Chairman’s Office · 2019-11-01 · Foundation Trust will be held in public on Tuesday 5th...

Chairman’s Office Trust Headquarters

Blackpool Victoria Hospital Whinney Heys Road

Blackpool Lancashire

FY3 8NR

Telephone: 01253 956856

[email protected]

29th October 2019 Dear Board Members Blackpool Teaching Hospitals NHS Foundation Trust – Board of Directors Meeting The next meeting of the Board of Directors of the Blackpool Teaching Hospitals NHS Foundation Trust will be held in public on Tuesday 5th November 2019 at 9.30 am in the Board Room, Victoria Hospital, Whinney Heys Road, Blackpool, FY3 8NR. Members of the public and media are welcome to observe the meeting but are advised that it is a meeting held in public, not a public meeting. If you wish to attend, please contact the Corporate Assurance Manager/Foundation Trust Secretary on 01253 956856 or [email protected] Any questions relating to the agenda or reports should be submitted in writing at least 24 hours in advance of the meeting being held. The Board may limit the public input on any item based on the number of people requesting to speak and the business of the Board. Enquiries should be made to the Corporate Assurance Manager/Foundation Trust Secretary on 01253 956856 or [email protected] Yours sincerely J A Oates (Miss) Corporate Assurance Manager/ Foundation Trust Secretary

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mailto:[email protected]



A G E N D A

Agenda Item Number

Agenda Item Duration Purpose/ Expected Outcome

01 (87/19) Chairman’s Welcome and Introductions

9.30 am (1 minute)

Information

02 (88/19) Declarations of Interests – Mr Butler to report. 9.31 am (1 minute)

Information

03 (89/19) Apologies for Absence – Mr Butler to report.

9.32 am (1 minute)

Information

04 (90/19) Minutes of the Previous Board of Directors’ Meeting held in Public on 3rd September 2019 – Mr Butler to report. (Enclosed).

9.33 am (1 minute)

Approval

05 (91/19) Matters Arising:- a) Action List from the Previous Board of Directors’ Meeting

held in Public on 3rd September 2019 – Mr Butler to report. (Enclosed).

b) Action Tracking Document – Mr Butler to report.

(Enclosed).

9.34 am (3 minutes) 9.37 am (3 minutes)

Discussion Discussion

06 (92/19) Chairman’s Report – Mr Butler to report. (Verbal Report). 9.40 am (5 minutes)

Information

07 (93/19) Chief Executive’s Report – Mr McGee to report. (Enclosed).

9.45 am (5 minutes)

Information

08 (94/19) Quality and Safety:- a) Nursing Times Award Presentation (Data and Technology

Category) – Veronica Southern (Digital Health Clinical Lead), Helena Palin (Clifton Ward 2 Manager) and Sarah Roberts (Palliative Care Nursing Manager, Hospice) to attend for this item to give a presentation.

b) CQC Improvement Plan – Mr McGee/Mr Murphy to report. (Enclosed).

c) Clinical Staffing Review – Mr Murphy to report.

(Enclosed).

d) National Standards: Learning from Deaths – Dr Goode to report. (Enclosed).

e) Emergency Preparedness Resilience and Response

(EPRR) Assurance 2019 – Mrs Groves to report. (Enclosed).

f) EU Exit Preparations Update – Mrs Groves to report.

(Verbal Report).

9.50 am (15 minutes) 10.05 am (10 minutes) 10.15 am (15 minutes) 10.30 am (5 minutes) 10.35 am (5 minutes) 10.40 am (5 minutes)

Discussion Discussion Discussion/ Approval Information Information Information

09 (95/19) Strategy

a) Developing Workforce Safeguards – Mr Moynes to report. (Enclosed).

10.45 am (10 minutes)

Discussion

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10 (96/19)

Performance:-

a) Integrated Performance Report (including Board

Assurance Framework). (Enclosed):- - Executive Summary – Mr McGee to report. - Quality – Mr Murphy to report - Finance – Mr Bennett to report. - Performance – Mrs Barnsley/Mrs Groves to report. - Workforce – Mr Moynes to report.

b) Integrated Performance Report: Development Proposal

Update – Mr Bennett to report. (Enclosed). (Mrs Charlotte Walton, NHSI Associate Improvement Director, to attend for this item)

10.55 am (10 minutes) 11.05 am (10 minutes)

Discussion/ Approval Discussion/ Approval

11 (97/19) Governance:- a) Board Committee Assurance – Committee Chairs to

report:-

- Workforce Transformation Committee Minutes (29th July 2019) – Mrs Whyham to report. (Enclosed).

- Audit Committee Minutes (30th July 2019) – Mr Hearty to report. (Enclosed).

- Finance Committee Minutes (18th September 2019) – Mr Cullinan to report. (Enclosed).

- Quality Committee Minutes (23rd September 2019) – Mr Hearty to report. (Enclosed).

- Clinical Effectiveness Committee Update (21st October 2019) – Mr Wilkie to report. (Verbal Report).

- Performance & Operations Committee Update (23rd October 2019) – Mr Beaton to report. (Verbal Report).


Discussion

12 (98/19)

Engagement:-

a) Freedom To Speak Up Report: Quarter 2 – Mr Moynes to report. (Enclosed).

(Mrs Terri Vaselli, Freedom To Speak Up Guardian, to attend for this item)


Discussion

13 (99/19) Items for Information/Discussion/Approval:-

a) Attendance Monitoring – Mr Butler to report. (Enclosed).

b) Trust Values / Examples of Value of the Month – Mr Butler to report. (Verbal Report).

c) Key Themes for Team Brief – Mr Butler to report. (Verbal Report).

11.35 am (1 minute) 11.36 am (2 minutes) 11.38 am (2 minutes)

Information Discussion Discussion

14 (100/19) Any other Business – Mr Butler to report.

11.40 am (1 minute)

Discussion

15 (101/19) Items Recommended for Discussion or Decision by Board Committees – Mr Butler to report.

11.41 am (1 minute)

Discussion

16 (102/19) Questions from the Public – Mr Butler to report. .


Discussion

17 (103/19) Formal Meeting Review – Mr Butler to report. 11.52 am Discussion

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Has the Board focussed on the appropriate agenda items? Any item(s) missing or not given enough attention?

Is the Board shaping a healthy culture for the Board and the organisation and holding to account?

Are the Trust’s strategies informed by the soft intelligence from local people’s needs, trends and comparative information?

Does the Board give enough priority to engagement with stakeholders and opinion formers within and beyond the organisation?

Does the Board take into account the collaboration agenda when setting its strategy?

To what extent have we made collaboration and system working part of our business as usual?

(6 minutes)

18 (104/19) Date of Next Meeting – Mr Butler to report. .

11.58 am (1 minute)

Information

19 (105/19) Resolution to Exclude Members of the Media and Public The Board of Directors to resolve “That representatives of the media and other members of the public be excluded from Part Two of the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest.” in accordance with Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960) and the Public Bodies (Admissions to Meetings) (NHS Trusts) Order 1997.

11.59 am (1 minute)

Information

Total Duration – 2 hours, 30 minutes

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Minutes of the Blackpool Teaching Hospitals NHS Foundation Trust

Board of Directors Meeting held in Public on Tuesday 3rd September 2019 at 9.30 am

in the Board Room, Trust Headquarters, Blackpool Victoria Hospital Present: Mr Pearse Butler – Chairman

Non-Executive Directors Mr Mark Beaton Mr Keith Case Mr Mark Cullinan Dr Jim Gardner Mr Michael Hearty Mr James Wilkie Mrs Mary Whyham

Executive Directors Mr Kevin McGee – Interim Chief Executive Mr Tim Bennett – Deputy Chief Executive/Director of Finance and Performance Dr Grahame Goode – Acting Medical Director Mr Kevin Moynes – Joint Director of HR & OD

In Attendance: Mrs Janet Barnsley – Interim Director of Operations (Planned Care)

Mrs Berenice Groves – Interim Director of Operations (Urgent & Emergency Care) Mr Peter Murphy – Interim Director of Nursing & Quality Miss Judith Oates – Corporate Assurance Manager/Foundation Trust Secretary Mrs Terri Vaselli, Freedom To Speak Up Guardian (for item 79/19d) Governors (observers) – 2 Members of Public (observers) – 12 Members of Staff (observers) – 10

69/19 Chairman’s Welcome and Introductions The Chairman welcomed Governors, members of staff and members of the public to the meeting; it being noted that there were more observers than usual. Observers were reminded that it was a Board Meeting in Public and not a Public Meeting. It was noted that the Chairman had received two questions in advance of the meeting, which would be addressed under agenda item 83/19, and that he had spoken to both individuals immediately prior to the meeting. The Chairman outlined the house-keeping rules in respect of mobile phones and fire alarm tests/fire exits.

70/19 Declarations of Interests Concerning Agenda Items The Chairman reminded Board members of the requirement to declare any interests in relation to the items on the agenda.

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It was noted that the following standard declarations applied:-

Mr Michael Hearty – Chair of Lancashire & South Cumbria ICS Board.

Dr Jim Gardner – Deputy Head of the School of Medicine at UCLAN.

Mr Keith Case – Chair of Atlas.

Kevin Moynes – substantive role as Director of HR & OD at East Lancashire Hospitals NHS Trust.

Mr Kevin McGee – substantive role as Chief Executive at East Lancashire Hospitals NHS Trust.

Mr Peter Murphy – substantive role as Director of Nursing at Salford Royal Hospital NHS Foundation Trust.

It was further noted that there were no specific declarations in relation to the items on the agenda and the Chairman asked Board members to raise such declarations during the meeting as appropriate.

71/19 Apologies for Absence

There were no apologies for absence.

72/19 Minutes of the Previous Board of Directors Meeting Held in Public RESOLVED: That the minutes of the previous Board of Directors Meeting held in public

on 2nd July 2019 be approved as a correct record of the proceedings and signed by the Chairman, subject to the following amendment:-

Page 11, Item 60/19 (b), First Paragraph: “breast care” to read “lung care”.

That the minutes be amended and subsequently signed by the Chairman.

Action To Be Taken Following The Meeting The minutes have been amended and signed by the Chairman.

73/19 Matters Arising:-

a) Action List from the Board of Directors Meeting held on 2nd July 2019 It was noted that there were 12 items on the action list, 9 of which had been completed and 3 of which were pending. An update was provided in respect of the pending items as follows:-

CQC Inspection (NHSI Enforcement Undertakings Letter) – the CQC draft report was expected during the current week and the Trust would have ten days to check for factual accuracy. The Chairman advised that the final report was expected during the first week in October at which point there would be a Quality Summit with stakeholders to consider the content of the report, following which the report would be issued and made available on the CQC website.

Integrated Performance Report – the document had been reviewed and a revised proposal would be discussed under agenda item 78/19(b).

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Seven Day Services Assurance – this item was scheduled for discussion by the Quality Committee on 17th September 2019 and would be reported to the Board in November 2019 if appropriate.

b) Action Tracking Document It was noted that there were 3 items on the action tracking document, 2 of which were overdue and one of which was pending. An update was provided in respect of the overdue items as follows:-

Developing Workforce Standards – this item was scheduled for discussion at the Workforce & Transformation Committee on 24th October 2019 and would be reported to the Board on 5th November 2019.

Board of Directors Terms of Reference – this item had been deferred and would be actioned as part of the review of all Terms of Reference.

74/19 Chairman’s Report

The Chairman reported on a number of items of process as follows:-

a) Chief Executive – Substantive Recruitment The Chairman reminded Board members that he had reported at the last Board meeting that a permanent Chief Executive had not been recruited due to the applicants not demonstrating the necessary skills determined by the Remuneration Committee. It was noted that efforts were being made to recruit to the post and, hopefully, an announcement would be made in the next few weeks. b) Executive Directors – Substantive Recruitment The Chairman reported that the substantive posts of Medical Director and Director of Nursing & Quality were currently being advertised and that interviews had been arranged for 2nd/3rd October 2019. With regard to the Joint Director of HR & OD post, which was a shared post with East Lancashire Hospitals Trust, it was noted that the Remuneration Committee had agreed to continue with the existing arrangement until 31st July 2020. c) Governor Elections Board members were advised of the results of the recent Governor elections as follows:- Public – Blackpool Lisa Robins (newly elected) Zacky Hameed (re-elected) Graham Curry (newly elected) Jeannette Beckett (newly elected) Public – Fylde Steven Gratrix (newly elected) Public – Wyre Patricia Greenhough (newly elected) Sue Crouch (re-elected) Ian Owen (re-elected)

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Public – North West Counties Constituency Stephen Cross (elected unopposed) Staff – Nursing & Midwifery Constituency Sharon Vickers (re-elected)

Staff – Clinical Support Constituency Jenny Gavin (re-elected unopposed) The Chairman explained that the North West Counties Constituency was included in the catchment area of the Foundation Trust due to a number of regional services being provided by the Trust, i.e. cardiac, haematology, cystic fibrosis. The Chairman congratulated the newly elected and re-elected Governors and expressed thanks to those Governors who had not been re-elected or had chosen not to stand for re-election for their contribution to the Trust.

75/19 Interim Chief Executive’s Report

Mr McGee explained the sections within his report and highlighted a number of issues as follows:- Section One – Major National Headlines

There had been a number of announcements regarding investments in mental health services which was pertinent to the Trust due to the pressures in the emergency pathway of patients with both physical and mental health issues. The investments were welcomed and supported.

There were issues around waiting lists and pensions and the Trust had made representations to NHS Providers about supporting a national review of pensions within the NHS because it was restricting capacity.

Section Two – Fylde Coast News

The Fylde Coast NHS Health Event, which was a joint event with the local CCGs, would take place on 16th September 2019 and would include exhibitions, statutory meetings and presentations. This would be the fourth consecutive joint event, demonstrating good systems working.

Section Three – Trust News and Initiatives aligned to the Trust Values

The applications for the celebrating success awards had recently been judged which had been an intense and humbling process and it had proved difficult to shortlist only three applicants in each category due to the high quality of the applications. The Celebration Ball, highlighting the good work within the Trust, had been arranged for 8th November 2019.

The interviews for the Medical Director and Director of Nursing & Quality posts would take place in early October, as reported by the Chairman.

Dr Grahame Goode had been appointed Acting Medical Director with effect from 21st August 2019 and was welcomed to the post and to the Board.

Section Four – External Communications and Engagement Interactions

It had been a busy time for social media, with great feedback being received about the Trust. Board members were encouraged to view the feedback which was generally positive.

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Section Five – Summary of Diary Commitments Meetings Summary

The Interim Chief Executive’s diary commitments were provided for information; it being noted that it had been a busy time despite it being holiday season.

Mrs Whyham made reference to the Impeller Heart Pumps highlighted in Section Three of the report which had been purchased with donations from the Blue Skies Hospitals Fund. Mrs Whyham praised the work of the Fund-Raising Department and the increasing number of purchases being made with donations.

76/19 Quality and Safety

a) Patient Story DVD The Chairman referred to the regular patient story agenda item which focused on a patient’s experience at the Trust, either in hospital or in the community, and explained that he thought both positive and negatives stories should be shown at Board meetings. It was noted therefore that this month’s patient story was negative. Mr Murphy introduced the patient story, which focused on a patient attending the Ophthalmic Out-Patient Clinic, and he encouraged Board members to think about the issues raised during the discussion of other items on the agenda. The Chairman stated that problems that were routine to staff were not, and should not, be routine to patients. He commented on the reference to eye to eye contact and pointed out the need to think about engagement. He further stated that it was encouraging to hear the positive feedback from the Out-Patient Department Sister. Mr Cullinan asked whether the patient story was shared widely with staff and it was confirmed that a link was included on the intranet and that it was featured in Team Brief. Mr McGee commented that more work needed to be undertaken on the culture of staff and the basics and that improvements were not always about increased resources. b) CQC Feedback Letter Mr Murphy referred to the CQC inspection which had taken place in early June 2019 and advised that the draft report was expected imminently. It was noted that, in advance of the draft report, an initial feedback letter had been received which had been included on the Trust website. Mr Murphy advised that a number of issues had been included in the initial letter, i.e. staffing levels, organisational culture, however, none of the issues were new to the Trust and they were already being addressed and would continue to be actioned going forward. The Chairman referred to the verbal feedback from the CQC and had been pleased to note that they had not raised any issues that the Trust was not aware of, however, there were a number of challenges to be addressed, in particular, engaging with BME staff and making them feel valued. Mr Moynes advised that “big conversations” had been introduced for all staff and that the BME Tsar would be visiting the Trust to meet with staff and Board members.

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c) Quality Improvement (QI) Strategy

Mr Murphy reminded Board members about the discussion at the Informal Board Meeting in August regarding quality improvement and he presented a report which detailed a comprehensive vision for the next three years outlining a number of principles and indicators that the Board would need to focus on over the next three years. Mr Murphy explained that the strategy focused on three aims as follows:-

Aim 1 – reduce preventable deaths.

Aim 2 – reduce avoidable harm.

Aim 3 – improve the last 1,000 days of life. Mr Murphy provided detailed information about the three aims and requested approval from the Board to invest in a core central Quality Improvement Team to support the delivery of the strategy at a cost of £750,000 (£500,000 in Year 1). It was noted that the post of Associate Director of Quality Improvement had already been advertised and that the successful applicant would be responsible for overseeing the faculty recruitment, subject to Board approval. It was further noted that a Communications Plan had been drafted. It was noted that it was planned to commence the system-wide improvement work in early October. Mr Murphy advised that Professor Brian Dolan would be working with Board members and some staff to ensure delivery of the strategy. Mr Hearty asked whether funding was available from the CCGs in view of the requirement to make system-wide improvements. Mr McGee advised that it was proposed to submit a request for CCG funding via the Quality Improvement Board. He stated than an investment in quality would reduce costs in the organisation. Mr Case asked whether the three aims were properly aligned with the strategic plan aims and commented on the need for broader quality improvement and suggested making contact with organisations where quality improvement had been successfully implemented. Mrs Whyham supported the approach and the investment and suggested that Board members should have the opportunity for more detailed discussion, perhaps with Professor Dolan, in order to ensure full understanding and Mr McGee agreed with this suggestion. Mr Beaton agreed with the need to invest in order to make improvements and supported the approach. He commented on the need for accountability in order to achieve the aims. Mr Wilkie commented on the powerful information presented in the strategy and stated that this should be taken into consideration when drafting future reports/strategies. Dr Goode stated that Mr Murphy had eloquently reported on the issues and advised that there was 100% support from medical and nursing staff for the proposed approach; it being noted that there had been discussion in the Scheduled Care Division and the Unscheduled Care Division and there had been positive feedback. Mrs Groves supported the approach and emphasised the need to transform culture and behaviour.

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Mr Bennett supported the proposal, commenting that having one project for quality improvement was a positive way forward and that this could be adopted in other areas, i.e. back office functions. However, Mr Bennett advised the Board, in his capacity as Finance Director, that there was no budget provision for the QI proposal (or for the nursing leadership proposal which was the next agenda item for discussion) and that the Board should not assume that funding would be made available. He agreed that quality was the priority but stated that the Board also had a responsibility in terms of the financial health of the organisation. Dr Gardner, in his capacity as Chair of the Quality Committee, strongly supported the QI approach and commented on the importance of the Plan On A Page document. Mr McGee agreed with the comments from Mr Bennett and Dr Gardner and stated that Executive Directors would need to consider the funding arrangements for additional resources and provide feedback to the Board. Mr Murphy expressed thanks to Charlotte Walton and Tracy Crumbleholme for their input to the QI Strategy. The Chairman emphasised the need for the Board to continue to discuss quality improvements and to involve staff.

RESOLVED: That the Quality Improvement Strategy be approved. That funding of £500,000 in Year 1 be approved. That Executive Directors would consider the funding arrangements for

additional resources and provide feedback to the Board.

That the Board would support quality improvements and continue discussions at future Board meetings.

That a PID regarding pressure sores would be submitted to the Board. Action To Be Taken Following The Meeting

Implementation of the Quality Improvement Strategy is progressing, with interviews for the post of Associate Director of Quality Improvement scheduled for 8th November 2019.

Executive Directors agreed at the meeting on 17th September 2019 to discuss the funding arrangements for additional resources with a wider audience and report to the Board. This item relating to quality improvements has been included on the Board work plan The item relating to pressure sores will be submitted to the Board in January 2020.

d) Nursing Leadership Structure Benchmarking and Ward Based Staffing

Benchmarking Mr Murphy presented a report relating to the management structure of the nursing team, noting that there was a request for investment funding in order to improve patient safety and quality outcomes and that a further report would be submitted to the next Board meeting in relation to benchmarking and providing a comprehensive improvement plan.

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Mr Murphy explained the current and proposed structure for the nursing leadership team and advised that a total investment of £520,000 was required in order to establish the proposed structure. Mr Cullinan welcomed the information from Mr Murphy and the indication that a comprehensive improvement plan would be provided following receipt of the CQC report. Mr Cullinan stated that he had previously raised the issue of leadership capacity and therefore he supported the proposed increase in nursing capacity. It was noted that length of stay was highlighted as an area for improvement and Mr Cullinan asked whether the improvements could be quantified. Mr Murphy reported that the Model Hospital indicated that a medium to higher nursing structure equated to high productivity therefore it was anticipated that there would be an improvement in length of stay. Mr McGee requested Board approval to the proposed structure, noting that a comprehensive improvement plan would be submitted to the Board in November 2019. Mrs Whyham referred to previous concerns regarding personal accountability in the organisation and thought that the proposals would address such concerns. Dr Goode supported the proposal but emphasised that the Board should not lose sight of involving the divisions and not working in isolation. The Chairman stated that it was important for decision-making to be devolved to divisions and for staff to be aware that not all decisions had to be made by the Board. Mrs Groves stated that it was evident that the lack of availability of nursing staff had an impact on length of stay and she emphasised the importance of giving accountability to staff. Dr Gardner referred to the recommendation relating to the 100% fill rate of the current funded establishments and commented that, by refreshing the leadership structure of nurses, this could be achieved, however, he queried how this would balance out in terms of finances. Mr Murphy advised that it would resolve some of the problems around nurse vacancies. Mr Beaton agreed with the proposal relating to the senior nursing posts but suggested that the Board should receive further information relating to benchmarking with the aim of achieving 100%. Mr McGee suggested having one improvement plan to include all key issues that the Board needed to focus on and details of the lead directors and the timescales.

RESOLVED: That the proposed nursing leadership structure be approved.

That a comprehensive improvement plan would be submitted to the Board meeting in November 2019. Action To Be Taken Following The Meeting Implementation of the Nursing Leadership Structure is progressing, with the advert for the Band 8b nursing staff now finalised. The item relating to a comprehensive improvement plan has been included on the Board agenda for the meeting on 5th November 2019.

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e) EU Exit Preparations Mrs Groves provided a brief update on the preparations for the EU Exit which included information on the background, national support, progress to date, next steps, risks, continuity of supply, operational readiness and additional expenditure.

Mr Hearty commented on the helpful and comprehensive report which focused on supply and he asked about demand and whether stress-testing had been undertaken in terms of additional demand on, for example, A&E. Mrs Groves advised that this issue had been discussed by the Working Group and that one area of concern was in relation to overseas visitors and that further information was needed about how to deal with such patients. It was noted that discussions were on-going with HR about the effect and impact on staff. Mr McGee stated that an increase in flu was anticipated and therefore appropriate plans were being made. In addition, discussions were continuing with the CCGs in respect of winter planning. The Chairman pointed out that there would not be another formal Board meeting before the proposed EU exit date of 31st October 2019 and therefore the Board Committees (and Board members via the informal Board meeting in October) would need to keep up to date with developments.

RESOLVED: That the structures and tasks outlined in the report be supported by the

Board. That the Board Committees (and Board members via the informal Board meeting in October) would need to keep up to date with developments. Action To Be Taken Following The Meeting An update was provided at the Informal Board Meeting on 2nd October 2019 and a further update will be provided at the Board Meeting on 5th November 2019.

f) Annual Medical Appraisal and Revalidation

Mr Moynes presented the report relating to medical appraisal and revalidation, which was self-explanatory, and requested approval from the Board for the Statement of Compliance to be signed by the Interim Chief Executive. Mr Moynes confirmed that there was a robust process in place for medical appraisal and revalidation and Mrs Whyham commented that she had been impressed with the rigour in which the process had taken place. It was noted that the report had been submitted to, and approved by, the Workforce & Transformation Committee on 29th July 2019.

RESOLVED: That approval be given for the Interim Chief Executive to sign the Statement

of Compliance (Annex D).

77/19 Strategy

Workforce Transformation Strategies Mr Moynes reminded Board members that it had been agreed to produce a Workforce Transformation Strategy and he presented three strategies which underpinned the Workforce Transformation Strategy as follows:-

Recruitment and Retention

Staff Engagement

Health and Well-Being

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It was noted that the strategies had been discussed with the Executive Directors, the JNCC and the Workforce & Transformation Committee and that the documents should align with the aim of improving workforce across the organisation. It was further noted that each of the strategies included key performance indicators which would be monitored using scorecards. Mr Moynes advised that this format would be used for other strategies, for example, Culture Strategy and Inclusive Leadership Strategy, which would be submitted to the Workforce & Transformation Committee in October 2019 and, subsequently, to the Board in November 2019. With regard to recruitment and retention, it was noted that the biggest challenge was staff turnover. Mr Wilkie queried how the reasons for staff leaving the Trust were known when only 40 out of 540 exit interviews had been undertaken. Mr Moynes stated that it was important to obtain evidence from staff and that he would be pursuing this outside the meeting.

RESOLVED: That Mr Moynes would pursue the issue of exit interviews outside the

meeting.

Mrs Whyham referred to the issues around staff engagement and advised that the Workforce & Transformation Committee would be considering whether there had been any positive effect from the microsite, which all Board members had now been given the opportunity to view. The Chairman stated that workforce was a significant challenge for the Trust and emphasised the need to increase staffing and to engage with existing staff. Mr Beaton supported the strategies but suggested more urgency on implementation, with more focus on actions on a quarterly basis. The Chairman advised that he would be expecting Mrs Whyham and Mr Beaton to progress this via the Workforce & Transformation Committee. Mrs Barnsley asked about promoting the strategies across the ICS.

RESOLVED: That Mr Moynes would consider how to address this with the ICS. That the following strategies be approved:-

Recruitment and Retention

Staff Engagement

Health and Well-Being Action To Be Taken Following The Meeting All staff are provided with an opportunity to undertake an exit interview either on-line or with a member of staff (Manager or HR). There are plans to move to "stay" interviews as part of the NHSI Retention programme.

Discussions within the ICP are progressing in terms of use of resource opportunities. Regional HRDs already share workforce transformation strategies and via .Local Workforce Action Boards.

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78/19 Performance

a) Integrated Performance Report

Executive Summary:- Mr McGee advised that that the organisation was under considerable pressure which had an impact in terms of performance and finances. It was noted that the 95% A&E performance had not been achieved but that improvements had been made, for which the clinical team should be applauded. It was further noted that the pressures continued in respect of cancer and RTT which affected the overall financial performance. An update on each section of the report was provided as follows:- Quality:-

Mr Murphy highlighted the increase in C Diff monitoring to monthly and the new process for responding to complaints. Dr Gardner confirmed that the two items highlighted by Mr Murphy were included on the Quality Committee agenda on a monthly basis. Finance:- Mr Bennett provided an update on the financial position as follows:-

There had been an overspend in-month of £1.4m.

The biggest area of overspend was pay, driven by additional agency staff, which was not sustainable and therefore it was likely that the Trust would breach the agency cap.

There had been a similar under performance against the CIP which could result in the control total not being achieved at the year end.

Significant cash and resource had been expected from the CCGs as part of the planned care initiatives and the Trust would need to be ready to deal quickly with any shortfalls.

The Chairman referred to the approval given at the Extraordinary Board Meeting in August to apply for interim revenue support and advised that it had not been necessary to date to submit a formal application. Mr Cullinan referred to the discussions earlier in the meeting regarding the quality improvement plan and the nurse leadership structure and expressed concern about not having sight of the wider picture and not having plans in place to deliver the CIP. The Chairman stated that the Board needed to have a clear view of the investment needed to improve quality and address the CQC concerns.

RESOLVED: That the Board would consider the investment needed to improve quality

and address the CQC concerns. Action To Be Taken Following The Meeting

This item will be addressed as part of the CQC improvement plan.

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Performance (Planned Care):- Mrs Barnsley highlighted the performance issues, namely RTT whereby there had been a slight increase in the overall volume but a corresponding decrease in the number of overall waiters, and cancer whereby breast care performance had improved considerably. Mr McGee paid tribute to the team for the improvement in breast care waiting times. Performance (Urgency & Emergency Care:-

Mrs Groves reported on the performance issues as follows:-

The A&E plan agreed with NHSE/I had been achieved.

There had been improvements in Type 1 performance.

There had been a reduction in the number of 12 hour breaches.

Work was being undertaken to improve pathways with the aim of achieving the upper quartile for length of stay.

Workforce Mr Moynes highlighted the workforce issues, in particular, sickness absence, staff turnover and staff satisfaction, all of which indicated under-performance.

b) Integrated Performance Report – Development Proposal Mr Bennett stated that it had previously been acknowledged by the Board that the existing 70 page IPR document was not particularly helpful and that an improved reporting process was needed at Board level. It was noted that a review of the IPR had been undertaken and a proposal had been developed for consideration by the Board. Reference was made to Appendix 1 which outlined the key findings and the requirements for developing the IPR. Mr Bennett expressed thanks to Charlotte Walton for her involvement in developing the IPR proposal. Mrs Walton reported that revised processes were needed in terms of how the organisation managed its data and advised that she would be meeting with each Board Committee to understand the type of real time data that was needed and how this would be reported through the committee structure. At this juncture, the Chairman explained to the public about the existing IPR process and the improvements that were needed. It was anticipated that the new reporting format would be available for the Board meeting in January 2020.

RESOLVED: That the IPR development proposal be approved. That progress on the development proposal would be reported to the Board.

That an options report on the format would be submitted to the Informal Board Meeting in October 2019.

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Action To Be Taken Following The Meeting An update on the development proposal was provided at the Informal Board Meeting on 2nd October 2019 and a further update will be provided at the Board Meeting on 5th November 2019.

An options report was provided at the Informal Board Meeting on 2nd October 2019.

79/19 Governance

a) Board Committee Assurance Reports

The feedback from the Board Committees, via the assurance reports, was presented to the Board as follows:-

Quality Committee:- Reference was made to the CQC Respiratory Mortality Report and Clinical Engagement.

Finance Committee:- The issues to be escalated, and the recommendations for approval, had already been addressed.

Workforce & Transformation Committee:- The issues to be escalated, and the recommendations for approval, had already been addressed.

Mrs Whyham asked about the Deanery Report and was advised that it had not yet been received and would be submitted to the Board in due course.

Audit Committee:- Reference was made to the BAF which had been given partial assurance as a result of the impact of the CQC report. Further work needed to be undertaken to make the connections between the Board Committees. The issue relating to the challenges of balancing quality, performance and finance would be included on the agenda for the Informal Board Meeting in October 2019. The issue relating to the induction arrangements for security and fraud would be included on the agenda for an Executive Directors Meeting in September 2019.

RESOLVED: That the challenges of balancing quality, performance and finance be included on the agenda for the Informal Board Meeting in October 2019.

That the induction arrangements for security and fraud be included on the agenda for an Executive Directors Meeting in September 2019. Action To Be Taken Following The Meeting An update was provided at the Informal Board Meeting on 2nd October 2019.

The induction arrangements for security and fraud were included on the agenda for an Executive Directors Meeting on 24th September 2019.

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b) Board Assurance Review

Mr McGee drew attention to the updated Board Assurance Review report which all Board members were aware of and had discussed in previous meetings. It was noted that the key changes to the committee structure were the establishment of two additional Board Committees, namely Performance & Operations Committee and Clinical Effectiveness Committee. In addition there was a change to the frequency of the Workforce & Transformation Committee meetings from quarterly to bi-monthly. The Chairman advised that he would be discussing the Governor representation on the Board Committees with the Council of Governors; it being noted that he had already discussed the possible Non-Executive Director representation with the Non-Executive Directors. Mr McGee requested approval to the following recommendations:-

To agree to the amendments to the Board Committee structure as follows; Finance and IMT Committee (monthly), Quality Committee (monthly), Workforce & Transformation Committee (bi-monthly), Performance and Operations Committee (monthly) and Clinical Effectiveness Committee (bi-monthly).

To agree to the new Committee membership model for Directors.

To agree to a review of the above recommendations in 6 months and 12 months.

To agree to the recruitment of a Committee Secretary to undertake the additional work.

To note that the Corporate Assurance Team would review all Committee and Sub-Committee Terms of Reference, Work Plans and Agendas, including the new committees, with Committee Chairs and Executive Directors.

RESOLVED: That the above recommendations be approved.

c) Governance Report

Mr McGee drew attention to the Governance Report and advised that there were three items for approval/information/action by the Board as follows:-

Board Assurance Framework

Annual Report & Accounts and Quality Report 2018/19

Review of Board Effectiveness


Mr Burrow advised that the Quality Committee, Finance Committee, Workforce & Transformation Committee and Audit Committee had reviewed the BAF since the last Board meeting and had made recommendations in relation to BAF 1 and BAF 7A. It was noted that the Audit Committee’s review of the BAF indicated only partial assurance that the risks were being sufficiently mitigated.

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With regard to BAF 6 (finance), Mr Murphy reported that the risk score was currently 16 and he queried whether the risk should be reviewed and escalated. Mr Bennett confirmed that this risk was reviewed at each Finance Committee meeting and the Chairman advised that he would be expecting the Finance Committee to report on the level of assurance.

RESOLVED: That the Board Assurance Framework be approved.

Annual Report & Accounts and Quality Report 2018/19 It was noted that the final version of the Annual Report & Accounts and Quality Report 2018/19 has been printed, laid before Parliament and uploaded to the Trust’s website.

Board Effectiveness Review Board members were reminded that the Board Committees had recently undertaken an effectiveness review and were advised that a review of the effectiveness of the Board would now be undertaken. Board members were requested to complete and return the questionnaire.

RESOLVED: That all Board members would complete and return the Board effectiveness questionnaire. Action To Be Taken Following The Meeting Completed questionnaires are outstanding from some Board members.

d) Freedom To Speak Up Quarterly Report

This item was deferred until the scheduled time of 11.50 am.

80/19 Items for Information/Discussion/Approval

a) Attendance Monitoring The attendance monitoring form identified that Board members were achieving the required attendance performance target.

b) Trust Values / Examples of Value of the Month

It was noted that the value of the month for August had been “Compassion” and reference was made to the following agenda items in terms of compassion:-

Patient Story DVD – demonstrated a lack of compassion during the patient’s clinic appointments.

IPR (workforce) – identified high sickness levels, possibly due to staff being under pressure, which highlighted the need to show compassion.

Quality Improvement Plan and Nurse Leadership Structure – identified pressures in the system which needed to be recognised.

c) Key Themes from Team Brief

Board members considered the key themes from the meeting to be included in Team Brief.

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RESOLVED: That the following items would be included in Team Brief:-

Patient Story

CQC Update

Quality Improvement

Nursing Leadership Structure

Workforce Transformation Strategies.

At this juncture, Dr Goode made a plea for Executive Directors to visit the wards to meet the staff and show that they cared. The Chairman advised that ward visits had been discussed with the Non-Executive Directors at an earlier meeting and that he would be liaising with Mr Murphy about future visits.

RESOLVED: That the Chairman would liaise with Mr Murphy regarding ward visits for the

Non-Executive Directors. Action To Be Taken Following The Meeting The agreed items were included in Team Brief. A report relating to ward visits is being drafted for consideration by the Board.

81/19 Any other Business

There was no other business.

82/19 Items Recommended for Discussion or Decision by Board Committees RESOLVED: That the following items be recommended for discussion or decision by

Board Committees:-

EU Exit Preparations – Board Committees and Informal Board Meeting.

Quality Improvement Plan / Investment Requirements – Formal Board Meeting.

Action To Be Taken Following The Meeting

The recommended items have been discussed/agreed by Board Committees. 83/19 Questions from the Public

The Chairman reported that two questions had been received in advance of the meeting from Mr Alexandrou and Dr Chauhan, both of whom had received an emailed response and both of whom were given the opportunity to raise their question at the meeting. a) Information Technology (Mr Phil Alexandrou) Mr Alexandrou advised that there was a significant difference in the take-up of the use of IT in communication with the patient base at other Trusts compared with Blackpool Teaching Hospitals Trust.

Mr Alexandrou informed the Board that, some years’ ago, he had asked the Chief Executive (Gary Doherty) why the Trust was not using IT more comprehensively with the patient base and that he had then met the subsequent Chief Executive (Wendy Swift) who had advised that text messaging was being introduced to avoid DNAs. Mr Alexandrou therefore asked again why technology was not being used to improve the patient experience, possibly saving money in the process.

