Bolton NHS Foundation Trust – Board Meeting April 24th 2014€¦ · Board of Directors minutes...

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Bolton NHS Foundation Trust – Board Meeting April 24th 2014

Location: Board Room Time: 0900 – 1230 hrs

Time Topic Lead Process Expected Outcome

0900 1. Patient Story Verbal Patient story and learning points noted

2. Apologies for Absence – Trust Sec. Verbal Apologies noted

3. Declarations of Interest Chairman Verbal To note any declarations of interest in relation to items on the agenda

4. Minutes of meeting held 27th March 2014 Chairman Minutes To approve the previous minutes

5. Action sheet Chairman Action log To note progress on agreed actions

6. Matters arising Chairman Verbal To address any matters arising not covered on the agenda

0920 7.1 Chairman’s Report Chairman Verbal To receive a report on current issues

7.2 CEO Report including BAF Summary and reportable issues

CEO Report To receive a report on any reportable issues including but not limited to SUIs, never events, coroner reports and serious complaints

Safety Quality and Effectiveness

0940 8. Integrated Performance Report Exec team Report To note and receive the integrated performance report

8.1 A & E performance April 2014 COO Verbal To receive a verbal update on performance in month 1

9. Late night patient transfers COO Report To receive information on late night transfers in response to Keogh letter (FT/14/15)

10. Revalidation MD Briefing To receive an update on consultant revalidation

11. Sickness absence Dir Workforce

Report To receive an update on actions taken to address sickness absence (FT/14/10 & FT/14/04)

Governance

10.30 12. Draft Annual Report Trust sec Report To review the draft annual report and discuss the overview of performance in 2013/14

13. Draft Annual Governance Statement Trust Sec Report To review the annual governance statement

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Time Topic Lead Process Expected Outcome

14. Draft Quality Account DoN Verbal To receive an update on the production of the Quality Account

15. Quarter four Monitor return Trust Sec Report To approve the Q4 Monitor return

Finance

16. Month 12 Finance Report DoF Report To receive an update on the current financial position.

16.1 Going Concern report DoF Report To approve the Going Concern report

For Information

Chair reports of the following sub-committees will be noted – if any member of the Board wishes to raise a question regarding one of these items they should indicate this before the start of the meeting.

17. Finance and Investment Committee – Chair Report (meeting held -22nd April 2014)

18. Quality Assurance Committee – Chair Report (meeting held 9th April 2014)

19. Council of Governors minutes – (meeting held 6th March 2014)

20. Audit Committee – no meetings held during the reporting period

21. Charitable Funds – no meetings held during the reporting period

22. Any other business

Questions from Members of the Public

23. To respond to any questions from members of the public that had been received in writing 24 hours in advance of the meeting.

Resolution to Exclude the Press and Public

To consider a resolution to exclude the press and public from the remainder of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted

Board of Directors minutes – March 27th 2014 Page 1 of 8

Meeting Board of Directors Meeting

Time 10.00 a.m.

Date 27th March 2014

Venue Breightmet Health Centre meeting room

Present:- Abbv.

Mr D Wakefield Chair DW

Dr J Bene Chief Executive JB

Dr M Harrison Vice Chair MH

Dr E Adia Non-Executive Director EA

Mrs G Ashworth Non-Executive Director GA

Mrs C Davies Non-Executive Director CD

Mr A Duckworth Non-Executive Director AD

Mrs T Armstrong Child Director of Nursing TAC

Mr A Ennis COO AE

Mr S Worthington Director of Finance SCW

In attendance:-

Mrs E Steel Trust Secretary ES

1. Patient Story

Mr C attended accompanied by his wife to tell his patient story. Mr C has been receiving

ongoing treatment for over 40 years for a DVT, above knee amputation and leg ulcers

caused by Buerger's disease. Mr C is currently under the care of the tissue viability team

for a leg ulcer which is still open but is healing.

Mrs C has received the support and education to provide care to her husband in the form

of routine dressing changes with a cycle of clinic attendance for anticoagulants and support

from the tissue viability team.

In answer to questions from Board members, Mr C confirmed that he was happy with the

treatment he received, had no complaints about the NHS and no problems with information

sharing.

Board members thanked Mr and Mrs C for their attendance and contribution to the

meeting.

2. Apologies

Mr S Hodgson Medical Director

Ms S Woolridge Acting Director of Workforce and OD

3. Declarations of Interest

No additional interests declared

4. Minutes of The Board Of Directors Meeting Held on 27th February 2014

The minutes of the Board meeting held on 27th February 2014 were approved as an

accurate record, the Board noted the resolution of item 9 should also reflect the decision to


receive a bi-annual staffing update at the Board.

5. Action Sheet

The action sheet was updated to reflect progress on agreed actions.

6. Matters Arising

No matters arising not covered elsewhere on the agenda.

7.1 Chairman’s Report

The Chairman welcomed attendees to the meeting, Board members agreed that the

change of venue to bring the Board out into community premises of which Breightmet was

a great example was a positive move and one that should be repeated.

Board appointments - Mr Steve Hodgson was congratulated in his absence on his

appointment to the position of Medical Director. The long listing of potential candidates for

the role of Director or Strategic and Organisational Development would be taking place

later in the day with an assessment centre and interviews scheduled for the end of April

2014.

Performance - performance in February was generally good, this is reflected in the

dashboard which shows improving trends for pressure ulcers and falls with the A&E and 18

week targets on track for the full year. The CQC have moved the Trust from band 4 to

band 5 in their risk assessment and the Trust is in a strong position to start the new

financial year.

Dr Foster - Following the review of coding and its impact on the reputation of the Trust in

2013, the Trust had made a formal complaint to the Dr Foster Ethics Committee. The

parties involved had received and commented on a draft report. The Trust has now been

notified that the final report will be issues shortly. We expect it to say that Dr Foster failed

to maintain the high standards expected of them will be published on the Dr Foster website

in the next week.

Horizon scanning - There have been recent items in the media on cancer performance

and fraud in the NHS; Board members agreed that, although they were well sighted on the

actions taken to ensure cancer targets are achieved, further assurance should be sought in

light of the media claim that five - six billion pounds a year are lost from the NHS to fraud

each year.

Resolved: Board members noted the Chair's update and agreed that the Audit Committee

should be delegated to seek further assurance regarding the adequacy of counter fraud

measures in the Trust.

FT/14/14 Audit Committee to seek assurance regarding counter fraud measures

7.2 CEO report

Stakeholder update - Contract negotiations with the CCG have now concluded. The

Trust had an update call with Monitor on Friday 28th 2014; Monitor remain pleased with

our progress although the Trust will remain red for governance until the financial position is

assured and Monitor have assurance that the recommendations from the governance and


quality reviews have been implemented. The Board discussed the implications of

remaining in breach and the calculation of the Continuity of Services rating which requires

the Trust to make a surplus and have available working capital; as the position with regard

to these two measures improves, the financial rating will also improve - the plan being to

achieve CSR of 2 by quarter two of 2014/15.

Reportable issues - there have been no new reportable issues since the February Board

meeting, the SUI reported in the performance report was reported in the February CEO

update.

Horizon scanning - All Trusts have received a letter from Professor Sir Bruce Keogh

regarding the disposal of foetal remains and late night transfers of patients. The Trust

meet the guidance with regard to the disposal of remains and further information has been

requested from the operational team to provide the Board with assurance that this issue is

being addressed.

Resolved: The Board noted the CEO report

FT/14/15 Board to receive report on late night transfer of patients

8 Integrated Performance Report

Quality

C. difficile - three cases in month in three different areas, one patient was identified as

high risk, the other two cases identified issues relating to the timing of samples being

taken. The Trust has now heard, that of the seven cases appealed, only one will go to

arbitration. Lessons learnt regarding the importance of early sampling when patients are

symptomatic on admission have been fed back to the clinical teams.

Mixed sex accommodation - the Trust reported two breaches in the month within the high

dependency unit with the cause found to be lack of a speciality bed and an infection control

issue; the rca for both cases concluded that the patients required clinically appropriate

treatment. The Board discussed the potential for penalties as a result of these breaches;

the Director of Finance confirmed that penalties can be levied.

Pressure Ulcers - Although good progress has been made particularly with regard to

reduction of severity ratings the area remains a high priority with the main focus on

elimination of grade 3 and grade 4 ulcers.

Information Governance SUI - The Director of Nursing confirmed that this had been

reported to the IG commissioner and an action plan is in place to tighten processes and

develop a more robust long term process

Operational targets

Accident and Emergency - The Trust is well on track to achieve the target for the year

and the month, achievement of the target in March will mean achievement of each month

of the financial year. This is a significant result with only one other Trust in Greater

Manchester equalling the achievement of all four quarters. Credit is due to the whole

Trust, not just A&E as the target can only be achieved when the flow through the whole

system is effective. The Trust has very few outliers which is a reliable indicator that flows

are good.

Diagnostics - performance back on track - the accuracy of the year to date figure in the

report was queried and will be confirmed in the next iteration of the report. The COO

confirmed that this improvement is sustainable.


Cancer performance - achievement of the 62 day target is still a challenge although it is

expected that it will be achieved for the quarter. Processes are now in place for improved

future quarters.

The issues with the two week wait target were as a result of capacity issues and should

have been predicted. These capacity issues have now been addressed. A review of the

gynaecology pathway has identified that some patients are on the wrong pathway, GPs

and consultants have welcomed this work to ensure patients are on the appropriate

pathway. Use of inappropriate pathways was felt to be an education issue rather than a

deliberate bypass of clinic waiting times. In response to a request for assurance that this

would not result in patients waiting too long for vital appointments, the COO advised that

they would always err on the side of caution.

60% of patients sent for urgent appointments are seen within eight days.

Anecdotally Board members had heard comments about lack of equipment, specifically

wheelchairs to move patients between departments. The COO agreed that while there

may be enough they might not always be in the right place. Board members discussed the

provision of wheelchairs and whether the Trust should be looking to use volunteer “meet

and greeters” to provide assistance when required.

Ambulance handover times - A query was raised with regard to performance on the

ambulance turnaround times and the potential for penalties to be levied against the Trust

for failure to achieve this target. this is a regional issue impacting on all North West Trusts,

in view of this the penalties will not be levied. It is an important target however and

improvements need to be made - this will be a challenge in the next financial year, it was

acknowledged that Healthier Together would make it difficult to predict future ambulance

flows.

FT/14/16 AE to check accuracy of reported ytd figure for diagnostics AE

FT/14/17

TAC/AE to provide update to QA Committee on proposals for volunteers and provision of

wheelchairs

TC/AE

Workforce - There has been a slight improvement in the reported sickness absence rate

with a further improvement anticipated as several staff returned from long term sickness

during the month. There is audit evidence that policies are not always followed, for some

areas this is a complex issue as up to four policies could be in place as a result of staff

joining the organisation by a TUPE transfer. There is clear evidence that processes are

not always followed to support staff back to work. The COO has been working with the

Acting Director of Workforce and OD to support this and ensure that sickness is managed

within wards and departments. A detailed update on sickness absence will be provided to

the April Board meeting

Resolved: The Board noted the performance report and the agreed actions.

9. Quality Account Preparation

The Director of Nursing provided an update on the production of the Trust's Quality

Account. The report will show demonstrable improvements against the targets agreed for

2013/14. Planning meetings have been held with the external auditors in preparation for


their review of the report to provide an overall view on the compliance with the guidance

and a review of the information reported for agreed indicators namely:

62 day cancer

C. difficele

community data completeness.

The Quality Assurance Committee discussed and agreed the priorities for 2014/15 which

will be based on the recently approved Quality Improvement, Patient Experience, falls and

pressure ulcer strategies.

The Quality Account will be approved by the Trust Board before submission to Monitor

within the Annual Report at the end of May.

Board members noted the proposed priorities and asked for assurance that this would

cover the care of the deteriorating patient, one of the key risks on the Board Assurance

Framework. The Director of Nursing confirmed that this would be covered in the section on

mortality.

With the knowledge that a significant number of the Bolton population are aged 75 and

over, Board members requested assurance that the report would cover care provided to

this demographic. The Director of Nursing confirmed that dementia would be included and

consideration would be given to including something on the work being done on frailty.

Resolved: the Board noted the update on the production of the Quality Account.

10. Staff Survey

The CEO presented the paper summarising the results of the National Staff Survey. The

higher scores for appraisal, equality and diversity and role making a difference were noted.

Discussions focused on those areas with lower scores - stress, work pressure,

communication and staff recommending the Trust as a place to work. Board members

discussed the proposed actions with challenge from Non Executive members of the Board

that these did not fully address the identified weaknesses.

Board members agreed that leadership development for middle managers and senior

nurses must be a priority to provide them with the skills to support and develop their staff

using a coaching approach. Staff need to be developed to articulate their views and need

to know that they will be heard. The Director of Nursing confirmed that an external

development partner has been identified with a programme for senior nurses scheduled to

start mid April.

Board members discussed the report and agreed that the issues should be addressed by a

balance of visible leadership with development and empowerment of other staff to give

staff the control and resilience required to respond and adapt to future changes.

Staff engagement will be measured using the Friends and Family test with results reported

on ward, community and corporate level.

Concern was expressed that the action plan in the report was lacking the "wow" factor with

more actions needed in terms of recognition and reward for staff if the ambition of being

the best is to be achieved.

Board members discussed the potential options to provide reward and recognition possible

supported by charitable funds to recognise teams and individuals for a job well done.

Resolved: The Board noted the report and asked for a structure plan of engagement and

recognition in three months.


FT/14/18 ES to email full report to NEDs

FT/14/19 Structured approach to recognise, engage with and develop staff - update in three months

11. Annual plan

The Trust Secretary advised that the Operational Plan had been produced in line with

Monitor's guidance and, as discussed in previous meetings, was the first of two

submissions with the second strategic plan due for submission to Monitor at the end of

June. The Quality Governance Section would be updated to reflect feedback from PwC

following their review of the implementation of recommendations in the Deloitte (2013)

review of quality governance.

Board members discussed the challenged facing the organisation in the next two years, in

particular the challenges of the integrated care agenda and the need for significant

transformational change to achieve this. It was agreed that regular updates should be

provided to inform and assure the Board of progress with the development of integrated

care.

Board members agreed that intuitively the integration projects feel right but will be a

challenge to deliver at the pace required to cope within a reduced financial envelope while

providing care for a growing elderly population.

The Trust Secretary confirmed that the plan for submission to Monitor would be updated to

reflect the discussions to include more on the development of the workforce and the risks

facing the organisation and to include more measurable indicators

Resolved: Board members approved the annual plan subject to updates as discussed.

FT/14/20 Board to receive regular updates on the integrated care agenda AE

12. Board Assurance Framework

Board members discussed the Board Assurance Framework and agreed that it was

pleasing to see that the key risks facing the organisation have changed significantly in the

last year. Board members debated whether as a group the Board had the same level of

familiarity with the risk profile. Board members agreed that the risks facing the

organisation in the coming year should be included in the performance report to raise the

level of awareness.

Resolved: Board members agreed that significant improvements had been made in the

previous 12 months although the BAF still has some areas for improvement particularly

with regard to timescales for actions.

FT/14/21 BAF risks to be incorporated in the integrated performance report ES/JP

13. Month 11 Finance Report


The Director of Finance presented the month 11 finance report - the following points were

noted:

The financial position for month 11 was a deficit of £1.0m which is in line with the

plan.

The year to date position is a £(5.9)m deficit compared to the planned £(7.8)m.

Income is £0.5m behind budget this month but remains ahead of plan year to date.

Pay costs have decreased by £540k compared with January, and are lower than

the average for the year

Non-pay underspend of £0.25m this month continues to support the overall

position.

Income and cost improvement are forecast to be ahead of plan by £2.1m for this

financial year.

Capital expenditure is below plan year to date. However high risk items have been

brought forward from 2014/15 and it is planned to spend the full amount by the end

of March

The Trust forecast shows that the Trust’s plan deficit of £7.8m will be achieved.

The full allocation of DoH cash support has now been drawn down

Activity levels show a significant reduction in the report, some of these are

estimated and any discrepancies with figures in operational reports are a short term

reconciliation timing issue - this has already been raised in the finance committee

and a full reconciliation is underway.

The challenge will continue in 2014/15

Resolved: Board members noted the update and thanked the Finance Director and his

team for their stewardship.

14. Finance and Investment Committee Chair report (18/03/14)

Resolved: The Board noted the Finance and Investment Committee Chair report

15. Quality Assurance Committee Chair report (12/03/14)

The Chair of the QA Committee provided a verbal update on the business transacted in the

previous meeting. The meeting had been observed by Karen Finlayson of PwC as part of

the review of the implementation of the quality governance recommendations, PwC have

offered to share the insights PwC have gained from supporting the new format of CQC

inspections.

Committee members discussed the quality account objectives and received positive

feedback from divisions on the implementation of the QIA process supported by the PMO.

The quality dashboard identifies a need to focus on medicines management, the Chief

Pharmacist has been invited to join the committee and will be providing an update on

actions taken in this area.

The Committee also received reports on the safety walkabouts and the maternity survey

action plan.

The review of the ward to Board heat map had identified concerns which had been

escalated to the Board for further discussion in the part two meeting


Resolved: The Board noted the Quality Assurance Committee Chair report

16. Audit Committee

No meetings held during the reporting period.

17. Charitable Funds Chair report (06/03/14)

The Board noted the Charitable Funds Chair report and supported the proposal to recruit a

fundraiser.

18. Any other business

None

19. Questions From Members of the Public

No questions were received in advance of the meeting

Date And Time Of Next Meeting

24th April 2014 0900

Resolved: to exclude the press and public from the remainder of the meeting because

publicity would be prejudicial to the public interest by reason of the confidential nature of

the business to be transacted.

March Board actionsCode Date Context Action Who Due CommentsFT/14/18 27/03/2014 staff survey ES to email full report to NEDs ES Mar-14 complete

FT/13/120 28/11/2013 revalidation update at end of Q4 with results for the year SH Apr-14 agenda item

FT/14/04 30/01/2014 sickness absence update report in three months SW Apr-14 agenda item

FT/14/05 30/01/2014 End of life care QA Committee to receive update on audits SH/TA Apr-14 agenda QA April 2014

FT/14/10 27/02/2014 sickness absence trajectory to be included in sickness update report SW Apr-14 agenda item

FT/14/13 27/02/2014 Readmissions report to be provided AE Apr-14 agenda item - part two meeting

FT/14/15 27/03/2014 CEO report - letter from

Keogh re late night

Report to Board on late night transfers of patients AE Apr-14 agenda item

FT/14/16 27/03/2014 performance report AE to check accuracy of reported ytd performance for diagnostics AE Apr-14 verbal update

FT/14/20 27/03/2014 Annual plan Board to receive regular reports on the integrated care agenda JB Apr-14 added to workplan for regular updates

FT/14/22 27/03/2014 community services - IT

provision

report to understand the issues and the immediate actions required to

address

AE Apr-14 agenda item

FT/14/08 30/01/2014 overseas visitors update report in three months SCW May-14

FT/14/07 30/01/2014 Charitable funds update on agreed actions for more strategic approach to funds SCW May-14

FT/14/12 27/02/2014 Keogh update Staffing levels paper TAC May-14

FT/14/14 27/03/2014 Chair report Audit Committee to satisfy themselves regarding counterfraud

measures

CD/SC

W

May-14

FT/14/21 27/03/2014 BAF BAF risks to be incorporated into integrated performance report ES/JP May-14

FT/14/22 27/03/2014 parking charge changes numbers to be validated and consideration given to installing more

modern machines

SCW May-14

FT/13/124 19/12/2013 SUI Audit on follow up of abnormal test results to be reported to QA

committee

SH Jun-14 agenda QA June 2014

FT/14/11 27/02/2014 WHO checklist update on WHO checklist compliance to April QA Committee SH Jun-14 now routinely completed on the dashboard - review QA

committee in June FT/13/103 31/10/2013 AHSN update in April 2014 - deferred to June/July 2014 AMS Jun-14

FT/14/19 27/03/2014 staff survey Structured approach to recognise, engage with and develop staff -

update to be provided in three months

SW Jun-14

FT/14/17 27/03/2014 performance report TAC to provide update to QA Committee on proposals fo volunteers TAC Jul-14

All information provided in this written report was correct at the close of play 15/04/2014 a verbal update will be provided during the meeting if required

Agenda Item No: 7.2

Meeting Board of Directors

Date 24th March 2014

Title Chief Executive Update

Executive Summary

The Chief Executive update includes a summary of key issues since the previous Board meeting, including but not limited to:

Monitor update

reportable issues log

o coroner communications

o Never events

o SUIs

o Red complaints

Board Assurance Framework summary

Next steps/future actions Clearly identify what will follow i.e. future KPI’s, assurance requirements

The Board are asked to note this update

Discuss Receive

Approve Note

This Report Covers (please tick relevant boxes)

Strategy Financial Implications

Performance Legal Implications

Quality Regulatory

Workforce Stakeholder implications

NHS constitution rights and pledges Equality Impact Assessed

For Information Confidential

Prepared by Esther Steel Trust Secretary

Presented by Dr J Bene Chief Executive


Chief Executive Update

1. Stakeholders

1.1 Bolton CCG

Update on contract negotiations to be provided in part two meeting.

A contract notice regarding CAMHS has been received, a remedial action plan will be

developed and implemented - it is proposed that the Board delegate follow up of this action

plan to the QA Committee

1.2 Monitor

The next call with Monitor is scheduled for 28th April; the main purpose of the call will be to

review the annual plan submission. The operational plan was submitted in line with

guidance, next Monitor submissions are the Q4 compliance report on this agenda for

approval, the annual report and accounts in May 2014 and the strategic plan at the end of

June 2014.

At the time of writing we had not received any feedback on the sustainability review.

2. Reportable Issues Log

Issues occurring between 28th March and 15th April 2014

Any new incidents will be discussed at the Quality Assurance Committee 14th May 2014

2.1 Serious Untoward Incidents

There was one new Serious Untoward Incidents in March, this will be investigated in the

usual manner in accordance with the policy with a final report to the Board and actions

monitored through the QA Committee

2.2 Never Events

There have been no never events since the last Board meeting.

2.3 Coroner Prevention of future Deaths (PFD) reports

There have been no coroner notices issued since the last report

2.4 Red Complaints

There have been six complaints with an initial rating of red these are currently being

investigated, further detail will be provided to the Quality Assurance Committee

2.5 Reputational Issues

No issues to report at the time of writing

3 Board Assurance Framework

3.1. Introduction

The Board Assurance Framework (BAF) is a tool which sets out the significant risks for each

strategic objective, along with the controls in place and assurances on their operation. The

BAF is used by the Board of Directors to ensure that all significant risks have been identified;


information on control, performance and assurance is timely and relevant; and to provide

leadership on risk management.

