plans for required UGME teaching and supervision THEN the Trust will not meet the requirements of the GMC, SHA and Medical School. Risk Lead: Chief Medical Risk Number: 2303 Likelihood Impact Key Control established 4 2 Consultant Clinical Teaching Fellow posts have been identified and implemented to provide leadership in Undergraduate Education. Specific teaching ratios included in job planning policy. Key Gaps in Controls Consultant Clinical Team leads and clinical supervisors need to have teaching time protected in job plans Control Assurance Gaps in assurance Action plan summary 3 Review and oversight None Hospital Dean is a by Corporate Education member of the and Research Standards and Scrutiny Governance Committee Committee for new job planning process and is thus able to agree Undergraduate SPAs for Education. Negotiations with divisions are continuing with updated SLAs to improve shortfall. Education Funding devolved to divisions from January 2017 shadow budget till end of financial year. Divisions need to update on shortfall of SPA allocations in job plans Closing Position 2016/ Opening Position 52

135 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 6. Enabling Strategies 2016/17 Principal Risks 6.2 Under & Post Graduate Education : Chief Medical Principal Risk IF the Trust fails to deliver GMC standards for PGME & Training THEN medical trainees may be removed by HENW reducing the medical workforce and the delivery of safe patient care will be compromised Risk Lead: Chief Medical Risk Number: 2304 Likelihood Impact Key Control established 3 4 PGME & Training governance processed and quality monitoring processes in place and overseen by the Director of PGME Department Key Gaps in Controls Shortage of medical manpower and high intensity workload for all doctors impacting on all aspects of PGME & Training No effective Trust wide strategy to recruit and retain Clinical Fellows to support medical rotas and achieve optimum medical staffing numbers Control Assurance Gaps in assurance Action plan summary 4 Review and oversight PGME & Training by Education & recognised in Research Corporate Consultant Job Plans Governance Committee.. Divisional agreement for optimum medical HENW/ monitoring staffing levels required Feedback from HENW/GMC review processes reports. Trust to recruit and retain clinical fellows Closing Position 2016/17 Opening Position

136 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 6. Enabling Strategies 2016/17 Principal Risks 6.2 Under & Post Graduate Education : Chief Medical Principal Risk IF the current workload and inadequate staffing arrangements to support trainees on some training placements remains under pressure THEN trainee placement quality is at risk. This will impact on future placements. Likelihood Impact Key Control established 3 4 Educator Training Opportunities Key Gaps in Controls Shortage of medical manpower. Control Assurance Gaps in assurance Action plan summary 4 HENW/ monitoring Workforce planning and Feedback from timely recruitment HENW/GMC review along with SRFT HR processes reports. working with Lead Employer to receive timely information regarding rota gaps Closing Position 2016/ Opening Position Risk Lead: Chief Medical 6.3 Hospital Redevelopme nt/estates Strategy : Chief Strategy and Organisationa l Development Risk Number: 2998 Principal Risk IF the Trust cannot secure sufficient and operational estate capacity THEN future service developments may be at risk. Risk Lead: Chief Strategy and Organisational Development Risk Number: ning process incorporates assessment of estate requirements. Capital programme in place in full consideration of affordability and current and future priorities. Key strategic developments such as HT and MTC are now at FBC stage. Improved bed capacity and utilisation required. Patient flow and winter escalation plans forcing utilisation of additional beds. Approval of BC s and confirmation of capital allocation. 4 Board approved Annual Plan. Board approved Capital programme. Regular capital updates to Board of Directors. None Better Care at Lower Cost Programme underway to improve bed capacity and utilisation. Stage 1 works to provide additional beds are underway. Review of future service requirements underway in conjunction with HT and MTC