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Mr Alexandrou advised that he had received a response from Mr Steven Bloor which was encouraging, in particular in relation to the roll-out of an electronic patient appointments system. It was hoped that the new Chief Executive would ensure that the plans were made into reality. The Chairman advised Mr Alexandrou that his analysis was correct in terms of the comparison with other Trusts, however, improvements were being made and the Board had considered information technology, in particular, an electronic document management system which is scheduled for further discussion in November 2019. b) Substantive Recruitment (Dr Anoop Chauhan)

Dr Chauhan asked about the interim Executive Director appointments and referred to the previous process for Mrs Swift from interim to substantive which had not been transparent. Dr Chauhan also asked about the recent about the chain model and whether there were any plans to work semi-permanently or permanently across Trusts, in particular with East Lancashire Hospitals Trust.

The Chairman advised that a number of changes had been made to the Executive Team and reiterated that interviews for the substantive posts of Medical Director and Director of Nursing & Quality were planned for early October 2019.

With regard to the Chief Executive post, it was noted that an interim joint arrangement was in place with East Lancashire Hospitals Trust but that it was not a chain arrangement and that the Trusts were separate legal entities. It was further noted that the post had been advertised, however, the calibre of candidates had not been sufficient and therefore the Trust was now considering alternative arrangements. The Chairman emphasised that there were no plans for a merger or take-over.

Mr Cullinan commented on the need to be clear about the timescales when making interim appointments which should be on a temporary basis.

79/19 Governance (continued)

e) Freedom To Speak Up Quarterly Report

It was noted that this item had been deferred until the scheduled time of 11.50 am. Mrs Terri Vaselli, Freedom To Speak Up (FTSU) Guardian, joined the meeting for this item. Mrs Moynes advised the Board that it was good practice for the Freedom To Speak Up Guardian to report at Board meetings on a quarterly basis. The Chairman asked for a brief introduction to the role of the FTSU Guardian. Mr Moynes reported that the FTSU Guardian was the single point of contact where staff could raise concerns without victimisation or discrimination and he stated that staff were encouraged to speak up, particularly around the quality of care. The Chairman advised that the introduction of FTSU Guardian nationally had arisen from the Mid Staffordshire report. Mrs Vaselli provided a summary of the FTSU activities during Quarter 1 and the future FTSU plans.

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It was noted that the FTSU Strategy was now in draft form and would be submitted to the Board in January 2020. It was further noted that October was national FTSU month and Mrs Vaselli advised on the events taking place, nationally, regionally and locally. She advised that plans were being made for Executive Directors and FTSU Champions to visit wards and community sites. Mr McGee asked for visibility from Board members; it being noted that he had already planned ward/community visits and that the Chairman, Mr Hearty and Mr Moynes had also expressed an interest.

RESOLVED: That Board members would contact Mrs Vaselli regarding their availability

for ward/community visits. Action To Be Taken Following The Meeting Some Board members have undertaken ward/community visits.

84/19 Formal Meeting Review

It was noted that this item required the Board to review the formal outcome of the meeting. The Chairman’s view was that it had been a good meeting in terms of the focus on quality but that the Board should be under no illusion that there was much work to be undertaken in terms of the patient experience and quality of care.

85/19 Date of Next Meeting The next meeting will take place on Tuesday 5th November 2019. 86/19 Resolution to Exclude Members of the Media and Public

RESOLVED: That representatives of the media and other members of the public be

excluded from Part Two of the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest.” in accordance with Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960) and the Public Bodies (Admissions to Meetings) (NHS Trusts) Order 1997.

The Chairman thanked the observers for their interest in the Trust and for the two questions raised in advance of the meeting.

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Board of Directors Meeting

Action List

3rd September 2019

Minute

Ref/No

Date Of

Meeting

Agenda Item Heading Action To Be Taken Person

Responsible

Date To Be

Completed

Change Of

Date

Progress RAG

Status

72/19 3.9.19 Previous Minutes Amend item 60/19(b) in the minutes prior

to Chairman's signature.

Judith Oates 10.9.19 This item has been actioned. Green

76/19© 3.9.19 Quality Improvement

Strategy

Implement the Quality Improvement

Strategy in terms of the £500,000 funding.

Peter Murphy on-going Implementation is progressing, with interviews for

the post of Associate Director of QI scheduled for

8.11.19.

Green

76/19(c) 3.9.19 Quality Improvement

Strategy

Consider the funding arrangements for

additional resources and provide feedback

to the Board.

Executive

Directors

5.11.19 EDs agreed at the meeting on 17.9.19 to discuss

with a wider audience and report to the Board in

November (deferred).

Amber


Strategy

Support the quality improvements and

continue discussions at future Board

meetings.

Board Members 5.11.19 This item has been included on the draft agenda

for the Board meeting on 5.11.19 (deferred).

Amber


Strategy

Submit a PID regarding pressure sores to

the Board.

Peter Murphy 7.1.20 This item will be submitted to the Board in

January 2020.

Amber

76/19(d) 3.9.19 Nursing Leadership

Structure Benchmarking

and Ward Based Staffing

Benchmarking

Implement the proposed nursing

leadership structure.

Peter Murphy on-going Implementation is progressing, with the advert for

the Band 8b nursing staff now finalised.

Amber

76/19(d) 3.9.19 Nursing Leadership

Structure Benchmarking

and Ward Based Staffing

Benchmarking

Submit a comprehensive improvement

plan to the Board in November 2019.

Peter Murphy 5.11.19 This item has been included on the Board agenda

for the meeting on 5.11.19.

Green

76/19(e) 3.9.19 EU Exit Preparations Ensure that the Board Committees (and

Board members via the informal Board

meeting in October) are kept up to date

with developments.

Berenice Groves 31.10.19 An update was provided at the Informal Board

Meeting on 2.10.19 and a further update will be

provided at the Board Meeting on 5.11.19.

Green

77/19 3.9.19 Workforce Transformation

Strategies

Pursue the issue of exit interviews outside

the meeting.

Kevin Moynes 30.9.19 All staff are provided with an opportunity to

undertake an exit interview either on-line or with a

member of staff (Manager or HR). There are

plans to move to "stay" interviews as part of the

NHSI Retention programme.

Green

77/19 3.9.19 Workforce Transformation

Strategies

Consider how to address the issue of

promoting the strategies across the ICS.

Kevin Moynes 30.9.19 Discussions within the ICP are progressing in

terms of use of resource opportunities. Regional

HRDs already share workforce transformation

strategies and via .Local Workforce Action

Boards.

Green

Page 1 of 225


Action List

3rd September 2019

78/19(a) 3.9.19 Integrated Performance

Report

Consider the investment needed to

improve quality and address the CQC

concerns.

Board Members on-going This item will be addressed as part of the CQC

improvement plan.

Amber

78/19(b) 3.9.19 IPR - Development Proposal Report progress on the development

proposal to the Board.

Tim Bennett 2.10.19 /

5.11.19

An update was provided at the Informal Board

Meeting on 2.10.19 and a further update will be

provided at the Board Meeting on 5.11.19.

Green

78/19(b) 3.9.19 IPR - Development Proposal Submit an options report on the format to

the Informal Board meeting in October

2019.

Tim Bennett 2.10.19 An update was provided at the Informal Board

Meeting on 2.10.19.

Green

79/19(a) 3.9.19 Board Committee

Assurance Reports

Include the challenges of balancing quality,

performance and finance on the agenda

for the Informal Board Meeting in October

2019.

Tim Bennett 2.10.19 An update was provided at the Informal Board

Meeting on 2.10.19.

Green

79/19(a) 3.9.19 Board Committee

Assurance Reports

Include the induction arrangements for

security and fraud on the agenda for an

Executive Directors meeting in September

2019.

Tim Bennett 30.9.19 This item was included on the agenda for the EDs

meeting on 24.9.19.

Green

79/19(c) 3.9.19 Governance Report - Board

Effectiveness Review

Complete and return the Board

effectiveness questionnaire.

Board Members 17.9.19 Completed questionnaires are outstanding from

nine Board members.

Red

80/19(C) 3.9.19 Team Brief Include the agreed items in Team Brief. Judith Oates 4.9.19 This item has been actioned. Green

80/19(C) 3.9.19 Team Brief Liaise with Peter Murphy regarding ward

visits for the NEDs.

Chairman 3.12.19 A report is being drafted by Peter Murphy for

consideration by the Board.

Amber

82/19 3.9.19 Items Recommended for

Discussion of Decision by

Board Committees

Include "EU Exit Preparations" on the

agenda for the next Board Committee

meetings and the Informal Board Meeting.

Berenice Groves Oct-19 This item has been actioned. Green

82/19 3.9.19 Items Recommended for

Discussion of Decision by

Board Committees

Include "Quality Improvement Plan /

Investment Requirements" on the agenda

for the Informal Board Meeting in October

2019.

Peter Murphy This item was discussed at the Informal Board

Meetings on 6.8.19 and 2.10.19.

Green

84/19(e) 3.9.19 Freedom To Speak Up

Quarterly Report

Contact Terri Vaselli regarding availability

for ward/community visits.

Board Members 30.9.19 This item has been actioned. Green

RAG Rating

Green Completed

Amber Pending

Red Overdue

Page 2 of 225


Action Tracking Document

Minute

Ref/No

Date Of

Meeting

Agenda Item Heading Action To Be Taken Person

Responsible

Date To Be

Completed

Change Of

Date

Progress RAG

Status

89/18 (d) 28.11.18 Strategy & Assurance

Performance Reporting -

Quality Committee Summary

Submit a summary report to a future Board

meeting relating to the document entitled

"Developing Workforce Safeguards".

Kevin Moynes /

Pete Murphy

18.4.19/

7.5.19

24.10.19/

5.11.19

This item will be discussed at the Strategic Workforce

Committee meeting in April 2019 prior to being reported

to the Board (deferred to the Strategic Workforce

Committee in July 2019). An initial review of the

document indicates that the Trust is on track and a

progress report will be submitted to the Strategic

Workforce & Transformation Committee meeting on

24.10.19 and the Board meeting on 5.11.19.

Red

24/19 (d) 27.3.19 Chief Executive's Report -

Board of Directors Terms of

Reference

Review the Board's practice in the context of the

Terms of Reference.

Chairman 30.6.19 7.1.20 This item will be actioned during the first quarter of the

new financial year. This item has been deferred and

will be actioned as part of the review of all Terms of

Reference.

Red

60/19 (a) 2.7.19 NHSI Enforcement

Undertakings Letter

Provide an update on the single plan once the

actions from the CQC inspection are known and

have been included within the document.

Peter Murphy Nov-19 This item will be actioned following receipt of the CQC

report and will be included on the agenda for the Board

meeting on 5.11.19.

Amber

60/19 (b) 2.7.19 Integrated Performance

Report - Workforce

Review and reformat the IPR and subsequently

consider the future format of the Committee

Chair Assurance Reports.

Executive

Directors

3.9.19 7.1.20 The IPR is being reviewed for sign-off by the Board in

January 2020. The Committee Chair Assurance

Reports will be replaced on the Board agenda with the

committee minutes.

Red

63/19 2.7.19 Any other Business - Seven

Day Services Assurance

Arrange for future seven day services data to be

submitted to the Quality Committee for

consideration/approval.

Peter Murphy 30.9.19 5.11.19 The timescales for both data submission and reports to

the Quality Committee and Board are being reviewed.

Red

31/10/2019 Page 1 of 225


Action Tracking Document

31/10/2019 Page 2 of 225

1


5th November 2019

Chief Executive Officer Report

Report Prepared By: Kevin McGee, Chief Executive Officer

Contact Details: Ext 55990

Date of Report: 22nd October 2019

Purpose of Report: To provide, for information, a summary of national, health economy and internal developments.

☒ For information

☐ For Discussion

☐ For Approval

Risks Associated with Report on BAF or CRR: BAF 4 - Due to national shortages in nursing, medical and support staff the Trust may deliver suboptimal care

☒ BAF

☐ CRR

☐ Not Linked to Corporate Risk

Assurance Level:

☒ Full

☐ Partial

☐ No Assurance

Recommendations:

Board members are requested to receive the report and note the information provided.

Sensitivity Level:

1

☒ Not sensitive: For immediate publication

2

☒ Sensitive in part: Consider redaction prior to release

3

☐ Wholly sensitive: Consider applicable exemption

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Board of Directors

5th November 2019

Chief Executive Officer Report Background This report is divided into five sections:-

Section One - details major national headlines;

Section Two - reports news from across the Fylde coast;

Section Three - notes Trust updates, news and initiatives which are aligned to the Trust’s values;

Section Four - shows the external communications and engagement interactions;

Section Five – provides a summary of the Chief Executive’s diary.

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Section One - National Headlines Top news reports gathered from NHS Improvement, NHS Providers, Health Service Journal and other reputable news sources. Brexit deal After the prime minister and the European Union (EU) agreed a deal on the UK's withdrawal from the EU, parliament met on Saturday to consider the deal. The government had intended for parliament to approve the deal, however MPs instead voted in favour of an amendment to withhold approval of the deal until all the necessary legislation to implement it had been passed. In accordance of the 'Benn Act' (designed to eliminate the possibility of a no-deal exit on 31 October) Boris Johnson wrote to the EU requesting a delay to the UK's departure. The EU have noted the extension request and will consider it next week. This week the government presented the EU (withdrawal agreement) bill to parliament – which is the legal framework for the prime minister's proposed Brexit deal. MPs voted in favour of the principle of the bill, but voted against the proposed timetable for the bill's passage through parliament. The government subsequently paused the Bill's passage through parliament and will await the EU's consideration of the prime minister’s request for an extension, before deciding on a new timetable for the bill or to call for a general election. NHS Providers will continue to monitor all Brexit related developments. Hospitals substitute nurses as staffing crisis worsens The number of hospitals falling short of their planned nurse staffing by 10 per cent or more has almost tripled in five years, HSJ has learned. An analysis of unpublished workforce data by HSJ reveals the gap between the number of nurses hospitals think they need, and what they are able to staff it with, has grown since 2014. The number of hospital trusts reporting a shortfall of 10 per cent or more on their day shifts increased from 20 in June 2014 to 55 in June 2019 – nearly triple. The data shows a small improvement over the year to June 2019, the reason for which is unclear. Meanwhile, in every single month from 2014 to June 2019, a majority of hospitals fell short of their planned nurse staffing number. Experts said the data showed the NHS was “drifting into massive skill mix change” as hospitals overstaff with support workers, while having to run shortfalls of nurses, despite evidence this has a “detrimental impact on patient outcomes including survival”. Developing allied health professional (AHP) leaders AHPs are the third largest clinical workforce in the NHS, working across organisational boundaries on most clinical pathways — providing solution-focused, goal-centred care to support patients’ independence. As the NHS Long Term Plan notes, there has never been such a need to harness the AHP workforce’s potential for transforming healthcare. NHS Improvement and NHS England have develop a document ‘Developing allied health professional leaders: a guide for trust boards and clinicians’ which combines trust executives’ expectations of AHP leadership, with individual accounts from chief AHP leaders, identifying the common features of AHP leadership journeys. It has been developed to provide ideas and opportunities for aspiring AHP leaders, and those who support the development of the AHP workforce, to ensure we are developing the leaders the NHS needs for the future. Report on the review of screening services in England NHS England have invited Professor Sir Mike Richards to carry out a review of adult cancer services in November 2018 following two national incidents being declared in breast and cervical screening. The remit of the review was then extended to all adult screening programmes. The report shows the NHS has a lot to be proud of with its screening services, but that there are still areas for improvement. The recommendations include opportunities to upgrade cancer screening, a call for people to be given greater choice over when and where they are screened and improvements to the design of screening programmes.

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https://improvement.nhs.uk/resources/nhs-long-term-plan/

https://improvement.nhs.uk/resources/developing-allied-health-professional-leaders-guide

https://improvement.nhs.uk/resources/developing-allied-health-professional-leaders-guide

https://www.england.nhs.uk/2019/10/modern-screening-can-be-more-personalised-and-convenient-to-save-lives-says-new-report/

4

Section Two - Fylde Coast and Lancashire Headlines Important updates and information reflecting work being carried out by the Integrated Care Partnership for the Fylde coast and across Lancashire. Blackpool’s Cancer Choir A choir has been set up for people who have been affected by cancer living on the Fylde coast. Blackpool Cancer Choir was developed by the Macmillan team at Blackpool Victoria Hospital, following an idea to engage with the community and with people who care for someone, are a relative, or a previous or present cancer patient. The group is for singers and non-singers and it will be held on the first Wednesday of the month at Blackpool Carers Centre on Newton Drive. The main idea of the group is to provide an opportunity to socialise and to tackle loneliness. Sepsis September The Trust and partners took part in a major campaign to raise awareness of sepsis throughout September. Sepsis survivor, Tom Ray and his wife Nicola, held teaching sessions for staff and saw the film of their experiences shown at Blackpool’s Regal Cinema to a packed house. Professor Morris Gordon, Quality Strategy Lead, from the Trust, said: “The idea of this event is to put a different light on the topic of sepsis. “Members of staff within the NHS were deeply moved by Tom and Nicola’s story when they visited the trust last October. Their experiences allowed us as healthcare professionals to not just consider the pathways and targets as ways of improving care, but to understand what sepsis means to individuals.’’ “Our continuing work in enhancing care for sepsis is not just occurring with our hospital trust, but in partnership with the wider health and social care footprint over the whole region. Sharing knowledge and understanding of Tom and Nicola’s story can help empower patients and the public regarding sepsis and we are very grateful to have this opportunity to share their experiences to such a wider audience.” Big White Wall A FREE mental health resource for people living with depression and other conditions is now available across the whole of Blackpool, Fylde and Wyre. Big White Wall, which is available at www.bigwhitewall.com, provides a clinically safe and anonymous online community providing peer to peer support, personal assessments and self-help courses for those who need it. And thanks to NHS Blackpool and NHS Fylde and Wyre Clinical Commissioning Groups (CCGs), the service is now available to all people with a Fylde Coast postcode. Dr Neil Hartley-Smith, a Blackpool GP and clinical adviser to the CCGs, said: “We are committed to supporting people living with mental health on the Fylde Coast by providing varied and high quality services for them to access. “Big White Wall is a fantastic tool for people who are suffering as they can log in anonymously and express how they are feeling to a community of people who feel the same way. Helping those bereaved by suicide A SERVICE providing support to those bereaved by a suspected suicide has received additional funding so that it can continue helping Lancashire residents. AMPARO (which means ‘shelter’ or ‘safe haven’ in Spanish) Fylde Coast and AMPARO East Lancashire have both had their funding extended until March 2020, so they can offer vital support to local people.

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http://www.bigwhitewall.com/

5

The service provides support for anyone affected by suicide, including family members, friends or colleagues. AMPARO provides support in a range of ways including; one-to-one individual support, help with media enquiries, support and guidance up to and including the inquest and signposting to further services. Louise Thomas, Suicide Prevention Lead for Healthier Lancashire and South Cumbria, said: “It’s fantastic news that AMPARO can continue to offer its invaluable service to people going through the unimaginable. “We have one of the highest rates of suicide in the country and we know that those bereaved by suicide are at much higher risk, therefore it is crucial we are able to provide immediate help and support to those bereaved.”

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Section Three – Blackpool Teaching Hospitals NHS FT Headlines CQC report praises staff The Care Quality Commission (CQC) has today published the findings of its inspection of the Trust in June. The outcome of this inspection is that the Trust has maintained its overall rating of REQUIRES IMPROVEMENT. It also, however, gave the Trust a rating of GOOD for caring which is testament to you, our staff. Inspectors repeatedly praised staff for being caring, kind, supportive and compassionate and we want to thank you all for your tremendous efforts. Medical Director and Director of Nursing appointments After full and extensive interview processes I am delighted to announce that Dr Jim Gardner has been appointed as the Trust’s Medical Director and Peter Murphy has been appointed to the role of Director of Nursing. As Peter is already working for the Trust he will commence his role with immediate effect. Jim’s start date has yet to be confirmed but we will advise all staff once this date is agreed.

Virtual reality to help train Blackpool clinicians

Virtual reality is about to revolutionise the way a Blackpool hospital trains the clinical staff of tomorrow. Blackpool Teaching Hospitals has received four virtual reality (VR) systems allowing state-of-the-art teaching within its Simulation and Skills learning suite. VR tests a student’s ability to analyse a situation and respond appropriately to the information available while keeping open communication channels with both the patient and other members of staff. Mark Hatch, Clinical Skills Facilitator, at Blackpool Victoria Hospital, said: “Using VR headsets the student gets complete immersion and can repeat scenarios they have done in simulation, it’s about learning from repetition.” Top accolade for Blackpool Teaching Hospitals’ radiology department Blackpool Teaching Hospitals’ Radiology Department has proved it is one of the best in the country after maintaining its accreditation with the Imaging Services Accreditation Scheme (ISAS) for the eighth year running. The accreditation, which is approved by the Royal College of Radiologists and Society of Radiographers, is a national mark of quality which is held by only a small number of NHS Hospital Trusts in the country. To receive an accreditation, organisations must showcase best practice in patient experience, clinical effectiveness, and patient and staff safety.

The Trust was the first radiology/diagnostic imaging service to achieve ISAS accreditation within the NHS. Vera Mountain, Radiology Manager at the Trust, said: “ISAS accreditation provides evidence for commissioners, providers and patients that this has been an externally assessed imaging service and is safe and of a high quality.’’

Top accolade for Trust Occupational health team

Blackpool Teaching Hospitals NHS Foundation Trust’s Occupational Health & Wellbeing department has been recognised for the high standard of service it provides to staff with a nationally recognised re-accreditation.

The team has achieved and was awarded with the Safe Effective Quality Occupational Health Service (SEQOHS) Accreditation following a formal, independent assessment.

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SEQOHS is a scheme run by the Royal College of Physicians in association with the Faculty of Occupational Medicine. The accreditation criteria is measured against a set of comprehensive standards designed to help raise the level and quality of care provided by Occupational Health & Wellbeing providers.

Launched in December 2010, the standards cover areas such as staff competency, safety and accessibility of facilities and equipment, and meeting specific NHS standards. Patients more likely to survive cardiac arrest in Blackpool Whenever a cardiac arrest occurs at Blackpool Victoria Hospital a team of highly trained, specialist staff are immediately alerted and rapidly get to that person to give them every chance possible of survival. Nationally the average chance of survival from cardiac arrest to hospital discharge is 19 per cent. But Blackpool has been named as one of the top hospitals for successful resuscitation with a survival rate identified at 40.8 per cent. The figures are released in the National Cardiac Arrest Audit Report (NCAA) which monitors the number of in-hospital cardiac arrests and their outcomes to identify possible patterns that could lead to improvements in resuscitation. The figure for initial Return of Spontaneous Circulation (ROSC), which is the resumption of sustained cardiac activity, is 45 to 50 per cent of all in-hospital cardiac arrests nationally. In Blackpool the figure is 71.4 per cent which means patients have a higher likelihood of neurologically-intact survival. The national report covers the quarter from April 1 to June 30, 2019 and shows how many cardiac arrests occurred and what the survival rate was. The report also shows the location, times and days of the week cardiac arrests happen to help clinicians identify themes.

Digital team scoops top innovation award A digital health team from Blackpool Teaching Hospitals have won an innovation award for their remote end-of-life service. The Trust team and Trinity Hospice, in partnership with The Hamptons and Sandycroft nursing homes, revolutionised patient care and improved effective use of time and resources, by introducing virtual technology which remotely connected patients and specialist clinicians. The results of this collaboration were so impressive the scheme has taken first place in the North West Skills Development Network’s innovation category. During a 12-month period, 360 patients were contacted using a weekly one hour virtual clinic at the three pilot sites. Only seven patients required a face-to face follow up which resulted in more than 867 clinical hours saved. A huge £21,052.51 was saved showing an increase in efficiency of 91%. Trinity Hospice community service manager, Sarah Roberts, said “Patient feedback has been extremely positive as they have found the interactions fun and convenient. “Patients at the end of their life don’t want to wait all day for an appointment to talk about death and dying, they want to be making the most of the time they have with their loved ones.” Use of the Seal

The Board of Directors is requested to note the use of the Seal on 25th September 2019 in relation to a Variation Agreement between the Trust and Lancashire County Council for the provision of Steady On! Fylde and Wyre (Section 75).

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Section Four – Communications and Engagement

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Section Five - Chief Executive’s Meetings Below is a summary of the meetings the Chief Executive has chaired or attended in September and October 2019. September 2019

Date

Meeting

3rd

September Formal Board of Directors Meeting Corporate Trustee Meeting Remuneration Committee Governor Strategic Focus Group

4th September Non-Executive Directors Conference Call

4th September Integrated Care System Board meeting

5th September EXPO Event, Manchester

6th September Chief Executives Provider Board

6th September Innovation for Health Call

6th September Tracey Longfield, DAC Beachcroft

6th September David Cockayne, The Value Circle

6th September Integrated Care System / Integrated Care Partnership Workshop

9th September Professor Anoop Chauhan, Cardiology Consultant (Chair of JLNC)

9th September Tim Bennett, Deputy Chief Executive/Director of Finance

9th September Pete Murphy, Director of Nursing and Quality

9th September Incident Co-ordination Panel

9th September Diagnostic Programme Board

10th September Chris Ryan, Staff Side Representative

10th September Senior Leadership Forum

10th September Executive Directors Meeting

10th September Pearse Butler, Chair

10th September Simon Raffaelli, Head of Transformation


12th September Quality Improvement Board

13th September Recruitment Panel (External Trust)

16th September Priya Bala, NHS Interim Management and Support


16th September Alan Wilson, Coroner and Pete Murphy, Director of Nursing and Quality

16th September Bill McCarthy, NHS Improvement – telephone call

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17th September Dr Achyut Guleri, Consultant Microbiologist

17th September Senior Leadership Forum

17th September Executive Directors Meeting

17th September Pearse Butler, Chair

18th September Future Doctors Briefing (London)


19th September Integrated Care Forum (Manchester)


23rd

September Bill McCarthy, NHS Improvement - Chairs of BVH and ELHT

24th September North West Leadership Forum, Royal Blackburn Hospital

25th September Nicki Latham, NHSI Improvement Director

25th September East Lancashire Hospital Annual General Meeting

26th September HSJ Judging Panel (London)

27th September Recruitment Panel (ELHT)

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October 2019

Date

Meeting

1st October Dr Grahame Goode, Acting Medical Director

1st October Pearse Butler, Chair

1st October Director of Nursing and Quality Interview Process

1st October David Holden, Governance Adviser

1st October Les Stove, Assistant Chief Executive, East Lancashire Hospitals

1st October Blackpool Better Start Board Meeting

2nd

October Informal Board of Directors Meeting

2nd

October Blackpool and Fylde System Assurance Meeting

2nd

October Integrated Care Partnership Development Meeting

3rd

October David Cockayne, The Value Circle and Pearse Butler, Chair

3rd

October Derek Quinn, Head of Communications

3rd

October Interview Process for Medical Director Post

7th-11

th October Annual Leave

15th October Senior Leadership Forum

15th October Executive Directors Meeting

15th October Nicki Latham and Charlotte Walton, NHSI Improvement Directors

15th October Winter Plan Conference Call

15th October Dr Grahame Goode, Acting Medical Director

15th October Dr Jim Gardner, Non-Executive Director

15th October David Holden, Governance Advisor

16th October Non-Executive Director Conference Call

16th October Integrated Care System - System Leadership Event

16th October Winter Stocktake Call, NHS England and NHS Improvement)

17th October Rory Deighton, NHS Confederation

18th October Dr Gavin Galasko, Consultant and Research and Development Lead

18th October Charlotte Walton, NHSI Associate Director

18th October Sandy Bradbrook, Mentorship Consultant

22nd

October Berenice Groves, Interim Director of Urgent & Emergency Care

22nd

October Senior Leadership Forum

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22nd

October Executive Directors Meeting

22nd

October Pearse Butler, Chair

22nd

October Penny Dash, McKinsey

22nd

October Feroz Patel, Chief Finance Officer

23rd

October Winter Performance and Risk Management Conference Call

23rd

October Dr Linda Hacking, Postgraduate Tutor

23rd

October Les Stove, Assistant Chief Executive, East Lancashire Hospitals

24th October CQC NHS External Event (London)

25th October Meeting with Consultant Anaesthetic Body

25th October Professor Brian Henderson, University of Central Lancashire and Pete Murphy, Director

of Nursing and Quality

25th October Steven Bloor, Chief Information Officer

25th October Freedom to Speak Up – Walkabouts

29th October Dr Jim Gardner, Non-Executive Director

29th October Financial Strategy Workshop

29th October Executive Directors Meeting

29th October Peter Mason, Odgersberndtson

29th October Pearse Butler, Chair

30th October Non-Executive Directors Conference Call

30th October Peter Higgins and Lancashire Consortium of Local Medical Committees

30th October Tim Bennett, Deputy Chief Executive/Director of Finance

30th October Peter Shanahan, Ernest Young

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CQC Diagnostic Improvement Plan.

Summary of the CQC Diagnostic Improvement Plan

BLUE Milestone successfully achieved

GREEN Successful delivery of the project is on track and seems highly likely to remain so, and there are no major outstanding issues that appear to threaten delivery significantly.

AMBER/GREEN Successful delivery appears probable however constant attention will be needed to ensure risks do not materialise into issues threatening delivery.

AMBER Successful delivery appears feasible but significant issues already exist requiring management attention. These appear resolvable at this stage and if addressed promptly, should not cause the project to overrun.

AMBER/RED Successful delivery is in doubt with major risks or issues apparent in a number of key areas. Urgent action is needed to ensure these are addressed, and to determine whether resolution is feasible.

RED

Successful delivery appears to be unachievable. There are major issues on project definition, with project delivery and its associated benefits appearing highly unlikely, which at this stage do not appear to be resolvable.

Version Version 1.0

Date 25/10/19

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CQC & BLACKPOOL TEACHING HOSPITALS TRUST – IMPROVEMENT PLAN AND OUR PROGRESS

2 08b - CQC Improvement Plan

What and why we need to improve

During June 2019, the CQC inspected all core services as part of an intelligence led comprehensive inspections at BTH. On 17th October 2019, the CQC Head of Hospitals Inspection wrote to confirm immediate actions that needed to be taken to address immediate patient safety concerns, discovered during the inspection. The concerns that require action are across the following main service areas:

Trust wide

Urgent & Emergency Care

Medical Care

Surgery

Critical Care

Outpatients

Child & Adolescent Mental Health Services

Community Services for Children and Young People

Community Dental Services In September 2019, following the appointment Kevin McGee as CEO, a Quality Improvement Strategy for Blackpool Teaching Hospitals was produced and approved by the Board of Directors following a comprehensive diagnostic review of the causes of risk to patient safety and care sustainability.

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The diagnostic focus was to identify areas for improvement that impacted on patient safety. It was not a full investigation into all aspects of operations of the trust. The diagnostic was informed and complimented the immediate concerns raised by the CQC – The following areas to improve patient safety, harm and outcomes will be prioritized and are to be delivered via the formal activity of the Quality Improvement Directorate and reported via the Board of Directors

Mortality

Avoidable Harm

Last 1000 days of life In addition, the following key areas for corporate improvement identified are:

Assurance and governance arrangements

Operational management and data quality

Workforce capacity and capability

Leadership and external relations The CQC report has now been published (October 2019). The CQC identified 32 ‘Must Dos’ and 86‘Should Dos’ to ensure sustainable improvement to care delivered across Blackpool Teaching Hospitals. The full report corroborates the findings of the Chief Executives Diagnostic. The full CQC report has established evidence that Blackpool Teaching Hospitals overall is rated Requires Improvement, Caring as Good, with Well Led being rated as Inadequate.

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All of the CQC ‘must dos’ and ‘should dos’ have been mapped across to the themes for improvement identified in the Chief Executives Diagnostic. This improvement plan sets out the immediate (first 9 months) improvement actions – this is to ensure we are getting the basics right, stabilising services and creating the right conditions upon which we can continue to improve and ultimately transform care delivery across BTH. Our quality improvement strategy aims to go beyond the immediate concerns raised by the CQC report, we will engage our staff in a quality improvement strategy that will result in our services to be rated good or outstanding by regulators, that our staff would rate as a good place to work and a good place for their relatives to be cared for. The 32 ‘Must Do’s’ have been allocated an executive lead, with operational managers identified and a relevant to provide assurance to. The 86 ‘Should Do’s’ will be further reviewed with the CQC and will be priortised to ensure we manage the program of improvement and not overwhelm the Trust. They will be allocated to the action plan once we have formally agreed with the CQC.

Who is responsible? The Trust Chief Executive, Kevin McGee, is ultimately responsible for implementing the actions in this document. The Trust executive team will provide the leadership to ensure we identify the right improvement actions that will tackle some of the long standing issues the Trust has faced and create the right conditions to deliver the changes required. Our site leadership teams, divisional triumvirates and clinical leaders across the Trust will be key to delivering the actions that will ensure service sustainability and transformation. The high level deliverables articulated in this plan are underpinned by weekly improvement actions that clinical and management teams have developed and own.

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The Fylde Coast System Improvement Board will bring together parts of the local health and care economies to ensure there is a shared understanding and collective commitment to the delivery of the improvement plan, including resources that need to be made available to enable the changes to happen. It is evident that the Trust has many thousands of staff trying to deliver good standards of care to patients. However, we need to create a culture of continuous improvement supported by robust governance and accountability arrangements from Board to ward which ensures leaders are focused on the key risks to the delivery of excellent care.

How will we measure our improvement? Measurement of our improvements will be fundamental to ensuring sustainability and the reliability of our care. We will develop a high level assurance dashboard against our key themes that measures our progress. We need to ensure that our improvement actions and activities are translating to improvement in outcomes for patients using a small number of key performance indicators. We will assure our improvement plan through our Trust board and Non-Executive assurance committees. Each ‘Must Do’ has been allocated to a Board Assurance Committee with both an Executive lead and a delivery lead. Each committee meeting agenda will be amended so that assurance against progress of the key milestones can be monitored and any risks mitigated. All must do’s will be allocated to the appropriate risk register entry. This will be facilitated by the corporate governance team and overseen by the Trust Company Secretary.

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How will we communicate progress? Internal Communication to staff within the Trust will utilise the full range of existing communication channels and our new leadership arrangements to listen, update and engage staff in the delivery of the improvement plan. Briefing of key issues through the line management structure; use of dedicated pages on the Trust intranet and articles on our improvement journey will feature in the weekly newsletter. Any matters which require immediate communication will be sent through an all user email. There are multiple routes for staff to feed-back comments including the Freedom to Speak Up. We have commenced our Senior Support and Sharing walk rounds. The Big Conversation events allow for face to face discussion with senior leaders. We are committed to increasing our Safety Walk rounds where structured engagement events with clinical teams will celebrate success and learn about key service risks. Working in partnership with the multi-agency communications group we will: • Ensure the clear, consistent and integrated delivery of all internal and external communications including staff,

patients, families and carers, commissioners, GPs; • Ensure the public/patients are informed and reassured that services are safe; • Ensure that all key partners and stakeholders are kept up to date and informed about developments, decisions and

any service changes that are required and their impact; • Ensure all related media enquiries are co-ordinated and managed effectively, to ensure clear and consistent

messages and to ensure media coverage is accurate;

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• Work together to manage and protect the reputation of the NHS and social care in Lancashire and the services provided across the local healthcare economy;

• Ensure any subsequent operational or service changes are communicated effectively across Blackpool Teaching Hospitals and the local healthcare system to staff, GPs, the public and externally.

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Must Dos - by Core Service & Theme

Core Service

• Policies

• Duty of Candour

• Culture

• Environmental Risk

Assessments

• Monitoring Quality & Safety

• Safe Storage of Medical Notes

• Risk Escalation and Mitigation

• Medical Staffing

• Nurse Staffing

• Consent

• Patient Choice and Treatment

Choice

• Mental Capacity Act

• Deprivation of Liberty

• Mental Health needs and risks


• Nurse Staffing

• Environmental Risk

Assessments

• Environment Risk Assessments

• Bed Rail Practice

• Consent

• Medical Record Management

• MCA

• DOLS

• Safe storage of personal

medicines

• Critical Care Environment &

Facilities

• Consent

• Medical Record Management

• Patient Choice and Treatment

Choice

• Bed Rail practice

• Record Management

• MCA & DOLS

• Safe storage for personal

medicines

• Safe Staffing

• Safe Storage of Medical Notes

• Surgical and Medical Escalation

• Pain Management Pathways

• Risk Escalation and Mitigation

• Patient Centred Care Treatment

Plans

• Pain Management

• Mixed Sex Accommodation

• CAMHS 18 week pathway

• CAMHS outcome management

• Wait times for Community CYP,

Community Dental, Community

Therapy Services and CAMHS

• National Standards for Critical

Care Environment and Facilities


• Nurse Staffing

• Mixed Sex Accommodation

• Transcatheter Aortic Valve

Implantation pathway & RTT

• Cancer Pathways & RTT

• 18 Week Wait Pathway

• Care and Treatment Outcomes

• Wait Times

• Access to therapy services

• Wait Times for Children GA lists

• Update Policies

• Duty of Candour

• Culture

Trustwide

Urgent & Emergency Care Medical Care

Critical CareSurgery

Outpatients CAMHS

Community DentalCommunity CYP

Governance Safe Staffing

Safe Care & Treatment Person Centred Care

Appendix 1: Must Dos by Core Service & Theme

Themes

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Must Dos by Key Actions and Proposed Leads/Committees

Core Services Must Do Exec Lead Delivery Lead Proposed

Committee

Risk Register

Reference

Trustwide

The trust must ensure there are effective processes to review and

update policies and guidelines based on national

guidance and evidence based practice.