The BAF is reviewed on a monthly basis by the Executive team who finalise the list of

strategic risks, confirm actions being taken and check assurances

3.2. 2013/14 Assurance Framework

The Risk Management Committee reviewed the BAF on 2nd April 2014 and agreed the

closure of the 2013/14 BAF and the implementation of the new BAF for 2014/a5 which is

currently being developed and will be presented to the May Audit Committee meeting.

The BAF is the framework setting out how the Board are assured that the Trust will achieve

its strategic objectives - the Annual Plan for 2014/15 builds on the five year strategic plan

submitted in September 2013 - the strategic objectives have not been changed and the

majority of the risks to achieving these objectives also remain and will be carried forwards

onto the new BAF.

The new interim risk manager is working with divisions to review division, ward and

department risk registers; the divisional risks with a validated score of over 15 are escalated

to the corporate risk register. In 2014/15 we will be strengthening the links between the BAF

and the corporate risk register.

Changes to risks

C3 Failure to comply with information

governance

Likelihood increased - information governance

not yet addressed and subject of incident

reports on a regular basis - NB these are

predominantly minor lapses not reportable to the

IG commissioner but nevertheless should be

considered a significant risk

At the January 2014 Board meeting Board members requested additional information in this

report on risks that have remained steady; executive members considered this in their

review of the BAF as below. For the majority of risks it has previously been recognised that

the impact is unlikely to change, risks are therefore likely to reduce when actions are

complete or increase when there is limited or no assurance regarding the impact of actions.

A1 Failure to reduce the number of cases

of CDT

The threshold for the year has been

breached, the risk score will be reviewed in

the 2014/15 BAF

12

A2

Failure to provide appropriate skill mix –

remains a significant risk in terms of

recruitment

While the recruitment programme there are

still a number of vacancies to be recruited

to risk remains unchanged

12

A3 Failure to provide timely response to

deteriorating patient

This risk will remain at a high level until the

work detailed in the business case for level

one care has been implemented

16

A4 Failure to comply with CQC standards Remains a risk 12


A6 Failure to continue to meet the A&E

target

No change in score 12

A7 Failure to continue to meet the 18 week

RTT target

No change in score, continued pressure in

orthopaedics and plastics

12

C1 Failure to address compliance

requirements

Having completed the majority of actions,

the likelihood of failing to address

compliance requirements is 2; risk

management committee members agreed

this should remain on the BAF on its

current score until the Board are assured

that actions have been completed. PwC

are currently assessing progress against

the Deloitte quality governance report.

10

C2 Failure to ensure safe management

and learning from incidents

Actions have been agreed to improve the

management of risks and learning from

incidents, the trust are recruiting for a new

Head of Governance - risk to remain at 16

16

D1 Failure to reduce sickness absence

The impact of the actions to address

sickness absence has not yet been

achieved - remains 16

16

E1 Healthier Together

The Trust continues to engage with

Healthier Together but has limited

influence on the outcome of the exercise.

15

E4 Failure to provide an efficient fit for

purpose estate

Whilst the position regarding funding for

the estates strategy remains uncertain this

risk remains at 16

16

3.3 NEXT STEPS

The new BAF will be reviewed at the May 2014 meeting of the Audit Committee.


Summary of Risks March 2014

= risk increased = risk decreased = new risk = no change

lead

Octo

ber

Decem

ber

Janu

ary

Febru

ary

March

Ap

ril

Ch

ange

A1 Failure to reduce the number of cases of CDT – current performance above target

DoN 20 20 12 12 12 12 -

A2 Failure to provide appropriate skill mix – remains a significant risk in terms of recruitment

DoN 12 12 12 12 12 12 -

A3 Failure to provide timely response to deteriorating patient DoN 16 16 16 16 16 16 -

A4 Failure to comply with CQC standards DoN 16 16 12 12 12 12 -

A6 Failure to continue to meet the A&E target COO 16 16 12 12 12 12 -

A7 Failure to continue to meet the 18 week RTT target COO 16 16 12 12 12 12 -

B1 Failure to achieve the planned deficit FD 15 10 15 15 5 5 -

B2 Failure to achieve run rate balance FD 20 20 20 20 15 15 -

C1 Failure to address compliance requirements CEO 10 10 10 10 10 10 -

C2 Failure to ensure safe management and learning from incidents DoN 16 16 16 16 16 16 -

C3 Failure to comply with information governance COO 9 9 9 9 9 12

D1 Failure to reduce sickness absence HR D 16 16 16 16 16 16 -

E1 Healthier Together CEO 15 15 15 15 15 15 -

E2 Failure to achieve integrated care CEO 12 12 12 15 15 15 -

E3 Failure to address legacy community IT issues COO 20 20 20 12 12 12 -

E4 Failure to provide an efficient fit for purpose estate COO 16 16 16 16 16 16 -

D2 Failure to strengthen communication and engagement HR D 16 16 Removed

Safe, High Quality Care, Fit for the Future

Quality and Safety

Valued Provider

Financially viable and sustainable

Great place to work

Fit for the future

Well Governed

Subject Integrated Performance Report – April 2014

Prepared By Performance and Information Team

Approved By Executive Management Team

Presented By Chief Executive – Bolton NHS Foundation Trust

Executive Summary

Please see the High level Executive Summary section at the beginning of the report

Key Recommendations

The Board are asked to receive the report and give approval.

Acronyms/Terms used in Report

TRUST BOARD

Trust Objectives

Purpose

This report sets out the Trust’s integrated performance against leading national and local targets and draws attention to key areas for specific review by the Trust Board. Driven by the Trust’s strategic objectives this report is underpinned by a strong platform of integrated governance and assured data quality controls allowing the Trust Board to make effective decisions and demonstrate its commitment to delivering high quality healthcare for the people of Bolton.

Report

Appendix A

Appendix B

Report change log

1 All Report data correct and verified as of Friday 11th April 2014


Executive Apex Reports High Level Executive Summary High Level Executive Dashboard High Level Executive Report • Monitor Risk Assessment Framework

Section 1 Improving the Quality of Care and Safety of our patients • Quality and Governance Scorecard • Quality and Governance Charts • Quality and Governance Report • Acquired Infection • Falls • Pressure Damage

Section 2 Valued provider of Integrated Services • Operations Scorecard

• Operations Charts • Operations Report

Contents



Section 3 Financially viable and sustainable • Finance Scorecard • Finance Report Section 4 A great place to work • Workforce Scorecard • Workforce Charts • Workforce Report Section 5 Ward to Board Heat Map

Section 6 Fit for the Future Section 7 Well Governed

Appendix A Acronyms/Terms used in Report

Appendix B Dashboard Change log - in month


Risk Management Strategy

Patient Experience Strategy

Electronic Patient Record

Provision for restructuring of £2.1m has been set

March as position as forecast before restructuring provision.

ICIP delivery is £18.3m and is £2.1m above plan.

Actual in year deficit of £7.8m in on plan.

All 7 cancer targets achieved in month. Performance is reported one month retrospectively.

Natural Staff Turnover remains at 9.2%.

Sickness % days lost continues to improve to 5.33% but is still above the target of 3.75%

Appraisal rates are still achieving the 80% target at 82.4%. The focus is now on improving the quality.

Mandatory training has been sustained at 83.9%. Target is 100%.

Quality Strategy

2 cases of C.Diff in March lie within the monthly tolerance although the yearly target of 28 remains breached at 38.

8 Community and 3 In-patient cases of pressure damage reported in month. No grade 3 or grade 4 cases reported.

A rise in medication incidents reported at 91.

Patient incidents (Clinical and non-clinical) have the highest number recorded this month at 675.

A&E 4 hour target achieved 95.3% in March and 96.09% overall for Quarter 4 .

Diagnostic waiting times have achieved at 0.3%, the best performance this financial year.

18 weeks admitted, non-admitted and incomplete pathways have all achieved in March.

Executive Summary

This executive summary provides an integrated overview of the Trust Board Performance Report. Supporting the Trust's Strategic Objectives it orientates executives quickly to the areas that have been escalated, are of particular note or political significance. The accompanying High-Level Dashboard and narrative gives further analyses. Compliance levels with the Monitor Risk Assessment Framework and CQC (Care Quality Commission) are also shown.

Improving the Quality of Care and Safety of our patients A great place to work

Valued provider of Integrated Services Fit for the future

Financially viable and sustainable Well GovernedOur Patients

The Trust continues to be licensed to carry out regulated activities with no conditions imposed

Monitor Risk Assessment Framework

CQC

Governance Finance ‐ Level 1

All Report data correct and verified as of Friday 11th April 2014

The Trust has been awarded a band 5 weighting by the CQC


Improving The Quality Of Care And Safety Of Our Patients Plan 13/14 Plan YTD

Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Financially Viable And Sustainable

Plan 13/14

Plan YTD

Plan Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Well Governed Status

Total number of new SUIs received within the month 0 0 14 0

Forecast year end deficit - FYE -7.8 -7.8 -7.8 0.0 0.0 0.0

Monitor Risk Assessment Framework On Plan

Total number of patient incidents (Clinical and non-clinical) 5000 5000 7562 675

Forecast year end recurrent run rate - FYE 0.0 0.0 -4.6 0.0 0.0 -4.6

CQC Intelligent Monitoring Report On Plan

Never Event 0 0 1 0

Forecast year end income and cost improvement - FYE 16.2 16.2 18.3 0.0 0.0 2.1CQC Essential Healthcare Standards (5) On Plan

All Patient Falls (Safeguard) 1034 1034 968 93

Actual position against plan - YTD -7.8 -7.8 -5.9 -1.0 -2.0 1.9CQUINS: National Clinical Quality Indicators (4) On Plan

Acute Inpatients acquiring pressure damage (grades 2+) 29 29 94 3

Actual Income and Cost Improvement -YTD 16.2 14.4 15.3 2.9 0.9 0.9 Report to prevent future deaths On Plan

Community patients acquiring pressure damage 80 80 134 8

Capital Expenditure YTD -5.9 -5.5 -2.9 -0.9 -0.7 2.6 Litigation On Plan

VTE Assessment Compliance 95.0% 95.0% 96.3% 96.6%

Cash Position YTD 0.3 0.3 0.4 -0.1 -0.1 0.1 Formal Contract Notices Off Plan

Total number of medication incidents 636 636 861 91

Continuity of services rating 1.0 1.0 1.0 1.0 0.0 0.0 Formal Performance Notices On Plan

MRSA Bacteraemia Post 48 Hours admission 10 10 2 0

Contract Fines/Penalties Off Plan

C Diff Hospital aquired 28 28 38 2

CHKS RAMI (Rolling 12 months) 100 100 80 80

SHMI 1.000 1.000 1.019 1.04

Local Induction Attendance (starters in the last 12 months) 100% 100% 72.8% 80.6%

Surgical WHO Checklist compliance (Elective) 100.0% 100.0% 92.00% 95.00%

Substantive Staff Turnover Headcount (rolling average 12 months) <=10% 10% 10% 9.4% 9.2%

Quality Improvement Strategy On Plan

Surgical WHO Checklist compliance (Emergency) 100.0% 100.0% 91.47% 94.00%

Appraisals completed % 80% 80% 82.2% 82.4%

Risk Management Strategy On Plan

Formal complaints from patients 240 240 583 47

Sickness days % of days lost 3.75% 3.75% 5.04% 5.33%

Patient Experience Strategy On PlanComplaints responded to within the time period % 95% 95% 86% 100%

Mandatory Training Compliance % 100% 100% 81.6% 83.9% Electronic Patient Record On Plan

Valued Provider Of Integrated Services Plan 13/14 Plan YTDActual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Cancer Treatment Targets (7)

Plan 13/14

Plan YTD

Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan

A&E 4 hour target 95.0% 95.0% 96.4% 95.3%

Patients 2 week wait (all cancers) % 93.0% 93.0% 94.7% 97.3%

RTT Admitted Clock Stops % 90.0% 90.0% 94.6% 93.4%

Patients 2 week wait (breast symptomatic) % 93.0% 93.0% 96.3% 93.9%

RTT Non-Admitted Clock Stops % 95.0% 95.0% 96.7% 97.4%

31 days to first treatment % 96.0% 96.0% 98.7% 100.0%

RTT: Incomplete pathways within 18 weeks % 92.0% 92.0% 96.2% 96.2%

31 days subsequent treatment (surgery) % 94.0% 94.0% 100.0% 100.0%

Diagnostic waits >6 weeks % 1.0% 1.0% 0.3% 0.3%

31 days subsequent treatment (anti cancer drugs) % 98.0% 98.0% 100.0% 100.0%

% of patients who spend 90% of their stay on the stroke unit 80.0% 80.0% 85.4% 91.4% 62 day standard % 85.0% 85.0% 87.1% 85.4%

% Readmissions within 30 days of discharge 8.0% 8.0% 12.5% 12.8%

62 day screening % 90.0% 90.0% 93.0% 100.0%

The On Plan / Off Plan Columns represent a projected Year End position. The status columns represents the current status of the initiative detailed

Status

High Level Executive Dashboard

Fit for the Future

Performance improved but off target in month

Performance deteriorated and off target in month

Monthly Change

On Plan Off PlanDeveloping Our Staff

Plan 13/14

Plan YTD

Actual YTD

Monthly Actual

Performance improved and on target in month

Performance deteriorated but on target in month


No. Area Indicator (All measured Quarterly) Threshold Weighting Oct-13 Nov-13 Dec-13Quarter 3 Actual Jan-14 Feb-14 Mar-14

Quarter 4 Actual

2.05

Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 90% 1.0 94.3% 94.9% 94.3% 94.9% 93.7% 94.2% 93% 94%

2.06

Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 1.0 95.9% 96.1% 96.3% 96.6% 96.5% 97.6% 97% 97%

2.07

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% 1.0 95.3% 95.9% 95.4% 95.4% 95.9% 96.3% 96% 96%

2.01

A&E: maximum waiting time of four hours from arrival to admission/ transfer/ discharge 95% 1.0 96.7% 96.1% 96.7% 96.5% 96.3% 96.8% 95% 96%All cancers: 62-day wait for first treatment from:

2.23 Urgent GP referral for suspected cancer 85% 88.6% 84.1% 81.2% 84.6% 85.4% 85% 85.4%2.24 NHS Cancer Screening Service referral 90% 95.0% 81.4% 100% 92.1% 100% 100% 100%

All cancers: 31-day wait for second or subsequent treatment, comprising:

2.21 Surgery 94% 1.0 100% 100% 100% 100% 100% 100% 100%2.22 Anti-cancer drug treatments 98% 1.0 100% 100% 100% 100% 100% 100% 100%

2.20

All cancers: 31-day wait from diagnosis to first treatment 96% 1.0 97.1% 98.9% 100% 98.7% 98.9% 100% 99%

Cancer: two week wait from referral to date first seen, comprising:

2.18 All urgent referrals (cancer suspected) 93% 94.7% 94.9% 93.5% 94.4% 90.9% 97.3% 94.1%

2.19

For symptomatic breast patients (cancer not initially suspected) 93% 94.6% 90.6% 96.9% 94.0% 97.4% 94% 95.7%

1.13

Clostridium (C.) difficile – meeting the C. difficile objective DM* 1.0 2 2 0 4 4 3 2 9

1.33

Certification against compliance with requirements regarding access to health care for people with a learning disability 100% 1.0 100% 100% 100% 100% 100% 100% 100% 100%

Data completeness: community services, comprising:Referral to treatment information 50% 99% 99% 99% 99% 99% 99% 99% 99%

Referral information 50% 100% 100% 100% 100% 100% 100% 100% 100%Treatment activity information 50% 100% 100% 100% 100% 100% 100% 100% 100%

Acc

ess

1.0

1.0

Monitor Risk Assessment Framework 2013/14

Out

com

es

1.0


High level Executive Report

Harm Free Care

There are no Serious and Untoward Incidents in March and no Never Events.

Patient Incidents – There has been a rise in the number of patient (clinical and non-clinical) incidents reported in March.

Whilst internal reporting is being actively encouraged it is evident that the severity of harm overall is decreasing. The work

continues to strengthen our internal governance processes and determine comparative benchmarking criteria. This review is

scheduled for completion end of April 2014. A weekly Incident Report Panel reviews all incidents and subsequent grading

decisions.

93 patient falls have been reported in March. Compared to previous months this is a significant rise. The table below shows

the areas with the highest numbers of falls.

Ward Number of falls

G4 (Orthopaedic female) 8

C1 (Cardiology) 8

D3 (Respiratory) 7

H3 (Stroke) 6

Intermediate Care Residential 6

C2 (Acute Adult) 6


In March there have been 3 In-patient grade 2 cases of pressure damage and 8 Community grade 2 cases. There are no

grade 3 or 4 reportable cases. This represents an overall reduction in the number of new cases and their level of severity.

The “Effective Management of Pressure Area Care Strategy” continues to be implemented across the organisation. There

have been no Grade 4 Pressure Ulcers reported from In-patients over the past 5 months as shown in the table below.

Category Performance Indicator Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Hospital

Patients acquiring pressure damage (grade 2) 8 3 4 2 3



Patients acquiring pressure damage (Total) 12 7 7 4 3

Community




Patients acquiring pressure damage (Total) 21 7 7 9 8

Same Sex Accommodation

There are 2 same sex accommodation breaches in March both in the High Dependency Unit. A root cause analysis is

underway.

Medication Incidents

This month the highest number of medication incidents has been reported at 91. Preparation and Administration errors feature highly at 27 with prescribing errors reported at 17. The Trust has a medicines safety committee who oversee all incidents. The Quality Assurance Committee have requested a quarterly report for further analysis and review.


Acquired Infection

No MRSA infections in month.

2 C. Diff cases reported from B1 (winter ward) and the central delivery suite.

Mortality

RAMI and SHMI remain within acceptable national thresholds. We continue to be banded as expected. The SHMI is

reported quarterly and reflects the position six months retrospectively. The dashboard shows the Quarter 3 update

representative of the position for June 2013. The next SHMI quarterly update is scheduled for release at the end of April

2014 and will be reflective of September 2013.

Surgical WHO Checklist

Improvement in March is due to the ‘Safer Surgery’ launch with theatre staff and anaesthetists. Compliance is shown at 95%

for Elective and 94% for Emergency.

Complaints

Formal complaints have reduced slightly with 100% of complaints responded to within the given timescales.


Valued provider of Integrated Services

National Targets

A&E 4 hour target has achieved in March at 95.3%. This year 2013/14 performance has been achieved for all 4 quarters and

all months except September 2013. The final position for Quarter 4 is 96.09%.This achievement should be noted and the

success recognised by all staff in the trust.

All 18 week admitted, non-admitted and incomplete pathway targets have achieved in month.

Diagnostic waits have achieved in month at 0.3% against a 1.0% National target. This represents the best performance in

year.

The National stroke target continues to achieve at 91.4%.

The 8% target for re-admissions within 30 days of discharge is under review with the CCG. The Trust is returning 12.8%

against this target.

All 7 cancer targets have achieved in month. Please note that all National cancer targets are reported one month

retrospectively.


Financially Viable and sustainable

Finance Report

The Trust is on plan for the year with a normalised deficit of £(7.8)m as was forecast. The underlying Trust deficit is £(5.7)m

before resetting our provisions by £2.1m for restructuring.

The full year actual for income and cost improvements is £18.3m v £16.2m plan.

The Trust has impairments due to revaluation of £0.35m which increases the reported deficit to £(8.1)m.

The Trust has reported a deficit financial position for month 12 of £(1.9)m against a planned breakeven position. This is as

forecast. The normalised underlying position (removing the restructuring provision) is a small surplus of £0.2m.

Income is £(0.26)m below budget this month. The Non-pay underspend of £0.9m (excluding the restructuring provision and

impairment) this month continues to support the overall position with a cumulative under spend of £2.4m. Pay costs have

increased by £0.6m compared with last month and are £0.4m under spent in the month.

The Trust capital plan as submitted to Monitor is £5.9m. As at the end of March capital expenditure was £6.2m (£0.3m

overspent).

Cash has been managed effectively with a £0.4m cash balance at the end of March. The year-end position includes the

drawn down of £17.25m from DoH


Workforce

Natural Staff Turnover remains at 9.2%

Appraisal rates are still achieving the 80% target at 82.4%. The focus is to now improve the quality.

Sickness % of days lost continues to improve at 5.33% but is still above the target of 3.75%.

Mandatory training compliance has been sustained at 83.9%.

Fit for the Future

The Risk Management Strategy continues to gain momentum with a divisional rolling programme of support in place. Risk

Registers are currently being reviewed.

A Year 1 work plan has been approved and is underway to take forward the Patient Experience Strategy. Patient Safety

walkabouts have been undertaken with the Quality Assurance Committee receiving regular reports on the main overall

themes. The new programme for the Patient Safety walks for 2014/15 has been agreed. Community services are to be

included in this programme.

Well Governed

The CQC inspection process is undergoing extensive change under the leadership of CQC’s new Chief Inspector of

Hospitals Professor Sir Mike Richards. The recent release of the CQC Intelligent Monitoring Report for Bolton Foundation

NHS Trust dated 13th March 2014 shows considerable improvement with an increased banding being awarded from 4 to 5.


There is one elevated risk and a further three risks identified within the Intelligent Monitoring Report shown as follows:

1. Elevated Risk – Monitor Governance Rating 2. Risk – Staff Sickness 3. Risk – Safety Incidents 4. Risk - PROMS returns for groin hernia operations

All of these identified risks have action plans in place.

There are 5 Essential Healthcare Standards which have 17 outcomes for delivery. The Trust remains compliant with all of

the standards.

The table below shows the fines and penalties for the year.

Penalties

The Trust has received penalties for 18 weeks breaches in T&O. The non-elective threshold adjustment has also moved in

the month due to an increase in non-elective activity above the 2008-09 baselines. The C-Diff has also been increased due

to an increase in the final out-turn position reported.