137 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 6. Enabling Strategies 2016/17 Principal Risks 6.3 Hospital Redevelopme nt/estates Strategy : Chief Strategy and Organisationa l Development Principal Risk IF the Trust cannot secure additional beds in the short term THEN elective patient cancellations will continue and the A&E 4 hour target will continue to deteriorate. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 3 4 Plan to reduce delayed transfers of care to 3.3% (circa 25 beds) Control Key Gaps in Controls Assurance Gaps in assurance Action plan summary None 3 Monthly Capital Report Stage 1 to provide to F,I&C Governance additional capacity is Committee. underway and capital identified. Regular review via Salford Directors Meeting. Works commenced to provide additional bed capacity. Closing Position 2016/ Opening Position 6.3 Hospital Redevelopme nt/estates Strategy : Chief Strategy and Organisationa l Development Risk Number: 3014 Principal Risk IF SRFT is unable to release theatre capacity THEN essential theatre maintenance and upgrade will not be possible, impacting on patient care and achievement of business objectives Risk Lead: Chief Strategy and Organisational Development 2 4 Back log and maintenance programme has been developed and being implemented. Availability of a decant theatre. Transfer of orthopaedic services to Trafford. Board approved adjustment to capital programme for work on Recovery to be brought forward. None 2 Monitored via Divisional Theatre Management, Executive Team and EARC None Maintenance Programme Programme on time and budget. Future programme being considered in conjunction with new build plans. 8 8 Risk Number:

138 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 6. Enabling Strategies 2016/17 Principal Risks 6.3 Hospital Redevelopme nt/estates Strategy : Chief Strategy and Organisationa l Development Principal Risk IF the Clinical Sciences Building (CSB) is not refurbished or demolished THEN the Trust may be noncompliant with the HTM and Estates Code and may be subject to enforcement action, along, with unsafe access to potentially unsafe buildings by staff and patients. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 1 5 Demolition of Bocks A, C and D underway. Refurbishment of B Block to follow. Conducting backlog maintenance to sustain the building running operations.. Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary 1 Planning and projects sub groups. Estates Liaison and facilities management meetings User group meetings Financial reports Monthly site progress meetings with contractors CSB demolition of Blocks A, C and D underway and upgrade of B Block to follow. Closing Position 2016/ Opening Position 6.4 IM&T & Innovation Strategy : Chief Strategy and Organisational Development Risk Number: 2660 Principal Risk IF the Trust is unable to improve the reliability, and extension of the shared health and social care clinical record THEN patient safety and productivity will be compromised in the community. Risk Lead: Chief Strategy and Organisational Development 3 4 IM&T prioritisation programme approved within available resource. Divisional Chief Clinical Information appointed and divisional board reporting strengthened. Deputy Clinical Information linked to each division. Detailed Implementation Plan. 3 Progress report to Finance, Information & Capital Governance Committee. No clear data to support the quality of connectivity and bandwidth Pilot programmes established to determine full solution. Roll out of the community IM&T system is underway, including administration support. Commence a pilot of a community scheduling system to support the effective utilisation of staff Risk Number:

139 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Operational Plan Theme: 6. Enabling Strategies 2016/17 Principal Risks 6.4 IM&T & Innovation Strategy : Chief Strategy and Organisationa l Development Principal Risk IF clinical leadership and engagement is not sufficient to progress the THEN TASR programme then TASR will not be delivered. Risk Lead: Chief Strategy and Organisational Development Likelihood Impact Key Control established 1 4 TASR implementation Plan via BCLC. TASR Clinical Leads in attendance at TASR steering group. 4 Clinical Information leads appointed to represent each division. Key Gaps in Controls Control Assurance Gaps in assurance Action plan summary 2 Productivity The Innovation Strategy Improvement Board has been significantly review. re focussed to deliver TASR, as such it will be incorporated into BCLC. Closing Position 2016/ Opening Position Risk Number: Corporate Social Responsibility & Public Health Strategy : Chief Strategy and Organisationa l Development Principal Risk IF the Trust does not fulfil its CSR responsibilities THEN its reputation with commissioners, partners and Salford patients and public may be adversely affected. Risk Lead: Chief Strategy and Organisational Development Risk Number: Public Health & CSR Strategy in place. None 2 PH and CSR Committee reporting annually to Corporate Quality and People Experience Governance Committee. Strong performance overall against public health indicators. None