Deputy Director of Quality

GovernanceGovernance Team Exec Directors

The trust must ensure that culture is improved in all staff groups so that

there is no impact on patient care.Director of HR and OD Triumvirates

Workforce

Transformation

Committee

The trust must ensure that the duty of candour is applied in line with

legislation.Director of Nursing

Deputy Director of

Quality GovernanceQuality Committee

Appendix 2: Must Dos by Key Actions and Proposed Leads/Committees

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Committee

Risk Register

Reference

Urgent &

Emergency Care

The trust must ensure that the care and treatment of service users is

appropriate, meets their needs and reflects their preferences. The trust

must ensure that it carries out an assessment of the needs for care and

treatment and it designs care and treatment that meets those needs.

Medical Director UCD TriumvirateClinical Effectiveness

Committee

The trust must ensure that care and treatment of service users is only

provided with the consent of the relevant person and that Mental

Capacity Act 2005 and Deprivation of Liberty legislation and trust policy

is adhered to and documented appropriately.

Nurse DirectorTriumvirate Nurse

Directors.

Clinical Effectiveness

Committee

The trust must ensure the trust meets the needs of patients who present

with a mental health need.Medical Director

Triumvirate Medical

Director of UCD


Committee

The trust must ensure that care and treatment is provided in a safe way

for service users and that the risks to the health and safety of service

users is assessed and that all is done to mitigate any such risks.

Director of NursingNursing lead for

A&E TriumvirateQuality Committee

The trust must ensure that systems and processes are established and

operated effectively to assess, monitor and improve the quality and

safety of the services provided.

Medical Director

Triumvirate Medical

Director for UCD

and Audit Team.

Quality committee

The trust must ensure consultant staffing in the adult emergency

department meets the minimum requirements of the Royal College of

Emergency Medicine.

Medical Director

Triumvirate Medical

Director and

Operational

Manager

Workforce

Transformation

Committee

The trust must ensure the trust deploys sufficient numbers of suitably

qualified, competent, skilled and experienced staff to make sure they

can meet people’s care and treatment needs.

Director of NursingTriumvirate Nursing

Director

Workforce

Transformation

Committee

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Committee

Risk Register

Reference

Medical Care

The trust must ensure that the care and treatment of service users is

appropriate, meets their needs and reflects their preferences. They

must ensure that they carry out an assessment of the needs for care

and treatment and design care and treatment that meets those

needs.


DirectorQuality Committee

The trust must ensure that care and treatment of service users is only

provided with the consent of the relevant person and that Mental

Capacity Act 2005 and Deprivation of Liberty legislation and trust

policy is adhered to.



The trust must ensure that care and treatment is provided in a safe

way for service users and that the risks to the health and safety of

service users is assessed and that all is done to mitigate any such

risks.



The trust must ensure that all medicines are stored properly and

safely.Director of Nursing

Triumvirate Nursing


The trust must ensure that systems and processes are established

and operated effectively to assess and monitor and improve the

quality and safety of the services provided.

Director of Nursing UCD Triumvirate Quality Committee

The trust must ensure that they maintain securely an accurate,

complete and contemporaneous record in respect of each service

user, including a record of the care and treatment provided to the

service user and of decisions taken in relation to the care and

treatment provided.

Director of Nursing &

Medical DirectorUCD Triumvirate


Committee and

Quality Committee

The trust must ensure they deploy sufficient numbers of suitably

qualified, competent, skilled and experienced staff to make sure they

can meet people’s care and treatment needs.

Medical Director

Triumvirate Medical

Director and

Operational

Manager

Workforce

Transformation

Committee

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Committee

Risk Register

Reference

Surgery

The trust must ensure the trust stores records securely.Director of Nursing &

Medical DirectorSC Triumvirate


Committee and

Quality Committee

The trust must ensure that patients have an accurate and timely

assessment of their condition, are monitored appropriately, and are

escalated to medical staff when they need to be.

Medical DirectorTriumvirate medical

director


Committee

The trust must ensure that patients receive appropriate pain relief

without delay.Medical Director

Triumvirate medical

director


Committee

The trust must ensure the trust improves how it monitors, acts, and

records the steps it has taken to reduce and mitigate risk.Director of Nursing

Deputy Director of

Quality

Governance

Quality Committee


Committee

Risk Register

Reference

Critical Care

The trust must ensure the trust follows national guidance and ensures

that the environment and facilities are suitable.Director of Finance Strategy & planning

Operations and

Performance

The trust must ensure the service has enough staff with the right

qualifications, skills, training and experience to keep patients safe from

avoidable harm and to provide the right care and treatment.


Director

Workforce

Transformation

Committee

The trust must ensure it reviews its systems to ensure that all mixed sex

accommodation breaches are reported.Director of Operations UCD Triumvirate Ops and performance

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Committee

Risk Register

Reference

Outpatients

The trust must develop and embed a process for the timely assessment,

monitoring and prioritisation of patients referred for or awaiting

transcatheter aortic valve implantation.

Director of Operations Triumvirate Ops and performance

The trust must ensure it improves waiting times for urgent cancer

referrals in line with operational standards; particularly for those patients

referred with suspected (symptomatic) breast cancer.


The trust must ensure it improves the proportion of people waiting less

than 62 days from urgent referral to first definitive treatment, in line with

operational standards.


The trust must ensure the service improves how it monitors, acts, and

records the steps it has taken to reduce and mitigate risk; particularly

with respect to patients referred with suspected (symptomatic) breast

cancer, and patients referred for or awaiting transcatheter aortic valve

implantation.



Committee

Risk Register

Reference

Child &

Adolescent Mental

Health Services

The trust must ensure that patients’ care and treatment address the

mental health problems identified during assessment.Director of Operations Triumvirate Ops and performance

The trust must ensure that patients wait no longer than 18 weeks from

the point of referral to start treatment.Director of Operations Triumvirate Ops and performance


Committee

Risk Register

Reference

Community

Services for

Children and

Young People

The trust must ensure that it reviews arrangements to admit and treat

patients in line with national targets. Waiting times from referral to

treatment need to improve particularly in therapy services.



Committee

Risk Register

Reference

Community Dental

Services

The trust must ensure it acts to reduce the waiting list for children

requiring a general anaesthetic in the south region.Director of Operations Triumvirate Ops and performance

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Action Plan Template for Completion

Action Plan for Completion

No. Key Actions Start Date End Date SRO

Core Service Delivery Lead

Delivery Lead

Must Do Action

Theme

Ref Date

Identified

Risk Description Risk Owner Risk Score

(LxI)

Mitigating Actions Action Owner

Actions

Risks/Issues

KPIs Baseline Target

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Proposed Governance

Appendix 4: Proposed Governance

Group Attendees Purpose

Delivery Assurance Group Divisional Triumvirate

Chief Nurse

To sign off all CQC action plans

To ensure that any KPIs have been achieved

To ensure that all actions and monitoring is sustainable and there is a forum for

overseeing these going forwards

To be assured that the action can be closed

Agree key actions and areas to highlight for future CQC preparedness reviews

Committees Committee Members To develop and agree to action plans for submission to the Delivery Assurance Group

To hold action owners to account to deliver key action plans

To monitor KPIs and ensure that there are continual check in place moving forwards to

ensure sustainability

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Proposed Governance

CQC Highlight Report: INSERT CORE SERVICE

3

Key

On TrackSlippageRequires attention

Summary to Date

Service Lead

Confidence in Delivery Oct Nov DecAuthor TBA

Upcoming Milestones Due Date Update

Area Status Due Date Key Actions this Month Key Actions Next Month Items to Escalate

Monthly Highlight Report

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3

Key

On TrackSlippageRequires attention

Ref. Date Identified Risk Description Risk OwnerRisk Score

(L x I)Mitigating Actions Action Owner

TBA DD/MM/YY Cause, Effect & Impact16

4 x 4

Service Lead

Author

Key Messages

CQC Highlight Report: INSERT CORE SERVICE

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5th November 2019

Key Leads & Support Roles Benchmarking and Ward Based Staffing Benchmarking.

Report Prepared By: Peter Murphy, Director of Nursing AHP and Quality Simone Anderton Deputy Director of Nursing and Quality.

Contact Details: Ext 53470

Date of Report: November 15th 2019

Purpose of Report: To provide details of benchmarking processes facilitated in relation to nurse staffing levels for wards and district nursing teams. To also provide a review, supported by NHSI, of Allied Health Professional (AHP) leadership and the provision of key support roles linked to end of life care and dementia / learning disabilities. These were triggered as part of a wider review the first part of which, in relation to nursing leadership, was presented at the Board of Directors meeting in August. The review has been in response to the on-going challenges discussed through the Quality Improvement Board, with regulators, of concerns in relation to the quality and safety of care delivery in the organisation and the staffing concerns raised in the CQC inspection report on inadequate staffing resulting in patient significant harm. Staffing concerns are the most frequent measure of quality reported at Board level (Fisk et al 2007) and when asked what one thing would most positively impact the quality of nursing care, CNOs, CEOs and Board Chairs had similar responses addressing staffing, work processes, environment-related improvements and strong leadership. This report relates to the first and last of these elements as part of a wider plan to build a workforce that can support requirements to address regulators current quality and safety concerns within the organisation which are reflected in the recent CQC Inspection Report (October 2019).

For information

For Discussion

For Approval

Risks Associated with Report on BAF or CRR: Maintaining safe staffing. Reducing harm and maintining patient safety. Maintaining CQC regulatory standards.

BAF

CRR

Not Linked to Corporate Risk

Assurance Level:

Full

Partial

No Assurance

Recommendations:

1. The Board supports the establishment of a Chief AHP role, reporting to the Director of Nursing,AHP and Quality to cover all of the AHP professions within the Trust, to compliment and work alongside the enhanced nursing leadership that was agreed at Trust Board in September 2019.

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2. Once appointed the Board supports the Director of Nursing, AHP’s and Quality to conduct a thorough benchmarking exercise of uni-professional leadership structures within and outside the organisation for further consideration by the Board

3. The Board supports the principle of development of a bereavement support team integrated into the palliative care and end of life care team. This will provide appropriate senior leadership that is equitable across the acute and community services and a specialist bereavement service that is available across the acute and community setting, eventually covering 7 days per week.

4. The Board supports the establishment of a Lead Dementia / Learning Disability nurse role, to compliment and work alongside the MCA and DOLS lead already in post, to ensure the care and support we provide patients with Dementia and Learning Disabilities is harm free, provides good patient experience and that patients are adequately assessed with implementation of relevant reasonable adjustments and support provided to meet their specific needs.

5. The Board supports the development of a Ward / Community Accreditation Programme and recognises the need of support mechanisms to realise successful implementation and embedding into the quality improvement programme

6. The Board notes the findings from the independent benchmarking review into ward based staffing. 7. The Board continues supporting 100% fill rate of the current funded establishments. 8. The Board supports alignment of the funded establishments to allow achievement of CHPPD

aligned to benchmarked Trusts. 9. The Board support the proposed funding to Fleetwood and Lytham St Annes team establishments to

ensure that safe caseload principles are met. 10. The Board notes the issue raised regarding therapy resource in the Blackpool neighbourhood care

teams as being inadequate and that this has been raised to Blackpool Council and the CCG along with options for future service provision and potential resource implication.

11. To note the nursing community establishment continues to not include uplift to support the management of planned and unplanned leave.

12. The Board supports the total investment requested and requests that the System Improvement Board discuss and support the proposal.

Sensitivity Level:

1 Not sensitive: For immediate publication

2 Sensitive in part: Consider redaction prior to release

3 Wholly sensitive: Consider applicable exemption

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5th November 2019

Key Leads & Support Roles Benchmarking and Ward Based Staffing Benchmarking Briefing Paper Introduction The purpose of this report is to provide a brieifng of benchmarking processes facilitated in relation to nurse staffing, AHP leadership and key support roles linked to end of life care and dementia / learning disabilities. A full pack of supporting papers is available providing the background detail to each of the sections set out below. The benchmarking process was triggered in response to the ongoing challenges discussed through the Quality Improvement Board, with regulators, of concerns in relation to the quality and safety of care delivery in the organisation and the specific staffing / leadership concerns sighted in the CQC Inspection Report October 2019 in realtion to insufficient numbers of suitable qualified, competent, skilled and experienced staff to make sure patients needs are safely met. The paper provides a view of the need to strengthen leadership and associated accountability to drive forward Quality and Safety agendas across all professional groups. Independent workforce analysts were commissioned to review staffing at Blackpool Teaching Hospitals NHS Foundation Trust as it is recognised that safe registered nurse & midwifery staffing levels are required to deliver safe, effective, quality care and treatment to patients and families accessing healthcare services. In order to deliver services that are efficient and sustainable the right numbers of appropriately skilled people need to be provided. A review of Model Hospital dashboard shows the Trust has a total pay cost per WAU which is in the second lowest quartile nationally and below the NHSI North median. Within this, the Trust has a low medical cost per WAU and a high nursing and AHP cost per WAU. This does not reflect the external assessor benchmarking findings presented below and does not translate to senior professional judgement reflections in practise. Upon exploring the detail with NHSI the WAU data is affected by and reflecting: the high % of clinical output relating to community activity; an increase in lengths of stay, which in part can be linked to the deprivation and associated health needs of the population. Trust-wide staffing sensitive indicators and Trust-wide quality and safety data provides a poor and in some indicators over the last 6 months a worsening trend. The Trust is recognised as an outlier for pressure ulcers prevalence with harm to 387 in-hospital patients to date and 817 community patients. 564 patients have been reported as suffering a harm following a fall year to date and 839 patients suffering harm following a medication error. This ongoing high level of patient harm also correlates to the increase in the number of serious incidents being reported to NRLS and subsequent number of formal SI investigations the Trust is currently holding. Poor quality and safety outcomes are also seen as the driver to a steady increase in the number of complaints the Trust receives. The lack of registered nurses to deal with concerns raised in a timely manner, at source, has attributed to a rise in formal written complaints as well as low staffing numbers contributing to the source of gaps in delivery of quality care. An accumulation of all of the proposals below will provide return from investment to reduce the current poor performance in quality and safety that has also been reflected within the recently published CQC inspection report. Allied Health Professional Leadership As the national profile of AHPs improves, so does the overview and scrutiny of the AHP workforce at a national level which requires a proportionate level of assurance at a provider level. There is a national view of the need to strengthen AHP leadership and associated accountability to drive forward Quality and Safety agendas across all AHP professional groups. The AHP workforce is a collection of 14 unique professions who are autonomous practitioners of which the Trust employs 10 of the 14 professions. The headcount of the combined AHP workforce at BTH NHS FT is currently 454 staff making it the second largest workforce behind Nursing (2084), marginally ahead of the Medical workforce (438). The majority of AHPs within the Trust sit within ALTC, however there are a number also employed directly through the four other clinical divisions. The only identifiable professional leadership at the Trust in relation to AHPs is the Head of Therapies, a role that sits within the ALTC Division and is predominantly operational yet has professional remit that relates to only 5 of the 10 AHP professions the Trust employs. The incumbent of this role supports the Trust to link with national and regional AHP programmes of work and has in the past represented the Trust during Use of Resource inspections with regulatory bodies. However, it is acknowledged that this role does not encompass the full range of AHP professions.

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As such, currently the Trust has no defined Chief AHP position to provide overarching professional and strategic leadership to the entire AHP workforce, ensuring it is engaged with the delivery of safe, high quality care and effectively contributing to the trusts strategic ambitions and priorities. Furthermore, there is no line of sight to the Executive Directors and relevant Board/ Sub-Board committees, which would be in place with a Chief AHP. It is crucial that the board are sighted on all potential opportunities and challenges facing the AHP workforce, to ensure it meets the requirements of the regulators. Finally in the absence of a Chief AHP, the Trust is unable to provide assurance that the AHP workforce is working towards delivery of the national AHP strategy, AHPs into Action (January, 2017), or developing appropriate workforce safeguards set out by NHS Improvement (October, 2018) to ensure we have the right AHP staff with the right skills in the right place at the right time. Not only does this pose a risk, but it also means that it is unlikely the workforce is working to the end of its license (advanced practice), and therefore being optimised. It is therefore recommended that:-

1. The Board supports the establishment of a Chief AHP role reporting to the Director of Nursing,AHP and Quality, to cover all of the AHP professions within the Trust, to compliment and work alongside the enhanced nursing leadership that was agreed at Trust Board in September 2019.

2. Once appointed the Board supports the Director of Nursing AHP and Quality to conduct a thorough benchmarking exercise of uni-professional leadership structures within and outside the organisation for further consideration by the Board

Post Current Band Current Cost New Band Cost at Mid-Point Cost Difference

Chief AHP None None 8D £98,718 £98,718 Bereavement / EOL Service The Fylde Coast Palliative and End of Life Care Teams commitment to the Fylde Coast End of Life Strategy is recognised and the team has sustained many ongoing service improvements that have been acknowledged at local and national level. However, the Trust provision of specialist bereavement support differs to other Lancashire and South Cumbria Trusts / North West Trusts. The Trust does have bereavement nurse specialist support in maternity for infant/ baby loss and a 0.2 wte provision in community paediatric services however, there are no services covering the general acute, including ED and critical care, or community services. The total number of deaths with families potentially requiring bereavement support in 2018/19 was 2659 (Hospital Deaths = 1998 Community Deaths = 661) and benchmarking against other Trusts provides a poor comparison of service provision within this specialist area of care. NICE guidance (within End of Life Care for Adults, quality statement 14: Care After Death - Bereavement Support 2017) dictates that “people closely affected by a death are communicated with in a sensitive way and are offered immediate and ongoing bereavement, emotional and spiritual support appropriate to their needs and preferences”. Timely and effective bereavement support can mitigate the risk of a complicated grief process and therefore improve human outcomes following the death of a loved one, and also lead to savings in terms of the resources needed to provide appropriate support once a complicated grief journey is embarked upon. The proposal of developing bereavement services at the Trust is in line with a wealth of national guidance and in keeping with what is considered good practice. It will help to address current concerns in relation to training in relation to bereavement care, which at best is described as patchy. A bereavement support service would be aware of the local and national support available for those who have experienced bereavement; at present within the organisation there is limited scope/knowledge of where people could be signposted to, arguably due to a lack of staff who have adequate knowledge of both the bereavement process (and ability to adequately risk assess the bereaved) and the services available. Development of the service would address the gap of little or no follow up support provided to families following the death of a loved one. It would also help to support families in conversations in relation to tissue donation, the rates of which in the organisation are low, as currently donation within the organisation is only a realistic prospect for those patients who die within the critical care or emergency departments due to there being no support to families and staff through the process outside these clinical areas. It is nationally recognised that Trusts who achieving outstanding in CQC standards in relation to End of Life Core Service provision have comprehensive bereavement services in place. The National Chief Coroner advocates a ‘swan model’ which works jointly between the coronial service and health care providers. It is proposed that a Trust wide introduction of Swan Model of Bereavement Care is introduced to provide a standardised framework for delivering end of life care and support. Swan offers dedicated support to patients in their last days of life and to their families into bereavement and beyond, offering choice and enabling staff to think outside of the box when delivering end of life care to cater to individual’s needs

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SWAN is an initiative that acts as an enabler for quality at the end of life. It enables all staff to provide equitable care and compassion for patients and their families who die in our care, encompassing end of life care, bereavement care and organ / tissue donation. It provides openness in the culture that providing quality end of life care is everyone’s business. It is planned that the model will be implemented through the End of Life Facilitators ensuring we support staff to provide the best experience for patients and their loved ones. Cost to implement will be initially funded via the Tree of Lights legacy funds and implementation supported through the existing End of Life Facilitators across Acute and Community and End of Life Leads in each area/department. The proposed structure to meet all of the above gaps and ensuring the service is aligned to the benchmarking findings is set out below.


Clinical / Service Lead EOL / Bereavement

Service Acute

None None B8A £58.159 £58.159

Bereavement Specialist Nurse

Acute

None None B7 £50,167 £50,167


Community

None None B7 £50,167 £50,167

EOL & Bereavement Support Worker

None None B4 £27,608 £27,608

TOTAL £186,101 It is further recommended that:- 3. The Board supports the principle of development of a bereavement support team integrated into the

palliative care and end of life care team. This will provide appropriate senior leadership that is equitable across the acute and community services and a specialist bereavement service that is available across the acute and community setting, eventually covering 7 days per week.

It is believed that the posts will demonstrate significant improvements to quality and high level of end of life care provided in the Trust, supporting the core service to achieve an Outstanding CQC rating and benefits to other areas supporting last days of life, rapid discharges and advance care planning preferred place of care outside hospital and the efficiency of the bereavement and mortuary services. Speciality Support Dementia and Learning Disabilities A key theme in the pending the CQC inspection report is a lack of comprehensive knowledge, skills and processes for managing and caring for patients with mental capacity challenges, including dementia patients with cognitive impairment and a theme of concern linked to outstanding regulatory actions from the CQC in relation to learning disability patients and prevention of deterioration. The Trust does currently have a three year dementia strategy but has no key lead to co ordinate this agenda or relate it into practise, which has been born out in the Trust Royal College of Physicians dementia audit results. The Trust does have a learning disabilities service which is community facing and they do provide, on a part time basis, a link nurse for internal support and advise on individual cases who also supported the completion of a national benchmarking exercise into experiences of patients and staff knowledge in caring for this patient group. The Trust does not however, have a lead role working within bed based services and, based on the grave concerns raised by CQC on the deterioration of this patient group, benefits are seen across other organisations in a role of a dementia and learning disability lead to link into MCA and DOLS lead. If aligned to other organisations the Trust would require a role with overarching responsibility for the Trusts Dementia Strategy and delivering NHS Improvements core standards for learning disability through a specialised nursing role. The specialised nursing post would work closely with the hospital safety team and the MCA and DOLS lead to ensure the care and support we provide patients with Dementia and Learning Disabilities is harm free and an enhanced experience, and that patients are adequately assessed with relevant reasonable adjustments and support provided to meet their specific needs. This senior position would challenge, advise and support staff groups so that these vulnerable patient groups are not disadvantaged and follow their respective care pathways. Providing expert knowledge and guidance they will be able to draw together the framework of support that is available whilst in hospital with a clear mandate to stop reliance on external agency 1:1 support, such as Northern Security.

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CQC recognise that Trusts that achieve outstanding in the care of patients with dementia, learning disabilities and cared for under DOLS or MCA have a lead post to oversee, co ordinate and manage pathway implementation for these groups of vulnerable patients. It is additionally recommended that:- 4. The Board supports the establishment of a Lead Dementia / Learning Disability nurse role, to compliment

and work alongside the MCA and DOLS lead already in post, to ensure the care and support we provide patients with Dementia and Learning Disabilities is harm free, provides good patient experience and that patients are adequately assessed with implementation of relevant reasonable adjustments and support provided to meet their specific needs.


Lead Nurse Dementia /Learning

Disabilities

None None 8A £58,159 £000 Off set by alternative

vacant clinical governance post.

Ward Accreditation NHSI recognise that improving nursing practice is not always easy and even good initiatives can fail if they do not have a structured approach to support the desired change. Nursing and midwifery staff in wards and units across the NHS regularly complete audits and assessments to provide information on how well they are doing in meeting standards of patient care. However, this information is not always used in a consistent way to define quality of care and performance at ward/unit level. Without a clear direction and sense of purpose, collecting the multiple pieces of data required at ward/unit level can seem like performance management rather than work to drive continuous improvement. This is born out in practise with staff across the Trusts clinical teams reflecting frustration at the requirement of data provision that they do not see the benefit of or understand its purpose, resulting in reduced staff engagement in quality initiatives. The impact of this has influenced a deteriorating picture in patient safety and harm KPIs, recognition at Quality Improvement Board with regulators, a deteriorating picture of quality and safety for patients and a lack of leadership ability to champion the voice for quality care delivery and patient / staff experience. Developing a set of standards against which to measure quality of care is central to demonstrating improvement. Accreditation brings together key measures of nursing and clinical care into one overarching framework to enable a comprehensive assessment of the quality of care at ward, unit or team level. When used effectively, it can drive continuous improvement in patient outcomes, and increase patient satisfaction and staff experience at ward and unit level. With a clear direction and a structured approach, it creates the collective sense of purpose necessary to help communication, encourage ownership and achieve a robust programme to measure and influence care delivery. The development of a ward / community accreditation system is proposed to the Trust Board which will be developed to fully align with the recently endorsed Quality Improvement Strategy and the current review of the organisations performance reporting approach and integrated performance report. A benchmarking process has been undertaken to review Trusts accreditation programmes which are already well established and endorsed by both NHSI and CQC. It is intended that a proposed programme of ward accreditation, the framework of which will be aligned to external assurances, eg the Care Quality Commission’s (CQC) , will be presented to the Quality Committee for approval The benchmarking process has identified that those Trusts with successful programmes have dedicated roles to implement and sustain the programme of work, which will ensure it is embedded within the culture of the organisation and provides a cultural move to standardised approach to Quality and Safety which is at the forefront of all roles priorities. Recommendation to the Board is that:- 5. The Board supports the development of a Ward / Community Accreditation Programme and recognises

the need of support mechanisms to realise successful implementation and embedding into the quality improvement programme.

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Lead Ward and Community

Accreditation

8A (Will be integrated into current patient

experience manager role)

£58,159 8B (Uplift to support

increased responsibility

and AFC rebanding)

£69261 £11,102 Off set by alternative

temp filled clinical governance post.

£000

Ward and Community

Accreditation Scheme

Manager

None None Band 7 £50,167 £000 Off set by alternative


Ward Based Staffing The Trust’s Improvement Plan identifies immediate actions and longer term strategies that will support an organisational focus to ensure that the basics for patient care are right, that services are stabilised and that there is a creation of the right conditions upon which the Trust can continue to improve and ultimately transform care delivery to meet priorities of safe, quality care. The Trusts Quality Improvement Strategy sets out key aims to delivering a structured programme of work to reduce harm and mortality. To deliver this programme of work will require adequate frontline staff to support improvement projects and deliver service developments to provide a safer place for patients and staff. The CQC highlighted in their recently published staffing report the shortfall in nursing staff numbers to ensure patients needs are met. They found the Trust in breach of Regulation 18:Staffing and gave an action the Trust must take to improve; ‘the Trust must ensure they deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure thay can meet people’s care and treatment needs.’ Independent workforce analysts have been commissioned to review staffing at Blackpool Teaching Hospitals NHS Foundation Trust. This was facilitated by reviewing data provided direct from the Trust and benchmarking data available through NHS Improvement on fill rates of Registered Nurses (RN) and Healthcare Support Workers (HCSW) for a period of one year (June 18-May 2019) and national Care Hours Per Patient Day (CHPPD) from NHS Improvement April & May 2019. The analysis looked at acute inpatient areas apart from ITU, paediatrics and Obstetrics/Midwifery. Safe registered nurse & midwifery staffing levels are required to deliver safe, effective, quality care and treatment to patients and families accessing healthcare services. Setting nationally agreed standards for safe staffing levels is problematic and each area needs to be assessed within the context of the patient case-mix seen and the expected level of activity. As acuity and activity can vary and at times behave unpredictably, a flexible and transferable nursing and midwifery workforce model is required to respond to fluctuating demand and operational pressures. To note the Trust does not currently use acuity or demand data and so although the review examined fill rates, CHPPD and other English standardised staffing metrics it was not possible to say if those alone were adequate. A selection of other Trusts were therefore used to compare and contrast against. Summary of Findings The reviewers noted that lack of acuity data is unusual in an NHS Trust as it is usually a cornerstone for setting and maintaining establishments. The Trust currently has a work programme to commence introducing acuity data recording that will be used to inform ongoing review of staffing level requirements. The review noted that the Trust tends to have lower RN CHPPD and fill rates lower than most comparable services. It also has higher HCSW CHPPD and fill rates than comparable organisations. It is noted that HCSW have traditionally been used to back fill where RNs have not been able to be sourced and that this is the driver for this trend. It is noted that the pattern of lower CHPPD across the Trust is a concern and for although there is no defined “safe” staffing level in the acute sector, there is enough research into levels of harms to understand levels of staffing associated with unsafe or higher harm/poorer survival. The reviewers, as specialists in workforce modelling, reflected that according to the work of authors such as Aitken et al (2014) that the Trust would appear to be in a staffing situation of which there could be risk to patients and staff (poor staffing is also associated with harm to staff, Jones et al 2019). Also noting that in previous investigations (Francis 2013) it has been found that poor RN staffing in general medical and specialist medical wards can drive mortality rates higher and the Summary Hospital-level Mortality Indicator for this Trust (SHMI) is higher than expected (NHS Digital, 2019). In addition, the compensatory mechanism of filling RN resource with support worker resource is evidenced by Aiken et al (2017) as a high risk strategy as this can affect mortality.

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Speciality / Unit Level CHPPD Data April 2019 There was a trend for Blackpool to be at the lower end of the average CHPPD at unit level and this was broken down by registered and unregistered showing below average RN CHPPD and above average HCSW CHPPD (reflecting over booking of HCAs to back fill for RN shortfall). Harms data, complaints data and patient experience data was also reviewed and reflected a link between low CHPPD and potential patient harm. Based on the number of patients for each speciality for the month of July and the planned staffing templates, the required WTE to increase CHPPD to align with benchmarked Trust CHPPD was calculated. This does not however, take into account patient acuity and the Director and Deputy Director of Nursing walked every ward area to discuss professional judgement with the ward manager / matron and ADON to robustly review the findings of the benchmarking and agree requirements to align to the benchmarking / address professional safety concerns / meet patient acuity. Initial review of the findings demonstrates a shortfall across the Trust for both registered and non registered nurses. Detail of WTE and associated costs based on mid point Bands, with oncosts, is presented in the table below. To note UnScheduled Care has the greatest challenge in terms of shortfall to meet benchmarking findings and this is in addition to an ongoing poor position of increased vacancy rates against current establishments. This is founded in the CQC Inspection Report Oct 2019, where Acute Services- Medical Care is rated inadequate with staffing being noted as a key driver for unsafe care. CQC findings reflect nurse staffing concerns of staff feeling unsafe, unable to maintain 1:1 support, staff not able to have a break and examples of patient care being compromised through documentation lapses, delays in administration of pain medication, failure to execute nursing care and an increase in medicines omissions. A recent directive, to book agency nurses to ensure the right number of WTE staff according to current templates are present in clinical areas, has helped to reduce the number of red flags raised in relation to the above. However, this does not address the longer term challenge of providing CHPPD in line with peer provision and associated risk of patient harm aligned to this. Ward establishment templates were reviewed to reflect the professional discussions held within each clincial area and approved by the Director of Nursing for presentation to the Board. If supported the templates will be formally signed off by the Director of Nursing and funded establishments will then be reflected in the e-rostering system. Changes to those agreed establishments will only be made when a full case is presented to the Director and Deputy Director of Nursing and if supported by them changes will be presented to Board for final approval. Annual review of staffing will continue to take place as per national guidance and requirements. It is noted that a blanket application to uplift is applied to all ward based posts but it is recognised that RN training and competancy requirements will be higher than non registered nurses. However, nationally it is recognised that non registered nurse sickness rates are higher than RNs and the Trusts blanket application of approximately 24% takes this into account. A benchmarking of uplift applications nationally is currently being undertaken to assess if there is any opportunity to readjust uplift percentages before this is applied to the costings table below.

Ward WTE required to meet prof judgement (PJ) in line with DON review

Cost £mid-point B6 with on cost

WTE required to meet Benchmark average CHPPD / PJ


Unqualified required to meet Benchmark average CHPPD / PJ


AMU 5.2 217,538 1.9 Inc in B6 0 0

Haematology Ward

6.0 251,004 -1.4 Inc in B6 0 0

ITU Not benchmarked - Not benchmarked - Not benchmarked -

Stroke Unit Part of separate business case

- Not comparable - Not comparable -

Ward 11 - - 5.2 175,390 15.55 339,689

Ward 12 - - 0.2 0 0 0

Ward 10 Part of separate business case

- Not comparable - Not comparable -

Ward 18 5.2 217,538 0 0 8.98 196,168

Ward 7 2.4 100,401 Inc in B6 - 0 0

Ward 5 1.4 58,567 Inc in B6 - 0.8 21,103

Ward 25 - - 1.3 43,875 3 79,137

Ward 26 - - 1.2 40,500 3 79,137

Ward 2 - - 0.4 13,500 0 0

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Recommendations are put forward that:-

6.The Board notes the findings from the independent benchmarking review into ward based staffing.

7.The Board continues supporting 100% fill rate of the current funded establishments. 8.The Board supports alignment of funded establishments to allow achievement of CHPPD aligned to

benchmarked Trusts District Nursing The NHS long term plan promotes new models of care with a focus on multi-professional teams supporting patient’s families and carers in homes and communities. The teams include registered and non-registered nursing staff and may include allied health professionals, social care workers and members from the voluntary sector. The model also includes new roles such as care-coordination and health and well-being roles. Describing a safe caseload in the community is complex. The National Quality Board paper (March 2017) describes ten principles which if achieved provide assurance of safe caseload and supporting papers are available which detail how these have been applied across the emerging neighbourhood and integrated care community teams. This review provides a level of assurance using the safe caseload principles across all three localities which has also been triangulated using locality harms data, specifically closed incidents with regard to medication errors and skin tissue damage and STEIS reportable incidents plus nursing care indicator data.

Ward 6 1.4 58,567 Inc in B6 - 0 0

Ward 8 - - 0 0 0 0

Ward 23 - - 1.2 40,500 3 79,137

Ward 3 - - 0 0 0 0

Ward 24 - - 1.1 37,125 2.7 71,223

CCU 2.24 75,552 0 0

CITU 4.48 187,416 - 4.48 97,865

Lancashire Suite

- - 2.24 75,552 0 0

Surgical Assessment Unit

- - 2.24 75,552 2.24 48,932

Ward 14 - - 4.48 151,105 0 0

Ward 15a - - 1.4 47,220 0 0

Ward 15b - - 0 0 2.3 50,243

Ward 16 - - 0 0 0 0

Ward 34 - - 1.4 47,220 3.64 79,515

Ward 35 - - 1.4 47,220 3.64 79,515

Ward 37 - - 0 0 0 0

Ward 38 - - 1 33,729 0 0

Ward 39 - - 0 0 0 0

Ward C 5.2 217,538 Inc in B6 - 3.38 73,835

Neonates Not benchmarked - Not benchmarked - Not benchmarked -

Children’s Ward / Adol Ward

Not benchmarked - Not benchmarked - Not benchmarked -

Maternity Unit Ward D

Not benchmarked - Not benchmarked - Not benchmarked -

CH Ward 1 1 33,750 1.4 36,930

CH Ward 2 1 33,750 1.4 36,930

CH Ward 3 1.1 37,125 1.5 39,568

CH Ward 4 1 33,750 1.2 31,654

Uplift

To be confirmed

To be confirmed

To be confirmed

TOTAL

1,308,569 1,042,415 1,449,581

Total Cost £3,800,565 plus confirmed uplift

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A review of all available evidence indicates that the current funded establishment for the neighbourhood resource within the Blackpool Locality is adequate; there is significant assurance that the teams are compliant with the safe caseload principles, which has a positive impact on delivery of safe high quality patient care and patient experience. However only limited assurance can be given in relation to the available therapy resource to support both the equipment provision and safe rehabilitation models. To note there is planned piece of review work which will better inform Blackpool council and the CCG of the current issues, options for future service provision and potential resource implications. A review of all available evidence indicates that the current funded establishment for the neighbourhood resource within the Fylde and Wyre Locality is inadequate in two of the neighbourgood care teams. The demand for Registered Nurse support for patients is increasing with the benchmark of the band 5 “productive day” of 10 visits per 7.5 hour day is exceeding best practice in two teams. Recruitment to band 5 vacancies remains a challenge, with an overall vacancy rate of 11% within the locality. The Locality has proactively recruited a number of newly qualified staff or staff with no community experience; this presents additional challenges in terms of the capacity of the experienced staff to adequately support this group of staff. Based on current data the additional resource requirement to meet safe staffing levels would be 1 additional wte band 5 registered nurse on duty for the extended day 7 days per week. This equates to 2.8 wte band 5 in each of the teams. The total costings for the additional 5.6wte is:

Post Cost at Mid-Point Number required Cost Difference

Band 5 RN £33,729 5.6 £188,882.40

It is noted that ongoing work will be needed to continue to benchmark the teams against “productive day” standards and monitor the increasing demand for Registered Nurse care hours per patient per day, triangulated with harms data. Guidance recommends that establishments should be set to include an uplift to support the effective management of planned and unplanned leave. Historically within the division the community nursing establishment does not include uplift which has been reported in each previous annual staffing review. The position remains unchanged and the current cost, not including Band 7 team leaders as it has been assumed they are supernumerary, for registered and non-registered nursing only uplift cost equating to £1,483,070 For the purpose of this report it is recommended that:-

9.The Board support the proposed funding to Fleetwood and Lytham St Annes team establishments to ensure that safe caseload principles are met.