Plan Actual

£'000 £'000

Penalties (500) (467)

C-Diff 0 (910)

TOTAL (500) (1,377)


Date Indicator Code Indicator Description Requested by Change Authorised by

19/11/2013Monitor Compliance Governance 1013-14

Monitor Compliance Governance 1013-14 Report Esther Steel Remove from Report. No longer used. Esther Steel

27/11/20131.07 - Total number of incidents (Clinical and non-clinical)

This metric is everything reported, patient, staff, visitors, contractors, non person. “Clinical & non clinical” infers just patient incidents. Eric Porter

Change to 1.07 - Total Incidents reported on Safeguard Trish Armstrong-Child

04/12/2013

4.02 - Substantive Staff Turnover Headcount (rolling average 12 months)

Labour turnover of substantive contracted employees Kelly King

This metric previously included turnover relating to contrived reductions in workforce over the course of the year, relating to Turnaround schemes, redundancies (voluntary and compulsory) etc. The data for this metric should be based on “natural” turnover in order to demonstrate a representative picture of the workforce. Retrospective figures have replaced the previously reported figures for the current year (2013/14). The 2012/13 figures have not been adjusted. The target remains at 10%. The metric definition has also been changed. Louise Ludgrove

13/12/2013 1.39 ‐ MRSA HA acquisitions N/A Julie Dziobon This is a duplicate of metric number 1.38 - MRSA Bacteraemia post-48 Hours admission Trish Armstrong-Child

13/12/20131.37 - MRSA Bacteraemia pre-48 Hours admission

No of pts identified as having MRSA presenting complaint 48 hrs before admission Julie Dziobon

All pre cases are now the responsibility of the CCG, for both CDT & MRSA bacteraemia cases, so despite having 4 pre cases of MRSA bacteraemia for the current year– none of them have been attributed to the Foundation Trust. Action: To remove this metric . Trish Armstrong-Child

17/01/2014 1.50 Infection Control Level 1 National Qualification David Wakefield Not Reportable David Wakefield17/01/2014 1.51 Infection Control Level 2 National Qualification David Wakefield Not Reportable David Wakefield

14/02/2014

1.36 Surgical WHO Checklist compliance (Emergency)

Checklist to reduce surgical morbidity and mortality Mike Steele Metric added Jill Patterson

19/02/2014

1.10 - pt incidents that resulted in severe harm or death %

Number of incidents involving pts that resulted in severe harm or death

Trish Armstrong-Child Target changed to 0%

Trish Armstrong-Child

19/02/2014 1.27 - complaints receivedTotal number of compliants received into trust


change target to 10% reduction on last yearsoutturn


11/03/2014

1.25 - NICE Guidelines Adoption of Technology Appraisals

% of Technology appraisals applicable to the Trust that are adopted or adopted with caveat Steve Hodgson

Use the percentages based on total adopted technology appraisals Steve Hodgson

03/04/20144.13 - Qualified Nurse to bed ratio

Compares the number of contracted WTE nurses against in the number of occupieed beds in the most recent month Nigel Moloney

Remove from Report. Replaced by ‘Budgeted Nurse: Bed Ratio’ and ‘Actual Nurse: Bed Ratio’ in the Board Staffing Assurance Heat Map Suzanne Woolridge

03/04/2014

1.33 - Compliance of 6 access criteria for learning disability %

to ensure equality of access and equity for all people with learning disabilities Mike Steele

After reviewing the 13-14 and 12-13 data there were incorrect figures in (83%). We were 100% compliant in year 12-13 and also in 13-14. Data changed to reflect this Bev Tabernacle

Report Change log


Agenda Item No: 9

Meeting Trust Board

Date 24/4/14

Title Transfer of Patients between the hours of 11pm and 6am

Executive Summary

The Trust received a letter from Sir Bruce Keogh

regarding disposal of foetal remains and transfers to

wards between 11pm and 6am.

The Board has already received confirmation that the

Trust follows best practice with regards to the Disposal of

Foetal remains.

This report reviews the current number of transfers based

on an audit of the last 5 years.

The number transferred after 11pm and between 6am

has been remarkably constant at an average of 11 per

night.

85% are from observation wards

15% are from other wards

The most likely reason for the transfer is to avoid

breaches in A/E although there is no audit evidence of

this.

Whilst this may be clinically important for the patient

being transferred from A/E for instance it is not for the

patient moved from the ward in the early hours of a

morning

Next steps/future actions

The Trust will introduce a policy that no patients should

be moved between the hours of 11am or 6 pm unless for

clinical need.

A prospective audit is being carried out on the reasons

for movements

An audit will be carried out every 6 months and be

reported at the Quality and Performance PAF

Discuss Receive

Approve Note X

For Information Confidential y/n


Strategy Legal Implications

Performance and Quality X Regulatory

Financial Implications Stakeholder implications

Workforce Risk

Prepared by A Ennis

Presented by

Bolton NHS Foundation Trust

Ward 2009/10 2010/11 2011/12 2012/13 2013/14 Total

Total 3823 4401 4196 4261 3920 20601Avg Per Day 10.5 12.1 11.5 11.7 10.7 11.3

Ward 2009/10 2010/11 2011/12 2012/13 2013/14 Total

Total 525 560 583 593 605 2866Avg Per Day 1.4 1.5 1.6 1.6 1.7 1.6

Ward 2009/10 2010/11 2011/12 2012/13 2013/14 Total

Total 86.3% 87.3% 86.1% 86.1% 84.6% 86.1%

Number of Ward Transfers between 11pm and 6am from assessment wards (D1,D2,F3,Blue-Bay, CDU and Paeds Observations - G5Obs/E5Obs/F5)

Transferred From

Ward

2009/10 2010/11 2011/12 2012/13 2013/14 Total

BLUE 8 24 10 42Avg per Day 0.0 0.0 0.0 0.1 0.0 0.0

CDU 49 107 156Avg per Day 0.0 0.0 0.0 0.1 0.3 0.1

E5OBS/G5OBS/F5 1074 1142 1105 1119 1079 2391Avg per Day 2.9 3.1 3.0 3.1 3.0 1.3

F3 157 383 554 524 448 2066Avg per Day 0.4 1.0 1.5 1.4 1.2 1.1

D1 1279 1290 1001 1024 820 5414Avg per Day 3.5 3.5 2.7 2.8 2.2 3.0

D2 788 1026 945 928 851 4538Avg per Day 2.2 2.8 2.6 2.5 2.3 2.5

Total 3298 3841 3613 3668 3315 17735

Avg per Day 9.0 10.5 9.9 10.0 9.1 9.7

Excludes obstetrics by removing data under specialty code '501' and any ward movements between CDS, M2, M3, M4 & M5 regardless of specialty recorded an LE2.2

% between 11pm and 6am from assessment wards (D1,D2,F3,Blue-Bay, CDU and Paeds Observations - G5Obs/E5Obs/F5)

Ward Transfer between 11pm and 6am excluding transfers from assessment wards (D1,D2,F3,Blue-Bay, CDU and Paeds Observations - G5Obs/E5Obs/F5)

Ward Transfer between 11pm and 6am including transfers from assessment wards (D1,D2,F3, Blue-Bay, CDU and Paeds Observations - G5Obs/E5Obs/F5)

Agenda Item No : 10

Meeting Trust Board

Date Thursday 24th April 2014

Title Medical Revalidation/Responsible Officer Role

Executive Summary

Medical revalidation is now happening with all doctors needing to be revalidated by 2016. This brief paper summarises for Trust Board the principles underpinning the process of revalidation. It also summarises the statutory duties of the Responsible Officer and Designated Body (Bolton FT)


The Framework of Quality Assurance for Responsible Officers and Revalidation Annual Board report will be submitted for Trust Board approval in May 2014

Discuss Receive

Approve Note

For Information √ Confidential y/n



Performance and Quality √ Regulatory √


Workforce √ Risk

Prepared by Mr S P Hodgson Presented by Mr S P Hodgson

Medical Revalidation and the Responsible Officer Role

1. Purpose

The purpose of this paper is to inform the Trust Board of the principles underpinning

medical revalidation. It also summarises the statutory duties of the Responsible Officer

and Designated Body (Bolton FT)

2.Background/Current Position

“Revalidation is something that the public expect their doctors to undertake and if implemented sensitively and effectively is something that will support all doctors in their innate professional desire to improve their practices still further” - Andrew Lansley, Secretary of State for Health Purpose of revalidation “To assure patients and the public, employers and other health care professionals that licensed doctors are up to date and are practicing to the appropriate professional standards”- GMC 2009 Revalidation “will be based on robust local systems that support high quality care in the organisations and practice settings where that care is delivered” “Appraisal and Clinical Governance will remain the key foundations of the process” “Must not create unnecessary burdens which distract doctors from caring for their patients but at the same time must be robust enough to provide assurance for the public” - GMC 2010 Roll out of revalidation commenced in 2012/13 with a target of all doctors being revalidated by the end of 2015/16. A provider of healthcare such as Bolton FT is termed a Designated Body. All doctors employed by the Designated Body have a prescribed connection with the GMC through their Responsible Officer. Currently Bolton FT have approximately 195 consultants and 150 non-consultant career grade doctors employed by the Trust. Junior doctors in designated training posts have a prescribed connection to the North West Deanery who are their Designated Body. The three main themes of revalidation are firstly to improve the quality of patient care, secondly to strengthen professional development and thirdly to improve patient safety be reinforcing systems which identify those doctors who require support. Revalidation is based on effective systems of appraisal and governance/quality assurance. These are the same symptoms which improve quality and safety. Revalidation is a bi-product of these strengthened systems. The Responsible Officer will recommend revalidation of individual doctors by the GMC on the basis of a series of satisfactory annual appraisals. The appraisals encompass personal development, audit of clinical outcomes, complaints monitoring, patient feedback and 360 degree multisource feedback

Responsible Officer Role The Responsible Officer Role is a statutory and has a prescribed regulatory framework (unlike the Medical Director Role). The Responsible Officer is accountable to the NHS England Regional Team Responsible Officer and subject to annual appraisal and quality assurance being required to provide evidence of attendance at relevant meetings, satisfactory appraisal and organisational appraisal rates, recommendation for revalidation rates and evidence of responding adequately to concerns. Responsible Officer responsibilities include:-

Evaluating fitness to practice Monitoring conduct and performance Establishing functions to ensure appraisal Investigation of concerns Taking actions to respond to issues and having systems in place for pre-

employment checks This builds on the clinical governance structure ensuring it is fit for purpose, being able to identify issues including system rather than individual issues. If issues are identified action must be taken to address concerns. Designated Body Responsibilities The Designated Body has a responsibility to appoint the Responsible Officer, resource the Responsible Officer to perform their duties and ensure that the Responsible Officer is not overloaded by other duties. “each Designated Body must provide the Responsible Officer nominated or appointed for that body with sufficient funds and other resources necessary to enable the officer to discharge their responsibilities”- GMC This resource will include clinical and administrative support for robust appraisal, timely and appropriate HR advice and flows of information to ensure monitoring of performance and identification of any concerns. Board Reporting System The framework for quality assurance (FQA) is a mechanism by which Responsible Officers and designated bodies demonstrate to stakeholders that systems are in place. This results in the generation of an annual organisational appraisal (AOA). This

includes performance against core standards of appraisal rates, monitoring performance and responding to concerns and workforce data. Our AOA is currently being generated and will be circulated for discussion ahead of the May Trust Board.

Recommendations

The Trust Board will be informed of our current position by submission of our Annual

Organisational Appraisal (AOA) for approval at the meeting on 29th May 2014

Agenda Item : 11


Date 24 April 2014

Title Sickness Absence Report

Executive Summary

Why is this paper going to

the Board To summarise the main

points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

The aim of this report is to provide an update to the Board of Directors on the measures taken to address the increase in sickness absence that began in November 2013.

Next steps/future actions Clearly identify what will follow a Board decision i.e. future KPI’s, assurance requirements

The Board is asked to receive the report.

Discuss / Receive /

Approve Note

Assurance to be provided by:

Workforce Committee


Strategy / Financial Implications

Performance / Legal Implications

Quality / Regulatory

Workforce / Stakeholder implications



Prepared by Nigel Moloney – Workforce Transformation Manager

Presented by

Suzanne Woolridge – Acting Director of Workforce

BOARD OF DIRECTORS – 24th April 2014

Sickness Absence Report

1. Introduction This report provides an update to the report presented at the January 2014 Board of Directors meeting. The report outlines the Trust’s current position and reviews the actions undertaken and those planned in order to reduce sickness absence levels.

2. Current situation

Current sickness rate The March 2014 sickness absence figure has reduced to 5.33%, bringing the rolling 12 month figure to 5%. In order to achieve a rolling 12 month figure of 4.0%, a trajectory for 2014/15 is shown below which gives an indication of the performance that would need to be achieved, showing the seasonal variations that are typically seen with a sickness absence rate.

Episodes of sickness (April 2013 – March 2014) The Trust in the last 12 months had 52 episodes of sickness of more than 6 months duration (of which 2 have been more than 12 months). The table below shows this compared to the position

shown in last report (data from December 2012 to November 2013). It shows improvement in the levels in short term sickness levels but the levels of the longest periods of sickness (6-12 months) have increased slightly.

Length of absence

Episodes (12 months up to Nov

2013)

Episodes (12 months up to Jan

2014)

Episodes (12 months up to March 2014)

0 - 14 days 5079 4878 4688

15 - 28 days 509 529 512

29 days - 3 months 590 608 623

3 - 6 months 204 187 172

6 - 12 months 36 45 50

> 12 months 4 2 2

Benchmarking data (January – December 2013) Benchmarking data against North West acute/integrated trusts indicates that the Staff Nurse role (part of the Nursing and Midwifery staff group) is the key outlier where the Trust needs to focus its attention as this staff group shows the biggest variation and covers the biggest group of staff.

Staff Group Bolton FT North West Average

Comment

Add Prof Scientific and Technical 3.14% 3.57% Better than Average

Additional Clinical Services 6.64% 6.54% Close to Average*

Administrative and Clerical 4.08% 3.97% Close to Average*

Allied Health Professionals 3.37% 2.78% Worse than Average

Estates and Ancillary 4.25% 5.75% Better than Average

Healthcare Scientists 2.26% 3.10% Better than Average

Medical and Dental 2.10% 1.27% Worse than Average

Nursing and Midwifery 5.75% 4.93% Worse than Average

Total 4.89% 4.39%

* Close to Average is defined as within 0.1% of average

3. Measures

The previous report described the management plan to address increasing sickness absence; the following table shows the activity that has taken place since 1 February 2014.

Action Number

Staff returned to work from long term sickness 115

Staff left the Trust due to sickness (short and long term) 6

Staff receiving formal cautions 49

Management referrals to Occupational Health 154

Physiotherapy appointments (for Back, Musculoskeletal treatment)

52

Mental Health Referrals 31

SIT team Audits 147

SIT contacts 68

The management plan has prioritised consistent management of sickness absence to ensure that the Trust is doing all it can to support people who are off work to return to the workplace. The following areas of work will continue: Hotspot areas Hot spot areas are identified and closely managed within Divisions, performance against the sickness absence target also features in the PAF meetings with the Executive and Divisions. The ten most poorly performing areas have now been escalated to the Director of Workforce/ Chief Operating Officer for review with the relevant manager. Audits The Sickness Intervention Team (SIT) has been auditing the use of our current policy and has found inconsistent application of the policy is contributing to our high level of sickness absence. Key findings are that in some areas:

- Return to work interviews are not always carried out or completed in a timely manner - Formal referrals to Workplace Health and Wellbeing not always being undertaken - ‘trigger’ points not always being followed up, thus delaying the start of formal

monitoring The results have been highlighted to the relevant Divisional Director of Operations for immediate action to ensure the policy is being followed by those managers whose audits were not favourable. Policy A new Attendance Management Policy has been developed, ready for consultation, to replace a number of legacy policies (from predecessor organisations of staff transferred to Bolton FT’s employment) and to ensure a consistency of approach across the Trust. Underutilisation of Staff Physiotherapy addressed Musculoskeletal and back problems are one of the Trust’s principal causes of sickness absence; a recent audit by the Workforce Committee found that not all the staff needing this treatment were aware of the support available from Physiotherapy for staff. This has now been re-publicised to staff and managers to ensure these cases are managed proactively. Management training and support More sessions have been delivered to managers on the management of sickness absence.

Where identified that additional coaching and support will be beneficial, the HR team is

providing initial support to managers at sickness absence meetings with staff, thereafter

managers will hold meetings independently of HR unless at the later stages of the policy or as

agreed necessary by both the manager and HR.

Sickness Intervention Team (SIT) In addition to the audit work, the SIT has also been focusing on hotspot areas to provide particular support to ensure as soon as a member of staff commences a period of sick leave they are contacted and offered support to ensure as an appropriate and speedy return to work as possible. This is a key opportunity to signpost all routes of support the individual can access; it also maintains a regular contact with the member of staff.

Underlying causes Whilst the nature of sickness absence is difficult to predict, certain pockets of higher sickness absence appear to be linked to known organisational challenges (for example organisational change) and so proactive work has begun with these teams. Mental Health Nurse With an increase in sickness episodes due to ‘anxiety/stress/depression’ reasons the mental health nursing resource in Occupational Health have targeted their work to align to work with managers who appear to have a significant proportion of the their sickness due to these reasons. 4. Conclusion A number of interventions have been commenced with the primary objective to reduce the amount of sickness absence of our workforce. A review of our neighbouring Trust’s sickness policies and approach has been undertaken to ensure the Trust is not missing any valuable initiatives. Improvement in sickness absence rates has been achieved, but the pace of change needs to accelerate in order to achieve 4% as demonstrated in the chart in section 2.

Agenda Item No : 12.


Date 24th April 2014

Title Draft Annual Report

Executive Summary

The Board is asked to formally review and comment on the

draft Annual Report.

This has been complied in line with Monitor guidance. The

format of the report has changed from previous years to be

more in line with reporting of listed companies, the majority of

the content previously in the Director’s report is now in a new

strategic section which can if required be published as a

separate report.

Board members will note that the report is a work in progress,

the deadline for submission to Monitor is the end of May and

a final report will be presented to the Board for approval on

May 29th 2014.


Directors are invited to comment on the content and format.

Any corrections of typographical and grammatical errors are

welcome - please send direct to the Trust Secretary

Discuss Receive

Approve Note




Performance and Quality Regulatory


Workforce Risk


Presented by Esther Steel Trust Secretary

Annual Report

and Accounts

2013/14

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Bolton NHS Foundation Trust

Annual Report and Accounts 2013/14

Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) of the National Health Service Act 2006

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Contents

Strategic Report

Directors’ Report

Remuneration report

Disclosures for NHS Foundation Trust Code of Governance

Quality Report

Staff Survey

Regulatory Ratings

Income disclosures

Other Public Interest Disclosures

Statement of Accounting Officer’s Responsibilities

Annual Governance Statement

Page numbers will be added

The strategic report has been prepared in accordance with sections 414A, 414C and 414D of the Companies Act 2006, as interpreted by the FReM (paragraphs 5.2.6 to 5.2.11) and in accordance with the direction issued by Monitor under the National Health Service Act 2006.

The accounts included within the annual report have been prepared under a direction issued by Monitor under the National Health Service Act 2006

The purpose of the strategic report is to inform users of the accounts and help them to assess how the directors have performed in promoting the success of the foundation trust.

This report is intended to be self-standing and comprehensive in its scope however where further information is available for example in the Trust’s five year strategic plan this will be cross referenced within the report.

Preparation of Accounts and adoption of going concern

The accounts provided with the Annual Report have been included under a direction issued by Monitor under the National Health Service Act 2006. After making enquiries, the directors have a reasonable expectation that the NHS foundation trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts.

Strategic Report

Chairman’s Review

Performance

It can sometimes be difficult to be completely objective about performance when looking back over the previous twelve months. However, I am delighted to say that, overall, 2013-14 was a hugely successful year for the Trust and one that we can rightly be proud of. Despite the difficulties faced, we delivered improved levels of care throughout the year, achieved better outcomes for patients and dealt with a severe financial challenge. I was particularly pleased with the focus we placed on improving the experience of all our patients and, during the final quarter of the year, the hard work of everyone was rewarded with significant improvements in all our Harm Free Care indicators, including the number of falls and pressure ulcers experienced by patients.

Perhaps our most visible success was our A&E performance where we beat the national target, of seeing 95% of all patients within four hour, in each and every month of the year. This was little short of extraordinary and placed us amongst the top 10% of trusts in the UK. There is little doubt that this result could not have been achieved without the help, flexibility and professionalism of many, many staff throughout the Trust and I, and the whole Board, am eternally grateful for their determination and commitment.

Governors

We are extremely lucky to have the benefit of a lively, engaged and energetic set of Governors. Throughout the year they supported the Board and ensured we remained focussed on the true aim of the trust; that of delivering great care to our patients. The Governors play a pivotal role in the development of the Trust and throughout 2013-14 they championed the voice of the patient at every opportunity. We are all very grateful for their contribution.

Board

2013/14 also saw a real strengthening of the executive team. The appointment of Dr Jackie Bene as Chief Executive was pivotal to the Trust developing and delivering the strategies and plans required in addressing the challenges we faced. Other appointments included Trish Armstrong-Childs as Nursing Director and Andy Ennis as Chief Operating Officer. In addition, Stephen Hodgson was confirmed as the substantive Medical Director. I believe that our clinical focus and operational capability have been greatly enhanced as a result of these appointments.

Finance

I should also highlight the success of our financial management strategy. Despite concerns to the contrary, we delivered income and cost improvements of £20m whilst improving quality. We also agreed a £2.4m investment in Nursing. The Board are grateful to our Finance Director, Simon Worthington, for his skilful guidance and management of our finances and for the engagement of all the Divisional teams in addressing the efficiencies required. Our plan was to reduce a previous year’s deficit of £14m to £7.8m and we achieved better than this. More importantly though, I am delighted to report that, from an opening position of losing £1.5m per month at the beginning of the year, we closed the final few months by breaking even.

Strategic Report

Looking forward

We now turn our attention to a new year and, as ever, we face incredible challenges once again. Our primary objective remains the continued improvement in patient care and in delivering the best possible experience for our patients. We are also keen to address the concerns of all our staff and to make Bolton a great place to work. We are determined to make real progress on these goals in the forthcoming year despite the widely published financial difficulties facing the NHS. The task facing Bolton Foundation Trust, although similar to all other trusts in percentage terms, requires us to deliver further efficiency improvements of £22m and to end the financial withy a small surplus. It is clear that, without a change in the way we deliver care, this would be impossible. Our plans therefore include the strategic aim of moving care closer to the homes of patients by working with our Primary Care colleagues and moving more services into our community centres. We will also be working very closely with our council colleagues as we strive to improve the integration of health and social care. We are also working with neighbouring trusts on the development of future models of care under the Healthier Together initiative and we await the consultation process of the future shape of health services in the Greater Manchester area. In terms of investments, the board aims to invest heavily in improving our estate and in the supporting IT systems. I am hopeful that you will all begin to see some of the improvements in the coming months.

2014-15 will therefore be an extremely difficult year but we enter it in good shape. I am confident that with the help and support of all our staff and patients it will be another successful year.

My thanks to you all.

David Wakefield

Chairman Bolton NHS foundation Trust

Strategic Report

Our Journey

Figure 1 - Bolton NHSFT journey 2012 - 14

Strategic Report

Bolton NHS FT at a glance

Bolton NHS Foundation Trust is an integrated care organisation providing care and support in the community at over 20 health centres and clinics, including the prestigious Bolton One complex in the town centre, as well as services such as district and school nursing. We also provide intermediate care in the community and a wide range of services at the Royal Bolton Hospital.