140 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Adult Social Care Initial Risk Register Risk Code & Title Current Risk Matrix Current Risk Likelihood Current Risk Impact Current Risk Score DEMOGRAPHIC CHANGES - Failure to ensure services and associated finances to meet changing demand levels. Meeting Adult Social Care Needs Managed By Bernie Enright; Keith Darragh Two operational controls were introduced in 2014/15 to assist with the fair and consistent assessment of service users - Independence led assessment process Background and Existing controls in place - Pathway to Independence Adult Social Care pathway - Defined pathway of interventions for 1. Advice/Support 2. Re-enablement 3. Long term care assessment. Modernised Adult Social Care Model developed transformed contact/re-ablement and long term assessment process to maximise personal independence and use of natural support. The service has embedded strategy of Personalisation, which maximises independence through re-ablement of vulnerable people. The Adult Social Care pathway remains as the main mitigation to manage demand. Progress The use of the assessment tool "Pathway to Independence", ensures the service group continues to assess people and meet need. Budget monitoring has indicated the main pressure is being experienced in Learning Difficulties. The Government Spring Budget announcement 2017 has identified additional funding for Adult Social Care and plans are being developed between Commissioners and Providers to secure investment in critical assessment and service delivery areas. 58

141 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Risk Code & Title Current Risk Matrix Risk Description SAFEGUARDING Scope of Risk: Safeguarding policies and procedures may fail in resulting in injury to vulnerable service users Risk Code & Title Current Risk Matrix Current Risk Likelihood Current Risk Impact Current Risk Score Adults Social Care Safeguarding Scope of Risk: Safeguarding policies and procedures may fail in resulting in injury to vulnerable service users Managed By Bernie Enright; Keith Darragh Background and Existing controls in place Safeguarding policy and procedures were revised and adopted by the Council in Workforce trained in safeguarding duties / investigation supported by guidance and procedures. Progress Reviewed and the mitigations remain the most effective approach to manage the risk, particularly the operation of multi agency procedures across public sector organisations. 59

142 Salford Royal NHS Foundation Trust/ Salford Care Organisation : Opening Board Assurance Framework Risk Code & Title Current Risk Matrix Risk Description DEPRIVATION OF LIBERTY SAFEGUARDS (DoLS) Scope of Risk: Non compliance with assessment / decision timescale for implementing deprivation of liberty decisions for individuals who lack capacity Risk Code & Title Current Risk Matrix Current Risk Likelihood Current Risk Impact Current Risk Score Adult Social Care Deprivation of Liberty Assessments Managed By Bernie Enright; Keith Darragh Background and Existing controls in place Progress The Cheshire West case law changed the number for DoLS assessments required to be undertaken annually from approx 60 annually to just over 1,000 almost a 1,600% increase in service demand. The service has reconfigured the business process for assessment, streamlined procedures increased staff resources (funded through the commissioners pooled budget) regularly reviews assessment backlogs priorities cases for review uses the Association of Directors of Adult Social Services recommended approaches engages with care providers to implement least restrictive practices Reviewed and the mitigations remain the most effective approach to manage the risk Further review will be undertaken with the ICO commissioners of service to consider impact and effectiveness of risk management and resource levels The team responsible for assessments have implemented new processes and managed to reduce the numbers of assessments which exceed the standard timescales in 2017, which has resulted in a reduced risk score. 60

143 Subject Opening Board Assurance Framework/Corporate Risk Register 2017/ /18: Pennine Acute Hospitals NHS Trust (Appendix B) Collated by Stuart Logan, Assurance Framework Manager Presented by Date of Meeting Summary Jane Burns, Director of Corporate Services 22 nd May 2017 The key risks scored at 12 and above on the Pennine Board Assurance Framework are as follows: Pennine Acute Hospitals Trust: Risk Score Risk Name 13 Stabilising the workforce in ED and AMU 13 Recruiting to establishment 13 Achieving the 62 day national cancer target 13 Learning Lessons from the Diagnostic Review 13 Clinisys Lab Systems 12 Caring for the deteriorating patient 12 Caring for patients with sepsiss 12 Learning Lessons 12 Delivering an effective Quality Improvement Strategy 12 Delivering the Cost Improvement Programme Target 12 Putting clinical leadership in place 12 Regaining JAG accreditation 12 Achieving planned activity and income levels 12 Retrieving clinical notes electronically (Evolve) 12 Cyber security threat 12 Improving patient flow 12 Patient tracking and booking system 12 National Referral To Treatment standards 12 Completing staff Personal Development Reviews 12 The estate at NMGH 12 IM&T clinical systems Page no FOIA Status: Elements of this document may be exempt under the FOIA 1