10.The Board notes the issue raised regarding therapy resource in the Blackpool neighbourghood care teams as being inadequate and that this has been raised to Blackpool Council and the CCG along with options for future service provision and potential resource implication.

11.To note the nursing community establishment continues to not include uplift to support the management of planned and unplanned leave.

Conclusion Generally, the Trust does not benchmark well in comparison with other Trusts or specialisms in relation to ward based safe staffing to meet patients CHPPD, acuity and leadership for AHP and some key support roles. It is also noted that some district nursing teams are not meeting the safe case load mix principles set with national guidance. It is noted that there are some very low CHPPD rates for example the Care of the Elderly wards, Respiratory Medicine, Cardiothoracic and Acute Medicine. There is considerable variance in staffing and fill rates consistently under 80% for RNs. When fill rates for RNs are low there seems to a “compensation” in numbers filled with support workers. Skill dilution such as this can have consequences for care, for example Aiken et al (2017) found that substituting one nurse assistant for a professional nurse for every 25 patients is associated with a 21% increase in the odds of dying. Although staffing is complex, there is now much evidence to support what is and what is not safe (NHS Improvement 2018,) and in the data provided for the Trust the reviewers noted that from the years data reviewed staffing appears to be a high risk.

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The cost to address all of the above is summarised in the recommendations below although it is recognised that the Trust is holding a large number of registered nurse vacancies that would be required to be filled and the additional registered nursed requirement proposed would follow as and when vacancies are achieved. However, immediate cash release would be required for the non registered nurse element of the ward based staffing review to enable clinical areas to deliver bay based nursing, drive down harms and achieve performance within nursing care sensitive performance indicators. Recommendations

1. The Board supports the establishment of a Chief AHP role, reporting to the Director of Nursing,AHP and Quality to cover all of the AHP professions within the Trust, to compliment and work alongside the enhanced nursing leadership that was agreed at Trust Board in September 2019.

2. Once appointed the Board supports the Director of Nursing, AHP’s and Quality to conduct a thorough benchmarking exercise of uni-professional leadership structures within and outside the organisation for further consideration by the Board

3. The Board supports the principle of development of a bereavement support team integrated into the palliative care and end of life care team. This will provide appropriate senior leadership that is equitable across the acute and community services and a specialist bereavement service that is available across the acute and community setting, eventually covering 7 days per week.

4. The Board supports the establishment of a Lead Dementia / Learning Disability nurse role, to compliment and work alongside the MCA and DOLS lead already in post, to ensure the care and support we provide patients with Dementia and Learning Disabilities is harm free, provides good patient experience and that patients are adequately assessed with implementation of relevant reasonable adjustments and support provided to meet their specific needs.

5. The Board supports the development of a Ward / Community Accreditation Programme and recognises the need of support mechanisms to realise successful implementation and embedding into the quality improvement programme

6. The Board notes the findings from the independent benchmarking review into ward based staffing. 7. The Board continues supporting 100% fill rate of the current funded establishments. 8. The Board supports alignment of the funded establishments to allow achievement of CHPPD

aligned to benchmarked Trusts. 9. The Board support the proposed funding to Fleetwood and Lytham St Annes team establishments to

ensure that safe caseload principles are met. 10. The Board notes the issue raised regarding therapy resource in the Blackpool neighbourhood care

teams as being inadequate and that this has been raised to Blackpool Council and the CCG along with options for future service provision and potential resource implication.

11. To note the nursing community establishment continues to not include uplift to support the management of planned and unplanned leave.

Recommendation 1&2


Chief AHP None None 8D £98,718 £98,718 Recommendation 3


Clinical / Service Lead EOL / Bereavement

Service Acute

None None B8A £58.159 £58.159

Bereavement Specialist Nurse Acute

None None B7 £50,167 £50,167


Community

None None B7 £50,167 £50,167

EOL & Bereavement Support Worker

None None B4 £27,608 £27,608

TOTAL £186,101 £186,101 Recommendation 4


Lead Nurse Dementia /Learning Disabilities

None None 8A £58,159 £000 Off set by alternative


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Recommendation 5


Lead Ward Accreditation

8A (Will be integrated into

current patient

experience manager role)

£58,159 8B (Uplift to support increased

responsibility and AFC rebanding)

£69261 £11,102 Off set by alternative

temp filled clinical governance post.

£000

Ward Accreditation Scheme Manager

None None Band 7 £50,167 £000 Off set by alternative


Recommendations 6-8

Recommendations 9-11

Post Cost at Mid-Point Number required Cost Difference

Band 5 RN £33,729 5.6 £188,882.40

Band 6 Band 5 Band 2

Uplift

To be confirmed To be confirmed To be confirmed

Total Cost per Band

1,308,569 1,042,415 1,449,581

Total Cost £3,800,565

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5th November 2019

Learning from Deaths Report

Report Prepared By: Dr Richard Morgan, Trust Mortality Reduction Lead on behalf of Medical Director

Contact Details: Dr Richard Morgan ext 55785

Date of Report: 31st October 2019

Purpose of Report: To advise the Board on current progress with mortality governance across the Trust.

1 For information

2 For Discussion

3 For Approval

Recommendations: That the Board receives and reviews the report.

Sensitivity Level:

1 Not sensitive: For immediate publication - Yes



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5th November 2019

Learning from Deaths Report

Learning from Deaths remains a high priority for the Trust. The latest nationally validated trust-wide SHMI for the BTH FT is 113 (12 month rolling average - July 2018 to Jun 2019). This represents a two point fall since the last reported value of 115 and brings the trust just within the 95%.confidence limits for only the second time in the past 18 months. It is important to appreciate that this is only one data point and should not be considered confirmation of a steady trend. The SPC graphical and SHMI/HSMR time series data below (Figs 1&2.) do suggest a gentle trending improvement in internal 12 month rolling average SHMI (as derived from HED) across the trust for the past few months with the improvement beginning in the early part of 2019. The SHMI values for acute and chronic respiratory illness (pneumonia & COPD) and for stroke represent the principle contributors to the trust-wide high SHMI value. A review of the Learning from Deaths dashboard for Q1 (2019/2020) reveals the following key points:

Total number of in hospital deaths in quarter was 391

Total number of case records of deceased individuals reviewed in quarter was 293 (75%)

This represents a significant increase in percentage reviewed when compared to the previous quarter.

3 deaths* were considered more likely that not to have resulted from problems in health care during Q1 all of which scored 3 on the RCP avoidability scale (probably/possibly avoidable – more than 50:50).

* Caution to be exercised when considering the significance of the small number of deaths graded as 3 on the avoidability scale. This low figure may suggest an inappropriate level of reassurance given the number of known SI’s reported in Q2/Q3 and currently under investigation. Specialities need to provide assurance that all cases graded <=3 on the avoidability scale have been subject to full structured judgement review

No feedback received as yet from LeDeR regarding the 4 deceased patients with known learning difficulties reported during the quarter.

The Learning from Deaths dashboard for Q2 (2019/2020) is currently being compiled from data returns from all specialities.

The external review of services provided by the trust for the treatment of pneumonia and sepsis, to be conducted by the Royal College of Physicians, is progressing satisfactorily, the trust having recently received a follow up request for further documentation prior to their site visit. It is anticipated that this will take place in mid-November 2019.

Cases of patients whose terminal hospital admission occurred against a background of learning difficulties will now be designated as incidents thus ensuring comprehensive diagnostic cohort capture, completion of 72hr reviews and timely initiation of the full LeDeR process which may otherwise be substantially prolonged in some cases. Feedback from the recent CQC inspection, under the Well Led section, underlines the need for the trust to improve on the implementation of action points and dissemination of learning points identified through retrospective case record review of deceased patients. In addition the trust needs to develop a robust tracking progress against associated action plans to ensure their timely completion.

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Fig 1.

Fig 2.

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SHMI SPC To May 2019 Source: HED

SHMI Avg Upper Lower 12 Month

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12 Month SHMI Over Time - National Data Releases 12 Month SHMI Over Time - HED Release

National SHMI HED SHMI HED HSMR

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Fig 3

Summary Hospital-level Mortality Indicator (SHMI), England, June 2018 – May 2019 Funnel Plot of Keogh Trusts

The updated funnel plot reflecting our current SHMI value will be released mid-November 2019

RJMM Oct 2019

Blackpool Teaching Hospitals

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5th November 2019

Emergency Preparedness Resilience and Response (EPRR) Assurance 2019

Report Prepared By: Neil Williams, Emergency Planning Manager on behalf of Berenice Groves – Interim Director of Operations Urgent and Emergency Care

Contact Details: Ext: 55568 and 56852

Date of Report: 29th October 2019

Purpose of Report: The EPRR Lead and Accountable Director have recently completed this year’s EPRR Assurance submission on behalf of the Trust. The detail and results can be found below. The purpose of this report is to make the Board of Directors aware of the EPRR assurance process and compliance along with supporting information. The report provides the following:-

Timeline for the assurance process

Breakdown of scoring criteria

Statement of compliance

Action Plan

1 For information

2 For Discussion

3 For Approval

Recommendations The Board is asked to:

Acknowledge this year’s EPRR Assurance return as identified in the Statement of Compliance.

Agree the content of the paper and actions identified to be undertaken to improve compliance and assurance levels.

Agree the assurance level provided.

Support the recommendation of transferring the ownership of the standards to the appropriate subject matter expert area. The Emergency Planning Team will maintain oversight and coordination.

Sensitivity Level:




x

X

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Summary of Key issues:

The results of the self-assessment were as follows:

Number of applicable standards

Standards rated as Red

Standards rated as Amber

Standards rated as Green

64 xx 7 57

Acute providers: 64 Specialist providers: 55 Community providers: 54 Mental health providers:54 CCGs: 43 NWAS: 49/163 NHS111:42

This year’s assessment criteria has been more detailed and challenging. There are no direct questions relating to EU Exit, this is being dealt with as a separate piece of work however the Board is asked to note that significant time has been spent by the EPRR team and others on EU Exit preparations resulting in competing demands and re-prioritisation of standard EPRR work. There are no areas of non-compliance with regard to the core standards however there are four areas of non-compliance with regard to adaptation to climate change in the deep dive section of the return. These non-compliance areas DO NOT contribute towards the Trust’s overall rating however there is an action plan for each of the items in table 3. Where areas require further action, this is detailed in the attached EPRR Action Plan (Table 3) and will be reviewed in line with the organisation’s governance arrangements and progress monitored via the Emergency Planning Steering Committee. Overall compliance with the standards is confirmed as ‘Substantial’. This has been submitted to the CCG’s as the governance timetable runs in parallel. It has been agreed that the Trust Board has the right to challenge, change and resubmit if it feels this is appropriate due to the competing timescales. In addition to the return a separate walkthrough with the Emergency Planning Officer from Fylde Coast CCGs was conducted on 27th August in relation to the Trust’s VHF plan to provide assurance against standard 16 – ‘the duty in order to have effective arrangements in place to respond to an infectious disease outbreak within the organisation or the community it serves’…This item is reported as compliant and this was supported by the CCG representative. This report highlights the current Trust position and recommendations of further actions to be taken to improve the compliance with the expected standards. Assurance Level: Significant assurance is provided organisationally in relation to compliance with the standards.

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Emergency Preparedness, Resilience and Response (EPRR) Assurance 2019

The timetable for this year’s EPRR process is highlighted in table 1 below. Internally the submission is required to go through our own governance process of which some of this will be need to be done in parallel to the process laid out in table 1.

Table 1

The timetable of the internal governance process for the return is identified below:

o 02nd September – BTH EP Steering Committee - Complete o Following approval by EP Steering Committee and AEO – Submit to CCG - Complete o 10th September – Executive Director’s Meeting (summary for information only) o 23rd September – BTH Quality Committee - Complete o 05th November – BTH Trust Board

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Breakdown of Scoring Table 2 below illustrates the breakdown of scoring for each of the criteria. Table 3 towards the end of this report is a detailed action plan of how the Trust aims to become fully compliant in each of the partially met criteria areas. This year’s Deep Dive challenged the response to severe weather emergencies and adaptation to climate change. This element is not a formal reporting topic and therefore the scoring does not count towards the Trust’s overall compliance rating. It has highlighted areas of non-compliance and therefore areas for improvement with regard to monitoring building temperature, the appropriate response to warmer temperatures that do not meet heatwave thresholds and adaptation to climate change issues with regard to future building capital projects. Actions to address these areas are contained in the action plan in table 3.

Table 2

External Assurance Walkthrough of Standard 16 – Infectious Diseases In addition to the return a separate walkthrough with the Emergency Planning Officer from Fylde Coast CCGs was conducted on 27th August in relation to the Trust’s VHF plan to provide assurance against standard 16 – ‘the duty in order to have effective arrangements in place to respond to an infectious disease outbreak within the organisation or the community it serves’…This item is reported as compliant and this was supported by the CCG representative.

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Emergency Preparedness, Resilience and Response (EPRR) Assurance 2019

STATEMENT OF COMPLIANCE

Blackpool Teaching Hospitals NHS Foundation Trust has undertaken a self-assessment against the NHS England Core Standards for EPRR.

Following self-assessment, and in line with the definitions of compliance stated below, the organisation declares

itself as demonstrating the following level of compliance against the 2019 standards: Substantial

Compliance Level Criteria

Full The organisation is 100% compliant with all core standards they are expected to achieve.

The organisation’s Board has agreed with this position.

Substantial

The organisation is 89-99% compliant with the core standards they are expected to achieve.

For each non-compliant core standard, the organisation’s Board has agreed an action plan to meet compliance within the next 12 months.

Partial

The organisation is 77-88% compliant with the core standards they are expected to achieve.


Non-compliant

The organisation is complaint with 76% or less of the core standards the organisation is expected to achieve.


The action plan will be monitored on a quarterly basis to demonstrate progress towards compliance.

The results of the self-assessment were as follows:

Number of applicable standards

Standards rated as Red

Standards rated as Amber

Standards rated as Green

64 xx 7 57

Acute providers: 64 Specialist providers: 55 Community providers: 54 Mental health providers:54 CCGs: 43 NWAS: 49/163 NHS111:42

Where areas require further action, this is detailed in the attached EPRR Action Plan and will be reviewed in line with the organisation’s governance arrangements. I confirm that the above level of compliance with the EPRR Core Standards has been or will be confirmed to the organisation’s board / governing body.

______________________________________________________________ Signed by the organisation’s Accountable Emergency Officer

____________________________ ____________________________

Date of board / governing body meeting Date signed

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Table 3 - Organisation: Blackpool Teaching Hospitals, Plan owner: Director of Nursing / Accountable Emergency Officer

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Interim Director of Ops and ATLAS

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5th November 2019

Developing Workforce Safeguards

Report Prepared By: Lee Tarren Associate Director for Resourcing and Transformation

Contact Details: [email protected] 01253 957925

Date of Report: 28.10.2019

Purpose of Report: To provide the Board with assurance that theTrust is developing workforce safeguards in line with the NHSI recommendations of October 2018. The report outlines the recommendations and standards that Trusts should follow and also where Blackpool Teaching Hospitals NHS Foundation Trust is at present in ensuring these workforce safeguards are embedded.

1 For information

2 For Discussion

3 For Approval

Recommendations: Board members are requested to note the report.

Sensitivity Level:




x

x

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5th November 2019

Developing Workforce Safeguards

Introduction In October 2018 NHSI released a guidance document for developing workforce safeguards, the document aims to provide boards assurance that their workforce decisions will promote patient safety and therefore comply with the Care Quality Commission’s (CQC) fundamental standards, our effective use of resources assessment as well as the boards statutory duties. The guidance states that each Trust should undertake the following:-

Must deploy sufficient suitably qualified, competent, and skilled and experienced staff to meet care

and treatment needs safely and effectively

Should have a systematic approach to determining the number of staff and range of skills required to

meet the needs of people using the service and keep them safe at all times

Must use an approach that reflects current legislation and guidance where available.

In addition there were 7 requirements that Trust must comply with:-

1) Trusts must formally ensure NQB’s 2016 guidance is embedded in their safe staffing governance

2) Trusts must ensure the three components are used in safe staffing process;

Evidence based tools (where they exist)

Professional judgement

Outcomes

NB: Annual review and assessment must be undertaken

3) Assessment based on annual governance statement in which the Trust will be required to confirm

their staffing governance processes are safe and sustainable.

4) Trust must have an effective workforce plan that is updated annually and signed off by the Chief

Executive and Executive leaders. Boards must discuss the workforce plan in public meetings.

5) Must agree a local quality dashboard that cross-checks comparative data on staffing and skill mix

with other efficiency and quality metrics such as the Model Hospital Dashboard. Trusts should report

on this to their board every month.

6) Bi-Annual re-setting of the nursing establishment and skill mix (based on acuity and dependency).

7) Quality Impact Assessment (QIA) review of all service changes

Workforce Planning Trust boards need assurance that annual workforce planning takes into account of activity levels, seasonal variation in demand, service development, contract and commissioning, service charges, staff supply and experiences, where temporary staff have been required above the set planned establishment, patient and staff outcomes measures as well as tools that assess patient acuity and dependency. In order to aid workforce planning decision making, NHSI recommend the use of:-

Electronic Staff Records (ESR), SNCT E-Rostering Systems (Bi-Annually reviewed and refreshed) E-Job Planning (annually reviewed and refreshed) Financial Systems Model Hospital

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Workforce Plan The Workforce Plan needs to ensure that each of the below are considered:- Constructed from robust plans focused at clinical service-line level that on is based on available evidence - particularly the Getting it Right First Time (GIRFT) programme 'What good looks like' Ensure multidisciplinary workforce numbers are evidence-based, while considering specific systems and organisational requirements; Ensure staff capacity and capability are sustainable and sufficient to provide safe and effective care to patients and service users, taking account of any predictable patterns of variation in demand; Take account of financial restraints by setting an accurate and achievable staffing budget agreed by clinicians and the finance department; Minimise or negate the need for expensive agency staff by effectively planning the workforce need for service requirements; Inform and be informed by organisation's clinical strategy, business cases and efficiency plans; Encourage leaders, managers and staff to work collectively on the workforce planning process, which should be informed by comprehensive staff engagement; Include a comprehensive QIA where there is any workforce transformation or redesign including a change in skill mix and/or the introduction of new roles (e.g. Physicians Associates, Nursing Associates, ACP’s); Set the Standard for expected staffing levels - encouraging transparency and enabling staffing decisions to be based on evidence; Be formulated by multidisciplinary teams and consider the whole service and the workforce required to deliver the activity, at the required standard; from a financial perspective, this should include realistic calculations of workforce 'headroom' for all professional groups and support workers, and consider the staff costs such as a percentage of parental or study leave, to avoid overspending where such leave is required. Promote a proactive rather reactive approach to staffing because workforce planning is a continuous process and should be continually monitored and reviewed. Actions Taken To Date In June 2019 the board approved the purchase of Allocate Software – SafeCare system, this will allow the Trust to review rosters based on Acuity and Dependency, so the appropriate level of skill mix is deployed to meet the needs of our patients in a safe and effective manner, in addition as part of Cohort 4 NHSI retention programme, the Trust is being supported in a clinical review of rosters to ensure the Care Hours Per Patient Per Day is being utilised in the most efficient way possible. Demonstrations have been undertaken and pilot wards identified, with the planned roll out to commence in November 2019. Throughout 2018-2019 the Trust engaged the services of 4eyes consultancy to review our current consultant level job plans to assess whether the programmed activity numbers mirrored that of the needs of the Trusts and also payments being made, this led to a number of anomalies being identified, this has allowed for the adjustment of pay and or job plans accordingly to meet activity and demand. Further work has been identified to match job plans based on capacity and demand, but this could only be achieved once the Consultants were brought in on the use of Allocate e-Job Planning. Now in our final stage, job plans will be assessed by department level at a check and challenge meeting, to confirm consistency and productivity across specialty. The centralisation of the Medical Deployment Officer (rota coordinators), the centralisation of bank and agency booking, spend (non-Medical) allows the Trust a full overview of bookings, requests, hours and spend at a single point, thus in turn assisting with effective workforce planning. Unscheduled Care have undertaken a review of service needs and presented a paper to board, seeking an additional 23 medical staff to undertake ward based work and out of hours activity, so the deployment of medical staff to meet patients acuity can be achieved, with the intention of reducing agency spend over a 2 year period. By working in partnership with an external recruitment company, the introduction of these staff has commenced with 6 staff already in post.

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In order to support with the development of the workforce plan and to ensure staff and patients’ needs are met a number of key strategies have been developed, with supporting Action Plans these being:

1) Recruitment and Retention

2) Employee Engagement

3) Clinical Education

4) Diversity and Inclusion

5) Health and Wellbeing

6) Compassionate Leadership

7) Just Culture

8) Apprenticeship Strategy

Next Steps Following on from the release of the NHS long term plans the Trust has been working on NHSI/HEE workforce plans, working as part of both the ICP and ICS workforce planning assumptions and will be undertaking a review of the Trust’s Establishment, Clinical Vacancies and review alternative workforce delivery models, so that we are able to meet our needs now and in the future with either substantive or contingent labour workforce. Medical and Dental Rostering to be updated in line with contractual changes, enhanced roll out of medical rostering and CAMS by the Medical Deployment Office. Roll out and deployment of Safe Care Template review in line with SNCT Lee Tarren Associate Director of Resourcing and Transformation

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Integrated Performance Report September 2019

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http://1.bp.blogspot.com/-mIBqeYmJGM4/ULxwpqTyXKI/AAAAAAAAB34/NrCq118koCc/s1600/Fylde+NHS+trust+logo.jpg

2

Contents Executive Summary Page 3 Reviewed by Full Board and all Sub Committees and Workforce Strategic & Compliance Reporting Page 4 Reviewed by Full Board and all Sub Committees and Workforce Sustainability & Transformation Fund Page 5 Reviewed by Quality Committee and Finance Committee Mortality Performance Page 7 Reviewed by Quality Committee National CQUIN Page 10 Reviewed by Quality Committee and Finance Committee Patient Safety Page 11 Reviewed by Quality Committee Patient Experience Page 15 Reviewed by Quality Committee Finance Page 17 Reviewed by Finance Committee CIP Page 32 Reviewed by Finance Committee Capital Expenditure / Estate Page 36 Reviewed by Finance Committee Operations Page 37 Reviewed by Finance Committee Workforce Page 44 Reviewed by Workforce Committee Board Assurance Framework Page 47 Reviewed by Full Board and Audit Committee

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Executive Summary – Lead Director: Kevin McGee The 4 Hour A&E target was not achieved in September – 85.16% (target 95%). The Trust did not achieve the Open pathway performance at 82.69%. The Trust did not achieve the 62 day urgent referral to treatment (target 85%) standard in August at 80.7%. The 62 day screening target was achieved in August at 90% (target 90%).

C Diff: There were 7 new cases of C Diff in month. We are above trajectory for the year. These are all awaiting validation. MRSA: There were no new cases of MRSA bacteraemia in September. Financial: The consolidated Trust incurred a deficit of (£2.2m) (excluding PSF / MRET) in September which is £1.8m worse than the budget. The year to date actual (excluding PSF / MRET) is a deficit of (£10.8m) which is £5.6m worse than the budget. The consolidated Trust has delivered a UOR of 4 which is worse than the plan. The consolidated Trust cash balance is £14.8m which is £0.5m better than the plan. The current cash forecast indicates that the Trust will not require support in the next 3 months. Key Performance Indicators Financial Performance (Page 23)

• Financial: The consolidated Trust incurred a deficit of (£2.2m) (excluding PSF / MRET) in September which is £1.8m worse than the budget. The year to date actual (excluding PSF / MRET) is a deficit of (£10.8m) which £5.6m worse than the budget. The key drivers of the worse than planned performance are investments to address quality, safety and regulatory concerns and lower than planned CIP. The reported position assumes full receipt of MOU and other monies due from the CCGs. There remains a risk around the remainder of the MOU funding.

• Cash: The consolidated Trust cash balance is £14.8m which is £0.5m better than the plan. The current cash forecast indicates that the Trust will not require support in the next 3 months.

• CIP Performance: Cumulatively, the Trust has delivered £4.8m CIP against the 2019-20 schemes, which is £2.6m worse than internal Trust Plan. This underachievement is due to the underperformance of Planned Care (Theatres, Outpatients, Diagnostics), Workforce (Reduction in Contingent Labour), Urgent & Emergency Care (Better Care Now), and Procurement schemes, which have been partly mitigated by the over-performance of Technical Flexibilities, Divisional and Medicines Management schemes.

• Use Of Resource Rating (UOR): The consolidated Trust has delivered a UOR of 4 which is worse than the plan. of 225

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• Capital Expenditure: Capital expenditure is £6.3m year to date which is £2.8m higher than the plan.

• Financial Assurance: The 2019/20 Operational Plan submitted to NHS Improvement (NHSI) included the following: -

o Income and Expenditure surplus of £5.6m; o CIP of £20.0m (including CIP stretch); o Year-end cash balance of £1.9m; o UOR of 3 for the financial year.

Financial Resilience – Limited Assurance based on the risks associated with the delivery of the 2019-20 financial plan.

Financial Sustainability – Limited Assurance based on the view that financial sustainability is dependent upon the successful implementation of the 5 year strategy.

Overall Assurance – Limited Assurance Operational Performance (Page 46) • The 4 Hour A&E target was not achieved in September – 85.16% (target 95%).

• 18 Weeks: The RTT open pathway target was not achieved in month at 82.69%. There were 18137 Open pathways in total.

• Cancer: The Trust did not achieve the 62 day urgent referral to treatment (target 85%) standard in August – 80.7%.

The 62 day screening target was achieved in August – 90% (target 90%). The Trust did not achieve the 2 week Breast symptomatic target for August at 91.7% (target 93%).

• Outpatients: The Trust continues to maintain a new to follow up ratio less than the contracted value at 1:2.44. The number of patients who did not attend their outpatient appointment is above the monthly target at 9.22% (target 8.30%).

• Length of Stay: Emergency length of stay for September has decreased to 5.49 days. The elective length of stay for September has increased to 3.47 days, which is below target (target 3.5 days). The Trust overall length of stay for September has decreased to 5.29 days (target 4.3 days).

• Diagnostics: The target is for less than 1% of patients to be waiting for a diagnostic test over 6 weeks and the Trust did not achieve this in September at 2.86%.

• Cancelled Ops: The Trust did not achieve the standard in September – 1.60% (target 0.8%).

Overall Assurance: – Limited Assurance Board Assurance Framework (Page 57)

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Strategic & Compliance Reporting – Lead Director: Kevin McGee

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Mortality – Two Year Trends – Lead Director: Graham Goode

Monthly Dashboard

Mar

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HSMR (Trust) 110 102 125 97 97 112 121 91 97 115 129 126 112 129 91 109 111 111 112 96 110 94 108 95 98 98 97HSMR 12 Month Roll ing (Trust) 113 112 113 114 112 113 115 113 110 112 110 111 111 113 110 111 112 112 112 112 113 112 109 106 105 103 103

SHMI (Trust) 126 103 120 101 94 106 124 98 101 127 136 133 120 127 117 118 121 117 122 111 114 102 122 106 106 100 121SHMI 12 Month Roll ing (Trust) 118 120 119 120 118 116 117 118 115 115 112 113 114 115 116 117 119 120 120 122 123 122 118 117 116 114 112

Red = >110.9; Amber >= 100; Green = < 100

105107109111113115117

HSMR 12 Month Rolling (Trust)

105

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Mortality Data – Lead Director: Graham Goode

Mortality * individual months Mar-15

2014/15 Outturn

2015/16 Outturn Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19

No of Deaths 183 1761 1698 159 130 129 130 140 134 116 134 139 189 130 128 136 138

No of Discharges 9,677 108635 110233 8,423 8,817 8,625 8,752 8,816 8,125 8,906 8,817 8,025 8,815 7,801 8,753 8,478 9,040

% Deaths 1.89% 1.62% 1.54% 1.89% 1.47% 1.50% 1.49% 1.59% 1.65% 1.30% 1.52% 1.73% 2.14% 1.67% 1.46% 1.60% 1.53%

HSMR 123 114 114 129 91 109 111 111 112 96 110 94 108 95 98 98 97

SHMI 117 117 117 134 127 113 124 116 117 120 116 121 110 113 101 120 101

HSMR ** rolling 12 months Mar-15 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19

Overall Observed Deaths 1,565 1,501 1,526 1,481 1,487 1,492 1,499 1478 1,477 1,476 1,430 1,396 1,347 1,311 1,290 1,307

Overall Expected Deaths 1,377 1,352 1,351 1,341 1,335 1,327 1,334 1323.51 1,316 1,301 1,282 1,278 1,265 1,246 1,256 1,268

Overall HSMR 114 111 113 110 111 112 112 112 112 113 112 109 106 105 103 103

SHMI ** rolling 12 months Mar-15 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19

Overall Observed Deaths 2,459 2,096 2,131 2,133 2,157 2,193 2,211 2,195 2,201 2,183 2,125 2,032 2,052 2,025 1,995 1,992

Overall Expected Deaths 2,054 1,844 1,851 1,842 1,841 1,841 1,838 1,833 1,805 1,774 1,744 1,719 1,750 1,746 1,749 1,773

Overall SHMI 120 114 115 116 117 119 120 120 122 123 122 118 117 116 114 112

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Mortality Summary – Lead Director: Graham Goode Trust wide HSMR rolling 12 month position has reduced to 103 (HED Data Only to May 19). SHMI 12 month rolling position for May 2019 has reduced to 112 (HED Data only). The three conditions with the highest excess deaths using SHMI are: Pneumonia Stroke

Superficial injury, contusion Crude mortality in hospital for May has increased compared to the same month in 2017. Heatmap – this report shows excess deaths and SHMI with larger boxes indicating highest numbers of excess deaths by condition and darkest colours representing highest SHMI scores. Very high SHMI scores can be skewed in conditions with very low volumes of patients, the Exception Report by SHMI limits this by only showing conditions with 10 or more deaths over the period, the three conditions with highest SHMI values with 10 or more deaths are: Pneumonia

Stroke Superficial injury, contusion

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Quality – National CQUIN – Lead Director: Peter Murphy No data currently available.

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Quality – Patient Safety – Lead Director: Peter Murphy

Quality – Patient Safety2018-19 Outturn

target(month) Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 YTD Target Responsible colleague

Clostridium Diffici le 35 5 3 14 6 15 9 7 54 65 Jo Lickiss

MRSA Bacteraemia 0 0 1 0 0 0 0 0 1 0 Jo Lickiss

Medication errors resulting in Near Miss 524 N/A 47 41 51 79 71 42 331 Andrew Heath

Medication errors resulting in Harm 1273 89 143 150 150 148 152 96 839 873 Andrew Heath

New Hospital acquired pressure ulcers actual 381 6 94 75 41 41 56 80 387 204 Andrew Heath

New Hospital acquired pressure ulcers spot prevalence 84 1 11 10 13 7 3 7 51 66 Andrew Heath

New Community acquired pressure ulcers, trust attributable actual 806 30 104 106 100 141 192 174 817 644 Andrew Heath

New Community acquired pressure ulcers, trust attributable spot prevalence

88 3 5 9 4 9 6 11 44 62 Andrew Heath

Device Related Pressure Ulcers N/a TBC 3 7 6 6 2 10 Andrew HeathMoisture Lesion N/A TBC N/A 137 192 168 287 242 Andrew HeathTotal Number of Patients with a Pressure Ulcer (Trust Acquired & Non-Trust Acquired)

N/A TBC N/A N/A N/A 544 303 223 Andrew Heath

Safety Thermometer (ST)- Harm free care % - Acute N/A 95% 93.20% 93.39% 93.30% 93.00% 93.60% 93.30% N/A 95% Andrew Heath

Safety Thermometer (ST)- Harm free care % - New Harms only Acute N/A 97.20% 96.43% 96.40% 98.50% 98.47% 96.99% N/A N/A Andrew Heath

Safety Thermometer (ST)- Harm free care % - Community N/A 95% 93.40% 94.85% 94.20% 93.80% 95.11% 93.11% N/A 95% Andrew Heath

Safety Thermometer (ST)- Harm free care % - New Harms only Community N/A 98.30% 97.65% 98.40% 97.90% 98.75% 98.31% N/A N/A Andrew Heath

Safety Thermometer (ST)- Harm free care % - Combined N/A 95% 93.40% 94.19% 93.80% 93.50% 94.41% 93.20% N/A 95% Andrew Heath

Safety Thermometer (ST)- Harm free care % - New Harms only Combined N/A 97.90% 97.09% 97.40% 98.20% 98.62% 97.69% N/A N/A Andrew Heath

Safety Thermometer (ST)- Harm free care % - Maternity (physical) N/A 95% 75% 87% 90% 96% 72% 100% N/A 95% Andrew Heath

Patient Falls resulting in harm (number) 1342 125 116 107 99 97 71 74 564 1491 Andrew Heath

% patients who have received a VTE Risk Assessment N/A 95.0% 71.7% 67.6% 70.4% 70.2% 70.2% 74.6% 70.1% TBC Andrew Heath

Hospital Acquired Pulmonary Embolism 1 N/A 0 0 0 0 0 0 0 TBC Andrew Heath

Hospital Acquired Deep Vein Thrombosis 4 N/A 0 0 0 0 0 2 2 TBC Andrew Heath

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Quality – Patient Safety2018-19 Outturn

target(month) Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 YTD Target Responsible colleague

% of dementia assessments completed – screening question N/A 90% 72.5% 61.7% 72.3% 64.5% 59.0% 42.6% N/A 90% Andrew Heath

% of initial dementia assessments completed – dementia assessment (AMTS10)

N/A 90% 96.0% 100.0% 100.0% 100.0% 100.0% 86.4% N/A 90% Andrew Heath

% of initial dementia assessments completed – referral for memory clinic

N/A 90% 100% 100% 100% 100.0% 100.0% 0.0% N/A 90% Andrew Heath

% compliance with Nursing Care Indicators - Acute N/A 95% Quarterly Quarterly 93% Quarterly Quarterly 96% N/A 95% Tracy Crumbleholme

% compliance with Nursing Care Indicators - ALTC (excl Clifton wards) N/A 95% Quarterly Quarterly 94% Quarterly Quarterly 90% N/A 95% Tracy Crumbleholme

% compliance with Nursing Care Indicators - ALTC (Clifton wards) N/A 95% Quarterly Quarterly 96% Quarterly Quarterly 94% N/A 95% Tracy Crumbleholme

% compliance with Nursing Care Indicators - Trust N/A 95% Quarterly Quarterly 93% Quarterly Quarterly 96% N/A 95% Tracy Crumbleholme

Number of Reported Incidents 27852 2533 2449 2242 2233 2363 2070 13890 N/A Andrew HeathNumber of Reported Patient Safety Incidents 23352 2115 2012 1865 1757 1966 1702 11417 N/A Andrew Heath

Number of SUI/StEIS incidents 50 5 4 2 5 3 5 24 N/A Andrew HeathNumber of Never Events 1 0 0 0 0 1 0 0 1 0 Andrew HeathNumber of new clinical negligence claims 177 12 16 16 11 2 12 69 N/A Andrew Heath

Number of new personal injury claims 15 0 1 1 1 2 0 1 6 0 Andrew Heath

% Clinical Audit Compliance N/A 95% 97% 95% 95% 96% 95% 98% N/A 95.0% Tracy Crumbleholme% NICE Compliance N/A 95% 96% 95% 95% 96% 95% 95% N/A 95.0% Tracy Crumbleholme

% TARN compliance N/A N/Acom-

pliantTracy Crumbleholme

Participated NCEPOD studies % N/A 100% 100% 100% 100% 100% 100% 100% N/A 100% Tracy Crumbleholme% compliance with Sepsis Pathway opportunities to care N/A 90% 89.10% 89.04% 93.63% 94.0% 92.86% 91.53% N/A 90% Tracy Crumbleholme

% compliance with AKI Pathway opportunities to care N/A 90% 84.38% 91.83% 93.06% 92.6% 89.63% 94.64% N/A 90% Tracy Crumbleholme

Missed opportunity DNACPR 19 TBC 5 0 1 0 2 3 11 16 Tracy CrumbleholmeReported incidents failure to rescue (Composite Score) 16 8 21 18 22 13 24 24 122 10.8 Tracy Crumbleholme

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Quality – Patient Safety Summary – Lead Director: Peter Murphy

• C Diff: There were 7 new cases of C Diff in month. We are above trajectory for the year. These are all awaiting validation.