The Trust was authorised as a Foundation Trust in October 2008 and became an integrated care organisation in July 2011 following the transfer of services from the provider arm of NHS Bolton.

Graphic to show: Number of staff Number of beds Number of a and e attendances No of appointments No of babies born

Strategic Report

Chief Executive’s Review of the year

Strategic Report

Business Review

Simon Worthington to provide

Strategic Report

Our Strategic Objectives

Figure 2 Bolton NHSFT Strategy 2013 - 18

Strategic Report

Principal Risks

The Board has ultimate responsibility for the effective risk management of the Trust’s strategic objectives. The Board Assurance Framework is used to monitor the key strategic and operational risks, and ensure appropriate mitigating actions are implemented.

The Board has considered and approved the risk management strategy. The Audit Committee receives regular reports from management, internal and external auditors, detailing the risks that are relevant to our activity, the effectiveness of our internal controls in dealing with these risks and any required remedial actions along with an update on their implementation.

The Audit Committee reports to the Board on the effectiveness of the risk management process. The day to day risk management is the responsibility of senior management as part of their everyday business processes.

Further detail on the governance processes supporting our risk management can be found in our Annual Governance Statement on page xx of this report.

The principal risks that could adversely impact on the achievement of our strategic objectives are set out below.

A brief description of each risk and the mitigating activities is included on the following page.

The key strategic risks are reviewed at each meeting of the Board of directors

1 Reduction in C. Difficile

2 Failure to provide appropriate staffing levels

3 Failure to provide timely response to the deteriorating patient

4 Failure to comply with CQC standards

5 Failure to achieve the A&E target

6 Failure to achieve the 18 week target in all specialities

7 Failure to learn from incidents

8 Failure to comply with information governance standards

9 Failure to reduce sickness absence

10 Organisational change as a result of Healthier Together

11 Failure to provide integrated care in Bolton

12 Failure to provide appropriate IT infrastructure

13 Failure to provide an efficient fit for purpose estate

14 Failure to achieve required level of financial savings Figure 3 risk profile

Strategic Report

Risk Mitigating Activities

1 A failure to reduce the number of cases of C difficile (CDT) could lead to harm to patients, increased length of stay, financial penalties and potential regulatory action

Cases are closely monitored by the infection control committee, a system of alerts to identify patients previously identified with CDT is in place. All rooms are fogged after CDT cases and facilities have been upgraded with sinks at ward entrances. The rate of cases decreased significantly in 2013/14

2 Failure to provide appropriate staffing levels could lead to compromised patient safety and experience

Staffing levels agreed with recruitment programme in place to recruit to agreed staffing levels. Staff encouraged to use incident reporting system to highlight incidences of unsafe staffing

3 A failure to provide a timely response to the deteriorating patient could impact on mortality and length of stay

This is a priority for the mortality reduction group, a business case has been approved for increased level 1 facilities and a closed HDU with extended acute physician presence

4 Failure to comply with CQC standards Compliance with CAC standards is monitored regularly through the

QA Committee. Work will continue in 2014 to improve ward to board risk management and incident reporting.

5 Failure to achieve the A&E target Although the Trust performed exceptionally well with regard to

the A&E target in 2013/14 this will remain a challenge in 2014/15 performance is closely monitored and the we are working with the CCG to develop appropriate pathways and demand management.

6 Failure to achieve the 18 week target in all specialities

The 18 week target remains a challenge in orthopaedics, performance is closely monitored and a plan has been developed to manage trauma patients outside the required elective care capacity

7 Failure to ensure safe management and learning from incidents

Review of incident reporting and development of ward and department risk registers. Daily report of all incidents to managers and directors. New SUI process approved

8 Failure to comply with information governance standards

Information Governance training for all staff, encryption standards for emails, laptops and mobile devices - moving towards electronic document management and Electronic patient records.

9 Failure to reduce sickness absence Focus on appropriate application of policies with a dedicated

sickness intervention team to provide proactive support and interventions to support staff back to work.

10 Organisational change as a result of Healthier Together may threaten the clinical and financial viability of the organisation

Continued engagement in Healthier Together through sector meetings and participation in planning forums. The Trust will continue to work with other providers in the NW sector of Greater Manchester

11 Failure to provide integrated care in Bolton may lead to escalating demand on hospital services and increasing pressure on the financial stability of the Bolton Health Economy

Full engagement with partners in primary care and social care in the planning and delivery of the vision for integrated care in Bolton

12 Failure to provide appropriate IT infrastructure

A business case to fund the IT strategy is being developed to support the Trust’s plans to be a digital organisation. Funding has been allocated to improve community IT infrastructure.

13 Failure to provide an efficient fit for purpose estate may restrict the implementation of service plans leading to an adverse impact on financial and quality indicators

A new Estates strategy and supporting business case has been developed. Estates performance is monitored on the estates dashboard overseen by the Estates Committee

14 Failure to achieve required level of financial savings

The Trust has a detailed cost improvement plan which has a good level of clinical engagement, is supported by a programme management office and overseen by the Finance and Investment

Principal Risks

Strategic Report

Committee

Table 1 - principal risks

Our Staff

The charts below provide a graphic representation of the demographic makeup of our staff and our Board. A more detailed breakdown of figures is included on page xx of this report

Gender profile of Trust employees

Figure 4 - gender profile Bolton NHS FT employees

Figure 6 - age profile Bolton NHS FT employees

Figure 5 - ethnicity profile Bolton NHS FT employees

Strategic Report

Our Values

We are committed to ensuring that the people who work within our organisation are treated with respect, and their health, safety and basic human rights are protected and promoted.

We have an agreed set of values which captures the attitudes and behaviour that staff said they wanted to see towards our patients, customers and each other.

Trust policies are reviewed on a regular basis and all are subject to an equality impact assessment.

Figure 7 - Bolton NHS FT values

Feedback welcome as to what else we can put to fulfil the requirement to provide information about social, community and human rights issues including information about any trust policies in relation to these matters and the effectiveness of these policies

Strategic Report

Environmental matters

Steve Tyldsley providing

Strategic Report

This Strategic report was approved by the Board of Directors on 27th May 2014 Signed on behalf of the Board Jackie Bene 27th May 2014

Directors’ Report

Companies Act disclosures

The Directors’ report has been prepared in accordance with:

Sections 415, 4165 and 418 of the Companies Act 2006;

Regulation 10 and Schedule 7 of the Large and Medium-sized Companies and Groups (Accounts and Reports) Regulations 2008 (“the Regulations”);

Additional disclosures required by the FReM,

Additional disclosures required by Monitor.

The names of individuals who were directors of the Foundation Trust between 1st April 2013 and 31st March 2014 are included within the remuneration report page ??

The relevant disclosures for compliance with the regulations listed above are included in section ?? of this report

Additional disclosures

Pensions Disclosure

The accounting policies for pensions and other retirement benefits are set out in note xx to the accounts and details of senior employees’ remuneration can be found in the remuneration report on page xx

Statement of accounts preparation

The accounts have been prepared under direction issued by Monitor, the independent regulator for Foundation Trusts, as required by paragraphs 24 and 25 of Schedule 7 to the National Health Service Act and in accordance with the NHS Foundation Trust Annual Reporting Manual 2013/14.

Statement of register of interests

The Trust Secretary maintains a register of other significant interests held by Directors and Governors which may conflict with their responsibilities. Access to the register can be obtained by submitting a written request to the Trust Secretary

Statement as to disclosure to Auditors

Each of the Directors at the date of approval of this report confirms that:

So far as the Director is aware, there is no relevant audit information of which the NHS Foundation Trust’s Auditor is unaware; and

The Directors have taken all the steps that they ought to have taken as Directors in order to make themselves aware of any relevant audit information and to establish that the NHS Foundation Trust’s auditor is aware of that information.

Directors’ Report

Quality Governance

In March 2013 the Trust commissioned an external, independent review of its arrangements for quality governance against the criteria described in Monitor’s Quality Governance Strategy (Deloitte QGAV report 2013).

The Deloitte Quality Governance report reviewed the Trust against the criteria as described in the Monitor Quality governance Framework including strategy, capabilities and culture, processes and structures and measurement. Deloitte found several areas of good practice including the engagement of staff and support for staff there were however areas where improvement was required including the management of risks, the production of information and the need for an overarching quality strategy.

During the course of 2013/14 the Board oversaw a programme of actions to address issues identified in this report and into other associated reports into governance and quality. The actions undertaken during the year include:

The development of a new integrated performance report

The publication of a Quality Strategy

Improved relations and communications with stakeholders

Development of a new complaints process

Review of the Board Assurance Framework (BAF)

A programme of Board and Governor development.

Significant progress has been made with the implementation of these actions. In February/March 2014 the Trust asked the internal auditors PwC to review the progress made against the Deloitte actions. The review has concluded that over 70% of actions have been completed with the others having evidence of being in progress but requiring further time to fully embed.

Further information on governance including quality governance can be found in the annual governance statement on page xx.

Further information on the quality of services provided by the trust can be found in our quality report which is included in this report from page xx

Remuneration Report

Remuneration Report

The remuneration report has been prepared in compliance with the relevant elements of sections 420 to 422 of the Companies Act 2006, Regulation 11 and Schedule 8 of the Large and Medium-sized Companies and Groups (Accounts and Reports) Regulations 2001 and elements of the NHS Foundation Trust Code of Governance.

Nomination and Remuneration committee

The remuneration and conditions of service of the Chief Executive and Executive Directors are determined by a Nomination and Remuneration Committee. The membership of the Nomination and Remuneration Committee consists of the Chair and Non-Executive Directors of the Trust and in addition, when appointing and reviewing the performance of Executive Directors (other than the Chief Executive), the Chief Executive.

The Nomination and Remuneration Committee met six times during the reporting period to consider the appointment, performance and remuneration of the Executive Directors. The Chief Executive and Director of Workforce and Organisational Development attended meetings other than when matters being discussed would have meant a conflict of interest. Minutes of meetings were recorded by the Trust Secretary. Attendance is shown in the table below

Nomination and Remuneration Committee Attendance

David Wakefield 6/6

Mark Harrison 5/6

Carol Davies 5/6

Ebrahim Adia 4/6

Gina Ashworth 5/6

Allan Duckworth 6/6

Dr Jackie Bene 4/4

Anthony Sumara 1/1

Nicky Ingham 1/1

Esther Steel 6/6 Table 2 Nomination and Remuneration Committee Attendance

Advice and Services provided to the nomination and remuneration committee 2013/14

In 2013/14 the Nomination and Remuneration Committee received advice/services to assist in the recruitment of high calibre Executive Directors

Advice from Appointed by Selection process Services provided Objectivity assured

by

fee

Table 3 - external advice provide to the Nomination and Remuneration Committee

Remuneration Report

In considering the Executive Directors’ remuneration, the Committee take into account the national inflationary uplifts recommended for other NHS staff, any variation in or change to the responsibility of Executive Directors and relevant benchmarking with other NHS and public sector posts. The performance of Executive Directors and the Chief Executive is discussed at the Remuneration Committee. Executive Directors are subject to annual appraisal by the Chief Executive who is appraised by the Chairman.

The contracts of employment of all substantive Executive Directors are permanent and are subject to six months’ notice of termination. No performance-related pay scheme (e.g. pay progression or bonuses) is currently in operation within the Trust and there are no special provisions regarding early termination of employment.

A small number of very senior managers who report directly to Board Directors and General Managers are employed on a local pay scale agreed by the Remuneration Committee. All of their other Terms and Conditions mirror Agenda for Change.

All other senior managers are subject to Agenda for Change pay rates, terms and conditions of service, which are determined nationally. The exception to this is a small group of staff who chose to remain on local terms and conditions when Agenda for Change was introduced. These individuals do not receive any inflationary pay uplift.

There is also a Governors’ Nomination and Remuneration Committee. This Committee met twice during the reporting period and as well as reviewing the performance of the Non-Executive Directors agreed a proposal to renew the appointment of two of the Non-Executive Directors and to substantively appoint the Chairman

Pension arrangements for the Chief Executive and all Executive Directors are in accordance with the NHS Pension Scheme. The accounting policies for pensions and other relevant benefits are set out in Note 1.8 to the accounts.

Off payroll engagements

The tables below provide detail of off payroll engagements of more than £220 per day lasting for longer than six months

Existing off payroll engagements as of 31 March 2014

No. of existing engagements as of 31 March 2014

No. that have existed for less than one year at time of reporting.

No. that have existed for between one and two years at time of reporting.

No. that have existed for between two and three years at time of reporting.

No. that have existed for between three and four years at time of reporting.

No. that have existed for four or more years at time of reporting.

Confirmation that all existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought.

Remuneration Report

New payroll engagements and those that reached six months in duration between 1 April 2013 and 31 March 2014

No. of new engagements, or those that reached six months in duration, between 1 April 2013 and 31 March 2014

No. of the above which include contractual clauses giving the trust the right to request assurance in relation to income tax and National Insurance obligations

No. for whom assurance has been requested

Of which...

No. for whom assurance has been received

No. for whom assurance has not been received

No. that have been terminated as a result of assurance not being received.

Off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2013 and 31 March 2014

No. of off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, during the financial year.

4

No. of individuals that have been deemed “board members and/or senior officials with significant financial responsibility” during the financial year.

This figure includes both off-payroll and on-payroll engagements.

12

Remuneration Report

Remuneration

The following tables provide information which is subject to audit review about the salaries, allowances and pension and pension entitlements of employees and appointees.

Remuneration tables to be included

Remuneration Report

Pension arrangements for the Chief Executive and all Executive Directors are in accordance with the NHS Pension Scheme. The accounting policies for pensions and other relevant benefits are set out in Note 1.8 to the accounts.

The median salary of the Trust at 31 March 2013 is £xxxxxx The ratio of the median salary to the highest paid director is xxx

Director expenses

Information on director and governor expenses has not been provided in previous years, in future reports prior year information will be included for comparison

Total number of Directors in office 15

Number of Directors receiving expenses 7

Aggregate sum of expenses £7112.72 Table 4 - Director expenses 2013/14

Governor expenses

Total number of Governors in office

Number of Governors receiving expenses

Aggregate sum of expenses Table 5 - Governor expenses 2013/14

Payments for loss of office

For each individual who was a senior manager in the current or in a previous financial year that has received a payment for loss of office during the financial year, the following must be disclosed:

the total amount payable to the individual, broken down into each component;

an explanation of how each component was calculated;

any other payments to the individual in connection with the termination of services as a senior manager, including outstanding long term bonuses that vest on or following termination; and

where any discretion was exercised in respect of the payment, an explanation of how it was exercised.

Payments to past senior managers

The report must contain details of any payments of money or other assets to any individual who was not a senior manager during the financial year but has previously been a senior manager at any time. The following payments do not need to be reported in this disclosure:

payments for loss of office (which are separately reported above);

payments that are otherwise shown in the single total figure table;

payments that have already been disclosed by the foundation trust in a previous remuneration report;

payments for regular pension benefits that commenced in a previous year; and

Remuneration Report

payments for employment or services provided by the individual other than as a senior manager of the foundation trust.

31st May 2014

Jackie Bene, Chief Executive

Code of Governance Disclosures

Statement of Compliance with the Code

The Trust Secretary reviews our compliance with the NHS Foundation Trust Code of Governance and prepares a report for the Audit Committee. The Audit Committee considered this report at its meeting on February 24th 2014 and agreed that Bolton NHS Foundation Trust complied with the main and supporting principles of the Code of Governance.

The Audit Committee has received assurance relating to the evidence base for compliance with the code of Governance for the year 2013/14 and is of the opinion that the Trust is compliant with all provisions of the code.

The Code is implemented through key governance documents, policies and procedures of the Trust, including but not limited to:

The Constitution

Standing Orders

Standing Financial Instructions

Scheme of Delegation

Schedule of Matters Reserved for the Board

Code of Conduct (for Directors, for Governors and for Senior Managers)

Staff Handbook

Governor Handbook

Summary Schedule of Matters Reserved for the Board

The schedule of matters reserved for the board details the decisions and responsibilities reserved to the Council of Governors, the Board of Directors and those delegated to the agreed committees of the Board of Directors.

In the event of any unresolved dispute between the Council of Governors and the Board of Directors, The Chair or the Secretary may arrange for independent professional advice to be obtained for the Foundation Trust. The Chair may also initiate an independent review to investigate and make recommendations in respect of how the dispute may be resolved.

The overall responsibility for running an NHS foundation trust lies with the board of directors. The council of governors is the collective body through which the directors explain and justify their actions - the council should not seek to become involved in the running of the trust.

Directors are responsible and accountable for the performance of the foundation trust; governors do not take on this responsibility or accountability. This is reflected in the fact that directors are paid while governors are volunteers.

The Council of Governors

As set out in the constitution, the Council of Governors consists of 23 publicly elected Governors, six staff Governors and nine appointed partner Governors.

The Council of Governors meet formally in public every two months


The role of the governor is to:

hold the non-executive directors individually and collectively to account for the performance of the board of directors

to represent the interests of NHS foundation trust members and of the public.

Set the terms and conditions of Non-Executive Directors

Approve the appointment of future Chief Executives

Appoint or remove the Trust’s external auditor

Consider the annual accounts, annual report and auditor’s report

Be consulted by the Board of Directors on the forward plans for the Trust.

Approve changes to the constitution of the Trust

Take decisions on significant transactions

Take decisions on non NHS income

The Board of Directors and the Council of Governors enjoy a strong and developing working relationship. The Trust Chairman chairs both and acts as a link between the two. Each is kept advised of the other’s progress through a number of systems, including informal updates via the Chairman, ad hoc briefings, exchange of meeting minutes and attendance of the Board of Directors at the Council of Governors and by individual Directors at Council of Governors sub-committees.

Governors have a responsibility to canvas the opinions of the trust’s members and the wider public with regard to their views on the forward plans of the trust. Governors attend local area forums to meet with members; Governors also took the opportunity to network with members at an informal session prior to the Annual Members Meeting where the main agenda item was the review of the proposed five year strategy for the trust.

Elected Governors - Public Constituency

Name Area Date Elected End of period

of office term

Attendance

(6 held)

Committee

Membership

Involved in other

groups

Robert Airey Farnworth Oct 13 Sept 16 1st 3/3

Mohammed Ayub Great Lever Oct 10 Sept 13 1st 1/3

Ann Bain Breightmet Oct13 Sept 16 2nd 6/6 P,S PEAT inspection

Derek Burrows Kearsley Oct 10 Sept 13 2nd 6/6 P

Michael Connolly

Westhoughton South Oct 13 Sept 16 1st 3/3 M,P, S

Kate Cowpe Out of Area Oct 11 Sept 14 3rd 6/6 P Making it Better Safety express

Hanif Darvesh Crompton Oct 10 Sept 13 1st 1/3

Margaret Evans Hulton Oct 11 Sept 14 1st 6/6 P

Debra Graham Out of Area Oct 13 Sept 16 1st 3/3 P

Ken Hahlo Heaton and Lostock Oct 12 Sept 15 2nd 6/6 M,P, S Mortality

Eric Hyde Little Lever and Oct 11 Sept 14 2nd 5/6 P,M, S Divisional quality


Elected Governors - Public Constituency

Name Area Date Elected End of period

of office term

Attendance

(6 held)

Committee

Membership

Involved in other

groups

Darcy Lever

Pauline Lee Westhoughton and Chew Moor Oct 12 Sept 15 3rd 6/6 P, M

100 voices, safety express

Carol McBride Horwich and Blackrod Oct 13 Sept 16 1st 3/3 P, M, S

Martin McLaughlin Halliwell Oct 13 Sept 16 1st 3/3 S

Kate McNulty Out of Area Oct 12 Nov 13 1st 2/3

Jeffrey Mangnall Rumworth Oct 13 Sept 16 1st 3/3 P, S

Geoffrey Minshull Bromley Cross Oct 11 Sept 14 2nd 6/6 A, S

Auditor appointment

Champak Mistry Harper Green Oct 13 Sept 16 1st 3/3 S

Ronald Parkinson Rumworth Oct 10 Sept 13 1st 3/3 S

Mike Phillips Out of Area Dec 10 Sept 13 1st 2/3 S

Jack Ramsay* Bradshaw Oct 11 Sept 14 2nd 5/6 Chair of M,P,N Pt. exp., workforce,

Bill Riley Astley Bridge Oct 13 Sept 16 1st 3/3 M

Barbara Ronson Horwich NE Oct 11 Sept 14 1st 5/6 P, S green issues

Sorie Sesay Great Lever Oct 13 Sept 16 1st 3/3 M, P, S

Jim Sherrington*

Tonge with the Haulgh Oct 10 Sept 13 2nd 6/6 P,N, S

Patient experience

Lynne Siddall Astley Bridge Oct 10 Sept 13 1st 1/3

Haroon Simjee Crompton Oct 13 March 14 1st

0/3

John Taylor Smithills Oct 11 Sept 14 2nd

5/6 M,P, S Divisional Board

Victor Williams Halliwell Oct 10 Sept 13 1st 3/3

Table 6 - Public elected governors Bolton NHS FT

Key: A: Audit. N: Nomination and remuneration. M: Membership and member communications. P: Patient, staff and visitor experience, S - Strategy

Elected Governors – Staff Constituency

Name Area Date Elected End of Period of

Office term

Attendance

(6 held)

Committee and Sub

Group Membership

Yousouf Adenwala Doctors and Dentists Oct 11 Dec 13 1

st 3/3

Caroline Greenhalgh

Nurses and Midwives Oct 12 Sept 15 6/6 P

David Hamer AHP and scientists Oct 10 Sept 13 2nd 2/3 N

Peter Hindle All other staff Oct 11 Sept 14 1st 5/6 S

Janet Roberts* Nurses and Midwives Oct 13 Sept 16 2nd 6/6 Chair of P

Table 7 - Staff governors Bolton NHSFT


Appointed Governors

Name Representing Date Appointed

Attendance (6

held)

Committee and Sub

Group Membership

Robert Allen Bolton Metropolitan Borough Council April 13 1/6

Jack Firth Bolton LINk Dec 10 4/6 S

Geoffrey Hargreaves Bolton Council For Voluntary Services Oct 08 6/6 P

Dr Jackie Leigh Salford University Feb 13 6/6 P

Samir Naseef Bolton Local Medical Committee Nov 12 5/6

Robert Nettleton Bolton University Dec 09 2/6

Thaira Qureshi Bolton Council For Voluntary Services Oct 08 6/6 P, S

Anna Maria Watters Bolton Metropolitan Borough Council Nov 12 1/6

Key: A: Audit. N: Nomination and remuneration. M: Membership and member communications. P: Patient, staff and visitor experience, S -

Strategy

Elections to the Council of Governors

Elections to the Council of Governors were held according to the constitution in September 2013. Results were as reported below.

Seat Turnout Governor elected

Astley Bridge 35.2% Bill Riley

Great Lever 19.2% Sorie Sesay

Tonge with the Hough 30.5% Jim Sherrington

Elections to the following seats were uncontested

Breightmet Ann Bain

Crompton Haroon Simjee

Farnworth Robert Airey

Halliwell Martin McLaughlin

Harper Green Champak Mistry

Horwich and Blackrod Carol McBride

Out of area Debra Graham

Rumworth Jeffrey Mangnall

Westhoughton South Michael Connelly

Nurses and Midwives Janet Roberts

All other staff Dipak Fatania


Lead Governor

In consultation with the Chairman and the Trust Secretary, the Council of Governors decided to nominate the three chairs of the sub-committees to jointly act as lead governor. The lead governor role is undertaken in accordance with Monitor guidance as the point of contact between Monitor and the Council of Governors with no additional responsibilities.

Directors’ and Governors’ Register of Interests

A register is kept of Directors’ and Governors’ interests. Access to the register can be gained either by contacting the Trust Secretary or from the Trust website.

Developing understanding

The Board of Directors has taken steps to ensure that Members of the Board, and in particular the Non-Executive Directors, develop an understanding of the views of Governors and members about their NHS Foundation Trust.

Mr David Wakefield chairs both the Board of Directors and the Council of Governors and with the assistance of the Trust Secretary is the link between the two bodies. The full Council of Governors meets a minimum of six times a year and these meetings are attended by representatives of the Executive Directors, the Senior Independent Director and the Non-Executive Directors. The Governors’ meetings provide the opportunity for the Governors to express their views and raise any issues so that the Executive Directors can respond. Minutes of the meeting are shared with the Board of Directors so they can pick up and respond to any issues raised.

The Governors have two formal sub-committees dealing with Auditor appointment, and nomination and remuneration. These are attended by the Chair of Audit and Director of Finance (Auditor appointment) and by the Senior Independent Director (nomination and remuneration).

The Governors also have three sub-groups, each chaired by a Governor nominated by the group. The chairs of the sub-groups meet with the Chairman on a regular basis, these groups are also attended by the Trust Secretary and other members of Trust staff as required.

The Trust recognises the importance of being accessible to members. Council of Governors meetings are held in public and publicised on the Trust website, member newsletters and notices around the hospital. The Governors representing the electoral wards of Bolton attend the local area forums run by Bolton Council to meet individual FT members and members of the public and hear their views.

Board of Directors

During the course of the year we have reflected on and altered the composition of our Board. The Board of Directors comprises the Chairman, Chief Executive, Senior Independent Director, four independent Non-Executive Directors and five Executive Directors. The Board meet monthly in public; papers for the meeting including the minutes of the previous meeting are available on the Trust website


The Directors have collective responsibility for setting strategic direction and providing leadership and governance.

The Scheme of Delegation which is included in the Trust’s standing orders, sets out the decisions which are the responsibility of the Board of Directors and those which have been delegated to a sub-committee of the Board.

The Executive Directors of the Trust meet weekly to consider the operational management and the day to day business of the Trust. These meetings are supported by monthly operational and financial Performance Assurance Framework meetings with the divisions to and bi-monthly Divisional Executive meetings attended by Executive Directors and the Senior Management team - the primary purpose of these meetings is to contribute to the forward strategy and review performance against the annual objectives agreed in accordance with the strategy.

Balance, Completeness and Appropriateness

There is a clear separation of the roles of the Chairman and the Chief Executive, which has been set out in writing and agreed by the Board. The Chairman has responsibility for the running of the Board, setting the agenda for the Trust and for ensuring that all Directors are fully informed of matters relevant to their roles. The Chief Executive has responsibility for implementing the strategies agreed by the Board and for managing the day to day business of the Trust.

All of the Non-Executive Directors are considered to be independent in accordance with the NHS Foundation Trust Code of Governance. Whilst on appointment the Chairman has to meet the Code’s ‘test of independence’, it does not apply to this role thereafter.

The Board considers that the Non-Executive Directors bring a wide range of business, commercial, financial and other knowledge required for the successful direction of the Trust.

All Directors are subject to an annual review of their performance and contribution to the management and leadership of the Trust.

A review of Board Governance was commissioned from KPMG in June 2012, the implementation of the recommendations was reviewed by the Trust’s internal auditors PwC in December 2013 80% of the recommendations which remained relevant were found to have been implemented and of the remaining 20%, 18% were in progress.

The external advisors used during 2013/14 have no other connections to the Trust.


Our Directors

Executive Directors

Directors serving at the time of reporting are listed first.

Dr Jackie Bene - Deputy CEO/CEO (appointed as CEO January 2014

Jackie was appointed to the Board in 2008 as Medical Director and after taking on the role of deputy CEO and acting CEO in 2012/13 she applied for and was appointed to the post of Chief Executive in January 2014. Jackie’s priorities are patient safety and quality improvement.

Simon Worthington (ACCA) – Director of Finance

Simon was appointed in February 2013 having previously held the post of Deputy Director of Finance at South London Healthcare NHS Trust, he has held a number of Board level posts in the NHS, including eight years at Yorkshire Ambulance Service NHS Trust. Simon has also operated successfully in the roles of Acting Chief Executive and Deputy Chief Executive whilst at previous NHS posts.

Trish Armstrong Child - Director of Nursing

Trish is a Registered General Nurse who has worked within the NHS since 1989. She has a vast wealth of experience within both nursing and operational management roles and has Executive leadership and professional responsibility for quality and patient safety. Her focus and primary aim is to ensure that excellent standards of care are received by patients and their carers and they have a positive experience of care both within hospital and community settings, including care in the home environment.

Andy Ennis - Chief Operating Officer

Andy joined the trust in January 2014. Andy has spent 33 years in the NHS originally as a nurse (including a spell as a Charge Nurse on the children’s ward at Bolton) but more recently in Operational Management roles. Andy’s main role on the Board is that that Trust achieves the national targets and has an Estate and IT infrastructure fit for purpose.

Steve Hodgson - Acting Medical Director/Medical Director

Steve was appointed Medical Director in March 2014. He has been a consultant orthopaedic surgeon with an upper limb interest in Bolton since 1993. He has previously held a number of leadership roles in the trust including clinical lead, associate medical director and Head of Elective Care Division. He was acting Medical Director for 7 months before being appointed to the substantive post. He is a member of the British Society for Surgery of the Hand Council for whom he leads their Overseas Aid project. Steve's priorities are the delivery of high quality care for our population and leading the medical workforce

Suzanne Woolridge - Acting Director of Workforce and Organisational Development

Suzanne has held a number of HR roles within the NHS since graduating in 1998. Suzanne started her career in North Cumbria and then went on to Stockport NHS Foundation Trust before she joined the team here in Bolton in 2009. Suzanne is a fellow of the Chartered Institute of Personnel and Development and was previously the Deputy Director of Workforce before starting her new role as Acting Director in December 2013.


Non-Executive Directors

David Wakefield – Chairman appointed by Monitor 8th August 2012 appointment ratified by Governors for a period of three years.

David is a qualified accountant and, in addition to his finance roles, has held senior posts in sales, operations and project management. He worked in the furniture trade for 12 years and with Royal Mail for 27 years. He joined the NHS as a non-executive director in Milton Keynes and later became non-executive Chairman of Milton Keynes Community Health Services and, subsequently, Chairman of Milton Keynes Hospital NHS Foundation Trust.

At the time of appointment David was Chair of Milton Keynes and Bolton, his tenure as Chair of Milton Keynes NHSFT ended in September 2013.

Dr Mark Harrison – Senior Independent Director appointed 1st April 2012 for three years

Mark Harrison, Controller of Production for BBC North, was appointed as a Non-Executive Director in April 2012. He has extensive Board level experience and has delivered large scale change, technology and efficiency programmes, negotiated and managed major contracts and partnerships, overseen strategic planning and delivery, and shaped and delivered output services to the public.

Mark is a member of the Finance Committee and the Audit Committee and is the nominated NED for whistle blowing.

Carol Davies (Chair of Audit Committee) appointed September 1st 2013 for a second three year term

Carol is currently Director of Finance and Resources at Mount St Joseph Business and Enterprise College. She has also held senior finance positions in a number of other organisations, including Bolton Council and Trafford Health Authority. She is a qualified accountant with the Chartered Institute of Management Accountants.

Carol is Chair of the Trust’s Audit Committee and a member of the Charitable Funds Committee

Dr Ebrahim Adia appointed November 30th 2013 for a second three year term

Ebrahim Adia is a Senior Lecturer in Education at the University of Central Lancashire and a member of the University Board. He is a former Joint Vice-Chair of NHS Bolton and former Cabinet Member of Children's Services of Bolton Council.

Ebrahim is a member of the Trust's Finance Committee, Quality Assurance Committee and Chair of the Trust's Charitable Funds Committee.

Gina Ashworth – Non Executive Director appointed 1st January 2013 for three years

Gina Ashworth was Director of Health Standards/Clinical Director at NHS Central Lancashire (Provider Services) before retiring in December 2010 having worked within the NHS for 37 years. A qualified nurse and midwife, Gina has given leadership and rigour to a range of services, programmes and initiatives keeping quality and corporate governance at the top of the agenda.

Gina Chairs the Quality Assurance Committee and is a member of the Audit Committee and the Charitable Funds Committee


Allan Duckworth – Non Executive Director appointed 1st January 2013 for three years

A Chartered Management Accountant, Allan brings twenty four years Board level experience in high profile, consumer facing businesses, including fourteen years as Chief Executive of Burnden Leisure PLC, the parent company of Bolton Wanderers FC and De Vere Whites Hotel. Prior to this role he spent ten years as a Finance Director at Umbro International Ltd, Lo-Cost Stores Ltd (Safeway Group PLC) and Vernons Organisation Ltd (Ladbroke Group PLC). He has also worked as a Senior Consultant with Price Waterhouse.

Alan is Chair of the Finance and Investment Committee and a member of the Charitable Funds Committee

Other Directors in post during the reporting period

Ann Schenk - Director of Strategy and Improvement (1996 - Dec 2013)

Nicky Ingham – Director of Workforce and Organisational Development (2005 - 2013)

Dee Sissons - Director of Patient Safety and Experience/Chief Nurse March 2011 - June 2013

Antony Sumara – Interim Chief Executive (25th March 2013 - 21st June 2013)

Jon Scott – Interim Chief Operating Officer (February 2013 - October 2013)

Louise Ludgrove - interim Director Workforce and OD (October 2013 - December 2013)

Sheila Roberts - Interim COO (October 2013 - December 2013)

Attendance at Board of Director meetings

David Wakefield 10/11

Ebrahim Adia 10/11

Trish Armstrong Child 10/10

Gina Ashworth 10/11

Jackie Bene 10/11

Carol Davies 11/11

Allan Duckworth 10/11

Andy Ennis 3/3

Mark Harrison 9/10

Steve Hodgson 5/7

Nicky Ingham 4/5

Louise Ludgrove 2/2

Sheila Roberts 2/2

Ann Schenk 6/7

Jon Scott 5/6

Dee Sissons 0/1

Anthony Sumara 2/2

Suzanne Woolridge 2/3

Simon Worthington 11/11


Audit Committee

The Audit Committee met on six occasions during the period April 1st 2013 and March 31st 2014.

The purpose of the Audit Committee is to provide the independent assurance to the Board that there are effective systems of governance, risk management and internal control for all matters relating to corporate and financial governance and risk management.

Key activities during the period April 1st 2013 and March 31st 2014 were:

Reviewing the Board Assurance Framework and Risk Register

Reviewing financial statements

Appointing new internal auditors

Supporting the Governor appointment of new external auditors

Receiving reports from the internal and external auditors

Receiving internal reports.

On occasion the Trust may decide to request additional services from the external auditor. The Council of Governors delegated specific authority for commissioning additional services to the Trust’s Audit Committee subject to an overall policy cap on directly attributable fees which should not exceed 50% in aggregate of the approved annual statutory audit fee in any twelve month period. This would be on the understanding that the Audit Committee takes responsibility for agreeing any specific areas of additional work to be undertaken and, in doing so, considers whether the external auditor or any other organisation is best placed to provide the service i.e. based on relevant experience, expertise in that particular area and value for money.

Auditor Appointment

During 2013 the Trust conducted a tender exercise for the provision of both internal and external audit services.

Prior to June 2013 internal audit services were provided by North West Internal Audit. A competitive

tender was undertaken supported by NHS Shared Business Services (SBS) to appoint new auditors.

Prospective providers were required to submit a detailed service and pricing specification which was

scored by a panel including the Deputy Director of Finance and the Trust Secretary. Six providers met

Audit Committee Attendance

Members

Carol Davies (chair) 6/6

Gina Ashworth 3/6

Mark Harrison 6/6

Allan Duckworth 3/3

Attendee

Simon Worthington 6/6

Esther Steel 6/6

Jackie Bene 2/2


the agreed criteria and were invited to attend to present to a panel including the Chair of the Audit

Committee and the Director of Finance. The outcome of this process was the appointment of PwC as

internal auditors to the Trust from June 2013 to May 2016 with an option to extend for two further 12

month periods.

Prior to September 2014 external audit services were provided by Grant Thornton, a contract had

been awarded to the Audit Commission in 2011, with the demise of the Audit Commission, this

contract had been novated to Grant Thornton for a period of one year in September 2012.

A similar process was followed as outlined above for internal auditors other than the panel to agree

the appointment was formed by the Governor sub group for auditor appointment. The Director of

Finance and the Chair of the Audit Committee attended the presentations to provide advice to

governors but the final decision was made by governors on the panel and ratified at the full council of

governor meeting in July 2013. The outcome of this process was the appointment of KPMG as external

auditors for a three year period from September 2013 with the option to extend for two further 12

month periods.

The effectiveness of both internal and external audit will be evaluated in 2014 using the ICAEW

guidance on evaluating auditors.

The value of external audit services (excluding the review of the charitable funds accounts) is £56,286

excluding VAT.


Membership

Every member of the public over the age of 16 can become an FT member of Bolton NHS Foundation Trust and give their views on how they think we should develop our services. Through our members, we can really get to know what the public wants and, more importantly, act on that as our services evolve.

Membership strategy

We are committed to building a membership that is representative of and reflects the local communities we serve in terms of disability, age, gender, socio-economics, sexuality, ethnic background and faith.

Public members

Membership of the Trust is open to anyone who resides in England although we would expect the majority of our members to reside in Bolton and the surrounding areas of Salford, Wigan, Bury and South Lancashire. There is a lower age limit of 16 but no upper age limit. There are no limits on the number of people who can register as members.

Public members are placed in constituencies based on where they live. There are 20 constituencies representing the electoral wards of Bolton and one to represent “out of area” members.

Staff members

We have elected to adopt an opt out arrangement in respect of staff membership. Under this arrangement, staff will automatically be registered as a member of the Trust unless they have completed the opt out form which was circulated with payslips prior to authorisation as a Foundation Trust. New members of eligible staff are provided with information and a form at induction.

Staff membership is open to everyone who is employed by the Trust full or part time on a contract with no fixed term or those staff on fixed term contracts of 12 months or more. Membership is also available to those bank staff who have an agreement to work for the Trust and have done for 12 months or more. Staff working for the Trust’s contractor for portering and domestic services are also eligible for staff membership if they meet the above criteria.

Staff membership ceases at the point that the member leaves the service of the Trust, but individuals can then choose to become a public member.

Benefits of membership

Although there are no financial benefits to FT membership, there are also no costs. There is, however, much satisfaction in being in a position which can help local people and local services. There are no benefits to members in terms of access to services.

We will use our members as a valuable resource calling on those who have expressed a willingness to participate in surveys and focus groups to gain a snapshot view of the user’s perspective.

Membership recruitment

We aim to continue recruiting new members and are using a variety of methods to ensure we reach as many people as possible. People wishing to join can do so by registering online at www.boltonft.nhs.uk or by calling 01204 390654. Alternatively application forms are available throughout the hospital.

http://www.boltonft.nhs.uk/


Contact procedures for members that wish to communicate with Governors and/or Directors

Members who wish to communicate with Governors may do so by email to [email protected] or by post c/o the Trust Secretary. To communicate with Directors contact [email protected]

Membership Statistics

Public Constituency 2013/14

At year start (1 April 2013) 4907

At year end (31 March 2014) 4783

Staff Constituency

At year start (1 April 2013) 5293

At year end (31 March 2014) 5159

Analysis of current public membership

Public Constituency Number of members Eligible membership

Age

0 - 16 217 3,646

17- 22 337 15,597

22+ 4121 252,135

unknown 108

Ethnicity

White 3,797 222,105

Mixed 81 4750

Asian or Asian British 592 38,309

Black or Black British 121 4457

Other 91 1757

not known 101 0

Socio-economic groupings

ABC1 687 38,240

C2 2,026 55,395

D 1103 31,522

E 967 74,159

Not known 0 72,062

Gender

Male 1,958 134,865

Female 2,806 136,513

Not known 19 0

mailto:[email protected]

mailto:[email protected]

Quality Report

Staff Survey

Results from the 2013 Staff Survey

The results from the 2013 staff survey show that the Trust has best/positive scores in 15 of the 28 Key Findings (KFs), average in 8 KFs and below average in 5 KFs.

Overall Response Rate

2012/13 2013/14 Trust Improvement or deterioration

Response Rate Trust National Average Trust

National Average

54% 49% 51% 49%

3% deterioration in response rate but remains above the national average

Top Four Ranking Questions

Top 4 Ranking Scores

2012/13 2013/14

Trust Improvement or deterioration Trust

National Average Trust

National Average

KF7 % of staff appraised in the last 12 months 91% 84% 94% 84% 3% improvement

KF26 % of staff having equality and diversity training in the last 12 months 59% 55% 78% 60% 19% improvement

KF2 % of staff agreeing that their role makes a difference to patients 92% 89% 93% 91% 1% improvement

KF10 % of staff receiving health and safety training in the last 12 months 78% 74% 83% 76% 5% improvement

Lowest Four Ranking Questions

Bottom 4 Ranking Scores

2012/13 2013/14

Trust Improvement or deterioration Trust

National Average Trust

National Average

KF11 % of staff suffering work related stress in last 12 months 39% 37% 42% 37% 3% deterioration

KF24 Staff recommendation of the trust as a place to work or receive treatment 3.50 3.57 3.45 3.68 0.05 deterioration

KF3 Work pressure felt by staff 3.09 3.08 3.16 3.06 0.07 deterioration

KF21 % of staff reporting good communication between senior management and staff 27% 27% 26% 29% 1% deterioration

Staff Survey

Key areas of improvement

During 2013, nursing staffing levels were uplifted in ward establishments across the trust. A significant recruitment exercise took place in late 2013 which has had a positive impact on staffing levels and staff’s experience of work pressure.

The Trust has continued to monitor staffing levels through acuity and dependency exercise to ensure staffing levels are appropriate in both acute and community settings.

The results on team working and staff feeling supported by their immediate manager were very good, however it was less strong between senior managers and staff and now the appointment of a substantive senior leadership team is in place, this will be priority for improvement.

Commentary

The rollout of the quarterly Staff Friends and Family test will be used to drive further increases in staff engagement.

The Trust regularly asks for feedback from staff as part of the quarterly staff engagement temperature check. The results identify where staff engagement is strong and areas where improvements can be made. Staff answer ten questions based on a sliding scale from 0 to 5. Two of the questions are presented below as an example

I am able to make suggestions to improve the work of my team / department

I receive recognition and appreciation from my line manager for the work that I do

Results are reported at Divisional Boards which encourage appropriate actions to be taken at local level. This mechanism will be strengthened further by the introduction of a Staff Friends and Family Test during 2014.

The results from the staff engagement temperature check show engagement scores are improving in some areas but other areas are being targeted to understand how we can enable staff experience to improve. The engagement scores (where 0 is the lowest and 5 the highest possible) from the most recent two temperature checks are shown below.

Division Quarter 3 2013/14

Quarter 4 2013/14

Acute Adult Care 3.68 3.75

Corporate 3.40 3.60

Elective Care 3.75 3.75

Family Division 3.92 3.78

Trust Average 3.73 3.74

Action Plan 2014

This action plan is currently being further developed by the Executives to ensure reward and recognition is built into the way we operate in Bolton. The trust will explore how we link the annual staff survey, quarterly staff temperature checks and friends and family tests to gain maximum learning and benefits from the results of all three to target continuous improvement across the organisation.

There are a number of further actions planned for 2014 shown in the following table.

Staff Survey

Action Timescale Lead

Implement quality improvement strategy May 2014 Medical Director

Introduction of a simplified appraisal procedure to enable staff to experience a better structured appraisal

May 2014 Director of Workforce

Increased walkarounds by the divisional management teams April 2014 Chief Operating Officer

Review of community staffing is currently underway May 2014 Director of Nursing

Enhanced management infrastructure in the community services

May 2014 Chief Operating Officer

Targeted ‘temperature check’ in corporate areas post re-structure

April 2014 Director of Workforce

CEO staff forums on Bolton FT The Future May 2014 Chief Executive

Staff awards ceremony October 2014

Director of Workforce/Trust Secretary

Regulatory Ratings

Regulatory Ratings

Change in regulatory regime 2013/14

In October 2013, Monitor replaced the Compliance Framework with a new Risk Assessment Framework.

The continuity of services risk rating - replaces the Financial Risk Rating (FRR)

The new continuity of services risk rating will not be calculated and used in the same way as the financial risk rating (FRR). Whereas the FRR was intended to identify breaches of trusts’ terms of authorisation on financial grounds, the continuity of services risk rating identifies the level of risk to the on-going availability of key services.

There are four rating categories ranging from 1, which represents the most serious risk, to 4, representing the least risk. A low rating reflects the degree of financial concern Monitor may have about a provider.

Governance rating

Monitor use a specified set of national metrics as proxies for overall standards of governance, including A&E waiting times, referral-to-treatment targets and rates of C. difficile infection. In addition, when the Care Quality Commission has serious concerns about a trust, Monitor will consider whether it is in breach of its licence and what action is needed

There are three categories to the new governance rating applicable to all NHS foundation trusts:

A green rating is assigned where there are no grounds for concern at a trust,

Where Monitor have identified a concern at a trust but not yet taken action, they will provide a written description stating the issue at hand and the action being considered

A red rating will be assigned when regulatory action has been taken.

The regulatory ratings are based on self-certification received from trusts in their annual plan, in-year quarterly submissions and any exception reports, including any reports from third parties such as the Care Quality Commission (CQC).

Monitor intervention

In April 2012, the trust was found to be in significant breach of two of the terms of its authorisation: its governance duty; and its healthcare targets and other standards duty.