• MRSA: There were no cases of MRSA bacteraemia in month.

• Pressure Ulcers Actual Count in Month: A total of 80 hospital acquired pressure ulcers were reported in month, 38 at Category 2, 4 at Category 3 and 0 at Category 4, with 16 unstageable and 22 Deep Tissue Injuries. There were also 10 device related pressure ulcers. These pressure ulcers have been validated clinically by the Tissue Viability team and the incident system has been updated to reflect TVN findings. A total of 174 non-hospital acquired (community) pressure ulcers were reported this month, of which 86 were at Category 2, 5 at category 3, with 52 Unstageable and 31 Deep Tissue Injuries. These pressure ulcers are currently subject to validation. There were 242 Moisture Lesions reported in the trust. The total number of patients with a pressure ulcer (trust acquired and non-trust acquired) is 223. Statistical Process Control charts have been amended to reflect this data and show an increase this month in comparison to last month. Work is currently underway to further revise the pressure ulcer reporting and investigation process to better support organisational learning, with each division tasked with setting up a category 2 panel to look at the root causes and identify themes, trends and lessons to be learned in order that we can reduce our pressure ulcers harms to patients. The Director of Nursing and Quality has mandated a Nursing Leadership forum to take in October place to discuss and address the deterioration in reported harms during September.

• Harm Free Care: The rate of harm free care for all harms in the acute setting decreased slightly from the previous month to 93.3%, and the rate for new harms decreased to 97.0%. Harm free care in the community decreased to 93.1% for all harms, and decreased slightly to 98.3% for new harms only. The combined all-Trust rate for all harms decreased to 93.2%, with the new harms only rate decreasing to 97.7%.

• Medication Errors: There were 96 medication errors resulting in harm in month, all of which were low level harms. These are subject to review and validation.

• Falls: In month, 74 harms as a result of a fall were reported. These are currently under review to validate as falls.

• Nursing Care Indicators: Trust overall NCI compliance was 96% in quarter 2. The data for Quarter 3 will be available in January.

• TARN: Non-compliance continues to be red due to CT not taking place within the required time or being identified as required for diagnosis. This has been raised to the trust trauma lead to be discussed at the quarterly trauma meeting.

• Pathways: Compliance with the sepsis pathway declined to 67.08%. Antibiotics were administered within the hour to 74.17% of patients. Compliance with 4 out of 9 elements of the pathway deteriorated in month. Senior review within the hour increased slightly to 30.42% and remains a concern. This has been highlighted at the Care of the Deteriorating Patient Group and is being addressed by the Interim Medical Director. AKI compliance increased to 67.86%, Bloods reviewed within 3 hours of cyber lab request and Serum creatinine test repeated within 24 hours of AKI alert deteriorated in month. Again, these will be highlighted for actions at the Care of the Deteriorating Patient.

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• NICE: Trust overall compliance with NICE guidance remained constant at 95% in month. Work continues with the Clinical Divisions to improve compliance.

• Missed Opportunity DNACPR: There were three incidents of Missed Opportunity DNACPRs this month.

• Failure to Rescue (Excl. near miss): There were 24 reported incidents of failure to rescue this month. These are currently under review. This is a composite score

consisting of Failure to Rescue, Missed Opportunity DNACPR and Unplanned Transfers to ITU/HDU. The SPC chart shows that Failure to Rescue performance is within normal variation. This reflects the improvement work being undertaken as part of the Deteriorating Patient Group.

• Never Events: No Never Events were reported this month.

• There were 5 SUI / SteiSS occurring this month, which are currently subject to internal investigation.

• There were two reported hospital acquired VTEs and no hospital acquired pulmonary embolism reported in month. There has been a recent Freedom of Information request regarding VTEs which has resulted in a deep dive investigation taking place. This has identified a different position and the findings of this investigation were provided to Quality Committee.

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Quality – Patient Experience (Local Surveys) – Lead Director: Peter Murphy

Overall Assurance: – Limited Assurance

Quality – Patient Experience Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-

19 Dec-19 Jan-20 Feb-

20 Mar-20 YTD Our Target

Complaints Formal (number) 54 45 53 46 52 43 N/A Complaints acknowledged within 3 working days 59.25% 35.5% 9.5% 35% 73% 63% 100%

Complaints DUE TO BE Responded to (number)

36 62 43 54 54 41 N/A

Complaints due to responded to and within 25/35 working day target

69.5% 61.5% 60.5% 40.75% 74% 56% 80%

Complaints Informal (number) – not including general enquiries 79 105 93 116 104 94 N/A

Compliments 338 454 535 592 500 600 N/A Mixed Sex Accommodation Breech 0 0 0 0 0 0 1 1 NHS Friends and Family Test overall % to recommend our services 97% 97% 97% 97% 96% 96% N/A 96%

NHS Friends and Family % inpatients to recommend 95% 96% 96% 95% 95% 95% N/A 96%

NHS Friends and Family % A&E patients to recommend 94% 98% 96% 95% 84% 85% N/A 92%

NHS Friends and Family Test Maternity % patients to recommend 98% 95% 90% 94% 98% 94% N/A 97%

NHS Friends and Family Test Community % patients to recommend 99% 99% 98% 99% 99% 98% N/A 98%

NHS Friends and Family Test Outpatients / Day Case % patients to recommend

96% 97% 96% 97% 95% 97% N/A 97%

NHS Friends and Family Test Children’s Services % patients to recommend

96% 95% 97% 90% 98% 97% N/A 95%

Daily inpatient spot survey - Were you involved as much as you wanted to be in decisions about your care and treatment?

85% 84% 90% 89% 87% 83% N/A 73%

Daily inpatient spot survey - Do you know which nurse is in charge of looking after you? (this would change to a different person after each shift)

57% 55% 67% 46% 51% 51% N/A 65%

Daily inpatient spot survey - How much information about your condition or treatment was given to you?

82% 79% 83% 88% 85% 75% N/A 88%

Daily inpatient spot survey - Do you feel that you have been treated with respect and dignity on the ward?

97% 98% 100% 98% 98% 95% N/A 90%

Daily inpatient spot survey - Did you feel that you had to wait a long time to get to a bed on a ward?

N/A N/A N/A 63% 83% 73% 75%

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Quality – Patient Experience Summary – Lead Director: Peter Murphy

Complaints:

In September 2019 there were 9009 admissions to Blackpool Teaching Hospitals NHS Foundation Trust. 43 formal complaints were received in this period which required investigation. 26 related to care provided in the hospital. This equates to 0.27% of hospital admissions. 63% of complaints were acknowledged within 3 working days in the Trust. 41 complaints were due to be responded to in September 2019. 23 of the 41 (56%) met the 25/35 working day response target, an 18% decrease from last month. A breakdown for the divisions is below:

• ALTC Division response rate was – 50% (36% decrease from August) • Clinical Support response rate was – 50% (equal to August) • Families Division response rate was – 40%(35% decrease from August) • Scheduled Care Division response rate was – 70% (5% decrease from August) • Unscheduled Care Division response rate was – 50% (21% decrease from August)

Mixed Sex Accommodation: There were no mixed sex breaches in September. The 2009 and 2010 DSSA guidance have recently been reviewed by NHS England and NHS improvement. Changes have been made to reflect current patient pathways, including further definition of what is and isn’t a mixed-sex accommodation breach and circumstances in which mixing may be justified and therefore not constitute a breach. The revised paper can be found at: https://improvement.nhs.uk/documents/6005/Delivering_same_sex_accommodation_sep2019.pdf

A paper will be going to Quality Committee in November providing more details around these changes which are due to be enforced in January 2020.

Friends & Family Test – Overall: In September the Trust received 4090 responses to the national NHS Friends and Family Test, an increase of 538 compared to August. 96% of our patients said that they would recommend the Trust’s services to friends and family if they needed similar care or treatment.

• Friends & Family Test – Emergency department: There were 302 responses to the survey, an increase of 26 compared to August. The texting trial is now underway with

patients starting to receive invitations to complete the survey via text message. Paper forms will continue to be used across the department to help maximise the number of responses being received. 174 patients chose to respond to the survey via text messages, which accounted for 58% of the overall number of responses received. Since the introduction of the texting pilot, we have seen the overall percentage of patients to recommend in this department decrease significantly to 85%, this is believed to be due to patients feeling they can be more honest when replying via text and they have more time to think about this experience and reflect on their journey.

• Friends & Family test – Inpatient: There were 942 responses to the survey, a decrease of 122 compared to August. Analysis of the data is underway to determine where

the decrease has been seen to address this ahead of next month. 95% of inpatients said they would be either extremely likely or likely to recommend our inpatient services.

• Friends & Family Test – Maternity: There were 127 responses to the survey, a decrease of 35 compared to August. This month a slight decrease has been seen across all four touch points, engagement with the departments involved continues to try and increase the responses further. 94% of women saying that they would recommend the department to their friends and family.

• Friends & Family Test – Community (ALTC & Families): There were 1548 responses to the survey, an increase of 123 responses when compared to August. This increase sees the number of responses recover to the growth we were seeing before the August holiday period. 98% said they would be extremely likely or likely to recommend the department to their friends or relatives.

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https://improvement.nhs.uk/documents/6005/Delivering_same_sex_accommodation_sep2019.pdf

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• Friends & Family Test – Outpatient & Day Case: There were 1098 responses to the survey, an increase of 551 responses compared to August. 97% of patients said that they would be extremely likely or likely to recommend the service.

• Friends & Family Test – Paediatric / Family Services: There were 352 responses to the survey, an increase of 63 compared to August. 97% of patients in paediatric services said they would be extremely likely or likely to recommend the department to their friends or relatives.

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Finance – Lead Director: Tim Bennett

For year ending 31 March 2020

Consolidated Trust Current Month

– Month 6

Consolidated Trust Year to Date

– Month 6

Budget Actual Variance against

Plan Budget Actual

Variance

against Plan

Annual Budget

£m £m £m £m £m £m £m Income 36.3 36.8 0.4 215.6 220.0 4.4 433.7 Pay -Substantive (24.3) (23.8) 0.5 (145.2) (143.2) 2.0 (290.7)

Pay - Agency (1.0) (2.6) (1.6) (7.2) (12.6) (5.4) (15.3)

Non-pay (11.9) (12.6) (0.7) (69.1) (73.4) (4.3) (138.5) EBITDA (0.9) (2.2) (1.3) (5.9) (9.2) (3.3) (10.8) Non-Operating Costs (1.2) (1.1) 0.1 (7.1) (6.8) 0.3 (14.2) Underlying Surplus / (Deficit) (2.0) (3.3) (1.3) (13.0) (16.0) (3.0) (25.0) Mth 6/YTD Mitigations 0.0 0.0 0.0 0.3 0.6 0.3 0.0

Reported Surplus / (Deficit) (2.0) (3.3) (1.3) (12.7) (15.4) (2.7) (25.0) Adj for Impairments / Donated Assets ** 0.0 0.0 0.0 0.1 (0.2) (0.3) 0.1

Reported Surplus / (Deficit) exc CIP / PSF (2.0) (3.3) (1.3) (12.7) (15.7) (3.0) (24.9)

CIP 1.7 1.1 (0.6) 7.4 4.8 (2.6) 20.0

Reported Surplus / (Deficit) exc PSF (0.3) (2.2) (1.8) (5.2) (10.8) (5.6) (4.9)

PSF / MRET 0.8 (0.6) (1.4) 4.3 2.9 (1.4) 10.5

Reported Surplus / (Deficit) post PSF 0.4 (2.8) (3.2) (0.9) (7.9) (7.0) 5.6 * The financial position excludes hosted services (Healthier Lancashire / NWLA) as these services are cost neutral and do not impact on the financial performance of the Trust. ** The adjusting items include adjustments relating to Donated Assets and 18/19 PSF.

Cash Balance

14.3 14.8 0.5 14.3 14.8 0.5 1.9

Capital Expenditure*** (0.6) (1.6) (1.0) (3.5) (6.3) (2.8) (14.4) *** See Capital Expenditure / Estate Section.

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Mth 01 Mth 02 Mth 03 Mth 04 Mth 05 Mth 06 Mth 07 Mth 08 Mth 09 Mth 10 Mth 11 Mth 12 Use of Resources (UOR) Plan 3 3 3 3 3 3 3 3 3 3 3 3

Actual 3 3 3 4 4 4

Mth 01 Mth 02 Mth 03 Mth 04 Mth 05 Mth 06 Mth 07 Mth 08 Mth 09 Mth 10 Mth 11 Mth 12

£m £m £m £m £m £m £m £m £m £m £m £m

CIP (see separate section below)

Plan 0.7 0.8 0.9 1.6 1.6 1.7 1.9 1.9 1.9 2.2 2.2 2.3

Actual 0.7 0.6 0.7 1.1 0.6 1.1

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Finance Summary – Lead Director: Tim Bennett

• This report compares actual performance to the 2019-20 budgets.

• Income and Expenditure: The consolidated Trust incurred a deficit of (£2.2m) (excluding PSF / MRET) in September which is £1.8m worse than the budget. The year to date actual (excluding PSF / MRET) is a deficit of (£10.8m) which £5.6m worse than the budget.

• The key drivers of the worse than planned performance are investments to address quality, safety and regulatory concerns and and lower than planned CIP.

• The reported position assumes full receipt of MOU and other monies due from the CCGs. There remains a risk around the remainder of the MOU funding.

• Operating income (excluding hosted services) is ahead of budget by £4.4m year to date linked to the following: -

o For 2019-20, the Trust has agreed an assured contract with our two local commissioners and therefore not driving any income variances. In activity terms, the Trust is currently underperforming on this contract by £1.2m, predominantly related to an underperformance in elective activity in Orthopaedics (£0.4m), General Surgery (£0.3m), Cardiology (£0.2m) and ENT (£0.2m); as well as lower than planned outpatient activity in Dermatology (£0.2m), Orthopaedics (£0.1m) and Gastroenterology (£0.1m). Non-elective activity has reduced significantly in-month, particularly in Cardiology (£0.1m) and Trauma & Orthopaedics (£0.1m). Births have also continued to under-perform against plan (£0.5m).These are partially offset by over-performances in Ophthalmology, ED attendances and adult critical care.

o Other Clinical Contracts are on a cost and volume basis and against these contracts the Trust is reporting an over-performance of £2.2m. This is predominantly driven by increased activity on the Cancer Drugs Fund contract (£0.7m), NHS England Specialised Commissioning contract (£0.7m) and increased out-of-area activity (£0.6m).

o The key Specialised Commissioning variances of £0.7m are: - Increased pass-through costs for drugs (£0.3m) (please note that a year to date transfer has taken place between Specialised Commissioning and

Cancer Drugs Fund); Increased day case & elective activity in Haematology (£0.7m); The under-performance of elective activity in Cardiothoracic Surgery of £0.4m which is offset by increased non-elective activity across tertiary services

and General Medicine (£0.6m); Reduced utilisation of adult and neonatal critical care areas (£0.2m); A delay in the introduction of the Cardiology Modular Lab (£0.2m).

o With current levels of under-performance on planned activities, the Trust will need to assess the impact on planned operational trajectories.

o Private Patient income is currently behind budget by (£0.2m).

o The Trust has received funding from NHS England for transitional relief to cover Local Authority inflationary pressures £0.2m.

• Operating expenditure (excluding hosted services) is (£7.7m) worse than the budget cumulatively predominantly driven by the following: -

o Quality and safety investments of £4.2m, made up of: Additional capacity for Urgent Care (£1.1m) including:-

• Extension to winter escalation - Ward 24 still open and diagnostics continuing winter escalated service (£0.4m); of 225

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• GP Admissions Unit pilot (£0.6m); • Urgent care flow project (£0.1m).

Stroke services critical incident cost pressure (£0.8m); CQC (May) / Immediate safety cost pressures (£0.5m); Net increase in agency costs to improve fill rates (£1.8m) (£2.8m agency costs offset by £1.0m substantive pay underspends).

o The 2019-20 plan was also based on the 2019-20 Medical & Dental pay award being implemented from the 1st October 2019 which was consistent with the 2018-19 Medical & Dental pay award agreement. The 2019/20 pay award was however backdated to the 1st April 2019 and the level of funding received from NHS England has only partly offset the higher than planned cost resulting in a cost pressure of £0.2m.

o The Trust is also facing cost pressures in relation to changes to the senior leadership team which were not included in the 2019/20 plan costing (£0.2m).

o Following a change to a previous decision, the Trust ran the 2017-18 Clinical Excellence Awards process, resulting in a cost pressure of (£0.4m) paid in April 2019.

The Finance Department will be reviewing the provenance and governance around the quality and safety investment decisions. Following the review, recommendations will be made to the Finance Committee and Board of Directors in relation to the governance arrangements.

• Balance Sheet: Annex F shows the consolidated Trust Balance Sheet as at 30th September 2019 and reports Total Net Assets of £90.1m which is £3.9m lower than plan which arises from: -

The Trust accounting for PSF Incentive income of £3.1m in 2018-19 notified by NHSI after submission of the 2019-20 annual plan; offset by, Other changes to the 2018-19 outturn position of (£0.2m) after submission of the 2019-20 annual plan; The impact of current year financial performance of (£6.8m).

o Working Capital: The key movements in working capital for the consolidated Trust are explained within the analysis of the cash variance to plan below.

o Cash: The consolidated Trust cash balance at the end of September is £14.8m which is £0.5m higher than plan. The higher than plan cash balance is mainly

due to: -

Impact of I&E performance on cash (£7.0m); Delay in Fylde Coast CCG’s support payment for 2018-19 (£2.3m); Delay in Fylde coast CCG’s support funding for 2019-20 linked to the MOU sign off (£8.7m); Delay in settlement of Healthier Lancashire funding (£0.3m); Capital cash payments higher than plan due to phasing net of PDC receipts (£1.6m); Receipt of unplanned 2018-19 PSF Incentive £3.1m; Delay in settlement of NHS Property Services invoices (Atlas) £2.6m; Part repayment of DHSC revenue support loan (£1.4m); Deferred contract income from commissioners £8.2m; Other deferred income £4.1m; Other working capital movements £3.8m.

o The latest thirteen cashflow forecast does not anticipate the Trust requiring DHSC cash support in the next three months.

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• CIP Performance: The Trust has delivered £1.1m CIP against the 2019-20 schemes in September, which is £0.6m worse than internal Trust Plan. This underachievement is due to the underperformance of Planned Care (Theatres, Outpatients, Diagnostics), Urgent & Emergency Care (Better Care Now) and Procurement schemes. Cumulatively, the Trust has delivered £4.8m CIP against the 2019-20 schemes, which is £2.6m worse than internal Trust Plan. This underachievement is due to the underperformance of Planned Care (Theatres, Outpatients, Diagnostics), Workforce (Reduction in Contingent Labour), Urgent & Emergency Care (Better Care Now), and Procurement schemes, which have been partly mitigated by the over-performance of Technical Flexibilities, Divisional and Medicines Management schemes.

• Use of Resource Rating (UoR): The consolidated Trust has achieved a UOR of 4 in September which is worse than the plan.

• Capital Expenditure: Capital expenditure is £6.3m year to date which is £2.8m higher than the plan.

• Overall Assurance: – Limited Assurance

• The consolidated Trust incurred a deficit of (£2.2m) (excluding PSF / MRET) in September which is £1.8m worse than the budget. The year to date actual (excluding PSF / MRET) is a deficit of (£10.8m) which £5.6m worse than the budget.

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Annex A1 – Income and Expenditure Performance for the Consolidated Trust for the period ending 30th September 2019

2018/19 Outturn Budget Actual Budget Actual

£'m £'m £'m £'m % Category £'m £'m £'m %

388.5 34.8 34.8 0.0 0.1% Clinical income 206.6 207.8 1.2 0.6%42.0 2.8 1.6 (1.2) (42.5%) Other operational income 16.1 15.7 (0.5) (3.0%)

430.5 37.6 36.4 (1.2) (3.1%) Total income 222.7 223.5 0.7 0.3%

(431.7) (36.0) (38.1) (2.1) (5.7%) Operating expenditure (216.6) (224.4) (7.8) (3.6%)

(1.2) 1.6 (1.6) (3.2) (204.7%) EBITDA 6.1 (0.9) (7.0) (115.1%)

(11.3) (1.2) (1.1) 0.1 5.0% Non-operating expenditure (7.0) (7.0) (0.0) (0.6%)

(12.5) 0.4 (2.8) (3.2) (801.4%) Surplus/(deficit) (0.9) (7.9) (7.0) (803.4%)

Current Month Year To Date

Variance Against Budget Variance Against Budget

(7.6)(7.4)(7.2)(7.0)(6.8)(6.6)(6.4)(6.2)(6.0)(5.8)(5.6)(5.4)(5.2)(5.0)(4.8)(4.6)(4.4)(4.2)(4.0)(3.8)(3.6)(3.4)(3.2)(3.0)(2.8)(2.6)(2.4)(2.2)(2.0)(1.8)(1.6)(1.4)(1.2)(1.0)(0.8)(0.6)(0.4)(0.2)0.0

£m

Cumulative budget and actual - Surplus / (Deficit)

Budget Actual

(2.5)(2.0)(1.5)(1.0)(0.5)

0.00.51.01.52.0

£m

Monthly budget and actual - Surplus / (Deficit)

Budget Actual

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Annex A2 – Clinical Income by Point of Delivery for the period ending 30th September 2019


£'m £'m £'m £'m % £'m £'m £'m %

0 Clinical Income0

97.4 8.9 8.6 (0.3) (3%) Non-elective inpatients 54.1 54.2 0.1 0%58.8 5.3 5.0 (0.4) (7%) Daycases and elective inpatients 30.8 29.9 (1.0) (3%)2.6 0.2 0.2 (0.0) (7%) Excess bed days 1.2 1.1 (0.0) (4%)6.3 0.6 0.7 0.1 15% Outpatient procedures 3.5 4.1 0.6 17%

30.7 2.8 2.7 (0.1) (2%) Outpatient attendances 16.4 15.2 (1.2) (7%)10.7 0.9 1.0 0.1 11% A&E 5.7 6.3 0.6 11%66.0 5.5 5.0 (0.5) (9%) Community Services 29.5 29.7 0.2 1%

116.1 10.7 11.6 1.0 9% Other 65.5 67.4 1.9 3%

388.5 34.8 34.8 (0.0) (0.1%) Total Clinical Income 206.6 207.8 1.2 0.6%

Current Month Year To Date

Variance against Budget Variance against Budget

0.0000

50.0000

100.0000

150.0000

200.0000

250.0000

APR-19 MAY-19 JUN-19 JUL-19 AUG-19 SEP-19 OCT-19 NOV-19 DEC-19 JAN-20 FEB-20£m

Cumulative budget & actual - Clinical income

Budget Actual

32.032.533.033.534.034.535.035.536.036.5

APR-19 MAY-19 JUN-19 JUL-19 AUG-19 SEP-19 OCT-19 NOV-19 DEC-19 JAN-20 FEB-20

£m

Monthly budget & actual - Clinical income

Budget Actual

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Annex A3 – Pay Expenditure for the Consolidated Trust for the period ending 30th September 2019

2018/19 Outturn Budget Actual Budget Actual Budget

£'m £'m £'m £'m % £'m £'m £'m % £'m

Pay - Payroll

(35.5) (3.4) (3.0) 0.3 10% Consultants (19.3) (18.8) 0.5 3% (38.7)(1.5) 0.1 (0.1) (0.3) (205%) Dental (0.5) (0.7) (0.2) (47%) (1.2)

(22.4) (2.1) (1.9) 0.2 9% Junior medical (11.8) (11.6) 0.2 2% (23.7)(96.5) (8.0) (7.8) 0.2 2% Nursing & midwifery (48.5) (47.3) 1.2 2% (96.3)(44.3) (3.7) (3.7) 0.0 0% Scientific, therapeutic & technical (23.0) (22.5) 0.4 2% (45.5)(25.0) (2.1) (2.2) (0.1) (4%) Other clinical (12.8) (13.2) (0.4) (3%) (25.5)(53.5) (4.6) (4.5) 0.1 2% Non clinical (27.2) (27.1) 0.1 1% (53.8)

(278.6) (23.8) (23.4) 0.4 2% Total payroll pay costs (143.0) (141.1) 1.9 1% (284.8)

Pay - Agency

(5.0) (0.3) (0.5) (0.2) (75%) Consultants (2.1) (3.1) (1.0) (50%) (4.0)(0.0) (0.0) (0.0) (0.0) (0%) Dental (0.0) (0.0) (0.0) (0%) (0.0)(4.7) (0.3) (0.6) (0.3) (94%) Junior medical (2.1) (3.2) (1.1) (54%) (4.3)(1.9) (0.1) (1.2) (1.0) (776%) Nursing & midwifery (0.9) (4.2) (3.3) (366%) (1.6)(1.1) (0.1) (0.1) (0.0) (37%) Scientific, therapeutic & technical (0.6) (0.6) 0.1 10% (1.9)(0.3) (0.0) (0.0) (0.0) (571%) Other clinical (0.1) (0.2) (0.1) (163%) (0.3)(1.7) (0.1) (0.1) 0.0 12% Non clinical (0.8) (0.8) (0.0) (0%) (1.5)

(14.6) (0.9) (2.5) (1.6) (169%) Total agency pay costs (6.5) (12.1) (5.5) (85%) (13.5)

(293.2) (24.7) (25.9) (1.1) (5%) Total pay costs (149.5) (153.2) (3.7) (0.0) (298.3)

AnnualVariance against

Budget

Year To DateCurrent MonthVariance against

Budget

24.0

24.5

25.0

25.5

26.0

26.5

27.0

£m

Monthly budget and actual - Pay expenditure

Budget Actual

0.020.040.060.080.0

100.0120.0140.0160.0180.0

£m

Cumulative budget and actual - Pay expenditure

Budget Actual

of 225

25

Annex A4 – Agency Expenditure for the Consolidated Trust for the period ending 30th September 2019


£'m £'m £'m £'m % £'m £'m £'m % £'m

Pay - Agency(5.0) (0.3) (0.5) (0.2) (59%) Consultants (2.1) (3.1) (1.0) (50%) (4.0)(0.0) (0.0) (0.0) (0.0) (0%) Dental (0.0) (0.0) (0.0) (0%) (0.0)(4.7) (0.3) (0.6) (0.3) (96%) Junior medical (2.1) (3.2) (1.1) (54%) (4.3)(1.9) (0.1) (1.2) (1.0) (789%) Nursing & midwifery (0.9) (4.2) (3.3) (366%) (1.6)(1.1) (0.1) (0.1) (0.0) (43%) Scientific, therapeutic & technical (0.6) (0.6) 0.1 10% (1.9)(0.3) (0.0) (0.0) (0.0) (0%) Other clinical (0.1) (0.2) (0.1) (163%) (0.3)(1.7) (0.1) (0.1) 0.0 15% Non clinical (0.8) (0.8) (0.0) (0%) (1.5)

(14.6) (0.9) (2.5) (1.6) (175%) Total agency pay costs (6.5) (12.1) (5.5) (85%) (13.5)

Variance against Budget

Year To Date AnnualCurrent MonthVariance against

Budget

-200,0000

200,000400,000600,000800,000

1,000,0001,200,0001,400,000

APR-19 MAY-19 JUN-19 JUL-19 AUG-19 SEP-19 OCT-19 NOV-19 DEC-19 JAN-20 FEB-20 MAR-20

£m

Actual Agency Spend 2019-20

AGENCY CONSULTANTS AGENCY DENTAL

AGENCY JUNIOR MEDICAL AGENCY NURSING, MIDWIFERY & HEALTH VISITORS

AGENCY SCIENTIFIC, THERAPEUTIC & TECHNICAL AGENCY OTHER CLINICAL STAFF

AGENCY NON CLINICAL STAFF

of 225

26

Annex A5 – Non-Pay Expenditure for the Consolidated Trust for the period ending 30th September 2019


£'m £'m £'m £'m % £'m £'m £'m % £'m

(37.4) (3.0) (3.6) (0.6) (21.1%) Drugs costs (18.2) (20.3) (2.1) (12%) (36.1)

Other non-pay costs

(43.0) (3.3) (3.5) (0.2) (6%) Clinical supplies & services (19.8) (20.7) (0.9) (5%) (38.5)(7.5) (0.6) (0.6) 0.0 3% General supplies & services (3.8) (4.1) (0.3) (8%) (7.5)

(22.8) (1.6) (1.6) 0.0 1% Establishment expenditure (10.1) (10.3) (0.2) (1%) (19.9)(0.2) (0.0) (0.0) (0.0) (0%) Ambulances (0.1) (0.1) (0.0) (0%) (0.2)(0.0) (0.0) (0.0) 0.0 100% Research & Development (0.0) (0.0) 0.0 100% (0.1)

(14.2) (1.4) (1.5) (0.2) (13%) Premises & fixed plant (7.5) (8.6) (1.1) (15%) (14.9)(21.2) (1.4) (1.3) 0.1 5% Other (7.6) (7.2) 0.5 6% (14.8)

0.0 (0.0) (0.0) (0.0) (0%) Other Finance Cost (0.0) (0.0) (0.0) (0%) (0.0)

(108.8) (8.3) (8.6) (0.3) (3%) Total other non-pay costs (49.0) (50.9) (2.0) (4%) (95.9)

(146.2) (11.3) (12.2) (0.9) (8%) Total operational costs (67.1) (71.2) (4.1) (6%) (131.9)

Current Month Year To Date AnnualVariance against

BudgetVariance against

Budget

9.510.010.511.011.512.012.513.0

APR-19

MAY-19

JUN-19

JUL-19 AUG-19

SEP-19 OCT-19

NOV-19

DEC-19

JAN-20

FEB-20 MAR-20

£m

Monthly budget and actual - Non-pay expenditure

Budget Actual

0.0

20.0

40.0

60.0

80.0

APR-19

MAY-19

JUN-19

JUL-19

AUG-19

SEP-19

OCT-19

NOV-19

DEC-19

JAN-20

FEB-20

MAR-20

£m

Cumulative budget and actual - Non-pay expenditure

Budget Actual

of 225

27

Annex B - Gross Contribution for the Consolidated Trust for the period ending 30th September 2019


£'m £'m £'m £'m % £'m £'m £'m %Division

14.2 1.8 1.1 (0.6) (36%) Scheduled Care 9.7 6.5 (3.2) (33%)

30.9 2.8 1.3 (1.5) (53%) Unscheduled Care 16.5 12.9 (3.6) (22%)

2.0 0.1 0.0 (0.1) (68%) Adult Community Services / Long Term Conditions

(0.0) (0.6) (0.5) (1274%)

14.1 1.2 1.1 (0.1) (9%) Families 6.9 6.7 (0.1) (2%)

(11.0) (1.2) (1.7) (0.5) (38%) Clinical Support (7.5) (8.0) (0.4) (6%)

(38.1) (3.5) (3.5) 0.0 1% Facilities Management (21.2) (21.2) (0.0) (0%)

(0.4) 0.5 (0.0) (0.5) (104%) Corporate Services 1.9 2.7 0.7 38%

11.7 1.6 (1.6) (3.2) (205%) EBITDA 6.3 (0.9) (7.2) (115%)

(10.9) (1.2) (1.1) 0.1 4% Non-operating expenditure (7.0) (7.0) 0.0 0%

0.8 0.4 (2.8) (3.2) (801%) Surplus/(deficit) (0.9) (7.9) (7.0) (806%)

Current Month Year To DateVariance against

Budget Variance against Budget

(4.0)(3.0)(2.0)(1.0)

0.01.02.03.0

£m

Monthly Budget & Actual - Gross contribution

Budget Actual

(9.0)(8.0)(7.0)(6.0)(5.0)(4.0)(3.0)(2.0)(1.0)

0.01.02.03.04.05.06.07.0

£m

Cumulative Budget & Actual - Gross contribution

Budget Actual

of 225

28

Annex C – Key Contract Performance for period ending 30th September 2019

2018-19 Outturn Budget Actual Budget Actual Budget

£'m £'m £'m £'m % £'m £'m £'m % £'m

NHS Blackpool CCG

5.6 0.5 0.6 0.1 10% A&E 3.2 3.5 0.3 10% 5.922.1 1.9 1.9 0.0 0% Community 11.5 11.5 0.0 0% 22.13.5 0.3 0.3 0.0 17% Critical Care Beddays 1.6 1.8 0.2 14% 3.13.7 0.3 0.4 0.1 24% Direct Access Diagnostics 1.8 2.0 0.1 8% 3.4

17.7 1.5 1.5 0.0 1% Electives Including Daycases 9.1 8.6 (0.5) (5%) 17.848.4 4.4 3.9 (0.4) (10%) Emergencies 26.7 26.2 (0.4) (2%) 48.025.9 3.3 3.5 0.2 7% Other Clinical Income 20.4 20.7 0.3 2% 24.112.5 1.1 1.1 (0.0) (3%) Outpatient Attendances 6.6 6.2 (0.4) (6%) 12.22.7 0.2 0.3 0.1 23% Outpatient Procedures 1.4 1.7 0.3 22% 2.5

142.1 13.5 13.5 0.0 0.0% NHS Blackpool CCG Total 82.2 82.2 0.0 0.0% 139.1

NHS Fylde & Wyre CCG

3.5 0.3 0.4 0.0 12% A&E 2.0 2.2 0.2 10% 3.917.6 1.5 1.5 (0.0) (0%) Community 9.1 9.1 0.0 0% 17.62.1 0.2 0.2 0.0 19% Critical Care Beddays 1.0 1.2 0.1 11% 2.43.4 0.3 0.3 0.0 16% Direct Access Diagnostics 1.7 1.8 0.1 5% 3.2

17.0 1.5 1.5 0.1 6% Electives Including Daycases 8.7 8.3 (0.4) (5%) 16.438.1 3.4 3.4 (0.1) (2%) Emergencies 20.9 20.3 (0.7) (3%) 37.820.1 1.6 1.5 (0.1) (7%) Other Clinical Income 9.6 10.6 0.9 10% 20.810.8 0.9 0.9 (0.1) (6%) Outpatient Attendances 5.7 5.2 (0.5) (8%) 10.52.6 0.2 0.3 0.0 18% Outpatient Procedures 1.4 1.6 0.2 18% 2.5

115.3 9.9 9.9 (0.0) (0.0%) NHS Fylde & Wyre CCG Total 60.3 60.3 0.0 0.0% 115.2

0.0 23.5 23.5 0.0 0.0% Key Contract Performance 142.5 142.5 0.0 0.0% 254.3

Current Month Year To Date Annual

Variance against Budget Variance against Budget

22,000,000.0022,500,000.0023,000,000.0023,500,000.0024,000,000.0024,500,000.0025,000,000.0025,500,000.00

£m

Monthly Contract Performance

Budget Actual Forecast

0.0020,000,000.0040,000,000.0060,000,000.0080,000,000.00

100,000,000.00120,000,000.00140,000,000.00160,000,000.00

£m

Cumulative Contract Performance

Budget Actual Forecast

of 225

29

Annex D – CIP Performance by Theme for the period ending 30th September 2019

Plan Actual Plan Actual Plan

£'m £'m £'m % £'m £'m £'m % £'mTheme

0.4 0.0 (0.4) (89%) Planned Care 1.3 0.3 (1.0) (80%) 4.50.1 0.0 (0.1) (97%) Urgent & Emergency Care 0.1 0.0 (0.1) (97%) 2.40.0 0.0 (0.0) (37%) Corporate Services 0.1 0.0 (0.1) (82%) 0.80.0 0.0 0.0 0% Innovation & Technology 0.0 0.0 0.0 0% 0.00.3 0.1 (0.2) (60%) Workforce 0.8 0.5 (0.3) (34%) 3.00.0 0.0 (0.0) (200%) Commercial Development 0.0 0.0 (0.0) (71%) 0.10.3 0.2 (0.1) (23%) Procurement 0.6 0.5 (0.1) (21%) 3.30.1 0.1 0.0 30% Medicines Management 0.2 0.3 0.2 86% 1.30.0 0.3 0.3 0% Technical Flexibilities 0.0 0.3 0.3 0% 0.00.3 0.4 0.1 33% Divisional 0.8 1.2 0.4 45% 3.60.1 0.0 (0.1) (104%) Mitigations being Developed 0.1 0.0 (0.1) (104%) 1.0

1.6 1.1 (0.5) (29%) TOTAL 4.1 3.1 (1.0) (24%) 20.0

Current Month Year To Date AnnualVariance against

PlanVariance against

Plan

0.00.20.40.60.81.01.21.41.61.8

APR-19

MAY-19

JUN-19

JUL-19

AUG-19

SEP-19

OCT-19

NOV-19

DEC-19

JAN-20

FEB-20

MAR-20

£'m

Monthly actual and plan Total CIP delivery

Plan Actual

0.71.72.73.74.75.76.77.78.7

APR-19

MAY-19

JUN-19 JUL-19 AUG-19

SEP-19 OCT-19

NOV-19

DEC-19

JAN-20FEB-20 MAR-20

£'m

Cumulative actual and plan Total CIP delivery

Plan Actual

of 225

30

Annex E – Capital Expenditure for the period ending 30th September 2019

2018/19Outturn Plan Actual Plan Actual

£'m £'m £'m £'m % £'m £'m £'m %

(3.8) (0.2) (0.1) 0.1 40% Building Works & Non-Medical Equipment (1.0) (0.6) 0.4 40%(5.7) (0.2) (0.6) (0.4) (261%) Electronic Information Projects (1.0) (3.8) (2.8) (278%)(1.9) (0.2) (0.9) (0.7) (263%) Clinical Equip. Replacement & Enabling (1.5) (1.9) (0.4) -25%

(11.4) (0.6) (1.6) (1.0) (167%) (3.5) (6.3) (2.8) (79%)

Variance Variance

0

1

2

3

APR-19 MAY-19 JUN-19 JUL-19 AUG-19 SEP-19 OCT-19 NOV-19 DEC-19 JAN-20 FEB-20 MAR-20

£m

Monthly actual and plan capital expenditure

Actual in month Plan

2

4

6

8

10

12

14

16

£m

Year to date actual and plan capital expenditure

Actual ytd Plan

of 225

31

Annex F – Balance Sheet Reconciliation for the Consolidated Trust as at 30th September 2019

of 225

32

Annex G – Cash Position for the Consolidated Trust for the period ending 30th September 2019

April May June July August September October November December January February March£'m £'m £'m £'m £'m £'m £'m £'m £'m £'m £'m £'m

Balance b/f 15.6 11.2 8.7 8.5 10.5 9.0 14.3 15.5 16.7 14.6 9.8 11.5

Cashflow Cash flow from operating activities (0.8) 0.6 0.6 1.3 (0.9) (1.7) 2.7 2.0 1.8 2.0 1.7 3.3Movement in working capital (0.9) (2.4) 0.4 2.0 1.5 11.4 (0.5) (0.2) (1.5) (5.1) 1.9 (8.1)

Cash Flow from operations (1.7) (1.8) 1.0 3.3 0.6 9.7 2.3 1.8 0.3 (3.0) 3.5 (4.8)

Capital expenditureCapex Spend (0.8) (0.7) (0.7) (1.3) (2.0) (0.9) (0.6) (0.6) (1.8) (1.8) (1.8) (1.8)

Cash Flow before financing (2.5) (2.5) 0.3 2.0 (1.4) 8.8 1.7 1.2 (1.6) (4.8) 1.7 (6.6)

FinancingPDC received 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.0PDC Dividend paid 0.0 0.0 0.0 0.0 0.0 (1.0) 0.0 0.0 0.0 0.0 0.0 (1.2)Interest paid loans and leases (0.1) 0.0 (0.2) 0.0 0.0 (0.6) (0.1) 0.0 (0.2) 0.0 0.0 (0.5)Drawdown of loans 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0Repayment of loans (1.8) 0.0 (0.3) 0.0 0.0 (1.7) (0.5) 0.0 (0.3) 0.0 0.0 (1.3)

Net Cash Inflow (4.4) (2.5) (0.2) 2.0 (1.4) 5.7 1.2 1.2 (2.1) (4.8) 1.7 (9.6)

Balance C/F 11.2 8.7 8.5 10.5 9.0 14.8 15.6 16.7 14.6 9.8 11.5 1.9

Plan 6.4 8.4 15.8 17.6 17.7 14.3 15.5 16.7 14.6 9.8 11.5 1.9

0.0

5.0

10.0

15.0

20.0

£'m

Monthly actual & planned group cash position 2019-20

Group cash balance P la n

of 225

33

Annex H – Use Of Resources Risk Rating Forecast for Consolidated Trust for the period ending 30th September 2019

Use of Resources Rating Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20Actual Actual Actual Actual Actual Actual Plan Plan Plan Plan Plan Plan

Liquidity 0.20 -23.5 -24.7 -25.6 -26.3 -27.8 -31.2 -25.1 -25.1 -25.8 -25.9 -26.2 -26.4Capital Service Cover 0.20 -0.4 -0.1 0.1 0.5 0.2 -0.1 1.8 2.1 2.1 2.4 2.5 2.4I&E margin 0.20 -5.3% -3.4% -2.9% -2.0% -2.7% -3.4% 0.3% 0.5% 0.6% 0.8% 0.9% 1.2%

0.20 0.2% -0.2% 0.0% -1.0% -2.0% -3.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Agency 0.20 0.0% 31.0% 53.0% 71.0% 93.0% 109.0% 14.0% 14.0% 14.0% 14.0% 14.0% 14.0%

Metric Rules 1 2 3 4Capital Service Cover 2.5x 1.75x 1.25x <1.25x 4 4 4 4 4 4 2 2 2 2 2 2Liquidity (days) 0 -7 -14 <-14 4 4 4 4 4 4 4 4 4 4 4 4I&E margin 1% 0% -1% <-1% 4 4 4 4 4 4 2 2 2 2 2 1I&E variance from control total 0 -1% -2% <-2% 1 2 1 2 3 4 1 1 1 1 1 1Agency 0 25% 50% >50% 1 3 4 4 4 4 2 2 2 2 2 2

Use of Resources Rating 3 3 3 4 4 4 3 3 3 3 3 3

Risk weighting

I&E performance against control total (excluding Provider Sustainability Funding)

of 225

34

CIP – Lead Director: Tim Bennett

Theme GroupPYE 2019-20

CIP TargetApr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD

Plan 217,290 306,580 329,874 428,242 399,663 459,663 424,075 442,163 358,338 363,119 361,207 409,786 2,141,311

Actual 25,271 79,848 112,189 45,200 (30,394) 194,763 426,877

Variance (192,019) (226,732) (217,684) (383,042) (430,057) (264,900) (424,075) (442,163) (358,338) (363,119) (361,207) (409,786) (1,714,434)

Plan 0 (0) (0) 144,000 144,000 144,000 264,000 264,000 264,000 384,000 384,000 408,000 432,000

Actual 0 0 0 0 0 0 0

Variance 0 0 0 (144,000) (144,000) (144,000) (264,000) (264,000) (264,000) (384,000) (384,000) (408,000) (432,000)

Plan 27,304 27,304 27,304 27,306 27,306 27,306 86,214 86,214 86,214 109,177 109,177 109,177 163,830

Actual 0 0 0 20,922 57,195 6,271 84,389

Variance (27,304) (27,304) (27,304) (6,383) 29,890 (21,034) (86,214) (86,214) (86,214) (109,177) (109,177) (109,177) (79,441)

Plan 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0 0 0 0

Variance 0 0 0 0 0 0 0 0 0 0 0 0 0

Plan 170,833 170,833 250,833 250,833 250,833 250,833 267,500 277,500 277,500 277,500 277,500 277,500 1,345,000

Actual 166,225 152,956 127,158 103,516 176,867 156,156 882,878

Variance (4,608) (17,878) (123,675) (147,317) (73,966) (94,677) (267,500) (277,500) (277,500) (277,500) (277,500) (277,500) (462,122)

Plan 2,000 3,000 4,000 5,000 6,000 7,000 9,000 10,000 12,000 13,000 14,000 15,000 27,000

Actual 0 0 0 0 0 87,508 87,508

Variance (2,000) (3,000) (4,000) (5,000) (6,000) 80,508 (9,000) (10,000) (12,000) (13,000) (14,000) (15,000) 60,508

Plan 117,823 117,823 117,823 264,275 264,275 264,275 310,854 310,854 310,854 407,047 407,047 407,047 1,146,296

Actual 173,178 75,289 42,295 200,170 149,934 137,870 778,736

Variance 55,355 (42,535) (75,529) (64,105) (114,341) (126,405) (310,854) (310,854) (310,854) (407,047) (407,047) (407,047) (367,560)

Plan 26,700 40,050 53,400 66,750 80,100 93,450 120,150 133,500 160,200 173,550 186,900 200,250 360,450

Actual 78,467 89,077 88,714 89,455 89,455 89,455 524,623

Variance 51,767 49,027 35,314 22,705 9,355 (3,995) (120,150) (133,500) (160,200) (173,550) (186,900) (200,250) 164,173

Plan 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 282,107 0 79,271 361,378

Variance 0 0 0 282,107 0 79,271 0 0 0 0 0 0 361,378

Plan 0 0 0 115,667 115,667 115,667 115,667 115,667 115,667 115,667 115,667 115,667 347,000

Actual 0 0 0 0 0 0 0

Variance 0 0 0 (115,667) (115,667) (115,667) (115,667) (115,667) (115,667) (115,667) (115,667) (115,667) (347,000)

Plan 161,624 161,624 166,624 303,653 303,653 350,081 319,576 319,576 319,576 389,350 389,350 389,314 1,447,259

Actual 277,468 179,338 288,657 406,031 157,188 379,098 1,687,780

Variance 115,844 17,714 122,034 102,378 (146,465) 29,016 (319,576) (319,576) (319,576) (389,350) (389,350) (389,314) 240,521

Plan 723,575 827,215 949,858 1,605,726 1,591,497 1,712,275 1,917,035 1,959,473 1,904,348 2,232,410 2,244,848 2,331,740 7,410,146

Actual 720,609 576,508 659,013 1,147,401 600,245 1,130,392 0 0 0 0 0 0 4,834,168

Variance (2,966) (250,707) (290,845) (458,324) (991,251) (581,883) (1,917,035) (1,959,473) (1,904,348) (2,232,410) (2,244,848) (2,331,740) (2,575,977)

Planned Care(Theatres, Outpatients, Diagnostics, etc)

4,500,000

Urgent & Emergency Care 2,400,000

Corporate Services 750,000

Innovation & Technology -

Workforce 3,000,000

100,000

3,300,000

-

1,335,000

20,000,000

1,041,000

3,574,000

Total Trust CIP Programme

Commercial Development

Procurement

Technical Flexibilities

Medicines Management

Mitigations being Developed

Divisional

of 225

35

CIP Summary (Continued) – Lead Director: Tim Bennett

of 225

36

CIP Summary (Continued) – Lead Director: Tim Bennett

of 225

37

CIP Summary (Continued) – Lead Director: Tim Bennett The CIP status as at 30th September 2019

RAG Rating Total Value of Schemes

% of Target

Green £9,134 45.7%Amber £3,386 16.9%

Red (Gap) £7,480 37.4%

Totals £20,000 100.0%

of 225

38

Group Capital Expenditure – Lead Director: Tim Bennett

£m (0.2) (0.1) 0.1 G (1.0) (0.6) 0.4 G

£m (0.2) (0.6) (0.4) R (1.0) (3.8) (2.8) R

£m (0.2) (0.9) (0.7) R (1.5) (1.9) (0.4) R

£m (0.6) (1.6) (1.0) R (3.5) (6.3) (2.8) R

Program BudgetRAG RAG

G G

R R

R R

Date

Sep-19

Building schemes are behind plan

Sep-19Clinical Equipment Replacement

Sep-19Building Schemes & Non-Medical Equip'

Electronic Information Projects

Equipment replacement schemes ahead of plan

IT Schemes are progressing ahead of plan

RAGMajor Capital Projects Next Major Milestone

YTD Plan M6

YTD Actual M6 Variance

Electronic Information Projects

Building Schemes

UnitIndicator Month 6 Plan

Month 6 Actual Variance

Capital

Total Capital Expenditure

Equipment Replacement

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Operations – Lead Director: Berenice Groves/Janet Barnsley

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19/20 Plan (M1-M6) 19/20 Actual vs Plan 19/20 % Actual vs Plan % Diff from 18/19

39823 400 1.00% 1.76%30905 -468 -1.51% 1.33%3381 896 26.52% 36.41%19917 571 2.87% 4.76%45358 -2,407 -5.31% -2.24%118790 -8,108 -6.83% -4.21%22680 2,892 12.75% 12.14%

£112,847,056.41 -£764,969

Blackpool Teaching Hospitals Contract Dashboardfor All Providers

April 2019 - March 2020As at Month 6 (September)

Point of Delivery 18/19 Actual (M1-M6) 19/20 Actual (M1-M6) Diff to 18/19 Actual (M1-M6)

A&E Attendances 39524 40223 699Elective Spells 30027 30437 410Non-Elective Non Emergency 3046 4277 1231Non-Elective Spells 19540 20488 948Outpatient First Attendance 43968 42951 -1017Outpatient Follow -up Attendances 115689 110682 -5007Outpatient Procedures 22819 25572 2753

Total Cost All PODs £103,788,070.55 £112,082,087.10

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Workforce –Director of Workforce: Jane Meek

Component Mar-19Targets/ Budget Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 YTD Average Sep-18 YTD Average

Staff in Post (Fixed Term & Perm) FTE 5905.76 N/A 5951.78 5941.17 5908.80 5948.41 5963.93 6034.97 N/A 5958.18 6208.88 N/A 6169.28

Staff in Post (Fixed Term & Perm) Headcount 6693 N/A 6766 6755 6727 6766 6780 6858 N/A 6775 7093 N/A 6909

Staff in Post (Fixed Term & Perm) Assignment Count 6796 N/A 6871 6861 6827 6871 6885 6957 N/A 6879 7228 N/A 7021

Nursing & Midw ifery % permanent staff 96.18% N/A 96.57% 96.39% 97.98% 97.99% 97.89% 96.83% N/A 97.28% 96.73% N/A 96.95%

Allied Health Professional % permanent staff 97.82% N/A 97.82% 97.82% 99.55% 98.66% 98.90% 98.70% N/A 98.58% 98.27% N/A 98.52%

Trust % permanent staff 91.17% N/A 91.76% 92.03% 93.37% 93.11% 92.95% 92.64% N/A 92.64% 92.35% N/A 92.54%

Sickness % (in Month) 4.62% 4.00% 4.84% 5.08% 5.32% 5.22% 5.04% 5.41% N/A 5.15% 5.19% N/A 4.71%

Sickness % (in Month) 2018-19 for comparison 4.52% 4.00% 4.36% 4.48% 4.55% 4.83% 4.85% 5.19% N/A 4.95% 4.53% N/A 4.68%

Sickness (Rolling 12 Mth) 4.90% 4.00% 4.94% 4.99% 5.05% 5.06% 5.09% 5.08% N/A 5.04% 4.82% N/A 4.75%

Sickness (Short Term) 54.12% N/A 51.56% 46.85% 49.07% 47.93% 41.54% 46.15% N/A 47.18% 51.77% N/A 51.07%

Sickness (Long Term) 45.88% N/A 48.44% 53.15% 50.93% 52.07% 58.46% 53.85% N/A 52.82% 48.23% N/A 48.93%

No. of staff >= trigger of 4 episodes in rolling 12 month period 720 N/A 745 744 731 741 737 727 N/A 738 665 N/A 676

No. of Staff absent for 29 days + 215 N/A 234 248 284 261 264 261 N/A 259 243 N/A 232

Trust Clinical Vacancy Rate % (Strategic Ambition Measure) 5.19% 4.28% 9.12% 9.50% 9.19% 8.98% 8.96% 7.67% N/A 8.90% 3.32% N/A 3.63%

Medical & Dental Vacancy Rate % (excluding Pennine Drs) 6.69% 4.28% 15.74% 16.28% 16.22% 18.52% 19.40% 17.63% N/A 17.30% 6.25% N/A 10.32%

Qualif ied Nursing & Midw ifery Vacancy Rate % 14.56% 4.28% 12.72% 12.42% 12.89% 12.72% 13.15% 11.00% N/A 12.48% 9.17% N/A 8.06%

Allied Health Professional Vacancy Rate % 4.07% 4.28% 6.99% 7.03% 6.54% 6.44% 5.56% 3.05% N/A 5.94% 5.15% N/A 7.63%

Trust Recruitment Activity % 12.32% 11.00% 13.85% 15.76% 16.68% 17.58% 17.98% 14.49% N/A 16.06% 14.01% N/A 13.34%

No. of jobs being actively recruited by FTE (excl overseas nurses) 724.1 N/A 824.3 936.6 985.4 1045.8 1072.5 874.2 N/A 956.5 869.8 N/A 823.0

No. of jobs being actively recruited by FTE (only overseas nurses) 94.0 N/A 63.0 63.0 63.0 63.0 146.0 146.0 N/A 90.7 66.0 N/A 66.7

Average time to f ill vacant posts (Weeks) (incl overseas nurses) 8.89 <14 w ks 8.28 8 8.31 8.76 8.97 9.57 N/A 8.65 8.76 N/A 9.00

Turnover % (all staff) – Rolling 12 months 15.16% <=11% 14.86% 14.76% 14.84% 14.02% 14.18% 9.72% N/A 13.73% 9.40% N/A 9.34%

Turnover % (Medical & Dental staff) – Rolling 12 months 20.07% <=11% 20.59% 20.23% 20.09% 12.29% 13.58% 13.35% N/A 16.69% 19.01% N/A 21.18%

Starters HC in month (Medical & Dental staff) 1 N/A 2 4 5 6 45 15 N/A 13 0 N/A 7

Leavers HC in month (Medical & Dental staff) 6 N/A 4 2 2 10 8 4 N/A 5 0 N/A 3

Turnover % (Nursing & Midw ifery staff) – Rolling 12 months 17.57% <=11% 17.04% 17.08% 17.33% 16.97% 17.08% 10.49% N/A 16.00% 7.56% N/A 7.52%

Starters HC in month (Nursing & Midw ifery staff) 6 N/A 16 19 8 13 4 28 N/A 15 22 N/A 15

Leavers HC in month (Nursing & Midw ifery staff) 116 N/A 9 7 19 3 5 11 N/A 9 18 N/A 16

Non-medical Appraisal Compliance % 83.71% >=90% 0.28% 1.58% 4.84% 11.61% 23.07% 42.54% N/A 13.99% 72.77% N/A 26.26%

Medical Appraisal Compliance % 93.33% >=100% 93.22% 89.10% 90.03% 88.86% 88.01% 92.39% N/A 90.27% 91.78% N/A 90.53%

Total Appraisal Compliance % 84.27% >=90% 5.66% 6.53% 9.71% 15.89% 26.73% 45.24% N/A 18.29% 73.78% N/A 29.28%

Medical Agency Spend £757,156 £586,847 £841,921 £1,062,437 £959,209 £1,077,187 £1,304,510 £1,085,913 £6,331,177 £1,055,196 £714,717 £10,491,513 £2,098,303

Medical Bank Spend £0 £238,044 £131,167 £231,463 £200,615 £801,289 £200,322 N/A N/A N/A

Medical Locum Spend £21,341 -£3,192 £23,370 £16,397 £31,738 £33,241 £38,006 £41,557 £184,309 £30,718 -£15 -£31,641 -£5,273

Nursing Agency Spend £169,785 £132,041 £263,742 £337,878 £772,464 £723,125 £938,548 £1,156,222 £4,191,978 £698,663 £74,412 £610,944 £101,824

Nursing Bank Spend £1,060,467 £813,918 £966,771 £1,021,238 £943,555 £947,072 £1,154,353 £1,056,458 £6,089,446 £1,014,908 £946,509 £5,678,879 £946,480

A & C Agency Spend £197,297 £123,630 £110,899 £144,603 £73,996 £121,550 £185,210 £112,403 £748,661 £124,777 £125,639 £824,753 £137,459

A & C Bank Spend £84,313 £71,631 £89,850 £104,561 £93,504 £99,025 £111,104 £113,418 £611,462 £101,910 £53,925 £280,959 £46,826

AHP Agency Spend -£18,454 £3,923 £59,819 £19,190 £39,018 £23,979 £42,605 £33,735 £218,346 £36,391 £15,439 £106,478 £17,746

AHP Bank Spend £25,215 £15,939 £21,141 £21,731 £22,664 £23,855 £20,642 £20,285 £130,318 £21,720 £16,776 £96,723 £16,121

Other Agency Spend £131,109 £74,108 £64,157 £103,843 £91,220 £93,543 £111,932 £98,596 £563,290 £93,882 £95,181 £478,080 £79,680

Other Bank Spend £51,976 £34,060 £45,586 £49,789 £44,537 £48,849 £53,313 £56,711 £298,785 £49,798 £43,385 £235,745 £39,291

Grand Total of Agency/Bank/Locum Spend £2,480,204 £1,852,905 £2,487,256 £2,881,667 £3,309,951 £3,322,592 £4,191,686 £3,975,912 £20,169,064 £3,361,511 £2,085,969 £13,223,687 £2,203,948

% of above spend against Pay Bill 10.67% 7.28% 9.54% 11.36% 13.00% 12.47% 15.52% 14.72% N/A 12.77% 8.68% N/A 9.07%

Bench Fill Rate % (all non medical staff groups) N/A 70.00% 65.00% 65.48% 58.20% 59.00% 58.20% 58.00% N/A 60.65% N/A N/A N/A

Agency Fill Rate % (all non medical staff groups) N/A 70.00% 8.00% 4.93% 16.00% 23.00% 21.00% 21.50% N/A 15.74% N/A N/A N/A

Annual Leave - % taken (all non medical staff groups) N/A 14% - 17% 11.80% 10.20% 14.20% 12.30% 15.40% 10.43% N/A 12.39% N/A N/A N/A

Nett Over Hours - % of staff (all non medical staff groups) N/A 10.00% 4.40% 4.80% 5.30% 5.20% 5.40% 7.36% N/A 5.41% N/A N/A N/A

Nett Under Hours - % of staff (all non medical staff groups) N/A 10.00% 23.10% 27.20% 30.10% 28.20% 29.60% 27.30% N/A 27.58% N/A N/A N/A

Additional Duty Hours - % (over budgeted establishment) N/A 5.00% 0.70% 0.90% 0.90% 1.10% 1.20% 1.40% N/A 1.03% N/A N/A N/A

Fully Approved Rosters -% N/A 90.00% 69.10% 73.30% 74.20% 74.00% 70.70% 64.38% N/A 70.95% N/A N/A N/A

Mandatory Training Trust Compliance % 83.81% >=95% 83.30% 85.05% 86.40% 87.29% 87.40% 86.98% N/A 86.07% 81.82% N/A 79.91%

Local Induction Compliance % 75.00% >=95% 71.68% 67.23% 62.26% 60.23% 53.30% 41.60% N/A 59.38% 50.67% N/A 54.72%

Trust Induction Compliance % 93.52% >=95% 94.01% 91.01% 84.62% 84.09% 77.20% 72.44% N/A 83.90% 89.57% N/A 87.75%

Number of open Exclusion cases (cumulative) 8 N/A 10 9 9 11 10 14 N/A 11 7 N/A 4

Number of open Exclusion cases (new this month) 0 N/A 2 0 0 2 0 4 N/A 1 1 N/A 1

Number of open Whistleblow ing cases (cumulative) 0 N/A 1 1 2 3 3 3 N/A 2 2 N/A 2

Number of open Whistleblow ing cases (new this month) 0 N/A 1 0 1 1 0 0 N/A 1 0 N/A 0

Management Referrals offered Appt. w ithin 10 days % 56.00% 100% 44.00% 55.00% 71.00% 54.00% 24.00% 20.00% N/A 44.67% 51.00% N/A 51.33%

Annual Staff Survey Response Rate % N/A N/A N/A N/A N/A N/A N/A

Family & Friends Test out of 10 (Quarterly) 3.88 /10 N/A 7.15 3.82 N/A 3.77

Recommend to Friends & Family for care and treatment % 76% Q2 = 84% N/A 75% 76 N/A 76

Recommend to Friends & Family as a place to w ork % 69% Q2 = 79% N/A 65% 65 N/A 63

Note - Turnover f igures do not include any staff on zero hours contracts. Prior to 2018-19 the AHP Agency & Bank Spends w ere included in the 'Other' category. Prior to 2019-20 the Bench and e-Rostering data w as not included in this report.An explanation of the budget/target source are recorded as a comment against each indicator - to view , hover the cursor over the red marker in the corner of the cell. The F&F Test scoring has changed from 'out of 5' to 'out of 10' for 2019-20.

7.11 7.18

75% 74%

64% 66%

PREVIOUS YEAR FOR COMPARISON

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Workforce – Director of Workforce: Jane Meek Overall Workforce Assurance - Staff in post has increased this month with a significant increase in Nursing and Midwifery numbers, the overall vacancy rate reduced for all staff from 8.96% to 7.67%. Futhermore a recent recruitment trip to the Philippines has also seen 103 offers made (qualified nursing and midwifery staff) and this includes some candidates either awaiting or with decision letters so hopefully this will boost the establishment quickly. Sickness absence increased significantly to 5.41% (highest rate for the year to date). Agency spend continued to be significantly higher than planned which is in keeping with the year long trend. ****Nursing and Midwifery Turnover Rate (12 month rolling rate) - has reduced significantly due to a large number of TUPE staff in September 2018 now falling outside of the rolling 12 month window.**** Staff in Post Overall workforce numbers increased for the 3rd month running and encouragingly there was a significant inxcrease in Nursing and Midwifery Staff......however there are still a significant number of clinical vacancies which is having a significant impact on the bank/agency spend across the organisation. Vacancy Rate (excluding Pennine doctors, estates and admin & clerical staff) is reported as a gap of 7.67% which equates to a variance of 373.60wte broken down into the following staff groups. Additional Professional & Technical 18wte Additional Clinical Services -2.88wte AHPs 12.58wte Healthcare Scientists -23.10wte Medical & Dental (excluding Pennine Drs) -89.91wte Nursing & Midwifery -231.44wte Registered Students - +13.92wte We currently have 56 job offers on medical posts with 6 booked start dates already for October and several others in the latter stages of recruitment. All posts are currently being advertised via NHS jobs, the BMJ and all framework agencies are also instructed to source appropriate candidates where possible and appropriate. We are currently in a strong position recruitment wise as we have an excellent number of posts under offer. We are also staying in frequent contact with the candidates to ensure we do everything we can to convert these offers into starters. We are also trying to work with the divisions to re-inforce the need to turn round shortlisting and interviews as quickly as possible as the market is moving so quickly any delays will mean candidates are no longer available. We have 17 external job offers pending for AHP posts, and whilst there has been a slight increase in the variance between staff in post and establishment. We are also working on a AHP dashboard, similar to that produced for Medical and nursing posts to give a regular overview of the current position and ensure that we can take appropriate action if any issues are highlighted. Whilst staff in post numbers for Nursing and midwifery continue to be a cause for concern. We have seen an increase in staff in post and further increases expected as the newly qualified and overseas nurses gain their pin numbers. A further trip to the Philippines has seen 103 offers made and this includes some candidates either awaiting or with decision letters so hopefully this will boost the establishment quickly.

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Sickness The Overall sickness rate for the Trust reduced very slightly in August for the second month in a row which is encouraging however the sickness absence rate remains high and continues to be a concern with the HR Team actively working with departments to identify specific areas and implement preventative measures. The top 3 reasons for sickness are documented below......

Appraisal rates Appraisal rate has risen this month and the window has been extended until the end of October to support staff in getting their appraisals completed. It is understood that managers have found this year’s appraisal process cumbersome and time consuming. A new process for recording and closing appraisals is being reviewed for 2020, in line with pay progression, which will make the process far easier. The focus will remain on the quality of the conversation, but the paperwork will be less onerous than this year. Mandatory Training The percentage for training has fallen slightly this month. An advert has now gone out for a B7 Learning and Development manager and this role will be responsible for ensuring that all aspects of Mandatory Training, across the Trust, meets and complies with both the legal and statutory requirements set by national regulators and the emerging needs of the Trust and its services.

Staff Friends & Family Test (quarterly) The 'Staff Satisfaction & Engagement Survey' (QTR2) was issued to the Clinical Support Services, Corporate, Research & Development and Unscheduled Care divisions only. The Staff FFT results from this survey show that 66% (a slight increase from QTR2 2018/19 – 65%) of staff would recommend the Trust as a place to work and 74% (a decrease from QTR2 2018/19 – 76%) of staff would recommend the Trust as a place to receive treatment or care. The staff engagement score was 7.18 (out of 10). To note, the 'SFFT' score 3.82 for QTR2 2018/19 was calculated using the previous scoring system (out of 5). Going forward, the engagement score will be out of 10.

e-rostering & Bench As we approach Winter pressures net under hours in particular will need monitoring to ensure utilisation of our substantive workforce is at full capacity. Net under hours definition is "The sum total of each person’s overall hours balance for those who have worked less than their contracted hours i.e. they have been paid for hours that they have not yet worked." Where hours are better utilised a reduction in bank and agency spend could be achieved. Although annual leave % has reduced in month - equal apprortionment of annual leave will need to be reviewed to ensure patient safety is not compromised in Q3 and Q4.

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BOARD ASSURANCE FRAMEWORK Board Assurance Framework for the delivery of Trust Strategy The Board of Directors has overall responsibility for ensuring systems and controls are in place, sufficient to mitigate any significant risks which may threaten the achievement of the Trust Strategy (as outlined in the Risk Management Policy). The Board of Directors therefore needs to gather assurance to ensure any significant risks are being mitigated. This assurance will be gained from a wide range of sources, but where ever possible it should be systematic, supported by evidence, independently verified, and incorporated within a robust governance process. The Board of Directors achieves it assurance primarily through the work of its Board Committees, and through use of Audit, other independent inspection and by the systematic collection and scrutiny of performance data, to evidence the achievement of the strategic ambitions.

Independent assurance (external): • External Audit • Internal Audit • NHS Resolution • Care Quality Commission inspections/reports • Well-led Framework inspections/reports • Royal College visits/reports • Deanery visits/reports • Investors In People visits/reports • Health and Social Care Information Centre

SHMI Report • External Benchmarking • Accreditation schemes • National or regional audits • Specifically commissioned reports • Peer review and accreditation • Patient Experience: Friends & Family Test • Staff Satisfaction: Family and Friends Test

Internal assurance: • Clinical Audit • Integrated Performance Report (quality,

finance and operational performance) • Turnaround Directors Report • Board of Directors • Audit Committee • Quality Committee • Finance Committee • Strategic Workforce and Transformation

Committee • Membership Committee • Remuneration Committee • Nominations Committee • Charitable Funds Committee • Local Counter Fraud reports • Appraisal and Revalidation • Great Place to Work Survey • Information Governance Toolkit • Quarterly Single Oversight Framework report

to NHS Improvement • Personal review/contact e.g. patient safety

walkabouts, patient story

Core management controls (to reduce the likelihood and/or consequences of risks):

• Executive Directors Meetings • Clinical Management Forum • Reservation of Powers and Scheme of

Delegation • Standing Financial Instructions and Standing

Orders • Risk Management Policy • Other Trust approved policies and procedures • Risk Registers • Trust Strategy • Quality Strategy • Workforce Strategy including training and

development plans • Financial and budget management

arrangements • The recruitment process for staff (checking of

registration and monitoring of CRB compliance

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Scope and Structure of Board Assurance Framework The Board Assurance Framework focuses on any significant risks which may threaten the achievement of the national compliance requirements and the Trusts strategic ambitions for 2016-2020. The document brings together all strategic risks expanding on the main controls and assurance, gaps in controls and assurance and relevant actions to be taken. The BAF follows the agreed ordering of national compliance requirements;

• Single Oversight Framework • Care Quality Commission Regulations

And the Trusts strategic ambitions, which are as follows:

• Strategic Ambition 1: QUALITY: Mortality – SHMI (Executive Director: Medical Director) We aim to achieve our lowest levels of mortality, reducing the SHMI to within the ‘expected’ range.

• Strategic Ambition 2: QUALITY: Patient Experience: Friends and Family Test (Executive Director: Director of Nursing and Quality)

We aim to achieve our highest levels of patient satisfaction; 98% by March 2021.

• Strategic Ambition 3: OPERATIONS: Length of stay (Executive Director: Director of Operations – Unscheduled Care) We aim to (TBC - proposal to change the measures to be total elective length of stay and total non-elective stay, ensuring consistency with operational measures).

• Strategic Ambition 4: WORKFORCE: Vacancy rate (Executive Director: Director of Workforce and Organisational Development)

We aim to significantly reduce our clinical vacancy rate, based on future workforce numbers; 2.5% by March 2021.

• Strategic Ambition 5: WORKFORCE: Staff Satisfaction: Friends & Family Test (Executive Director: Director of Workforce and Organisational Development) We aim to achieve our highest levels of staff satisfaction; 85% by 2021.

• Strategic Ambition 6: FINANCE: Finance (Executive Director: Deputy Chief Executive/Director of Finance and Performance)

Delivery of sustainable surpluses from 2021/22

• Enablers (Executive Director: Relevant Executive Directors) Putting in place enablers such as improved use of information technology, making good use of our estate and enhancing our communications

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Risk Matrix Score Consequence Rating Likelihood Rating

Almost Certain Likely Possible Unlikely Rare 5 4 3 2 1

Catastrophic 5 25 20 15 10 5

Major 4 20 16 12 8 4

Moderate 3 15 12 9 6 3

Minor 2 10 8 6 4 2

Insignificant 1 5 4 3 2 1

Consequence Definitions

Score 1 2 3 4 5

Safety Short-term, minor injury or illness, first aid treatment needed Semi-permanent injury/damage

Major injuries or long term incapacity / permanent disability

Patient harm that is StEISS reportable RIDDOR reportable incident

An Avoidable Death Staff death in the workplace Multiple Avoidable Deaths

Quality

Formal Complaints Non-compliance with standards. e.g.

departmental policy or procedure Loss of person identifiable

information inc limited health information e.g. clinic appointment

date/time details. Local Media – short term Social Media – short term

Multiple Formal Complaints up to 25 day resolution

Loss of person identifiable information such as ward handover sheet including Investigations, treatment or diagnosis

Non-compliance with standards. e.g. Trust policy or procedure

Non-compliance with national standards. e.g. NICE guidance

Local Media/Social Media–long term National Media < 3 days

Critical Internal/External Audit Report Multiple Formal Complaints up to 35 day

resolution Loss of person identifiable information inc

detailed health information e.g. patient health record.

National Media > 3 Days. MP Concern (Questions in House)

Critical National Report (Dr Foster/CQC) Inquest

Ombudsmen Inquiry HSE - Improvement Notice

HTA Enforcement Action MHRA Enforcement Action

ICO Enforcement Action Whistleblowing with evidence

Loss of person identifiable information inc sensitive health information e.g. patient

health record relating to HIV, STD, Mental Health, Children.

Enforcement Action by a Regulator Civil/Criminal Prosecution

Operational Delivery Loss of a Trust Business Continuity

Plan Required Service 0-10% reduction in staffing levels

Loss of a Trust Business Continuity Plan Necessary Service

10-20% reduction in staffing levels

Loss of a Trust Business Continuity Plan Important Service


Loss of a Trust Business Continuity Plan Essential Service


Loss of a Trust Business Continuity Plan Vital Service

Over 40% reduction in staffing levels Loss of Provider License through failure to deliver

a commissioner mandated service Financial Loss/Unfunded Cost £1M - £2.5M Loss/Unfunded Cost £2.5M - £5M Loss/Unfunded Cost £5M - £10M Loss/Unfunded Cost > £10M Trust become insolvent

Likelihood Definitions

Score 1 2 3 4 5 Frequency Could occur annually Could occur quarterly Could occur monthly Could occur weekly Could occur daily

Board Assurance Framework Overview Board Committee National Compliance Requirements Trust Strategic Ambitions Finance Committee BAF 7A – Failure to meet planned care performance targets BAF 6 – The Trust has a significant (£34m) underlying

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within the Single Oversight Framework (RTT, Cancer, Diagnostics)

deficit. Without mitigations this would mean insufficient working capital to meet day to day needs.

BAF 7B – Failure to meet Emergency Department 4 hour performance standard within the Single Oversight Framework.

BAF 10 – Unnecessarily prolonged stays in hospital may adversely affect patient care and increase Trust costs. BAF 11 – Failure to embed the systems within staff duties and hold them to account will risk the implementation of the national EPR target of 2020

Quality Committee

BAF 9 – Failure to maintain the CQC Standards could lead to the provision of suboptimal care to patients and incur reputational damage to the Trust

BAF 1 – Failure to reduced SHMI to within the expected range may indicate suboptimal standards of care and may damage the reputation of the Trust. BAF 2 – Poor Patient Family and Friends Test score implies that patient care is not optimal. This will affect patient outcomes and may result in reputational damage.