The decision was triggered by the failure of the Trust to meet healthcare targets (specifically A&E waiting times and the Referral to Treatment (RTT) 18 week target) and failings in Board governance

In August 2012 Monitor exercised their formal powers of intervention after finding the Trust had failed to comply with its terms of authorisation.

The Trust remained in breach of the Terms of Authorisation for the remainder of 2012/13 and with the transfer to the new Provider Licence on 1st April 2013 the Trust became licenced with conditions which included discretionary requirements and enforcement undertakings

Table 8 - progress with Monitor requirements sets out the progress made to address these areas.

Regulatory Ratings

Requirement Due Comments

30/04/2013 Complete - RTT

performance achieved in all quarters of 2012/13

-

30/06/2013 Financial improvement plan in place - review of implementation provides assurance that xx of actions implemented at date

31/07/2013

31/05/2013

Table 8 - progress with Monitor requirements

The ratings for Bolton NHS Foundation Trust over the last two years are summarised in the tables below.

The ratings awarded at the start of the year are based on the expected performance at the time of the annual risk assessment in our annual plan. The quarterly ratings are based on actual performance reported to Monitor, via quarterly in-year submissions.

Annual Plan

2013/14 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 2013/14

Under the Compliance Framework

Financial risk rating

1 1 1

Governance risk rating

red red red

Regulatory Ratings

Table 9 Compliance Framework ratings 2013/14

Under the Risk assessment framework

Continuity of Service rating

1 1

Governance rating

red red

Table 10 - Risk Framework ratings 2013/14

The table above outlines the ratings received during 2013/14. The table below shows performance in 2012/13

Annual Plan

2012/13 Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2012/13

Financial risk rating

3 2 1 1 1

Governance risk rating

Amber red red red red red

Table 11 - Compliance Framework ratings 2012/13

Other disclosures in the public interest

Income disclosure required by section 43 (2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012)

The Trust meet the requirement for income from the provision of goods and services for the purposes of the Health Service in England to be greater than its income from the provision of goods and services for any other purposes.

The small amount of other income received by the Trust helps support the provision of NHS care. The Trust will continue to meet the requirement for its prime business to be the provision of goods and services for the purpose of the health service in England

Actions taken by Bolton NHS Foundation Trust to maintain or develop the provision of information to, and consultation with employees

Communication with our staff takes many forms, we have a weekly newsletter, a monthly face to face teambrief, alongside team meetings that cover a variety of practice based topics. If we are considering a change that will impact on an individual or a team then we would always discuss our proposals within a consultation framework with the staff affected. The Trust also has a monthly meeting with the staff side organisations where information is shared on the Trust’s quality, finances, performance and workforce matters. To compliment this the Chief Executive and Executive Directors undertake regular visits to different wards and departments across hospital and community teams to gain feedback from staff working at the front line.

Bolton NHS Foundation Trust policies in relation to disabled employees and equal opportunities

It is our policy to give full and fair consideration to applications for employment received from disabled persons, having regard to their particular aptitudes and abilities; and wherever possible to continue the employment of, and to arrange appropriate training for, employees who have become disabled persons during the period of their employment. Bolton NHS FT provides the same opportunities for training, career development and promotion for disabled people as for other employees.

Equality and Diversity

The following tables represent the diversity of the workforce of the Trust (31st March 2014)

Age

Ethnic Origin

16-20 24

White 4326

21-25 294

Mixed 38

26-30 471

Asian/Asian British 338

31-35 531

Black/Black British 54

36-40 603

Chinese 20

41-45 777

Any Other Ethnic group 34

46-50 880

Not Stated 287

51-55 734 56-60 518

Gender

61-65 205

Female 4344

66+ 60

Male 753 Table 12- Age, gender and ethnicity breakdown


Sexual Orientation Religious Belief

Bisexual 9 Atheism 235

Gay 11 Buddhism 10

Heterosexual 2722 Christianity 2320

Lesbian 16

Hinduism 75

Not Disclosed 2339

Not disclosed 2089

Islam 136

Judaism 10

Disability

Other 219

No 2833

Sikhism 3

Not Known 2109

Yes 155

Total (31st

March 2014) 5097 Table 13 - further equality and diversity information

Equality and Diversity Training Strategy

The Trust has an Equality and Diversity Strategy for staff training in conjunction with 5 Boroughs Partnership NHS Foundation Trust. There are four levels of training provided linked to the Knowledge and Skills Framework (KSF). The Trust now has commissioned an e-learning package to support the delivery of Equality and Diversity basic and intermediate modules. This is in addition to the bespoke training that will be delivered based on identified need.

In October 2010, the Equality Act came into effect, prior to this time there had been over 100 pieces of legislation covering equalities protection and alongside them there are three associated public duties for race, gender and disability. The Equality Act has nine protected characteristics defined as:

Age

Disability

Gender

Gender Reassignment

Marriage and Civil Partnership

Pregnancy and Maternity

Religion or belief - this includes lack of belief

Sexual Orientation

Ethnicity/Race.

As such when we are writing or making any changes to Policies, services or functions, we complete an EIA form this helps us to consider the impact any changes have on different groups and what can be done to reduce discrimination and increase equality.

Workplace Health and Wellbeing

The Workplace Health and Wellbeing department is dedicated to ensuring a provision for staff which is targeted, proactive and accredited. The approach is holistic and provides staff with a “wrap around” service which covers both physical and mental wellbeing. Supporting staff to be healthy in work benefits the patients they treat and the organisation as a whole.


Following is a selection of health and wellbeing initiatives and interventions which are provided for staff within the Trust:-

Staff health clinics

Mental wellbeing drop-in sessions

Counselling

Fast track physiotherapy

Flu vaccination

Stress risk assessments and follow up

Pre-employment checks

Workplace assessments

Healthy walks

Gym and Zumba

Healthy fruit and vegetable van

There are still areas for improvement and further work is on-going to review the correlation between our wellbeing interventions and staff attendance management.

Sickness Absence Data

We work hard to ensure our staff are healthy and enjoy work and to see a year-on-year improvement in attendance. We have a comprehensive attendance management policy and encourage staff to seek professional medical support through our extensive occupational health and well-being services if needed.

Compared with 2012/13, in 2013/14 there has been a slight decrease in attendance levels. There is an improvement programme to support the organisation achieve reduction in sickness absence rates.

Sickness Absence Data

Sickness Absence 2012/13 Sickness Absence 2013/14

Apr-12 4.67% Apr-13 4.56%

May-12 4.69% May-13 4.50%

Jun-12 4.52% Jun-13 4.55%

Quarter 1 4.63% Quarter 1 4.54%

Jul-12 4.97% Jul-13 5.00%

Aug-12 4.29% Aug-13 4.86%

Sep-12 4.29% Sep-13 4.97%



Oct-12 4.73% Oct-13 4.88%

Nov-12 4.67% Nov-13 5.13%

Dec-12 4.83% Dec-13 5.53%


Jan-13 5.00% Jan-14 5.68%

Feb-13 4.73% Feb-14 5.52%

Mar-13 4.83% Mar-14

Quarter 4 4.86% Quarter 4

Table 14 - sickness absence data 2012 - 14

Health and Safety Performance

There have been no prosecutions or enforcement notices issued to the Trust by the Health and Safety

Executive (HSE) during the reporting period. Similarly, the Trust has maintained its excellent

accident/incident record very low numbers of staff accidents requiring over 7 days absence from work.

Information on policies and procedures with respect to countering fraud and corruption

The Trust has a Counter Fraud and Corruption Policy in place. A counter fraud work plan is agreed

with the Director of Finance and approved by the Audit Committee. The local counter fraud specialist

is a regular attendee at Audit Committee meetings to provide an update on the on-going programme

of pro-active work to prevent any potential fraud and investigatory work into reported and suspected

incidents of fraud.

Better payment practice code

The Trust is expected to pay 95% of all creditor invoices within 30 days of goods being received or a

valid invoice (whichever is the later) unless other payment terms have been agreed with the supplier.

The table below shows performance against this target in 2012/13 and 2013/14.

Year ended 31 March 2014 Year ended 31 March 2013 Number £'000 Number £'000 Total non-NHS trade invoices paid within the target 46,500 49,159 50,290 53,099 Total non-NHS trade invoices paid in the period 66,349 69,963 60,225 67,177 Percentage of non-NHS trade invoices paid within the target 70.1% 70.3% 83.5% 79% Total NHS trade invoices paid within the target 1,671 16,923 1,756 18,177 Total NHS trade invoices paid in the period 2,259 22,223 2,139 23,617 Percentage of NHS trade invoices paid within the target 74.0% 76.2% 82.1% 77%

Table 15 - better payment practice performance


Consultations

There have been no formal stakeholder consultations during the reporting period. As discussed elsewhere in this report changes to the provision of services are anticipated across Greater Manchester as part of Healthier Together. These changes will be commissioner led, the Trust will participate in and support these consultations as appropriate.

Disclosures in relation to “other income”

The “other income” figure in the accounts is not considered significant.

Cost allocation and charging requirements

The Trust remains compliant with cost allocation and charging requirements laid down by HM Treasury and the Office of Public Sector Information.

Details of Serious Untoward Incidents (SUIs) involving data loss or confidentiality breach

The Trust had one Serious Untoward Incident (SUI) involving data loss – the details of this are declared in our Annual Governance Statement on page 107.

Statement of Accounting Officer’s Responsibilities

Statement of the Chief Executive's responsibilities as the accounting officer of Bolton NHS Foundation Trust

The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by the Monitor.

Under the NHS Act 2006, Monitor has directed Bolton NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Bolton NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year.

In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to:

observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis;

make judgements and estimates on a reasonable basis;

state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements;

ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance; and

prepare the financial statements on a going concern basis.

The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS foundation trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum.

Signed

Jackie Bene

Chief Executive

Date…31st May 2014

Annual Governance Statement

Independent Auditor Report

Annual Accounts

Agenda Item No : 13.



Title Draft Annual Governance Statement

Executive Summary

The Board is asked to formally review and comment on the

draft Annual Governance Statement AGS.

As laid down by Monitor in the NHS Foundation Trust Annual

Reporting Manual 2013/14 – the Annual Report and Accounts

of an NHS Foundation Trust will include an Annual

Governance Statement which details the risk management,

control and review processes in place for the financial year.

Trusts are expected to use a pro-forma AGS and all systems

of internal control should be considered, not just financial

systems

Any comments received following the Board meeting on April

24th 2014 and the Audit Committee on April 28

th 2014 will be

considered for inclusion in the final statement for approval


Further discussion at audit committee, and any

revisions/additions prior to approval at the May Board meeting

Discuss Receive

Approve Note






Workforce Risk



ANNUAL GOVERNANCE STATEMENT 2013/14

Annual Governance Statement 2013/14 Page 1 of 12

Scope of responsibility

As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum.

The purpose of the system of internal control

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an on-going process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of [insert name of provider] NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Bolton NHS Foundation Trust for the year ended 31 March 2013 and up to the date of approval of the annual report and accounts.

Capacity to handle risk

Leadership

As Accounting Officer I have overall accountability for internal control. To support this role there are clear systems of accountability within the organisation with each Executive Director having specific areas of responsibility

The Risk Management Strategy sets out details of the risk management structure and key risk manager roles. The role of the Board and Standing Committees is detailed, together with the individual responsibilities of the Chief Executive, Executive Directors and all staff in managing risk. In particular, the Risk Management Committee, the Quality Assurance Committee, the Informatics Committee, the Finance and Investment Committee and the Divisional Governance Boards provide the mechanisms for managing and monitoring clinical, operational, financial and information governance risks throughout the Trust. The Audit Committee oversees the systems of internal control and overall assurance process associated with managing risk.

The Board of Directors routinely receives reports from its Standing Committees and also receives reports on all serious untoward incidents. The Quality Assurance Committee receives detailed reports on the management of actions agreed following investigations into serious untoward incidents (SUIs).

The executive team is supported by a divisional management structure consisting of three clinical divisions and an Estates and Facilities Division. Each division has a clinical Head of Division and a Divisional Director of Operations who are jointly responsible for the delivery of key objectives in their areas. Each division is supported by a professional lead with specific responsibility for delivering on patient safety, quality and the governance agenda. Each of the Clinical Divisions provides a detailed quarterly report to the Quality Assurance Committee

In 2013 the Trust implemented a new integrated performance report; this report provides comprehensive information to the Board and its sub-committees and to the divisions. The report includes a ward to board heat map to provide ward level information which the Quality Assurance Committee monitor on behalf of the Board

Training

To ensure the successful achievement of the Risk Management Strategy and implementation of the Risk Management Policy, staff at all levels are provided with appropriate training in carrying out risk assessments and the reporting of incidents. The on-going programme of training within the Trust includes: managing safely, risk register training, fire safety training, manual handling, safeguarding training, major incident training and conflict resolution training.

Medicine management training is delivered at doctors’ induction programmes and during educational and developmental sessions. Support and advice on medicine management is also provided at ward and departmental level by the Chief Pharmacist and link pharmacists.

Risks and safety in respect of clinical equipment and devices are discussed and disseminated by the Medical Devices and Equipment Management Committee. All divisions are represented on this committee which also has a training sub group and each ward has a link nurse.

General awareness raising on risk management issues is achieved through staff briefings, team brief, safety bulletins, induction and the intranet.

The Executive Team and the Board of Directors monitors management capability, (leadership, knowledgeable and skilled staff, adequate financial and physical resources), to ensure the processes and internal controls work effectively.

The risk and control framework

Risk management in the trust

Risk management is recognised as a fundamental part of the Trust’s culture, and an integral part of good practice. It is integrated into the Trust’s philosophy, practices and business plans. Risk management is the business of everyone in the organisation.

The Trust Risk Assessment process, investigating incidents, complaints and claims procedures are the principal sources of risk identification. The Risk Assessment process identifies the criteria for risk scoring both likelihood and consequence on a scale of 1 to 5, with the highest risk being accorded a score of 25 (5x5). The risk assessment process also requires an appropriate risk management plan.

The Risk Assessment process clearly states the escalation of management seniority to monitor management and mitigation of the risk according to its overall likelihood and consequence. The Risk Assessment process is applied to all types of risk, clinical, financial, operational, capital, and strategic.

The Trust Risk Register procedure requires Divisions to maintain and monitor their own Risk Registers. All risks with a score rating of 15 or above are reviewed by the Risk Management Committee with a view to being placed on the Corporate, Risk Register.

All “business cases” have to be supported with a risk assessment. The scored risk rating strongly influences priorities within the Trust Capital Programme.

The Board Assurance Framework helps provide assurance to internal and external stakeholders in relation to meeting the Trust objectives. Assurance of the system is also supported by

independent assurance processes – internal and external, and achievement of satisfactory outcomes or results.

The Assurance Framework identifies Bolton NHS Foundation Trust’s principal objectives and their associated principal risks and is developed in consultation with the Executive Team. The control systems which are used to manage these risks are identified together with the evidence for assurance that these are effective. Lead managers and Directors are identified to deal with gaps in control and assurance and are responsible for developing action plans to address the gaps.

The Board ensures effective communication and consultation at all levels within the organisation and with external stakeholders. Engagement with stakeholders at various forums such as the Council of Governor’s Meetings and Healthwatch meetings provides an opportunity for risk related issues to be raised and discussed.

A Board approved assurance framework (BAF) was in place for the period 1st April 2013 – 31st March 2014. The format and use of the BAF was reviewed by the Risk Management Committee between September and November 2013. The BAF is now on a shared drive and is updated on a regular basis by the lead director for each risk.

The Board receive a monthly update on the BAF within the Chief Executive’s report. This update highlights any changes to risks and also at the request of the Board in January 2014 includes the rationale for the risk score when a risk has remained static for three successive months.

Key Organisational Risk in 2013/14 and 2013/15

The organisation’s key risks are recorded in the Assurance Framework and Trust Risk Register. Forward risks and mitigation plans are also considered in the Trust’s Annual Plan submission.

Failure to sustain A&E targets

Failure to sustain 18 weeks

Infection Control

Management of the physiologically deteriorating patient

The achievement of financial targets

Addressing governance and financial issues

Failure to reduce sickness absence

Estate risks.

The risks posed by wider health economy changes through Healthier Together and integration

The Risk Management Committee met on April 2nd 2014 to review these risks and agreed that these should remain on the BAF for 2014/15

Risk Appetite

The Trust is committed to not taking risks that affect the quality of care and the experience of every person accessing our services. We recognise the need for a clearly defined risk appetite and will be using the GGI risk appetite matrix to develop our risk appetite statement in the first quarter of 2014/15.

Quality Governance Arrangements

The Quality Governance Framework has been developed by Monitor as an assessment tool for Trusts to use to benchmark their arrangements for effective quality governance in four categories:

Strategy

Capabilities and culture

Process and structure

Measurement

Strategy - Quality is embedded in the Trust’s overall strategy, the safety and effectiveness of care and the experience of patients are at the heart of all that we do. In 2013, the Trust approved and adopted a new Quality Strategy and strategies to reduce the rate of falls and pressure ulcers

Capabilities and Culture - The Board is assured that quality governance is subject to rigorous challenge with full NED engagement in the Audit Committee and NED involvement in the assurance providing committees.

Process and Structure - The Corporate Governance Structure was reviewed in 2013 to ensure clarity or reporting between wards and departments and the Board and between the Board and its supporting committees. A new Risk Management Committee was formed in September 2013 and the remit of the Clinical Governance Committee and the Quality Assurance Committee was clarified. Performance Assurance Framework (PAF) meetings which had been established in early 2013 were formalised through the programme management office to ensure clear routes of escalation to the Executive team.

The Trust has clear process in place for:

Clinical incident and accident policy

Whistle blowing

Complaints

Management of SUIs

Action plans are put in place to address issues arising from these processes.

Measurement - A new integrated performance report was developed during 2013/14. This report provides a clear dashboard and high level apex report for the Board of Directors and Council of Governors with full reports reviewed in the Board sub committees.

Deloitte LLP undertook a review of data quality in 2013; the recommendations were addressed in the development of the new report and will be reviewed by internal audit in the 2013/14 work programme.

Review of Quality Governance

In March 2013 the Trust commissioned Deloitte LLP to undertake a review of quality governance in the Trust. This report showed that although the Trust had some area of good practice there were weaknesses which needed to be addressed.

An action plan was produced to implement the recommendations focusing on:

Development of an Assurance and Escalation Framework

Development of an overarching Quality Strategy

Board and Governor Development / Board Effectiveness

Communication and Engagement

Development of the new integrated performance report

Review of the complaints strategy

Board Assurance Framework and risk management escalation and reporting of risks.

The Trust’s Internal Auditor PwC have recently undertaken a review of the implementation of these actions and have concluded that over 70% of the actions that remain relevant have been fully implemented with the remaining actions all evidenced as having been initiated but not yet fully implemented. Work to embed these remaining actions will be a priority in the first quarter of 2014/15.

Risks to data security

In June 2013, the Trust reviewed its Information Risk Management Policy. The policy sets out key principles, the legislative and good practice framework, revised information governance structures, and roles and responsibilities, including the concept of Information Asset Owners.

The Trust has encrypted all laptops and desktop PCs. Centralised storage has been rolled out across the Trust to ensure that all critical and sensitive data is held securely, not on local equipment. All portable devices such as memory sticks that are plugged into PCs and laptops have enforced encryption.

Email encryption software has been procured which allows the encryption of emails containing sensitive information. An updated Email and Internet Access Policy has been approved to reflect the capabilities that new security applications now give the Trust. Staff have been reminded that email must not be used to send personally identifiable data, unless it is encrypted or NHSmail is used and messages remain within the NHS.

The Trust recognises the information governance risks relating to the use of tablet devices and “cloud sharing” and has purchased the software to support and protect information processed on these devices.

Compliance with NHS foundation trust condition 4

In 2012 Monitor found the trust to be in breach of the terms of authorisation; in 2013 with the introduction of the Provider Licence Monitor found the Trust to be in breach with the following provisions of condition FT4 - FT4(2); FT4 (4)(a, b & c); FT4(5)(a - f); FT4(6)(a - 4); FT4(7)

Since being found in breach the Trust has commissioned and responded to a number of external reviews with follow up audits to provide assurance that the recommendations have been actioned.

Actions taken include:

A review of the systems and processes for good corporate governance including a detailed review of compliance with the revised Code of Governance

A review of Board and committee structures to ensure clear responsibilities for committees reporting to the Board and for staff reporting to the Board and its committees with clear accountability for escalating and resolving quality issues including escalating them to the Board where appropriate

A review of reporting lines to ensure clear lines of accountability and a “gold thread” from ward to board

The implementation of a new integrated performance report to enable timely and effective scrutiny and oversight by the Board with actions to ensure compliance with health care standards

in 2013/14 the Trust achieved the A & E four hour target and the 18 week RTT target - breach of these targets triggered the initial breach of authorisation

A robust financial improvement programme for effective financial decision making, management and control.

An improved Board Assurance Framework to identify and manage material risks to the overall strategy of the Trust

A review of board membership and a Board development programme to provide effective organisational leadership

The capabilities of the Trust to respond to risks and improve performance have been addressed through new permanent appointments at and below Board level

Stakeholder engagement has been enhanced; views are actively sought particularly with regard to the development of the new Quality Strategy and other supporting strategies.

Assurance of the validity of the Corporate Governance Statement

As discussed elsewhere in this statement we have been working with our internal auditors to assess the extent to which the recommendations in external governance reports have been implemented. At the time of reporting we are assured that over 70% of recommendations are fully implemented. In June 2014 the Board will be asked to consider the Corporate Governance Statement, to assure validity of this statement a schedule of evidence of compliance with each element of the statement will be prepared for review by the Board prior to final sign off.

Care Quality Commission Registration

The foundation trust is fully compliant with the registration requirements of the Care Quality Commission. A CQC inspection carried out in April 2013 identified that actions were needed for full compliance with the standards for cleanliness and infection control, staffing and assessing and monitoring the quality of service provision. An action plan to address these concerns was implemented and overseen by the Quality Assurance Committee - a follow up unannounced inspection in September 2014 found the Trust compliant with all standards. The Risk and Assurance team provide assurance to the Executives and the Quality Assurance Committee on compliance with CQC registration.

Other Risk Areas

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that

member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.

Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.

The foundation trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with.

Review of economy, efficiency and effectiveness of the use of resources

The Trust regularly reviews the economic, efficient and effective use of resources with robust arrangements in place for setting objectives and targets on a strategic and annual basis. These arrangements include:

Ensuring the financial strategy is affordable

Scrutiny of cost savings plans

Co-ordination of individual and departmental objectives with corporate objectives using lean methodology.

Performance against objectives is monitored and actions identified through a number of channels:

Approval of the annual budgets by the Board of Directors

At Executive Director meetings

Bi-monthly reporting to the council of Governors

Monthly reporting to the Board of Directors and the Executive Board on key performance indicators

Monthly review of financial targets by the Finance and Investment Committee

Quarterly reporting to Monitor.