Strategic Workforce and Transformation Committee

BAF 4 - Due to national shortages in nursing, medical and support staff the Trust may deliver suboptimal care BAF 5 – Due to a lack of support and poor engagement, the Trust has poor retention levels and low levels of productivity BAF 14 – The Trust will not meet its Strategic Ambitions due to the failure to deliver transformational change

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Single Oversight Framework

Risk & Source Owner Main Controls/Assurances

Gaps in Controls/Assurances

Mitigated Current Score (C x L)

Opportunities to address Gaps in Controls/Assurances

Target Residual

Score (C x L)

Risk Ref: BAF 7A Risk: Failure to meet planned care performance targets within the Single Oversight Framework. - RTT - Cancer - Diagnostics Could lead to the provision of suboptimal care to patients and damage the reputation of the Trust Objective/Source: Compliance with the Single Oversight

Director of Operations – Planned Care

Independent assurance: IA - Compliance with Performance Reporting – Significant assurance with minor improvement opportunities - 2018 NHSI Segmentation Report – 3 - Mandated support: Support needs identified in Quality of care, Finance & use of resources and Operational performance 2019 Internal assurance: Finance Committee Integrated Performance Report Quarterly Single Oversight Framework report to NHS Improvement

NHSI Enforcement Undertakings letter, the Trust has not delivered the Cancer target since May 2018 External: • Assured value contract,

not reflective of available capacity. Ongoing discussion re 19/20 RTT work

• Potential shortfall in funding, no health economy agreement to address RTT backlog

• Management of demand with the CCGs

• Delays in progressing

9 (3x3)

Internal: • Develop a Quality and Performance

Improvement Plan to address mortality, A&E and cancer performance - 30 September 2019

• Centralisation of the validation team, ensuring application of the access policy and RTT rules

• Continued improved utilisation via OP and theatres work programmes – Continue into 2019/20 including endoscopy and radiology

• Implementation of the Cardiology Modular Catheter Laboratory and WLI work in the interim – Sept 2019

• Business case to expand breast cancer capacity – Ongoing

• Business case for additional MRI

3 (3x1)

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Framework and Provider Licence.

Core management controls: Board Performance Dashboard EDs Meetings Trust Strategy DPR Meetings Weekly PTL Meetings Contract Review Meetings Cardiology EP Plan Performance Trajectories Outpatient and Theatres efficiency programmes Planned Care Steering Group Planning trajectories submitted; -RTT volume will be maintained, little improvement in the proportion waiting less than 18 weeks - 2 week rule performance only improves from mid-year 2019 CCG Contract/Performance meetings Integrated Care Partnership Steering Group NHSI monthly meeting

business cases with commissioners

• Provision of sufficient capacity by partner organisation – i.e. Oncology

• Patient choice • Potential to utilise IS

contracts being explored. Internal: • Insufficient diagnostic

capacity – i.e. mammography and MRI

• Workforce challenges in recruiting staff

• The existing estate configuration is not ‘fit for purpose’ in some areas

• Risk of choice at 26 weeks

capacity • Demand and capacity work-

programme – Continue into 2019/20

External: • Cancer Alliance support in funding

short term initiatives – Ongoing Further discussions underway for 2019/20 support.

• Collaboration with other Lancashire providers – Ongoing

• ICS programme of theatre productivity

Board Committee oversight: Finance Committee

0

5

10

15

20

25

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Target Residual

Score (C x L)

Risk Ref: BAF 7B Risk: Failure to meet Emergency Department 4 hour performance standard within the Single Oversight Framework. Could lead to the provision of suboptimal care to patients and damage the reputation of the Trust Objective/Source: Compliance with the Single Oversight Framework and Provider Licence.

Director of Operations – Unscheduled Care

Independent assurance: IA - Compliance with Performance Reporting – Significant assurance with minor improvement opportunities - 2018 NHSI Segmentation Report – 3 - Mandated support: Support needs identified in Quality of care, Finance & use of resources and Operational performance 2019 Internal assurance: Finance Committee Integrated Performance Report Quarterly Single Oversight Framework report to NHS Improvement Core Management Controls: Board Performance Dashboard EDs Meetings Trust Strategy DPR Meetings Weekly PTL Meetings Contract Review Meetings Cardiology EP Plan Performance Trajectories Outpatient and Theatres efficiency programmes Planned Care Steering Group

NHSI Enforcement Undertakings letter, the Trust has not delivered the A&E target since 2017 External: Potential shortfall in funding to support new pathways & developments/ funding of winter plan Management of demand with the CCGs reducing non elective admissions Delays in progressing business cases/ support for STP development Response and provision of services from mental health assessments and beds Provision of sufficient capacity by partner organisation – i.e. Packages of Care/ 24 hour support Internal: Workforce challenges in recruiting staff The existing estate configuration is not ‘fit for purpose’ and does not support streamline flow Inconsistent implementation

16 (4x4)

Internal: • Develop a Quality and Performance

Improvement Plan to address mortality, A&E and cancer performance - 30 September 2019

• Manage GP patients outside of ED, create sufficient capacity to support demand – Two month trial May/June 19

• Further develop patient flow team as a system enabler - next actions by June 19

• Following demand and capacity work completed – need to secure additional workforce to match demand profile – FC priority

• Jointly develop business case for additional diagnostics support - MRI – requires approval and funding

• Use of data and information to highlight opportunities and support patient flow.

• Embedded electronic escalation plan for the organisation – July 2019

• Deliver all actions from Emergency Care Improvement Plan - on going

• Use information to measure improvement

External: • Secure external support to deliver

reduction in LoS – implementing improved end to end pathways across the Integrated Care Partnership

12 (4x3)

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56

CCG Contract/Performance meetings Integrated Care Partnership Steering Group NHSI monthly meeting Assess to admit policy for the organisation

and use of internal professional standards Patient Flow and Discharge Teams separate resulting in segregated pathways Delays in accessing diagnostics and timely reporting

• Digital solutions which improve flow, increase access to alternatives to ED

• Commission adequate mental health support/ capacity

• Develop single point of access to neighbourhood teams - admission avoidance/ in reach – 2019/20


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Care Quality Commission Regulations





Target Residual

Score (C x L)

Risk Ref: BAF 9 Risk: Failure to maintain the CQC Standards could lead to the provision of suboptimal care to patients and incur reputational damage to the Trust Objective/Source: Compliance with CQC Regulations

Director of Nursing and Quality

Independent assurance: CQC Full Report – Requires Improvement – 2018 CQC A&E Report - Requires Improvement – 2019 IA – CQC Follow Up - Significant assurance with minor improvement opportunities – 2019 NHSI Segmentation Report – 3 - Mandated support: Support needs identified in Quality of care, Finance & use of resources and Operational performance 2019 Internal assurance: Quality Committee Patient Safety Walkabouts Quality Improvement Board

NHSI Enforcement Undertakings letter, raised Trust breaches CQC 2019; 5 Regulatory Breaches – person-centred care, safe and caring, equipment and premises, good governance, staffing IA 2019; Poor evidence of compliance with ED corridor patient risk assessments Poor evidence of compliance with antibiotic therapy on applicable treatment cards recorded Poor compliance with documentation of mental health risk assessments CQC 2018; 4 Regulatory Breaches – staffing, good governance, safeguarding and safe and caring

20 (5x4)

Opportunities: Develop a Quality and Performance Improvement Plan to include all CQC actions for NHSI - 30 September 2019 Develop a 2019 CQC action plan – 30 June 2019 Trial ED Corridor Risk Assessment in place used in conjunction with Departmental OPEL levels - 30 June 2019 Training and reminder on the need of antibiotic review within 72hours and quarterly spot checks of empiric review evidence and feedback at divisional meetings - 31 December 2019 The MH risk assessment recommendation will be discussed at the next ED & MH meeting to review current process - 30 June 2019 Implement the remaining 8 actions on the 2018 CQC Action plan to address the 2018 inspection report findings – 30 June 2019

10 (5x2)

Core management controls: Trust Strategy Quality Strategy Workforce Transformation Strategy including training and development plans Interim Quality

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Improvement Directors 15 complete CQC Actions

Board Committee oversight: Quality Committee

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Strategic Ambition 1: QUALITY: Mortality – SHMI (Executive Director: Medical Director) We aim to achieve our lowest levels of mortality, meeting and then falling below our expected number of deaths; <=100 by 2019.


Gaps in

Controls/Assurances



Target Residual

Score (C x L)

Risk Ref: BAF 1 Risk: Failure to reduced SHMI to within the expected range may indicate suboptimal standards of care and may damage the reputation of the Trust. Objective: Reducing the SHMI to within the ‘expected’ range. Source: HSCIC

Medical Director

Independent assurance: Health and Social Care Information Centre SHMI Report – BTH were one of the 11 Trusts with a higher than expected number of deaths - 2019 NHSI Segmentation Report – 3 - Mandated support: Support needs identified in Quality of care, Finance & use of resources and Operational performance 2019 Internal assurance: Quality Committee Mortality Governance Committee includes CCG, GP and NHSE representation Integrated Performance Report

NHSI Enforcement Undertakings letter; • The Trust has been

a SHMI outlier since June 2014

• The Trust has 6 CQC mortality outlier alerts at January 2019

CQC alerts for our outlier status in several diagnostic groups including stroke, intestinal obstruction (without hernia) and skin & subcutaneous tissue infection. SHMI values for acute respiratory

15 (5x3)

Opportunities: Develop a Quality and Performance Improvement Plan to address mortality, A&E and cancer performance - 30 September 2019 Identify the workforce and associated governance structures to address the NHSI concerns relating to patient safety and mortality indices - 30 September 2019 Commission a medical engagement survey with NHSI to address the NHSI concerns – 30 August 2019

10 (5x2)

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60

Core management controls: Executive Directors Meetings Trust Strategy Quality Strategy Mortality Policy Mortality Governance Committee Learning from Deaths Policy Dr Morgan appointed Mortality Reduction Lead Dr Chalil appointed Deputy Mortality Reduction Lead

illness (pneumonia & COPD) and stroke are high) Clinical staffing levels Clarity over coding.


0

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Strategic Ambition 2: QUALITY: Patient Experience: Friends and Family Test (Executive Director: Director of Nursing and Quality)

We aim to achieve our highest levels of patient satisfaction; 98% by 2019.





Target Residual

Score (C x L)

Risk Ref: BAF 2 Risk: Poor Patient Family and Friends Test score implies that patient care is not optimal. This will affect patient outcomes and may result in reputational damage. Objective: Patient Family and Friends Test score of 98% by March 2021. Source: PFFT

Director of Nursing and Quality

Independent assurance: Patient Family and Friends Test score Internal assurance: Quality Committee Integrated Performance Report Patient Safety Walkabouts

4 (4x1)

Opportunities: Expansion of Always Events and John’s Campaign in 2019

4 (4x1)

Core management controls: Trust Strategy Quality Strategy Divisional Performance Review Meetings


Strategic Ambition 3: OPERATIONS: Length of stay (Executive Director: Medical Director)

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We aim to achieve top quartile performance, moving to top decile performance, for both non-elective and elective lengths of stay, whilst at the same time maintaining high quality care; Non-elective - 5.1 days by 2018 and 4.4 days by 2021; Elective - 2.2 days by 2018 and 1.7 days by 2021 and Readmissions within 30-days - 94.2 by 2019 and 79.5 by 2021.





Target Residual

Score (C x L)

Risk Ref: BAF 10 Risk: Unnecessarily prolonged stays in hospital may adversely affect patient care and increase Trust costs. Objective: (TBC - proposal to change the measures to be total elective length of stay and total non-elective stay, ensuring consistency with operational measures). Source: Trust Strategy


Independent assurance: ECIP Report IA- Advisory Demand and Capacity Review Internal assurance: Finance Committee

Increased ED attendances, admissions and delayed discharges of care place pressure on bed closures Inability of the Trust to affect directly the capacity of external organisations which impairs ability to discharge patients in a timely fashion. Recommendations made Internal Audit Review. Recommendations made by Jeremy Pease Review. Recommendations from ECIP report Shortfalls in clinical staffing affect ability to reduce LoS

16 (4x4)

Opportunities: Implemented the internal audit recommendations External partner currently being secured to assist with managing the significant reduction required to enable flow Daily management of discharge by ward and securing daily golden patients (before 10am discharge), this is being monitored via Transformation Team, robust system Regular running of multi-disciplinary discharge events with all partners to reduce delays – on going Increased use of patient tracker to manage patient activities, managing medically fit for discharge patients – define required actions - June 2019 Increased development of Clinical Utilisation of Resources - aim to roll out to all wards to provide detail on ready for discharge, ensure all critical daily activities are actioned – July 2019

12 (4x3)

Core management controls: Executive Directors Meetings Trust Strategy Quality Strategy Divisional Performance Review Meetings Better Care Now Delivery Group now merged with Urgent and Emergency Care steering group Relaunch of BCN as major quality initiative in the Trust

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Strategic Ambition 4: WORKFORCE: Vacancy rate (Executive Director: Director of Workforce and Organisational Development)

We aim to significantly reduce our vacancy rate, based on future workforce numbers; 2.5% by 2021.


Gaps in Controls/ Assurances



Target Residual

Score (C x L)

Risk Ref: BAF 4 Risk: Due to national shortages in nursing, medical and support staff the Trust may deliver suboptimal care.

Objective: Vacancy rate of 2.5% by March 2021. Source: Higher than expected levels of vacant roles and the Trust Strategy

Joint Director of Human Resources

Independent assurance: Internal assurance: Strategic Workforce Committee Integrated Performance Report

1. Funding gap for workforce transformation from HEE 2. Inability to grow our own at the pace required to meet gaps in professional roles- lead in educational time required 3. National Skills shortages in key professional groups 4. Uncertainty about ICP progression and opportunities to share resources 5. As of March 2019, the Trust is running at a vacancy rate of just over 230

16 (4x4)

Opportunities: Regional approach to agency and bench solution Recruitment microsite Apprenticeship levy to develop clinical staff Fill rate from the Bench for nursing shortfall. Weekly staffing report available demonstrating fill rates ICP workforce transformation development discussions commenced Work is being done to address the workforce supply by working with international recruitment agencies, offering retire and return programmes as well as working with Health Education England on the Global Health Exchange programme. The Trust is engaged in cohort 4 of NHSI Retention Programme and also has a retention and recruitment board in situ, to address and mitigate risks wherever possible. Winter pressures staffing contract with Medacs has been renegotiated and a request to extend for a further 3 months to ensure consistency and quality of care is delivered by maintaining safe staffing numbers on wards/departments as necessary.

8 (4x2)

Core management controls: HR Senior Management Team Trust Strategy Workforce and Transformation Strategy including education, training and development plans Divisional Performance Review Meetings

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(adjustment after TUPE staff) nursing staff

Board Committee oversight: Strategic Workforce and Transformation Committee

05

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8

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18

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Strategic Ambition 5: WORKFORCE: Staff Satisfaction: Friends & Family Test (Executive Director: Director of Workforce and Organisational Development)

We aim to achieve our highest levels of staff satisfaction; 85% by 2021.





Target Residual

Score (C x L)

Risk Ref: BAF 5 Risk: Due to a lack of support and poor engagement, the Trust has poor retention levels and low levels of productivity.

Objective: Staff Satisfaction score of 85% by 2021. Source: Lower than expected levels of staff satisfaction reported by the SSFFT


Independent assurance: Staff Satisfaction: FFT score (recommend as a place to work) – 69% - March 2019 Staff Engagement score Internal assurance: SWC SFFT ¼ly surveys IPR Patient Safety Walkabouts Appraisal and Revalidation Transformation Board Freedom to Speak Up Guardian Service

Staff Satisfaction gap of 16% Disengagement and resistance leading to lost productivity and innovation.

16 (4x4)

Opportunities: NSS results as a driver for improvement to communicate areas of good practice and areas for improvement. Better marketing of health and wellbeing initiatives to support all staff NHSI Cohort 4 retention programme roll out Review the “Blackpool Way” – behavioural framework Review the communications approach to support staff engagement Incentivise staff to complete surveys Staff Engagement Team should address this concern and work towards achieving Trust target

8 (4x2)

Core management controls: Trust Strategy Workforce Transformation Strategy including education, training, support, health and wellbeing and development plans Divisional Performance Review Meetings

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Strategic Ambition 6: FINANCE: Finance (Executive Director: Deputy Chief Executive & Director of Finance and Performance)

We aim to achieve a FSRR of 3; 3 by 2019.





Target Residual

Score (C x L)

Risk Ref: BAF 6 Risk: The Trust has a significant (£34m) underlying deficit. Without mitigations this would mean insufficient working capital to meet day to day needs. Objective: Delivery of sustainable surpluses from 2021/22 Source: Trusts ability to continue as a Going Concern and the SOF

Director of Finance and Performance

Independent assurance: EA – ISA 260 – modified conclusion VfM - 2019 IA – Core Financial Controls - Significant assurance with minor improvement opportunities – 2019 NHSI Segmentation Report – 3 - Mandated support: Support needs identified in Quality of care, Finance & use of resources and Operational performance 2019 Internal assurance: Finance Committee Integrated Performance Report Quarterly Single Oversight Framework report to NHSI Local Counter Fraud Work CIP Directors Report Cash Committee Turnaround Consultant

The 19/20 mitigations, which also carry strategic risk, are a cost saving target of £17.5m & non-achievement of the savings and failure to comply with the terms of the MoU in relation to the financial support. CIP not all CIP schemes have been developed for 19/20. In addition the terms of the MoU have not been agreed.

16 (4x4)

Opportunities: Establish a process for accessing interim finance should the mitigations not be sufficient to manage the risk. Agreement to manage a joint CIP/QIPP programme across the ICP. Agree a single control total with CCGs and implement an ICP financial model. Need to develop a costed, resource and affordable plan to ensure the Trust meets all safety requirements and can achieve operational performance standards. Beyond 19/20 the Trust needs to develop and implement a strategy to return to at least a financial balance. This will require both transformational change which reduces costs and / or recurrent additional income to support the cost base.

12 (4x3)

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Core management controls: Executive Directors Meetings Reservation of Powers and Scheme of Delegation Trust Strategy Financial and budget management arrangements Current and Forecast Outturn Position – January 2019 Divisional Performance Review Meetings CIP Board Turnaround Director Recovery Board

Non-recurrent support from the Fylde Coast CCGs. Failure to manage cost pressures and / or new investments (including capital) within the affordability envelope agreed with the ICP. Supplier Risk has not been fully implemented in practice. Stress testing on cash flow forecasts is not formally documented in a format that details the modelling of various potential scenarios with including their consequences and the impact on the Trust’s cash position.

Board Committee oversight: Finance Committee 0

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Enablers (Executive Director: Relevant Executive Directors)

Putting in place enablers such as improved use of information technology, making good use of our estate and enhancing our communications


Gaps in Controls/Assuranc

es



Target Residual

Score (C x L)

Risk Ref: BAF 11 Risk: Failure to embed the systems within staff duties and hold them to account will risk the implementation of the national EPR target of 2020

Objective/Source: Key enabler within the Trust Strategy


Independent assurance: IA – EPR and IT Strategy Delivery Review - Partial assurance with improvements required - 2018 Internal assurance: Finance Committee Health Informatics Committee

Trust financial position may mean we cannot implement the EPR within the stated timeframes. In addition, other resource constraints may mean more focus is placed on operational delivery rather than strategic development.

8 (2x4)

Opportunities: Development of an investment plan in support of the IT strategy. Consider an Informatics Alternative Delivery Model.

2 (2x1)

Core management controls: Trust Strategy Business Case Chief Clinical Information Officer in post




Mitigated Current


Target Residual

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es

Score (C x L)

Score (C x L)

BAF Ref: BAF 14 Risk: The Trust will not meet its Strategic Ambitions due to the failure to deliver transformational change Objective/Source: Key enabler within the Trust Strategy


Independent assurance: None Internal assurance: Strategic Workforce and Transformation Committee

Capability – lack of specific skills set to address transformation Capacity – lack of sufficient time to address transformational issues Accountability – clear accountability is required

16 (4x4)

Opportunities: NHSI/HEE workforce return demonstrated little workforce transformation is planned over the next 12 months, however the Trust has engaged in the implementation of new roles, such as Physicians Associates (PAs), Nurse Associates (NA), Advanced Clinical Practitioners (ACP).

8 (4x2)

Core management controls: Executive Directors Meeting Trust Strategy Better Care Now Delivery Group


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5th November 2019


Report Prepared By: Matthew Burrow

Contact Details: 01253 955990

Date of Report: 31st October 2019

Purpose of Report: To present the Board Assurance Framework (BAF) and draw attention to the recommended update. The BAF has been reviewed by the Board Committees. The Audit Committee received a recommendation from the Finance & IMT Committee for an increase to BAF 6 and to increase the likelihood score from 4 to 5, with the new score being 20. The Audit Committee accepted the recommendation and it is presented to the Board for discussion and approval.

For information

For Discussion

For Approval

Risks Associated with Report on BAF or CRR:

BAF

CRR


Assurance Level:

Full

Partial

No Assurance

Recommendations: The Board of Directors is requested to approve the Board Assurance Framework, in particular the increase of BAF 6.

Sensitivity Level:




X

X

X

X

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Dated Version: 25/10/2019

BOARD ASSURANCE FRAMEWORK Board Assurance Framework for the delivery of Trust Strategy The Board of Directors has overall responsibility for ensuring systems and controls are in place, sufficient to mitigate any significant risks which may threaten the achievement of the Trust Strategy (as outlined in the Risk Management Policy). The Board of Directors therefore needs to gather assurance to ensure any significant risks are being mitigated. This assurance will be gained from a wide range of sources, but where ever possible it should be systematic, supported by evidence, independently verified, and incorporated within a robust governance process. The Board of Directors achieves it assurance primarily through the work of its Board Committees, and through use of Audit, other independent inspection and by the systematic collection and scrutiny of performance data, to evidence the achievement of the strategic ambitions.

Independent assurance (external):

External Audit

Internal Audit

NHS Resolution

Care Quality Commission inspections/reports

Well-led Framework inspections/reports

Royal College visits/reports

Deanery visits/reports

Investors In People visits/reports

Health and Social Care Information Centre SHMI Report

External Benchmarking

Accreditation schemes

National or regional audits

Specifically commissioned reports

Peer review and accreditation

Patient Experience: Friends & Family Test

Staff Satisfaction: Family and Friends Test

Internal assurance:

Board of Directors

Audit Committee

Quality Committee

Finance and IMT Committee

Clinical Effectiveness Committee

Workforce Transformation Committee

Performance and Operations Committee

Clinical Audit

Integrated Performance Report (quality, finance and operational performance)

Local Counter Fraud reports

Appraisal and Revalidation

Great Place to Work Survey

Information Governance Toolkit

Personal review/contact e.g. patient safety walkabouts, patient story

Core management controls (to reduce the likelihood and/or consequences of risks):

Executive Directors Meetings

Reservation of Powers and Scheme of Delegation

Standing Financial Instructions and Standing Orders

Risk Management Policy

Other Trust approved policies and procedures

Risk Registers

Trust Strategy

Quality Improvement Strategy

Workforce Strategy including training and development plans

Financial and budget management arrangements

The recruitment process for staff (checking of registration and monitoring of CRB compliance

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Scope and Structure of Board Assurance Framework The Board Assurance Framework focuses on any significant risks which may threaten the achievement of the national compliance requirements and the Trusts strategic ambitions for 2016-2020. The document brings together all strategic risks expanding on the main controls and assurance, gaps in controls and assurance and relevant actions to be taken. The BAF follows the agreed ordering of national compliance requirements;


Care Quality Commission Regulations And the Trusts strategic ambitions, which are as follows:

Strategic Ambition 1: QUALITY: Mortality – SHMI (Executive Director: Medical Director) We aim to achieve our lowest levels of mortality, reducing the SHMI to within the ‘expected’ range.

Strategic Ambition 2: QUALITY: Patient Experience: Friends and Family Test (Executive Director: Director of Nursing and Quality) We aim to achieve our highest levels of patient satisfaction; 98% by March 2021.

Strategic Ambition 3: OPERATIONS: Length of stay (Executive Director: Director of Operations – Unscheduled Care)

We aim to (TBC - proposal to change the measures to be total elective length of stay and total non-elective stay, ensuring consistency with operational measures).

Strategic Ambition 4: WORKFORCE: Vacancy rate (Executive Director: Director of Workforce and Organisational Development) We aim to significantly reduce our clinical vacancy rate, based on future workforce numbers; 2.5% by March 2021.

Strategic Ambition 5: WORKFORCE: Staff Satisfaction: Friends & Family Test (Executive Director: Director of Workforce and Organisational Development) We aim to achieve our highest levels of staff satisfaction; 85% by 2021.

Strategic Ambition 6: FINANCE: Finance (Executive Director: Deputy Chief Executive/Director of Finance and Performance) Delivery of sustainable surpluses from 2021/22

Enablers (Executive Director: Relevant Executive Directors) Putting in place enablers such as improved use of information technology, making good use of our estate and enhancing our communications

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Risk Matrix Score

Consequence Rating Likelihood Rating

Almost Certain Likely Possible Unlikely Rare

5 4 3 2 1

Catastrophic

5 25 20 15 10 5

Major

4 20 16 12 8 4

Moderate

3 15 12 9 6 3

Minor

2 10 8 6 4 2

Insignificant

1 5 4 3 2 1

Consequence Definitions

Score 1 2 3 4 5

Safety Short-term, minor injury or illness,

first aid treatment needed Semi-permanent injury/damage

Major injuries or long term incapacity / permanent disability

Patient harm that is StEISS reportable RIDDOR reportable incident

An Avoidable Death Staff death in the workplace

Multiple Avoidable Deaths

Quality

Formal Complaints Non-compliance with standards. e.g.

departmental policy or procedure Loss of person identifiable

information inc limited health information e.g. clinic appointment

date/time details. Local Media – short term Social Media – short term

Multiple Formal Complaints up to 25 day resolution

Loss of person identifiable information such as ward handover sheet including Investigations, treatment or diagnosis

Non-compliance with standards. e.g. Trust policy or procedure

Non-compliance with national standards. e.g. NICE guidance

Local Media/Social Media–long term National Media < 3 days

Critical Internal/External Audit Report Multiple Formal Complaints up to 35 day

resolution Loss of person identifiable information inc

detailed health information e.g. patient health record.

National Media > 3 Days. MP Concern (Questions in House)

Critical National Report (Dr Foster/CQC) Inquest

Ombudsmen Inquiry HSE - Improvement Notice

HTA Enforcement Action MHRA Enforcement Action

ICO Enforcement Action Whistleblowing with evidence

Loss of person identifiable information inc sensitive health information e.g. patient

health record relating to HIV, STD, Mental Health, Children.

Enforcement Action by a Regulator Civil/Criminal Prosecution

Operational Delivery Loss of a Trust Business Continuity

Plan Required Service 0-10% reduction in staffing levels

Loss of a Trust Business Continuity Plan Necessary Service


Loss of a Trust Business Continuity Plan Important Service


Loss of a Trust Business Continuity Plan Essential Service


Loss of a Trust Business Continuity Plan Vital Service

Over 40% reduction in staffing levels Loss of Provider License through failure to deliver

a commissioner mandated service

Financial Loss/Unfunded Cost £1M - £2.5M Loss/Unfunded Cost £2.5M - £5M Loss/Unfunded Cost £5M - £10M Loss/Unfunded Cost > £10M Trust become insolvent

Likelihood Definitions Score 1 2 3 4 5

Frequency Could occur annually Could occur quarterly Could occur monthly Could occur weekly Could occur daily

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Board Assurance Framework Overview

Board Committee National Compliance Requirements Trust Strategic Ambitions

Finance and IMT Committee

BAF 6 – The Trust has a significant (£34m) underlying deficit. Without mitigations this would mean insufficient working capital to meet day to day needs.

BAF 13 – Due to a lack of shareholder strategy for the subsidiary company (Atlas) will lead to a failure to maximise the full commercial benefits of the arrangements and associated reputational damage to the Trust.

BAF 11 – Failure to embed the systems within staff duties and hold them to account will risk the implementation of the national EPR target of 2020

Performance and Operations Committee

BAF 7A – Failure to meet planned care performance targets within the Single Oversight Framework (RTT, Cancer, Diagnostics)

BAF 10 – Unnecessarily prolonged stays in hospital may adversely affect patient care and increase Trust costs.

BAF 7B – Failure to meet Emergency Department 4 hour performance standard within the Single Oversight Framework.

Quality Committee

BAF 9 – Failure to maintain the CQC Standards could lead to the provision of suboptimal care to patients and incur reputational damage to the Trust

BAF 2 – Poor Patient Family and Friends Test score implies that patient care is not optimal. This will affect patient outcomes and may result in reputational damage.

Clinical Effectiveness Committee

BAF 1 – Failure to reduced SHMI to within the expected range may indicate suboptimal standards of care and may damage the reputation of the Trust.

BAF 15 - Failure to engage medical staff in improvement initiatives risks patient safety and regulatory action

Workforce Transformation Committee BAF 4 - Due to national shortages in nursing, medical and support staff the Trust may deliver suboptimal care

BAF 5 – Due to a lack of support and poor engagement, the Trust has poor retention levels and low levels of productivity

BAF 14 – The Trust will not meet its Strategic Ambitions due to the failure to deliver transformational change

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Target Residual

Score (C x L)

Risk Ref: BAF 7A Risk: Failure to meet planned care performance targets within the Single Oversight Framework. - RTT - Cancer - Diagnostics Could lead to the provision of suboptimal care to patients and damage the reputation of the Trust Objective/Source: Compliance with the Single Oversight Framework and Provider Licence.

Director of Operations – Planned Care

Independent assurance: Internal Audit - Compliance with Performance Reporting – Significant assurance with minor improvement opportunities – 2018. NHSI Segmentation Report – 3 - Mandated support: Support needs identified in Quality of care, Finance & use of resources and Operational performance 2019 Internal assurance: Performance and Operations Committee reports to the board of Directors. Operational Performance has been reviewed by the Finance Committee and now the Performance and Operations Committee. The Board of Directors reviews the Board Performance Dashboard. Quarterly Single Oversight Framework report to NHS Improvement

NHSI Enforcement Undertakings letter, the Trust has not delivered the Cancer target since May 2018 External:

Assured value contract, not reflective of available capacity. Ongoing discussion re 19/20 RTT work and risks of 52 week breaches

Potential shortfall in funding, no health economy agreement to address RTT backlog

Management of demand with the CCGs

Delays in progressing business cases/priorities with commissioners

Provision of sufficient capacity by partner organisations – i.e. Oncology

Patient choice

Potential to utilise IS

12 (3x4)

Internal:

Develop a Performance Improvement Plan to address cancer performance

Centralisation of the validation team, ensuring application of the access policy and RTT rules

Continued improved utilisation via OP and theatres work programmes – Continue into 2019/20 including endoscopy and radiology

Implementation of the Cardiology Modular Catheter Laboratory and WLI work in the interim – October 2019

Business case for additional MRI capacity

Demand and capacity work-programme – Continue into 2019/20

RTT internal action plan being developed and monitored.

External:

Cancer Alliance support in funding short term initiatives – Ongoing Further discussions underway for 2019/20 support.

Collaboration with other Lancashire

3 (3x1)

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Core management controls: Trust Strategy is in place. DPR Meetings review performance monthly. Weekly Patient Target Listing Meeting takes place. Contract Review Meetings in place. Cardiology EP Plan in place. Performance Trajectories Outpatient and Theatres efficiency programmes Planned Care Steering Group Planning trajectories submitted; -RTT volume will be maintained, little improvement in the proportion waiting less than 18 weeks - 2 week rule performance only improves from mid-year 2019 CCG Contract/Performance meetings Integrated Care Partnership Steering Group NHSI monthly meeting Business case to expand breast cancer capacity has been approved. Action plan in place for short, medium and long term actions.

contracts being explored. Internal:

Insufficient diagnostic capacity – i.e. mammography and MRI

Workforce challenges in recruiting staff

The existing estate configuration is not ‘fit for purpose’ in some areas

Risk of choice at 26 weeks

providers – Ongoing

ICS programme of theatre productivity

Support being provided by partners to support breast back log.

RTT position being further highlighted to CCGs.

of 225


Board Committee oversight: Performance and Operations Committee

0

5

10

15

20

25

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Target Residual

Score (C x L)

Risk Ref: BAF 7B Risk: Failure to meet Emergency Department 4 hour performance standard within the Single Oversight Framework. Could lead to the provision of suboptimal care to patients and damage the reputation of the Trust Objective/Source: Compliance with the Single Oversight Framework and Provider Licence.


Independent assurance: Internal Audit - Compliance with Performance Reporting – Significant assurance with minor improvement opportunities – 2018. NHSI Segmentation Report – 3 - Mandated support: Support needs identified in Quality of care, Finance & use of resources and Operational performance 2019. Internal assurance: Performance and Operations Committee reports to the board of Directors. Operational Performance has been reviewed by the Finance Committee and now the Performance and Operations Committee. The Board of Directors reviews the Board Performance Dashboard. Quarterly Single Oversight Framework report to NHS Improvement Core Management Controls: Trust Strategy is in place. DPR Meetings review performance monthly. Weekly Patient Target Listing Meeting takes place.

NHSI Enforcement Undertakings letter, the Trust has not delivered the A&E target since 2017. External: Potential shortfall in funding to support new pathways & developments/ funding of winter plan Management of demand with the CCGs reducing non elective admissions Delays in progressing business cases/ support for STP development Response and provision of services from mental health assessments and beds Provision of sufficient capacity by partner organisation – i.e. Packages of Care/ 24 hour support Internal: Workforce challenges in recruiting staff The existing estate configuration is not ‘fit for purpose’ and does not support streamline flow Inconsistent implementation and use of internal professional standards Patient Flow and Discharge

16 (4x4)

Internal:

Develop a Performance Improvement Plan to address A&E.

Following demand and capacity work completed – need to secure additional workforce to match demand profile – recruitment underway.

Jointly develop business case for additional diagnostics support - MRI – requires approval and funding / interim plan in place

Use of data and information to highlight opportunities and support patient flow.

Embedded electronic escalation plan for the organisation

Deliver all actions from Emergency Care Improvement Plan

External:

Agree a winter plan for 2019/20.

Secure external support to deliver reduction in LoS – implementing improved end to end pathways across the Integrated Care Partnership – ECIST/CSU

Digital solutions which improve flow, increase access to alternatives to ED

Commission adequate mental health support/ capacity – recruitment underway

Develop single point of access to neighbourhood teams - admission avoidance/ in reach – 2019/20

12 (4x3)

of 225


Contract Review Meetings in place. Cardiology EP Plan Performance Trajectories. A&E Delivery Board has reviewed the winter plan. Head of Patient Flow appointed.

Teams separate resulting in segregated pathways Delays in accessing diagnostics and timely reporting

CCG Contract/Performance meetings Integrated Care Partnership Steering Group NHSI monthly meeting Assess to admit policy for the organisation. Manage GP patients outside of ED.

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0

5

10

15

20

25

30

Series1

Series2

of 225


Care Quality Commission Regulations




Actions/Opportunities to address Gaps in Controls/Assurances

Target Residual

Score (C x L)

Risk Ref: BAF 9 Risk: Failure to maintain the CQC Standards could lead to the provision of suboptimal care to patients and incur reputational damage to the Trust Objective/Source: Compliance with CQC Regulations

Director of Nursing, AHP and Quality

Independent assurance: Full CQC Report – Requires Improvement – 2018 & 2019. CQC A&E Report – 2019. Internal Audit – CQC Follow Up - Significant assurance with minor improvement opportunities – 2019. NHSI Segmentation Report – 3 - Mandated support: Support needs identified in Quality of care, Finance & use of resources and Operational performance - 2019. Internal assurance: Quality Committee and Clinical Effectiveness Committee in place and report to Board of Directors and link with the System Improvement Board. Quality Committee receives monthly CQC updates on action plans. Monthly Patient Safety Walkabouts reported to the Quality Committee. Safe staffing report to the Quality Committee. Links to Board Assurance Framework Risk - BAF 15.

NHSI Enforcement Undertakings letter, raised Trust breaches CQC 2019; 5 Regulatory Breaches – person-centred care, safe and caring, equipment and premises, good governance, staffing IA 2019; Poor evidence of compliance with ED corridor patient risk assessments, Poor evidence of compliance with antibiotic therapy on applicable treatment cards recorded and Poor compliance with documentation of mental health risk

20 (5x4)

Developing a Corporate Assurance/ Governance Plan to include all CQC actions which will be monitored by the Quality Committee. Developing a new Integrated Performance Report to provide robust assurance to the Committee on quality key performance indicators. Implementing the new senior nursing structure to provide greater assurance to the Committee which was approved by the Board of Directors. Implementing the Quality Improvement Strategy – improving the last 1,000 days of life, reducing preventable deaths and reducing avoidable harm. Review of the assurance system and the sphere of accountability.

10 (5x2)

of 225


Core management controls: Trust Strategy, Quality Improvement Strategy and Workforce Transformation Strategy in place.

assessments CQC 2018; 4 Regulatory Breaches – staffing, good governance, safeguarding and safe and caring


0

5

10

15

20

25

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Series2

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Strategic Ambition 1: QUALITY: Mortality – SHMI (Executive Director: Medical Director) We aim to achieve our lowest levels of mortality, meeting and then falling below our expected number of deaths; <=100 by 2019.