Assurance is provided:

Internal audit - PwC were appointed as the internal auditor in June 2013. At the time of appointment a three year audit plan was agreed. This plan has been formulated based on PwC’s risk assessment of the inherent risk and the control environment. The Head of Internal Audit meets regularly with the Director of Finance and the Chair of the Audit Committee to review progress against the plan and to ensure the plan remains tailored to the needs of the Trust.

In 2013/14 the Trust worked alongside Deloitte LLP to undertake a wide range of financial, productivity and efficiency benchmarking.

The Trust also participates in initiatives to ensure value for money for example:

Procurement of goods and services is undertaken thorough professional procurement staff and through working with neighbouring organisations within a procurement hub.

In year cost pressures are rigorously reviewed and challenged, and alternatives for avoiding cost pressures are always considered.

Annual Quality Report

The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual.

In producing the Quality Account 2013, the Trust identified key areas for improvement of patient safety, clinical effectiveness and experience. To ensure a balanced view, the Board worked with Governors and other internal and external stakeholders to select the priorities on which the Trust would be reporting in 2014/15.

Quarterly forums have been held to share performance on the achievement of priorities with Bolton Healthwatch

We have used existing performance management arrangements to track progress throughout the year on the targets selected and have reported at year end on these to the Board. An external audit report on our 2012/13 Quality Account and a review of data accuracy conducted by Deloitte LLP in March 2013 provided assurance that the Trust has arrangements to ensure the accuracy of data.

In developing the report, consideration has been given to the comments made by internal and external stakeholders including our partner organisations and the External Auditors on previous reports.

Review of effectiveness

As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, and the executive managers within the NHS foundation trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised of the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit Committee and the Quality Assurance Committee, and a plan to address weaknesses and ensure continuous improvement of the system is in place.

In the latter part of 2012/13 and the first half of 13/14 the Trust received reports from external consultants which identify weaknesses in the system of internal control; in addition to this the internal auditor has provided limited assurance with regard to both the controls and the operation of the system of internal control. Although significant progress has been made to implement the recommendations in these reports I am unable to provide assurance that the system of internal control has been fully effective throughout the Trust.

Maintaining and reviewing the system of internal control

The Board

The Chief Executive and Board of Directors have overall responsibility for the Trust’s Risk Management programme.

The Audit Committee

This Committee acts independently from the Executive, to provide assurance to the Board, based on a challenge of evidence and assurance obtained, that the interests of the Trust are properly protected in relation to financial reporting and internal control. It keeps under review the effectiveness of the system of internal control; that is the systems established to identify, assess, manage and monitor risks both financial and otherwise, and to ensure the Trust complies with all aspects of the law, relevant regulation and good practice.

This Committee reports to the Board any matters in respect of which the Committee considers that action or improvement is needed, and makes recommendations as to the steps to be taken.

The Risk Management Committee

This Committee provides the Board with an objective review of, in relation to: -

Risk governance, the risk management frameworks and the promotion of behaviours and cultures that drive approaches to risk management.

the systems of internal control in relation to governance and risk management, in that these are fit for purpose, adequately resourced and underpin the Trusts performance and reputation

the overall risk governance process in that it gives clear, explicit and dedicated focus to current and forward-looking aspects of risk exposure

The Quality Assurance Committee

This Committee provides the Board with an independent and objective review in relation to:

all aspects of quality, specifically: clinical effectiveness, patient experience and patient safety; monitoring compliance against the essential standards of quality and safety set out in the registration requirements of the Care Quality Commission

governance processes for driving and monitoring the delivery of high quality, clinically safe, patient-centred care

performance against internal and external quality and clinical improvement targets, and directing management on actions to be taken on sub-standard performance

the overarching Quality Strategy

assurance on safeguarding quality and to provide appropriate scrutiny to clinical effectiveness, patient safety and patient experience

The Finance and Investment Committee

This Committee provides the Board with an objective review of, and assurances, in relation to: -

finance, contracting and commissioning issues; presenting reports and recommendations in relation to ensuring we maintain cash liquidity and are an effective going concern

financial governance processes

business cases referred to it by the Capital and Revenue Investment Group requiring major capital investment

compliance with legislative, mandatory and regulatory requirements in terms of the Committee’s scope

The Executive Team has responsibility for the development and maintenance of the system of internal control and the outputs from its work provide me with assurance.

The Board Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed.

The following internal audits have been received during the year:

Monitor Action Plans: PwC ‘External Review of Financial Governance’ follow up review;

Quarter 3 Internal Audit Follow Up Report.

Key Financial Controls – Medium Risk;

Financial Management and Reporting – High Risk;

Cost Improvement Plans – Medium Risk;

Estates – High Risk;

My review is also informed by external assessments and achievements during the year as follows:-

Date Review Author Assurance

April

2013

C difficile Kiernan Identified areas for improvement around environment,

policies and reporting, antibiotic stewardship and

communication

May

2013

Financial Governance Review Grant

Thornton

June

2013

Quality Governance Framework

Review incorporating stakeholder

review and review of never events

Deloitte Score of 5 on Deloitte Quality Governance Framework -

action plan agreed

June

2013

Data Quality Review Deloitte Some elements of good practice identified but also gaps for

action to improve data quality

June

2013

Sepsis review - independent review

of sepsis reporting

Deloitte Supportive of Trust processes, raised issues for national

follow up

July

2013

Finance Capability and Capacity

review

Deloitte One of the key recommendations from that review were that

the Trust consider the finance structure within management

accounts with a particular focus on ensuring the right level of

senior capacity and capability

Sept

2013

Sepsis external review Doran Follow up from Dr Foster report - identified national rather

than local issues

Nov

2013

A and E intensive support team ECIST Sign off from ECIST that actions have been completed

The following Significant Control Issues have been identified during the year

Data Loss

The Trust had one information governance incident in 2013/14 when a batch of labelled samples were declared as missing during the process of transportation from GP premises to the Trust’s laboratories. A SUI investigation was implemented which concluded that the incident had occurred as a result of human error and the lack of robust systems being in place in relation to the safe transportation, receipt and reconciliation of samples.

Governance

In June 2013 Deloitte LLP undertook a review of compliance with the Monitor Quality Governance Framework as referred to earlier in this statement actions were identified and the Trust are now assured that significant progress has been made to address these recommendations. Further reviews were also commissioned to provide assurance with regard to data quality and the management of sepsis.

Financial Governance

The PwC report in 2012 and the Grant Thornton review of Financial Governance in 2013 identified weaknesses in financial governance. During 2013/14 the Finance team continued to implement the actions agreed on the Finance Improvement plan. A follow up review undertaken by PwC as the Trust’s internal auditor gave assurance that 83% of actions had been fully implemented and significant progress made with regard to all other recommendations. Progress to embed the remaining actions is monitored by the Audit Committee

Clostridium Difficile

During 2013/14 although the Trust achieved a significant reduction in the number of cases Clostridium Difficile the actual number of cases was in excess of the agreed threshold. However a review of the number of cases during the year shows the rate of infection reduced considerably during the course of the year. I am assured that this is as a result of the implementation of the actions taken and am confident that the threshold set for 2014/15 will not be exceeded.

Internal Audit Reports providing limited or no assurance:

Assurances are provided to the Board by the Trust’s internal and external auditors; in 2013/14 the Trust conducted a tender exercise for the provision of both internal and external audit services appointing PwC as internal auditor from June 2013 and supporting the Governors in their appointment of KPMG as external auditor from September 2013.

The Head of Internal Audit opinion is that….

The External Auditor has…

Conclusion

The Trust has made significant progress in addressing the failures in internal control identified since 2012. We are committed to continuing to improve on this position and to fully implement all recommendations in order to continue to provide sustainable quality care for our local population.

Signed………………..

Chief Executive Date:

Agenda Item No: 15



Title Q4 compliance framework declaration

Executive Summary

As a Foundation Trust regular declarations are required with

regard to compliance with targets and financial performance.

These declarations are made on a template provided by Monitor

which includes worksheets for financial performance,

governance declarations and performance against targets.

The governance and target templates will be uploaded with the

monthly financial templates by 4.00 pm on April 30th 2014

The Trust will remain red rated until Monitor are satisfied that

actions taken have led to a sustained improvement and

compliance with the Provider Licence


The Board are asked to approve the Q3 submission to Monitor In

view of the timing of the Board meeting and the submission the

Board are asked to delegate the authority to review the final

submission to the Executive team at their meeting on 30th

Discuss Receive

Approve Note






Workforce Risk



Compliance Declaration Q4 2013/14

1. PURPOSE

The purpose of this paper is to inform the Board’s consideration of the quarter four

submission to Monitor.

2. BACKGROUND

As a Foundation Trust regular declarations are required with regard to compliance with

targets and financial performance.

These declarations are made on a template provided by Monitor which includes

worksheets for financial performance, governance declarations and performance

against targets.

3. CURRENT POSITION

An update on the current position with regard to operational performance, quality and

finance is included on the Board agenda.

4. RECOMMENDATIONS

Board members are asked to agree that the following statements are signed for

submission to Monitor for the Q4 return.

The Continuity of Service risk rating replaces the FRR – this remains at 1 – response

must therefore be “not confirmed”

Board members are asked to consider this statement in light of the performance report

and revised threshold for CDT in 2014/15 to agree the response - confirmed or not

confirmed

During quarter 4 exception reports on SUIs were provided to Monitor in line with the

requirements of the Risk Assessment Framework.

Diagram 6 from the RAF is included for information.

A new template was added at Q3 for executive turnover as an indicator of Board

governance.

This declaration relates to the quarter ending 31 March 2014 and has been completed

on the basis of the information below

Position Q4 position Substantive/acting

Chief Executive Jackie Bene substantive

Director of Finance Simon Worthington substantive

Medical Director Steve Hodgson substantive

Chief Operating Officer Andy Ennis substantive

Director of Nursing Trish Armstrong Child substantive

The three appointments in the quarter were:

Andy Ennis as COO - started in post 02/01/14

Jackie Bene as CEO - formally approved by Governors on 21/01/14

Steve Hodgson as Medical Director - substantively appointed 20/03/14

The return requires the number of voting executives, the position of Director of

Workforce and OD which is currently filled by Suzanne Woolridge in an acting role is a

non-voting position and is therefore not included in the figures

Agenda Item No : 16



Title Finance & Activity Report Month 12

Executive Summary

• Why is this paper going to the Board

• To summarise the main points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

Please find attached the monthly Financial Board Reporting pack The key points to note are:-

• The Trust is on plan for the year with a normalised deficit of £(7.8)m as was forecast. The Trust has impairments due to revaluation of £0.35m which increases the reported deficit to £(8.1)m

• The Trust has reported a deficit financial position for month 12 of £(2.2)m against a planned breakeven position. After taking the £2.1m restructuring provision and £0.3m impairments into account the underlying position in month is a small surplus of £0.2m

• The full year actual for income and cost improvements is £18.3m v £16.2m plan

• The year-end position includes the full drawn down of £17.25m from the Department of Health


Discuss Receive

Approve Note





Quality Regulatory




Prepared by Andrea Bennett Deputy Director of Finance Presented by Simon Worthington

Director of Finance

Finance Report for the year to the end of March 2014 (Month 12)

1. Introduction

1.1 This report is intended to update the Board and provide more information on the financial position of the Trust as at month 12. The final accounts for the financial year 2013/14 will be subject to External Audit review.

1.2 The Trust delivered a deficit of £(7.8)m before impairments in line with plan. The reported deficit after impairments is £(8.1)m.

2. Month 12 Financial position

2.1 A summary of the financial position is set out in the table below:

Plan Actual

Normalised deficit £(7.8)m £(7.8)m

Reported deficit (after impairments)

£(8.1)m

ICIPs £16.2m £18.3m

PDC Drawdown £17.25m £17.25m

Cash £0.3m £0.4m

Capital Spend £5.9m £6.2m

Continuity of services rating

1 1

2.2 The Trust is on plan for the year with a normalised deficit of £(7.8)m as was forecast. The Trust has impairments due to revaluation of £0.35m which increases the reported deficit to £(8.1)m.

The Trust has made provision for £2.1m for restructuring. The underlying Trust deficit is £(5.7)m before restructuring and impairments

This is summarised in the table below:

Mar Mar Mar YTD

Mar YTD

Plan Actual Plan Actual £m £m £m £m

Underlying Surplus/(deficit) 0.0 0.2 ‐7.8 ‐5.7

Restructuring Provision ‐2.1 ‐2.1

Normalised Surplus/(deficit) 0.0 ‐1.9 ‐7.8 ‐7.8

Impairment 0.0 ‐0.3 0.0 ‐0.3

Reported Surplus/(Deficit) 0.0 ‐2.2 ‐7.8 ‐8.1

2.3 The Trust has reported a deficit financial position for month 12 of £(2.2)m against a planned breakeven position. After taking the £2.1m restructuring provision and £0.3m impairments into account the underlying position in month is a small surplus of £0.2m

2.4 The Trust has seen an increase in the underlying pay and non pay spend in month 12. This has been predominately in the Elective Care Division. The Division are now required to submit a formal report to the Executive to explain the unexpected increase in expenditure.

2.5 The full year actual for income and cost improvements is £18.3m v £16.2m plan. This is due to additional non recurrent ICIP delivery in the divisions as part of their financial recovery plans.

2.6 Cash has been managed effectively with a £0.4m cash balance at the end of March. The year-end position includes the full drawn down of £17.25m from the Department of Health

2.7 The Trust capital plan as submitted to Monitor is £5.9m. As at the end of March capital expenditure was £6.2m (£0.3m overspent). As highlighted previously to the Board the Trust planned an over commitment on its capital programme in order to ensure cash targets were met. A number of high risk items were brought forward from 2014/15 and there was additional expenditure due to the impact of the recent weather damage. Appendix 1 shows the changes to the capital programme

2.8 The Continuity of services rating for the Trust was 1 in line with plan

.

3. Recommendation

3.1 It is recommended that the Board notes the content of the report.

Appendix 1 Since the last update to the Board in March the changes in the capital program are summarised in the table below.

£'000ReplacementsArjo Scale Hoist 6.0 Sonicaid & Encore System 12.9 Defibrillators 14.7 Bladder Scanner 7.4 Stroke Data Capture System 18.0 Net Underspend 40.8‐

MaintenanceChillers c/f to 2014/15 99.9‐ Net Underspend 28.0‐

EnhancementsNet Underspend 100.8‐

Forecast slippage/other, did not occur 526.2

Total variance 315.7

1. Executive Dashboard

1

(10.0)(9.0)(8.0)(7.0)(6.0)(5.0)(4.0)(3.0)(2.0)(1.0)

-

Apr il May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Surplus / (deficit) £m

Cumulative P lan Cumulative Actual / Forecast

0.0

5.0

10.0

15.0

20.0

02-M

ar

09-M

ar

16-M

ar

23-M

ar

30-M

ar

06-A

pr

Cash Actual at year end(£m)

Cash actual

0.0

1.0

2.0

3.0

4.0

5.0

6.0

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Forecast month end cash balance (£m)

Forecast Actual

(25.0)

(20.0)

(15.0)

(10.0)

(5.0)

0.0


Net Current assets / (liabilities) (£m)

Actual Plan

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0


Cumulative capital expenditure (£m)

Actual spend Annual Budget

(0.5)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5


In-month ICIP delivery(£m)

Plan Actual

1. Executive Commentary

2

Income and Expenditure• The Trust is on plan for the year with a normalised deficit of £(7.8)m as was forecast. The Trust has impairments

due to revaluation of £0.35m which increases the reported deficit to £(8.1)m. The Trust has made provision for £2.1m for restructuring. The underlying Trust deficit is £(5.7)m before restructuring and impairments


• Income is £0.6m behind budget this month but overall is £0.3m ahead of plan for the year..• Pay costs have increased this month decreased by £0.6m. This includes an increase of £430k on agency spend

(mainly in Adult Acute and Elective Care Divisions).• Non-pay spend includes £2.1m of restructuring costs

ActualM1£m

M2£m

M3£m

M4£m

M5£m

M6£m

M7£m

M8£m

M9£m

M10£m

M11£m

M12£m

YTD£m

Income 23.1 22.8 23.0 23.5 22.8 22.5 24.8 23.7 23.9 25.3 23.1 25.1 283.4Pay ‐16.9 ‐16.7 ‐16.6 ‐16.6 ‐16.6 ‐16.6 ‐16.8 ‐16.9 ‐16.5 ‐17.0 ‐16.4 ‐17.0 ‐200.6Non‐pay ‐7.4 ‐7.3 ‐7.1 ‐7.2 ‐7.6 ‐6.6 ‐8.0 ‐7.1 ‐7.6 ‐7.3 ‐7.7 ‐10.3 ‐91.1Deficit ‐1.2 ‐1.2 ‐0.7 ‐0.3 ‐1.4 ‐0.7 0.0 ‐0.3 ‐0.2 1.0 ‐1.0 ‐2.2 ‐8.1Budget ‐1.8 ‐1.4 ‐1.9 0.0 ‐0.4 ‐0.6 0.2 ‐0.5 ‐0.5 0.2 ‐1.0 0.1 ‐7.8Variance 0.6 0.2 1.2 ‐0.3 ‐1.0 ‐0.1 ‐0.2 0.2 0.3 0.9 0.1 ‐2.3 ‐0.3

1. Executive Commentary

3

Cash and Capital

• Cash has been managed effectively with a £0.0m cash outflow and a £0.4m cash balance at the end of the year.

• PDC funding of £7.5m was acquired in Mar ‘14.

• The year end position included support of £17.25m from the DoH in the year.

• The Trust cash position at the end of March came in on plan.

• The capital budget for the year was £5.9m profiled equally by month. The year end position was £6.2m resulting in an over spend of £0.3m against plan.

2.1 Income & Expenditure

4

2.1.1 Summary I&E


• Income shows an adverse variance of £0.6m in month

• There is a favourable variance on pay in month of £0.4m

• Non-pay is over spent this month by £1.8m due to the restructuring provision otherwise it would be £0.3m under spent as in previous months.

2.1.1 I&E

Income and Expenditure M12Annual Budget Budget Actual Var.

Prior Year Budget Actual Var.

£m £m £m £m £m £m £m £mPatient income 255.1 23.0 22.5 (0.6) 254.1 255.1 255.3 0.3Other Income 28.1 2.7 2.6 (0.1) 29.1 28.1 28.1 (0.0)Total Income 283.2 25.7 25.1 (0.6) 283.2 283.2 283.4 0.3Pay (200.0) (17.4) (17.0) 0.4 (216.9) (200.0) (200.6) (0.5)Non-Pay (80.1) (7.4) (9.2) (1.8) (79.4) (80.1) (79.9) 0.1Total Expenses (280.1) (24.8) (26.2) (1.4) (296.3) (280.1) (280.5) (0.4)EBITDA 3.1 0.9 (1.2) (2.1) (13.1) 3.1 2.9 (0.2)Depreciation, interest & dividends (9.6) (0.8) (1.0) (0.2) (14.1) (9.6) (9.4) 0.2Normalised Surplus/ (Deficit) (6.5) 0.1 (2.1) (2.2) (27.2) (6.5) (6.5) 0.0Non-recurrent & exceptional (1.3) (0.1) (0.1) (0.0) - (1.3) (1.6) (0.3)Deficit (7.8) (0.0) (2.2) (2.2) (27.2) (7.8) (8.1) (0.3)

Year To DateIn-Month

2.1 Income & Expenditure

5

(7.8)(8.1)

0.3

0.1 0.2

(0.0)

(0.5)

(0.3)

(9.0)

(8.5)

(8.0)

(7.5)

(7.0)

(6.5)

(6.0)

Budget deficit YTD Patient Income Other Income Pay Non-Pay Depreciation, interest& dividends

Non-recurrent andExceptional

Actual deficit YTD

2.1.2 YTD deficit bridge (£m)

(9.0)

(8.0)

(7.0)

(6.0)

(5.0)

(4.0)

(3.0)

(2.0)

(1.0)

-

April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2.1.3 Surplus / (deficit) £m

Cumulative Plan

Cumulative Actual / Forecast

2.2 Income

2.2.1 Income summary

• PbR income is £0.08m above plan in March(M12). Year to date we are reporting an overperformance of £2m.

• The position in the month is driven by theimproved performance of Non-Elective activitysupported by the increase seen in A&E acrossthe month of March.

• Year to date income reductions are £0.487mhigher than expected, this position hasdeteriorated compared to last month due to theincrease in the non-elective threshold marginalrate adjustment and recognition of the increasedC-Diff trajectory compared to plan.

• The ledger timings differences is made up ofseveral component parts (1) FP10 communityprescribing (2) AQP (3) penalty reductions (4)risk reductions and (5) coding catch-up from theprevious months.

6

2.2.1 Income Summary

Plan Actual Var Plan Actual Var£'000 £'000 £'000 £'000 £'000 £'000

Gross PbR income (2.2.4) 13,491 13,567 75 160,811 162,823 2,013Income reductions (2.2.6) (309) (471) (162) (3,707) (4,194) (487)Other patient income (2.2.7) 9,839 7,903 (1,936) 97,874 96,782 (1,092)Ledger timing differences(1) 3 1,454 1,451 106 (66) (172)Total patient income 23,025 22,453 (572) 255,083 255,345 262Other income (2.2.8) 2,670 2,600 (70) 28,105 28,099 (6)Total income 25,695 25,053 (642) 283,189 283,445 256

Month 12 Year to date

(1) reflects impact of coding of prior month activity and in respect of the plan represents agreed contract variation

283.2 283.4(1.0)

(0.5)(1.1)

(0.0)

+3.0+0.0

282.0

283.0

284.0

285.0

286.0

287.0

288.0

Budget Income YTD PbR - Volume PbR - Price Reductions - Contract Reductions - Other Other patient income Other income Actual Income YTD

2.2.3 YTD Income variance (£m)

2.2.2 Monthly IncomeAug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 YTD

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Gross PbR income 12,807 13,162 14,058 13,764 13,527 14,746 13,129 13,567 162,823Income reductions (299) (175) (449) (135) (221) (105) (887) (471) (4,194)Other patient income 8,071 7,860 8,094 7,984 7,804 9,285 8,814 7,903 96,782Ledger timing dif ferences(1) (272) (212) 937 (423) 857 (1,557) (279) 1,454 (66)Total patient income 20,306 20,636 22,640 21,190 21,967 22,369 20,778 22,453 255,345Other Income 2,446 1,893 2,120 2,465 1,915 2,894 2,354 2,600 28,099Total income 22,753 22,529 24,760 23,655 23,882 25,263 23,133 25,053 283,445

2.2 Income

7

2.2.4 Gross PbR Income• PbR income is £0.07m 0.6% above plan in M12. Underperformance against maternity which is consistent with the trend seen all year, outpatients

£(0.173)m and excess bed days £(0.18)m.• Elective income and activity are both above plan in the month. The main two specialities are General Surgery and General Medicine.• Day cases are slightly behind plan in the month for activity but a strong case mix has resulted in an over achievement of income. • The Non Elective over-performance is predominantly in Medical specialties and continues to follow the trend seen in the last quarter. A&E has also

seen a 10% increase over the month of March.• Outpatients is behind plan and this is due to significant underperformance of outpatient procedures in the month.• Adult Acute Division reports income £0.414m above plan in March, this is all being driven by the increased amount of non-elective activity in the

month.• Elective is reporting an under-recovery of income against plan (£0.25)m in the month. Day Case is the main area of over performance in the month.• Family Care Division is £(0.09)m behind plan in March, due to the underperformance being reported on deliveries. This is being off-set by reported

over performance for non-elective activity and elective inpatient activity.

2.2.4 Gross PbR Income

Plan Actual Var Var Plan Actual Var Var Plan Actual Var Var Plan Actual Var Var# # # % £'000 £'000 £'000 % # # # % £'000 £'000 £'000 %

A&E 9,541 10,286 745 7.8% 970 1,091 121 12.5% 114,129 112,311 (1,818) (1.6%) 11,604 11,606 2 0.0%Day Cases 2,386 2,381 (5) (0.2%) 1,544 1,579 35 2.3% 27,038 27,124 86 0.3% 17,888 18,456 568 3.2%Elective IP 539 572 33 6.2% 1,291 1,330 39 3.0% 6,443 6,616 174 2.7% 15,453 15,885 432 2.8%Non-Elective IP 3,063 3,382 318 10.4% 5,006 5,372 366 7.3% 36,671 38,716 2,044 5.6% 59,885 61,755 1,870 3.1%Delivery Episodes 527 477 (50) (9.6%) 934 782 (152) (16.3%) 6,277 5,905 (372) (5.9%) 11,171 10,302 (870) (7.8%)Outpatients 22,751 21,200 (1,552) (6.8%) 2,485 2,312 (173) (6.9%) 272,150 269,508 (2,642) (1.0%) 29,725 30,000 275 0.9%Ante/Postnatal Pathw ays 986 996 10 1.1% 911 929 18 2.0% 11,793 11,800 7 0.1% 10,897 10,874 (23) (0.2%)Excess Bed Days 1,473 735 (738) (50.1%) 350 170 (180) (51.4%) 17,619 17,045 (574) (3.3%) 4,188 3,945 (242) (5.8%)Gross PbR Income 41,266 40,028 (1,238) (3.0%) 13,491 13,567 75 0.6% 492,120 489,024 (3,096) (0.6%) 160,811 162,823 2,013 1.3%Income Reductions (2.2.6) (309) (471) (162) 52.5% (3,707) (4,194) (487) 13.1%Other patient income (2.2.7) 9,839 7,903 (1,936) (19.7%) 97,874 96,782 (1,092) (1.1%)Ledger timing dif ferences 3 1,454 1,451 n/a 106 (66) (172) n/aTotal income from activities 23,025 22,453 (572) (2.5%) 255,084 255,345 262 0.1%Memo: Divisional PbR IncomeAcute Adult 19,510 20,100 590 3.0% 5,200 5,614 414 8.0% 232,365 234,253 1,888 0.8% 61,939 65,194 3,254 5.3%Elective 16,874 15,369 (1,505) (8.9%) 5,175 4,926 (249) (4.8%) 201,349 198,529 (2,820) (1.4%) 61,588 61,009 (579) (0.9%)Family 4,883 4,559 (323) (6.6%) 3,117 3,027 (90) (2.9%) 58,405 56,242 (2,163) (3.7%) 37,283 36,621 (662) (1.8%)Gross PbR 41,266 40,028 (1,238) (3.0%) 13,491 13,567 75 0.6% 492,120 489,024 (3,096) (0.6%) 160,811 162,823 2,013 1.3%

Month 12 Year To DateIncome IncomeActivityActivity

2.3 Pay

2.3.1 Pay spend

• In month pay has underspent by £0.39m against the plan.

• Although the pay budget is now overspent by £0.5m YTD, a proportion of this will have been spent generating the extra income received by the trust over budget

• The classification as “other pay budgets” arises because although the division and speciality has agreed the savings these are only allocated at specialty level not subjective code level.

• The ‘other pay budget’ contains the ICIP gap where costs have not yet been allocated to individuals budget lines. No further allocation of costs to other areas happened this month.

• .

8

2.3.1 Pay - Actual vs Budget

Annual Budget Budget Actual Var.

Prior Year Budget Actual Var.

£m £m £m £m £m £m £m £mSenior Managers (5.1) (0.4) (0.3) 0.1 (6.5) (5.1) (4.3) 0.8Medical and Dental (48.3) (4.2) (4.1) 0.1 (46.8) (48.3) (47.4) 0.9Nursing, Midw ifery And Health Visiting (75.7) (6.5) (6.0) 0.5 (74.7) (75.7) (72.9) 2.7Scientif ic, Therapeutic and Technical (23.4) (2.0) (1.8) 0.1 (24.0) (23.4) (22.1) 1.3Professional and Technical (5.2) (0.4) (0.4) 0.0 (5.2) (5.2) (4.7) 0.5Administrative and Clerical (23.2) (2.0) (1.7) 0.3 (23.5) (23.2) (21.6) 1.6Healthcare Assistants and Other Suppo (20.6) (1.8) (1.6) 0.1 (19.4) (20.6) (18.8) 1.8Other Pay Budgets 4.1 0.0 (0.1) (0.1) (9.3) 4.1 (0.1) (4.2)Agency Staff (2.5) (0.2) (1.0) (0.7) (7.4) (2.5) (8.5) (6.0)Pay (200.0) (17.4) (17.0) 0.4 (216.9) (200.0) (200.6) (0.5)Bank (included in above) (3.3) (0.3) (0.5) (0.2) (6.1) (3.3) (5.8) (2.4)

Agency SplitNursing (0.1) (0.0) (0.3) (0.2) (0.1) (2.2) (2.1)A&C (0.7) (0.1) (0.1) (0.0) (0.7) (1.4) (0.7)Locum Doctors (1.6) (0.1) (0.5) (0.3) (1.6) (4.0) (2.4)Other (0.1) (0.0) (0.2) (0.1) (0.1) (0.8) (0.8)

Year To DateIn-Month

919

(2,925)

204

1,264

(537)

404

(433)

181 235 388

(4,000)

(3,000)

(2,000)

(1,000)

-

1,000

2,000

Acute Elective Family Corporate Trust

2.3.2 Pay variance to budget (£'000)

YTD In month

5. Cashflow

5. Cashflow summary

• The cash position at the end of the year includes PDC funding of £7.5m in March.

• Redundancy payments of £0.6m were paid in March.

9

0.0

4.0

8.0

12.0

16.0

20.0

02-M

ar

09-M

ar

16-M

ar

23-M

ar

30-M

ar

06-A

pr

5.1 Cash actuals at year end (£m)

Cash actual

0.0

1.0

2.0

3.0

4.0

5.0

6.05.2 Actual month end cash balance (£m)

Forecast Actual

6. Capital expenditure

6.1 Capital expenditure

• The Trust capital plan as submitted to Monitor at the end of May was £5.9m

• At the end of March capital expenditure was £0.3m overspent as planned.

• The Trust spent 105% of the year to date capital plan, this is below the 115% Monitor threshold.

10

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0


Cumulative capital expenditure (£m)

Actual spendAnnual Budget

6.1 Capital expenditure YTD

Budget Actual Var£000 £000 £000

ReplacementsSigmoid Flexiscope 113.0 0.0 113.0Blood Gas Analyser 53.0 40.2 12.8Laporoscopic Stacking System 59.0 0.0 59.0Upgrade of Haemoglobin Testing Systems 342.0 0.0 342.0Tissue Processor 40.0 41.2 (1.2)Replacement of Franking Machine 16.2 (16.2)Retinal Camera - community 15.5 (15.5)Wireless Endoscopy 8.4 (8.4)Diagnostic Immunocytochemistry 48.0 (48.0)Orthopaedic Drills 22.9 (22.9)Retinal Camera 223.9 (223.9)Examination Lamps 34.7 (34.7)Defibrillators 465.0 (465.0)Sonosite Nanomaxx 20.0 (20.0)CATS's Plus Machine 12.6 (12.6)Arjo Scale Hoist 6.0 (6.0)Sonicaid & Encore System 12.9 (12.9)Defibrillators 14.7 (14.7)Bladder Scanner 7.4 (7.4)Stroke Data Capture System 18.0 (18.0)Replacements Subtotal 607.0 1,007.6 (400.6)MaintenanceUrology Fire Precautions and Structural Floor 320.0 0.0 320.0Urology Scheme Design and Consultancy Fees 6.3 (6.3)Repairs to Highw ays Churchill Drive 40.2 (40.2)Upgrade of Ward A4 802.0 733.2 68.8Churchill Service Duct Fire Precautions 1,297.0 1,332.9 (35.9)C. Dificile 87.0 619.7 (532.7)Ugrade of Parental Accomodation for MIB 10.0 5.7 4.3A&E (Bandit screen and ambulance handover) 42.0 (42.0)Chillers 438.3 (438.3)Air conditioning 7.5 (7.5)Storm damage 42.2 (42.2)HSDU - f ire precautions 32.0 (32.0)Road resurfacing 118.8 (118.8)Maintenance Subtotal 2,516.0 3,418.7 (902.7)EnhancementsEndoscopy 850.0 363.0 487.0PACS 300.0 373.1 (73.1)CT Enabling Works 50.0 1.4 48.7Information Technology 807.0 703.9 103.1E-rostering 109.8 (109.8)Enhancements Subtotal 2,007.0 1,551.0 456.0OtherCapitalised Salary Costs 130.0 130.0 0.0Fees Maternity Unit 40.0 1.7 38.3Other Subtotal 170.0 131.7 38.3

2012/13 SlippageEndoscopy - phase 1 365.0 0.0 365.0Other 235.0 106.6 128.42012/13 Slippage Subtotal 600.0 106.6 493.4

GROSS CAPITAL EXPENDITURE 5,900.0 6,215.7 (315.7)

Year End

9.1 Appendix: Activity trends

11

7,000

7,500

8,000

8,500

9,000

9,500

10,000

10,500

11,000

A&E activity

13/14 Actual 13/14 Plan 12/13 ActualThis image cannot currently be displayed.

15,000

17,000

19,000

21,000

23,000

25,000

27,000

O/P activity (including procedures)

13/14 Actual 13/14 Plan 12/13 Actual

1,500

1,700

1,900

2,100

2,300

2,500

2,700

2,900

3,100

3,300

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Elective / day case activity (spells only)

13/14 Actual 13/14 Plan 12/13 Actual

Agenda Item No : 16.1



Title Going Concern

Executive Summary

• Why is this paper going to the Board of DIrectors

• To summarise the main points and key issues that the Board of Directors should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

To provide information to the Board to enable it to confirm that the 2013/14 accounts should be prepared on a going concern basis.


Discuss Receive

Approve Note





Quality Regulatory




Prepared by Simon Worthington Finance Director Presented by Simon Worthington

Finance Director

2013/14 Accounts Going Concern Assumption

1. Introduction

1.1 This report gives information to the Board to enable it to confirm that the 2013/14 accounts should be prepared on a going concern basis.

2. Background

2.1 It is good practice that the Board should formally consider whether the 2013/14 accounts should be prepared on a going concern basis or not. For the accounts to be prepared on this basis the Board needs to be assured that the Trust will remain as a solvent entity throughout the next twelve months. If the Board did not believe this then the accounts could not be prepared on a going concern basis. This would potentially have a material effect on the carrying values of assets and liabilities as well as the income and expense reported for the period.

2.2 Fundamentally all NHS bodies are financially backed by the government in the form of the Secretary of State for Health so it is not possible for Foundation Trusts to become insolvent in the way that a private company might. To ensure this the Department of Health (DoH) operates a system to provide cash support funding to Trusts in financial distress. Bolton NHS Foundation Trust received funding under this system in 2012/13 and 2013/14.

2.3 The DoH operates a formal system to deal with Trusts that are designated as being financially unsustainable (the failure regime). Trusts in this position continue to receive cash support from the DoH and they themselves continue to prepare accounts on a going concern basis.

2.4 If the Trust was considering merger then this would have to be taken into account when preparing the accounts, but the accounts would still be prepared on a going concern basis.

2.5 In addition to the above the Board can be assured that the accounts should be prepared on a going concern basis because of the following:

• Successful delivery of the 2013/14 financial plan gives confidence in the organisation’s ability to deliver on its financial plans going forward.

• The Board has approved a five year strategic financial plan that shows the Trust returning to surplus in 2014/15.

• A detailed operational financial plan has been prepared to support the delivery of the planned £1.6m surplus for 2014/15. This plan which has been approved by the Board contains detailed

o Income and expenditure plans o Income and cost improvement plans o Capital expenditure plans o Monthly cash flow plans.

2.6 In terms of risk management the Trust has considered potential downside risk on the 2014/15 financial plan and the potential range of outcomes that might occur. The Trust is able to deal with a £5m deficit in 2014/15 without requiring distress funding from the DoH. The finance committee reviewed a detailed cash downside risk management plan in January 2014.

2.7 The Trust is part of the NHS risk pooling scheme, the contributions for this are already fixed. Any risks as a result of litigation will not impact on the Trust’s solvency position in 2014/15.

3. Recommendation

3.1 Based on the above it is recommended that the Trust Board agree

i) To prepare the 2013/14 accounts on a going concern basis

Committee Chair Report

Name of Committee: Quality Assurance Committee

Date of Meeting: 9th April 2014

Report to: Board of Directors

Chair: Gina Ashworth

Key Issues Discussed

Chairman’s report - the Board have asked the QA Committee to seek further assurance on

medication incidents and to receive a report back on the location and management of

wheelchairs following an issue highlighted by one of the NEDs.

Following discussions at the March QA meeting the Board had received further assurance

on actions being taken to address specific quality and staffing concerns on wards C4 and

D1.

After attendance at the March QA meeting PwC had offered to attend a future Board

meeting to provide an insight to the new regime of CQC inspections - this has been

scheduled for the April Board meeting. It was also agreed that the Director of Nursing

should approach Salford to ask them to talk about their quality movement as part of the

preparation for CQC inspection.

Agenda Items

In addition to the discussions on routine standing agenda items the committee received

reports on pressure sores, end of life care, CQC standards and monitoring and the cleaning

audits.

A report from the DDO for Estates and Facilities identified management issues with regard to

medical devices, the committee agreed that these actions should be addressed as a matter

of urgency to understand the gap and implement a staged approach with any risks being

recorded on the BAF or risk register as appropriated - the May meeting will receive a

workplan to address the issues identified.

A recurring theme identified in several of the agenda items was with regard to staffing

issues, particularly nurse staffing - the QA Committee asked the workforce committee to

provide assurance with regard to the risks around recruitment and retention of the nursing

workforce and the need to train staff both on an on-going basis and with regard to specific

issues such as medical devices.

For Escalation to the Board:

management of medical devices

Any changes made to coding to be notified by the Medical Director

Apologies received from

J Bene, S Woolridge J Wood, K Bancroft, B Bradley and H Bharaj

Date of next meeting – 14th May 2014

Bolton NHS Foundation Trust Council of Governors’ Meeting – March 6th 2014 Page 1 of 4

Meeting Council of Governors

Time 5.30 p.m.

Date 6th March 2014

Venue Seminar Room 1, Education Centre

Present

David Wakefield Chairman

Robert Airey Public elected governor

Ann Bain Public elected governor

Derek Burrows Public elected governor

Michael Connolly Public elected governor

Kate Cowpe Public elected governor

Margaret Evans Public elected governor

Debra Graham Public elected governor

Caroline Greenhalgh Staff governor

Kenneth Hahlo Public elected governor

Eric Hyde Public elected governor

Pauline Lee Public elected governor

Jackie Leigh Appointed governor

Jeffrey Mangnall Public elected governor

Carol McBride Public elected governor

Martin Mcloughlin Public elected governor

Geoffrey Minshull Public elected governor

Champak Mistry Public elected governor

Samir Naseef Appointed governor

Robert Nettleton Appointed governor

Thaira Qureshi Appointed governor

Jack Ramsay Public elected governor

Janet Roberts Staff governor

Sorie Sesay Public elected governor

Jim Sherrington Public elected governor

John Taylor Public elected governor In Attendance

Carol Davies Non Executive Director

Gina Ashworth Non-Executive Director

Ebrahim Adia Non-Executive Director

Allan Duckworth Non-Executive Director

Trish Armstrong-Child Director of Nursing

Andy Ennis Chief Operating Officer

Steve Hodgson Medical Director

Simon Worthington Director of Finance

Esther Steel Trust Secretary

Heather Edwards Head of Communications

Observers

D Balcer


Apologies

Jack Firth

Peter Hindle

2. Declarations of Interest

None

3. Minutes of the Council of Governors’ Meeting

Approved as an accurate record.

3.1 Matters Arising

A question was raised regarding the impact of extended GP opening over Christmas on A&E

performance - the impact was minimal - possibly as a result of the lack of publication

regarding extended opening.

4. Chairman’s Update

Performance - The Chairman gave an update on performance since the previous meeting -

overall performance has been good, the Trust has continued to meet the A & E four hour

target and recent calls with Monitor have been very positive. Monitor were recently on site at

the Trust undertaking a sustainability review, the findings of which will inform the decision

about the provision of future PDC funding to address IT and Estates issues.

Board changes - Interviews for the Medical Director will be on 20th March 2014; the Trust is

also advertising for a Director of Strategic and Organisational Development - interviews for

this position will be in late April.

Sector update - Monitor recently published the Q3 results for all Foundation Trusts. This

shows the level of financial pressure facing acute Trusts, particularly small and medium sized

organisations with 40% of the 83 acute FTs reporting a deficit. In Q3 17 trusts failed the 18

week target, 48 failed the C. Difficile target and 28 failed the A & E target.

Governors discussed performance in the context of the wider sector performance, in

response to a question regarding recruitment to A & E vacancies, the COO advised that this

has not been an issue in Bolton - there have been no problems recruiting to consultant

vacancies.

Governors agreed that staff should be congratulated on the achievement of the A&E target

and noted that although the A&E staff work incredibly hard success requires the whole

system to flow and operate smoothly.

5. Performance Update

Governors had been provided with the January integrated performance report, members of

the Executive team highlighted the performance against key indicators on this report and

invited Governors to raise questions on any other indicators:

Quality

The plan to reduce the number of falls and pressure ulcers is now having an impact, both

metrics show an improvement, this has been a big challenge and all teams have done a

fantastic job focusing on the quality indicators. Governors requested further information with


regard to this improvement, the Director of Nursing advised that having gaining a detailed

understanding of the issues enabled teams to deliver focused interventions - for the reduction

of falls these interventions focused on the care of orthopaedic and frail elderly patients.

Operational

As discussed previously, A and E performance has been good however there have been

issues with the achievement of the diagnostic wait and 62 day cancer targets; for the

diagnostic target this was a true blip following slippage on MRI scanning which is now back

on track. With regard to the 62 day cancer target, this is back on the regional COO agenda

with Trusts across Greater Manchester struggling to achieve the target. The target has

complex rules regarding the allocation of breaches- however the failure is a disappointment

that could have been avoided.

Readmissions performance, although better than average across the North West, the Trust is

failing to achieve the local 9% target, negotiations with the CCG with regard to this target

continue.

Finance

The Trust will achieve its financial target and will have achieved over £18m of cost

improvements while also improving quality. The end of year balance sheet will be as strong

as possible given the position the Trust has been in; underlying performance is better than the

headline number and cash will not be needed for operational support next year.

The anticipated end of year position is an underlying deficit of approximately £5.9m.

The Chairman and Governors extended their thanks to the Finance Director and his team for

supporting this achievement.

6. Quality Account indicators

The guidance for the external audit of Quality Accounts has now been published. Auditors

will review the overall content of the Quality Account to check compliance with Monitor

guidelines and will also conduct a more in-depth review of three indicators - two of these are

mandated; the other should be selected by the Governors of the Trust.

Governors were asked to spend time in groups discussing and selecting an indicator for this

review. A list of potential indicators was provided for guidance.

Following discussions in groups the majority choice was to review community data

completeness, two groups proposed a review of did not attends - this indicator was not

included on the list but remains a concern to governors - an update on the steps being taken

to reduce the number of did not attends will be added to the workplan for the September

Council of Governor meeting.

7. Annual Plan

Monitor guidance requires the Trust to submit a two year operational plan in April 2014

followed by a five year strategic plan by the end of June 2014. Governors were reminded

that, as one of the actions to contribute to its recovery, a five year plan had been submitted to

Monitor in September 2013. This plan had been developed with the support of Deloitte LLP -

the operational plan would build on the objectives stated in the strategic plan. The five year

plan due for submission in June would also be in line with the September 2013 plan but would

be updated to reflect any new developments as a result of Healthier Together or integration.

Governors noted the plan and the steps taken by the Trust to improve quality and governance

within the organisation.


8. Feedback from Governor Sub Committees

8.1 Patient Staff and Visitor Experience Sub Group - 21/01/14

The Director of Nursing attended to respond to a question and answer session, this meeting

was very well attended, the items discussed will be used to inform the workplan for future

meetings, the Director of Nursing has agreed to be a regular attendee at this meeting and the

next meeting in April 2014 will focus on the management of complaints.

8.2 Governor Strategy Group

Governors agreed to reconstitute the More than a Hospital Group as a Governor Strategy

group. This newly convened group will provide a useful forum for the Board to meet with

Governors to share and debate strategy issues.

8.3 Membership and Member Communications Sub Group

The group has not met since the last Governor meeting - next meeting scheduled for March

10th 2014. Membership has remained static and just under the 5000 total; the sub group will

discuss recruitment and engagement of members.

9. Constitution Change Update

Following the proposal to review the areas of the constituency governors had discussed the

proposed change and considered other options and recommended that the constitution

remain unchanged.

10. Feedback from Evaluation Exercise Conducted at January Governor Meeting

Governors noted the actions being taken to address issues raised during the evaluation

exercise conducted at the January meeting.

10. Date and Time of Next Meeting

1st May 2014 at 5.30pm Seminar Room One Education Centre

Bolton NHS Foundation Trust – Board Meeting April 24th 2014€¦ · Board of Directors minutes...

Documents

Transcript of Bolton NHS Foundation Trust – Board Meeting April 24th 2014€¦ · Board of Directors minutes...