Target Residual

Score (C x L)

Risk Ref: BAF 1 Risk: Failure to reduced SHMI to within the expected range may indicate suboptimal standards of care and may damage the reputation of the Trust. Objective: Reducing the SHMI to within the ‘expected’ range. Source: HSCIC

Medical Director

Independent assurance: Health and Social Care Information Centre SHMI Report – BTH were one of the 11 Trusts with a higher than expected number of deaths – 2019. NHSI Segmentation Report – 3 - Mandated support: Support needs identified in Quality of care, Finance & use of resources and Operational performance 2019. Internal assurance: Clinical Effectiveness Committee in place reporting to Board of Directors and links with the System Improvement Board. A Mortality Governance Committee is in place reporting to the Clinical Effectiveness Committee

NHSI Enforcement Undertakings letter;

The Trust has been a SHMI outlier since June 2014

The Trust has 6 CQC mortality outlier alerts at January 2019

CQC alerts for our outlier status in several diagnostic groups including stroke, intestinal obstruction (without hernia) and skin & subcutaneous tissue infection. SHMI values for acute respiratory illness (pneumonia & COPD) and stroke are

20 (5x4)

Developing a Corporate Assurance/ Governance Plan to include the NHSI Enforcement Undertakings letter actions. Developing a new Integrated Performance Report to provide robust assurance to the Committee on clinical effectiveness key performance indicators. Implementing the Quality Improvement Strategy – improving the last 1,000 days of life, reducing preventable deaths and reducing avoidable harm. The Trust has commissioned a medical engagement survey with NHSI. The Trust has commissioned an RCP external review, which is being undertaken in November 2019. The Trust has established a Clinical Effectiveness Committee with a principle duty to focus on mortality.

10 (5x2)

of 225


Core management controls: Trust Strategy, Quality Improvement Strategy and Mortality Policy in place. Dr Morgan has been appointed as Mortality Reduction Lead A Nexus Board App has been created for mortality SJR

high) Limited assurance for mortality SJR

An improved learning from deaths report will be presented to the Clinical Effectiveness Committee and Board of Directors. Challenge provider funding has been approved for a clinical effectiveness lead until March 2019.

Board Committee oversight: Clinical Effectiveness Committee

0

5

10

15

20

25

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Series2

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Strategic Ambition 2: QUALITY: Patient Experience: Friends and Family Test (Executive Director: Director of Nursing and Quality)

We aim to achieve our highest levels of patient satisfaction; 98% by 2019.


Gaps in

Controls/Assurances



Target Residual

Score (C x L)

Risk Ref: BAF 2 Risk: Poor benchmarking of patient experience reports from the CQC identifies that patient care is not optimal. This will affect patient outcomes and may result in reputational damage. Objective: Patient Family and Friends Test score of 98% by March 2021. Source: PFFT

Director of Nursing, AHP and Quality

Independent assurance: Patient Family and Friends Test score National Inpatient Survey 2018 Internal assurance: The Quality Committee receives regular Complaints Reports and the national Inpatient Survey.

In the National Inpatient Survey 5 questions were rated lower than the national average. Poor engagement with the learning disabilities benchmarking pilot. Need to develop a patient experience plan.

4 (4x1)

The complaint process and resource is being reviewed and proposed changes reported to the Quality Committee. The learning disabilities benchmarking pilot will be discussed Learning Disabilities Partnership Board.

4 (4x1)

Core management controls: Quality Improvement Strategy is in place.

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Strategic Ambition 3: OPERATIONS: Length of stay (Executive Director: Medical Director) We aim to achieve top quartile performance, moving to top decile performance, for both non-elective and elective lengths of stay, whilst at the same time maintaining high quality care; Non-elective - 5.1 days by 2018 and 4.4 days by 2021; Elective - 2.2 days by 2018 and 1.7 days by 2021 and Readmissions within 30-days - 94.2 by 2019 and 79.5 by 2021.

Risk & Source Owner Main

Controls/Assurances




Target Residual

Score (C x L)

Risk Ref: BAF 10 Risk: Unnecessarily prolonged stays in hospital may adversely affect patient care and increase Trust costs. Objective: (TBC - proposal to change the measures to be total elective


Independent assurance: ECIP Report Internal assurance: Performance and Operations Committee reports to the board of Directors. Operational Performance has been reviewed by the Finance Committee and now the Performance and Operations Committee. The Board of Directors reviews the Board Performance

Increased ED attendances, admissions and delayed discharges of care place pressure on bed closures Inability of the Trust to affect directly the capacity of external organisations which impairs ability to discharge patients in a timely fashion. Recommendations from ECIP report Shortfalls in clinical

16 (4x4)

ECIST & CSU engaged with to support bed day reduction programme. This is split into a number of areas

Extended Length of stay Reduction by 36% March 2020

Reduce variability in Ward level processes

Simplification of Discharge processes – establish new ways of working

Emergency department Improvements – linked to EDS performance improvement

12 (4x3)

of 225


length of stay and total non-elective stay, ensuring consistency with operational measures). Source: Trust Strategy

Core management controls: Trust Strategy and Quality Improvement Strategy are in place. Divisional Performance Review Meetings take place monthly. Better Care Now Delivery Group now merged with Urgent and Emergency Care steering group Weekly LoS Group in place with the directorate managers monitoring Los. Weekly ELoS reviews between DDoN with Ward Managers, MADE reviews, check and balance event.

staffing affect ability to reduce LoS

Increased development of Clinical Utilisation of Resources - aim to roll out to all wards to provide detail on ready for discharge, ensure all critical daily activities are actioned


0

5

10

15

20

25

No

v-1

8

De

c-1

8

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

Series1

Series2

of 225


Strategic Ambition 4: WORKFORCE: Vacancy rate (Executive Director: Director of Workforce and Organisational Development)

We aim to significantly reduce our vacancy rate, based on future workforce numbers; 2.5% by 2021.


Gaps in Controls/

Assurances



Target Residual

Score (C x L)

Risk Ref: BAF 4 Risk: Due to national shortages in nursing, medical and support staff the Trust may deliver suboptimal care.

Objective: Vacancy rate of 2.5% by March 2021. Source: Higher than expected levels of vacant roles


Independent assurance: None Internal assurance: Workforce Transformation Committee in place and report to Board of Directors. Regular reports to the Workforce Transformation Committee on staffing.

Funding gap for workforce transformation from HEE Inability to grow our own at the pace required to meet gaps in professional roles- lead in educational time required National Skills shortages in key professional groups Uncertainty about ICP progression and opportunities to share resources As of August 2019, the Trust is running at a vacancy rate of just over 315 nursing staff

16 (4x4)

Developing a regional solution to agency and bench. The Apprenticeship Levy is being used to develop clinical staff – Nursing Associates and RGNs has commenced. ICP workforce transformation development discussions have commenced. Work is being done to address the workforce supply by working with international recruitment agencies, offering retire and return programmes as well as working with Health Education England on the Global Health Exchange programme. The Trust is engaged in cohort 4 of NHSI Retention Programme and also has a retention and recruitment board in situ, to address and mitigate risks wherever possible.

8 (4x2)

Core management controls: Workforce Transformation Strategy including education, training and development plans are in place. A recruitment microsite up and running. A daily and weekly staffing report is available demonstrating fill rates. Staffing contract with Medacs has been agreed to ensure consistency and quality of care is delivered. Recruitment and Retention NHSI

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Programme in place. (13.15% nursing vacancy rate; overall vacancy rate 8.96%)

Board Committee oversight: Workforce Transformation Committee

0

5

10

15

20

25

30

No

v-1

8

De

c-1

8

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

Series1

Series2

of 225


Strategic Ambition 5: WORKFORCE: Staff Satisfaction: Friends & Family Test (Executive Director: Director of Workforce and Organisational Development)

We aim to achieve our highest levels of staff satisfaction; 85% by 2021.


Gaps in Controls/

Assurances



Target Residual

Score (C x L)

Risk Ref: BAF 5 Risk: Due to a lack of support and poor engagement, the Trust has poor retention levels and low levels of productivity.

Objective: Staff Satisfaction score of 85% by 2021. Source: Lower than expected levels of staff satisfaction reported by the SSFFT


Independent assurance: Staff Satisfaction: FFT score 64% Q1 Staff Engagement score Internal assurance: Workforce Transformation Committee in place and report to Board of Directors. SFFT ¼ly surveys Monthly Patient Safety Walkabouts reported to the Quality Committee. Regular reports to the Workforce Transformation Committee on Appraisal and Revalidation, Freedom to Speak Up and Guardian of Safe Working.

Staff Satisfaction gap 21% Disengagement and resistance leading to lost productivity and innovation.

16 (4x4)

Sharing of the National Staff Survey results across the Trust as a driver for improvement to communicate areas of good practice and areas for improvement. Better marketing of health and wellbeing initiatives to support all staff. The NHSI Cohort 4 retention programme is being rolled out. The Trust is reviewing the “Blackpool Way” – behavioural framework. Development of BAME focus groups is planned. The national BAME lead is being invited to support the Trust. Review the communications approach to support staff engagement.

8 (4x2)

Core management controls: Workforce Transformation Strategy including education, training, support, health and wellbeing and development plans are in place. Big Conversations being held with staff on a rolling programme. A buddy ward system is n in place for senior managers.

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Strategic Ambition 6: FINANCE: Finance (Executive Director: Deputy Chief Executive & Director of Finance and Performance)

We aim to achieve a FSRR of 3; 3 by 2019.





Target Residual

Score (C x L)

Risk Ref: BAF 6 Risk: The Trust has a significant (£34m) underlying deficit. Without mitigations this would mean insufficient working capital to meet day to day needs. Objective: Delivery of sustainable surpluses from 2021/22 Source: Trusts ability to continue as a Going Concern and the SOF


Independent assurance: CQC Use of Resources – Requires Improvement – 2019. External Audit – ISA 260 – modified conclusion VfM – 2019. Internal Audit – Core Financial Controls - Significant assurance with minor improvement opportunities – 2019. NHSI Segmentation Report – 3 - Mandated support: Support needs identified in Quality of care, Finance & use of resources and Operational performance 2019. Internal assurance: Finance and IMT Committee in place and report to Board of Directors. Finance and IMT Committee receives regular reports on the operational plan, CIP and strategy. Cash Committee and CIP Board are in place and report to Finance Committee.

The 19/20 mitigations, which also carry strategic risk, are a cost saving target of £17.5m & non-achievement of the savings and failure to comply with the terms of the MoU in relation to the financial support. The MOU has now been agreed but the CGGs believe only £10m will be paid of the £17.5m. Non-recurrent support from the Fylde Coast CCGs. Failure to manage cost pressures and / or new investments

20 (4x5)

Developing an operational plan for 2020/21 being reported to the Finance Committee. Developing a medium term financial strategy to include a costed, resourced and affordable plan to ensure the Trust meets all safety requirements and can achieve operational performance standards, and go beyond 2019/20 to return to at least a financial balance. This will require both transformational change which reduces costs and / or recurrent additional income to support the cost base and will be reported to the Finance Committee. Reviewing all business cases and priorities for 2019/20 at Executive Directors meetings. Agreement to manage a joint CIP/QIPP programme across the ICP. Agree a single control total with CCGs and implement an ICP financial model.

12 (4x3)

of 225


Core management controls: Standing Financial Instruction and Reservation of Powers and Scheme of Delegation are in place. A process for accessing interim finance has been established.

(including capital) within the affordability envelope agreed with the ICP. Stress testing on cash flow forecasts is not formally documented in a format that details the modelling of various potential scenarios with including their consequences and the impact on the Trust’s cash position.

Board Committee oversight: Finance and IMT Committee

0

5

10

15

20

25

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Enablers (Executive Director: Relevant Executive Directors)

Putting in place enablers such as improved use of information technology, making good use of our estate and enhancing our communications


Gaps in

Controls/Assurances



Target Residual

Score (C x L)

Risk Ref: BAF 11 Risk: Failure to embed the systems within staff duties and hold them to account will risk the implementation of the national EPR target of 2020

Objective/Source: Key enabler within the Trust Strategy


Independent assurance: Internal Audit – EPR and IT Strategy Delivery Review - Partial assurance with improvements required - 2018

Internal assurance: Finance and IMT Committee in place reporting to the Board of Directors. Health Informatics Committee reports to the Finance and IMT Committee

Trust financial position may mean we cannot implement the EPR within the stated timeframes. In addition, other resource constraints may mean more focus is placed on operational delivery rather than strategic development.

8 (2x4)

Develop an investment plan to support the IT strategy. An EDMS Business Case has been agreed by the Finance and IMT Committee and is being presented to the Board of Directors in November 2019

2 (2x1)

Core management controls: IT Strategy in place. Chief Clinical Information Officer in post.

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0

5

10

15

20

25

Series1

Series2

of 225






Target Residual

Score (C x L)

Risk Ref: BAF 15 Risk: Failure to engage medical staff in improvement initiatives risks patient safety and regulatory action Objective: TBC Source: NHSI Enforcement Undertakings letter

Medical Director

Independent assurance: Staff Satisfaction: FFT score 64% Q1 Staff Engagement score Internal assurance: A Clinical Effectiveness Committee is in place and reports to Board of Directors. Links to Board Assurance Framework Risk - BAF 5.

Concerns raised in the NHSI Enforcement Undertakings letter

15 (5x3)

The Trust has commissioned a medical engagement survey with NHSI and the University of Warwick, due to report in January 2020.

10 (5x2)

Core management controls: A Quality Improvement Strategy and Workforce Transformation Strategy are in place

Board Committee oversight: Clinical Effectiveness Committee

of 225


0

2

4

6

8

10

12

14

16

Jul-19 Oct-19

Series1

Series2

of 225




es



Target Residual

Score (C x L)

BAF Ref: BAF 13 Risk: Due to a lack of shareholder strategy for the subsidiary company (Atlas) will lead to a failure to maximise the full commercial benefits of the arrangements and associated reputational damage to the Trust. Objective/Source: Key enabler within the Trust Strategy


Independent assurance: Internal Audit – Governance – Operational - Significant assurance with minor improvement opportunities & Strategic - Partial assurance with improvements required – 2019 Internal Audit - Governance Arrangements –Procurement - Partial assurance with improvements required – 2019 Internal assurance: The Trust Finance and IMT Committee and Board of Directors receive reports from the Chairman of Atlas A Shareholder Panel meeting bi-annually to review shareholder matters. A Client Monitoring Officer and Client Director have been appointed.

Strategic aims for Atlas need defining. Governance documents need reviewing. Trust has limited experience in Group and Company governance. Knowledge gap has arisen within the Shareholder in terms of Estates.

4 (2x2)

Implementation of the KMPG internal audit review recommendations. Reviewing the Standing Financial Instructions of the Trust and Atlas to operate with the Lancashire Procurement Cluster Awaiting the outcome of an external review (Value Circle)

2 (2x1)

of 225


Core management controls: Articles of Association, Governance Framework and BMA are in place.


0

2

4

6

8

10

12

14

16

Series1

Series2

of 225




es



Target Residual

Score (C x L)

BAF Ref: BAF 14 Risk: The Trust will not meet its Strategic Ambitions due to the failure to deliver transformational change Objective/Source: Key enabler within the Trust Strategy


Independent assurance: None Internal assurance: Workforce Transformation Committee in place and report to Board of Directors.

Capability – lack of specific skills set to address transformation Capacity – lack of sufficient time to address transformational issues Accountability – clear accountability is required NHSI/HEE workforce return demonstrated little workforce transformation is

16 (4x4)

A Compassionate leadership and Just Culture approach are being developed to support a change in culture required to deliver transformation and change A review of our leadership offer is taking place to ensure we have the right leaders driving the changes we need to make The Trust has engaged in the implementation of new roles, such as Physicians Associates (PAs), Nurse Associates (NA), Advanced Clinical Practitioners (ACP). Implementing the Quality Improvement Strategy – improving the last 1,000 days of life, reducing preventable deaths and reducing avoidable harm and training staff.

8 (4x2)

Core management controls: Trust Strategy in place. Better Care Now Delivery Group established. Big conversations are taking place with staff regarding transformation and improving services. Quality Improvement Programme is underway.

of 225


planned over the next 12 months.


0

5

10

15

20

25

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Series2

of 225


5th November 2019

Integrated Performance Reporting: Development Update

Report Prepared By: Jane Rowley, Head of Performance on behalf of Tim Bennett

Contact Details: [email protected] (01253) 955567

Date of Report: 29/10/2019

Purpose of Report: To update the Board of Directors on the progress against the IPR development plan.

For information

For Discussion

For Approval

Risks Associated with Report on BAF or CRR:

BAF

CRR


Assurance Level:

Full

Partial

No Assurance

Recommendations: The Board of Directors is asked to:

Sign off the high level metrics for the Summary level and reporting committees (Page 4)

Review and agree all the metrics proposed to be reported via the Board Committees (Pages 5 & 6)

Discuss and consider the risk associated with the renaming of efficient as well led.

Sensitivity Level:




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Integrated Performance Highlight Report

SRO: Tim Bennett October 2019

Draft in Confidence

of 225

October 2019

2

Key

On Track Slippage Requires attention

Summary to Date

• The IPR metrics were presented to the Executive Directors on 2/10/19

• As a result of feedback from Executive directors:

• The additional metrics of Crude mortality was added to the IPR Summary

• The domain “Effective” was reworded to “Well-led” in line with requests from the CEO.

• The Board function leads have worked with all Executive Directors to agree:

• The level 1 IPR Metrics each Board Committee is responsible for - see Page 3

• The additional board committee metrics to be reported into the IPR to support Board

Committee Dashboards

• Further development of the new Business Intelligent reporting application has been undertaken

which will incorporate an automatic notification process to alert when a metric is required and/or

missing by set deadlines.

• There have been delays with the accountability framework

• Once the high level IPR is complete for January 2020 Board the following proposals are

suggested:

• Development of Committee Level Dashboards

• Development of Triumvirate operating dashboards

• Development of Data Quality Kite Marks

Lead Jane Rowley

Confidence in Delivery Oct Nov Dec Jan On Track

Author Kristian Heaton

Milestones Milestones Due Date Update

Review of Current State IPR October ‘19 Complete

Options Appraisal to Board October ‘19 Complete

Future State Identified October ‘19 Level 1 complete

Accountability Test Paper to Executives re. 14/10/19 Delayed to December until meeting with Board Secretary

Alignment with Transformation Projects 28/10/19 1-2 weeks slippage

Develop Test Site 15/11/19 On Track for informal board December 2019.

Review Levels 2 & 3 30/11/19 On Track

Align to Board Governance Framework 15/11/19 Board Secretary attending project meeting 31/10/2019

IPR Monthly Highlight Report

Key Messages

Ask from the Board of Directors

• Sign off the high level metrics for the Summary level and reporting committees (Page 4)

• Review and agree all the metrics proposed to be reported via the Board Committees (Pages 5 & 6)

• Discuss and consider the risk associated with the renaming of efficient as well led.

of 225

3

Ref. Date Identified Risk Description Risk Owner Risk Score

(L x I) Mitigating Actions Action Owner

IPR 001 01/10/2019 Renaming of “efficient” domain with “well led” may lead to false assurance on well

led domain and not address the improvements required under this domain. T Bennett

3 x 4

12 For discussion at Board of Directors T Bennett

IPR Monthly Highlight Report

Progress Against Areas

Area Status Due Date Key Actions this Month Key Actions Next Month Items to Escalate

IPR On Track 30/11/19

• Refinement of Metrics for IPR

and Boards/Sub Committees

• Development of test site and

key metrics

• Task and finish group to support weekly User Experience Testing

• Board function leads to review key data fields to support the

development of the application for testing in November. To develop

levels 2 and 3:

• DataType, Target, Forecasting and Trajectories

• Email of who Responsible for data input

• Email of Manager

• Email of Director Responsible

• Email of who will complete Comments

• The first few iterations of the IPR will require manual

inputting into the NEXUS application and reliant on

each area to manually upload the data in a timely

manner.

• Following test implementation, a plan will be produced

to develop ways to automate and feed data into the

NEXUS application.

Accountability

Framework Delayed 14/10/2019

• Document in Draft for

refinement • Meet with Board secretary to draft • Delayed due to changes in committee arrangements.

Board

Dashboards To be scoped N/A

• Metrics identified for Board

oversight

• Review source of data metrics and review pulling into board

dashboard • New Scope

Data Quality Kite

Mark To be Scoped N/A

• Initial Discussions held with

Model Hospital to understand

support offer.

• Scope out work and requirements with Head of Performance and

develop action plan/scoping document • New Scope

Triumvirate

Reporting To be Scoped N/A

• Meet with triumvirates to identify requirements for operational

management of key metrics to support day to day operational

management.

• New Scope

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Proposed IPR Developments

Level 1: Domain/Trust High Level Summary – Entry Page and Responsible Governance Committee Provides a high level summary of performance against the Trusts’ Key Performance Indicators. The indicators are grouped by the

Care Quality themes of Safe, Caring, Responsive, Effective and Well led. The summary page reflects the Trusts’ performance

against the Single Oversight Framework indicators as monitored by NHS Improvement.

Safe Effective Caring Responsive Well Led Strategic Partnerships

Population Health

Metrics (TBA)

Change Log:

• Addition of Crude Mortality

• Renaming of Efficient with Well Led

• Removal of Mental Health Metrics not aligned to

Blackpool Teaching Hospitals

• Agreement of Finance Metrics

NHS Long Term Plan

Metrics (TBA)

Never Event

Quality

VTE


C. Difficile


MRSA


E. Coli


Patient Safety Alerts

Quality

MH Admissions


HSMR


SHMI


Crude Mortality


Complaint Rate

Quality

FFT In Patients

Quality

FFT A&E

Quality

FFT Maternity

Quality

FFT Community

Quality

FFT Mental Health

Quality

Mixed Sex Breaches

Quality

Emergency C section


RTT Incomplete

Ops & Performance

62 Day Cancer

Ops & Performance

Dementia Standards

Ops & Performance

6 WW Diagnostic

Ops & Performance

IAPT Wait Times

Ops & Performance

IAPT Recovery

Ops & Performance

MH DQ Standard

Ops & Performance

Staff Sickness

Workforce

Staff Turnover

Workforce

Temporary Staffing

Workforce

Capital Service

Finance & IMT

Liquidity

Finance & IMT

I&E Margin

Finance & IMT

Financial Plan

Finance & IMT

Agency Spend

Finance & IMT

A&E 4 Hour

Ops & Performance

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Proposed Board Committee Metrics and Reporting Sub-Committees

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Proposed Board Committee Metrics and Reporting Sub-Committees Sickness % (in Month) Efficient Workforce Transformation Committee

Trust Vacancy Rate % (Strategic Ambition Measure) Efficient Workforce Transformation Committee

Turnover % (all staff) – Rolling 12 months Efficient Workforce Transformation Committee

Total Appraisal Compliance % Efficient Workforce Transformation Committee

Grand Total of Agency/Bank/Locum Spend £ Efficient Workforce Transformation Committee

Mandatory Training Trust Compliance % Efficient Workforce Transformation Committee

Family & Friends Test out of 10 (Quarterly) Efficient Workforce Transformation Committee

Agency Spend Well Led Finance Committee

Distance from financial plan Well Led Finance Committee

Income & Expenditure (I&E) margin Well Led Finance Committee

Liquidity (days) Well Led Finance Committee

Capital service capacity Well Led Finance Committee

RTT Open Pathways % Responsive Performance & Operations Committee

A&E Type 1 Performance % Strategic partnershipsPerformance & Operations Committee

AE+ UCC % Strategic partnershipsPerformance & Operations Committee

31 day subsequent treatment (surgery) % Responsive Performance & Operations Committee

31 day subsequent treatment (drugs) % Responsive Performance & Operations Committee

62 day screening performance % Responsive Performance & Operations Committee

62 day upgrade performance % Responsive Performance & Operations Committee

Maximum 2 week wait from urgent GP referral to outpatient appt for all suspected cancer referrals %Responsive Performance & Operations Committee

Maximum 31 day wait from diagnosis to treatment for all cancers % Responsive Performance & Operations Committee

Maximum 62 day wait from urgent referral to treatment for all cancers % Responsive Performance & Operations Committee

Symptomatic breast (not thought to be cancer) % Responsive Performance & Operations Committee

% of patients waiting over 6 weeks for a diagnostic test Responsive Performance & Operations Committee

Improving Access to Psychological Therapies - Patients referred within 6 weeks NEW measure (from Q4 2015/16)Responsive Performance & Operations Committee

Length of Stay Responsive Performance & Operations Committee

Readmission Responsive Performance & Operations Committee

52 Week Breaches Responsive Performance & Operations Committee

12 hour DTA breach numbers Responsive Performance & Operations Committee

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Minutes of the Strategic Workforce Committee

held on 29th July 2019 at 10.00am

in the Seminar Room, Women’s and Children’s Unit Members Present: Mrs M Whyham Non-Executive Director – Chair Mr M Beaton Non-Executive Director Mrs J Meek Operational Director of HR & OD Mrs M Heaton SS Chair Mr M Burrow Head of Corporate Assurance Mr L Tarren Associate Director for Resourcing and Transformation Ms V Kerley Interim Head of Strategic HR Mrs C McCann Assistant Director of Nursing Mrs L Holt Director of Adult Community Services Mrs J Lickiss Associate Director of Nursing Mr D Quinn Head of Communications Mr M Casson Head of ESR and Workforce Dr A Yuet Meng Ng Guardian of Safe Working Hours Dr L Hacking Director of Medical Education Mrs L Smith-Payne Interim Deputy Director of HR &OD Mr A Gibson Director of Pharmacy

Mrs S Adams Deputy Director of Workforce Education and Organisational Development Mrs P Roche Governor Mrs J Barnsley Director of Operations (for items 3, 5a, 5e, 5g and 5h)

In Attendance: Miss K Briggs Executive Assistant - Minutes It was noted that the meeting was not quorate. Mr Burrow would arrange for an Executive Director to attend for the items which require approval. On behalf of the Committee, Mrs Whyham thanked Dr Hacking for all her hard work as it was her last meeting before leaving the Trust. 1. Declarations of Interests

There were no declarations of interest. 2. Apologies for Absence

Apologies for absence were received from Mrs Stannard, Mrs Anderton, Mrs Parry, Mrs Conley, Mr Lane, Dr Sweeney and Mr Moynes.

3. Minutes of the Previous Meeting

This item would be discussed when an Executive Director joined the meeting.

4. Matters Arising

a) Action Log from the previous meeting

The action log was noted by the Committee.

b) Action Tracking Document The action tracking document was noted by the Committee.

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Mrs Roche reported that the topic of cadets had been discussed at another meeting she attends and it appeared that more cadets wanted a job at the Trust. It was agreed that Mrs Meek would investigate this further.

ACTION That Mrs Meek would look into the possibility of recruiting more cadets.

c) Benefits Realised from the Centralisation of the Rota Coordinators Mr Tarren advised that the rota coordinators had been based centrally as of May this year.

It was noted that the new junior doctors start next week and the department hope to see an improvement then. Mr Beaton queried how success was being measured and suggested it should be based on figures. It was requested that a quarterly update report be presented to the Committee. Mr Beaton requested that the report be split by division at the next meeting.

ACTION That a quarterly update report, split by division, be presented to future meetings.

d) NHSi Cohort 4 Retention Programme Figures Mr Tarren drew attention to the NHSi Cohort 4 Retention Programme report and advised that there was a number of schemes ongoing to improve the figures.

Mr Tarren advised that he had drafted a recruitment plan where the Trust needed to recruit 15 nurses a month. It was requested that this report be presented to the next meeting.

Mrs Smith-Payne noted that the Flexible Working Group was reviewing a range of options. Mrs Whyham stated that she would like to see an outcome from this at the next meeting.

ACTION That Mr Tarren would present the recruitment plan at the next meeting. 5. Governance

a) Board Assurance Framework/Corporate Risk Register This item would be discussed when an Executive Director joined the meeting.

b) Governance Action Plan

Mr Burrow drew attention to the Governance Action Plan and advised that it was a first draft for all Board Committees to review and for the Board to gain assurance from. It was noted that this would be a standing agenda item.

ACTION That the Governance Action Plan be added to the workplan as a standing agenda item.

c) Preliminary Deanery Report

Dr Hacking distributed the Preliminary Deanery Report which was discussed by the Committee. Concerns were raised regarding medical engagement and management of the medical take in the preliminary report from the visit on 4th July. It was noted that once the final report had been received it would be presented to the Board of Directors.

d) Quarterly Guardian of Safe Working Update Dr NG drew attention to the Guardian of Safe Working Update and advised that there had been improved engagement with exception reporting. . Dr NG advised that there had been amendments to the junior doctors contracts.

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It was noted that a new medical bank system had been introduced and this required communication across the Trust.

Mrs Roche expressed concern regarding consultant appraisals not linking in with the Trusts values. It was noted that Consultant appraisals were undertaken by the regulator. It was agreed that Mrs Whyham would discuss this issue with Dr Harper and report back to the next meeting.

ACTION That Mrs Whyham would liaise with Dr Harper regarding the Trusts values being linked in with

the consultant appraisals and report back to the next meeting.

e) Gender Pay Gap Data This item would be discussed when an Executive Director joined the meeting.

f) NHS Workforce Disability Equality Standard and Workforce Race Equality Standard

Concerns were raised about the Trust’s engagement with the BAME networks and the Committee agreed to publicise and reenergise engagement opportunities with these groups.

Mrs Whyham requested an update on the current position on appraisals across Trust.

ACTION That the current position on appraisals across the Trust be provided to Mrs Whyham.

g) Improving People Practices and Just Culture This item would be discussed when an Executive Director joined the meeting.

h) Annual Medical Appraisal and Revalidation This item would be discussed when an Executive Director joined the meeting.

6. Performance

a) Key Strategic Workforce Measures Assurance Report

Concerns were raised that the turnover, vacancy and sickness rates of staff were increasing; these would be escalated to the Board of Directors and the Committee requested a one year recruitment plan to mitigate these issues.

7. Strategy

a) Workforce Transformation Strategy

Mrs Meek advised that the overarching strategy had been approved. A further three strategies (Health and Wellbeing, Recruitment and Retention and Staff Engagement) had been to the Executive Directors meeting. The Committee approved the strategies and agreed for them to be presented to the Board of Directors meeting. It was noted that a further four strategies would be presented to the next meeting.

b) Communications from Board of Directors

Mr Quinn drew attention to the report and discussed the key issues which were noted by the Committee.

c) NHS People Plan Mrs Smith-Payne drew attention to the NHS People Plan report which was noted by the Committee. d) Quarterly Monitoring of Workforce Developments within ICP

Mrs Meek reported that workforce planning had been raised at the Fylde Coast Executive meeting.

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8. Procedural Items/Information

a) Findings from the Self-Assessment

Mr Burrow drew attention to the findings from the Self-Assessment of the Committee which were discussed and noted. Mr Beaton emphasised the importance of receiving papers on time and suggested that a communication be sent out to ban late papers.

9. Minutes/Actions from Reporting Committees

a) Minutes from the Multi-Disciplinary Educational Governance Committee (MEG)

The minutes from the Multi-Disciplinary Educational Governance Committee were noted by the Committee

b) Minutes from the Voluntary Services Committee

The minutes from the Voluntary Services Committee were noted by the Committee.

c) Minutes from the Great Places to Work Committee

The minutes from the Great Places to Work Committee were noted by the Committee.

At this juncture Mrs Barnsley joined the meeting and the following items for approval were discussed. 3. Minutes of the Previous Meeting

The minutes of the meeting held on 18th April 2019 were agreed as a correct record. 5. Governance

a) Board Assurance Framework/Corporate Risk Register

Mr Burrow drew attention to the Board Assurance Framework.

Mr Burrow advised that the Quality Committee had challenged whether a different score was required for Medical Engagement. After discussion, it was agreed to keep as one score but with very clear actions.

It was also agreed that the transformation risk would be refreshed to include the Just Culture and Compassionate Leadership.

ACTION That the staff engagement risk would be refreshed to clearly identify all staff group

engagement and associated actions.

That the transformation risk would be refreshed to include the Just Culture and Compassionate Leadership.

e) Gender Pay Gap Data

Mrs Smith-Payne drew attention to the Gender Pay Gap report which the Committee considered and approved.

g) Improving People Practices and Just Culture The Committee approved the introduction of a Just Culture involving the introduction of a comprehensive Behavioural Standards Framework, development of a Respect and Support Campaign, refreshed Mediation Training, introduction of a disciplinary triage process, introduction of dedicated Bullying and Harassment case investigators and a roll-out revised Bullying and Harassment training.

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h) Annual Medical Appraisal and Revalidation The Committee recommended that the Board of Directors approves the Annual Medical Appraisal and Revalidation.

10. Items Recommended for Decision or Discussion by the Board

The following items were recommended for decision or discussion by the Board:-

Deanery report (when issued)

Network energising re ethnicity

One year recruitment plan

Increase in turnover, vacancy and sickness rates of staff 11. Attendance Monitoring

The attendance monitoring form identified that Committee members were achieving the required attendance performance target with the exception of the Unscheduled Care division.

ACTION That Mrs Whyham would contact the Unscheduled Care Division regarding their attendance at this Committee.

12. Any other Business

There was no other business. 13. Declaration of Confidentiality

It was agreed that there were no items of confidentiality which may be exempt from disclosure under the Freedom of Information Act 2000.

14. Date of Next Meeting

The next meeting of the Strategic Workforce Committee will be held on Thursday 24th October 2019 at

9.30am in the Boardroom, Trust Headquarters.

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Minutes of the Audit Committee Meeting held on Tuesday 30

th July 2019 at 12.30pm

in the Board Room, Trust Headquarters, Blackpool Victoria Hospital Members Present: Mr Michael Hearty – Chairman Mrs Mary Whyham – Non-Executive Director Mr James Wilkie – Non-Executive Director In Attendance: Mr Tim Bennett – Deputy Chief Executive/Director of Finance & Performance Mr David Holden - Governance Advisor (Interim) Mr Matthew Burrow – Head of Corporate Assurance Miss Harriet Fisher - KPMG, Internal Audit Mr John Marsden – Local Counter Fraud Specialist Miss Kayleigh Briggs – Executive Assistant (minutes) Mr Mark Cullinan – Non-Executive Director (for item 5c) Mrs Jane Meek - Operational Director of HR & OD (for item 7b) Mr Lee Tarren – Associate Director for Resourcing and Transformation (for item 7b) Mr Jonathan Heath - Consultant Surgeon – (for item 7c) Mr Simon Donovan – Lancashire Procurement Cluster (for item 7h) 1. Declarations of Interests

There were no declarations of interest in relation to the items on the agenda.

2. Apologies for Absence

Apologies for absence had been received from Mrs Gissing and Mr Seddon.

3. Minutes of the Previous Audit Committee Meeting held on 22nd May 2019 The minutes of the previous meeting held on 22

nd May 2019 were agreed as a correct record of the

proceedings and therefore be signed by the Chairman.

4. Matters Arising:-

a) Action List from the Previous Meeting The actions taken were noted by the Committee.

b) Action Tracking Document The Action Tracking document was noted by the Committee and updates were provided as follows:- Whistleblowing Policy Mr Marsden would liaise with Mrs Smith-Payne regarding progress.

5. The Trust’s Assurance Framework a) Board Assurance Framework

Mr Burrow drew attention to the Board Assurance Framework and advised that updates had been made since the Board Committees had met. The amendments made by the Board Committees were discussed and noted.

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Mrs Whyham queried whether the document was discussed within the wider organisation or just at the Board. Mr Burrow advised that the Board and Board Committees reviewed the document and it formed the basis of the agenda for these meetings. It was noted that an electronic system was being considered in order for it to be a live document and kept more up to date.

Mr Hearty stated that the Audit Committee took assurance from the covering paper that the Board Committees had examined and scrutinised the document and given a more appropriate calibration of the risks they were monitoring, however the Committee had only partial assurance that the risks were being mitigated sufficiently.

b) Risk Committee Assurance Report The Committee noted that the Risk Committee did not meet in June 2019 and that the arrangements were being reviewed by the Chief Executive and Executive Directors. The Committee took some assurance that Interim Chief Executive had assessed the effectiveness of Risk Committee and was working to get something more effective in place with clinical engagement. It was noted that the Risk Committee was viewed as an extremely important Committee. Mr Marsden reported that the CFMS viewed the Risk Committee as a necessity. It was agreed that Mr Marsden and Mr Burrow would meet to ensure fraud was being recognised as a risk at divisional level.

Mr Hearty requested that the Terms of Reference for the Risk Committee be shared.

ACTION That Mr Marsden and Mr Burrow would meet to ensure fraud was being recognised as a risk

at divisional level. That Mr Burrow would share the Terms of Reference for the Risk Committee.

c) Assurance Framework Discussion – Finance Committee Mr Hearty welcomed Mr Cullinan to the Audit Committee. The Committee noted several challenges the Trust faced; the most significant, the balance between quality, performance and finance, which had been discussed by the Board members and will be refocused as part of the pending CQC report, the requirement to develop a 3-year financial strategy, and the approach towards the cost improvement programme which recently had been transactional, with few transformation schemes. In addition, the Committee noted the concern regarding the Trust cash position due to the ongoing discussions with the CCGs regarding £17.5M funding.

Mr Bennett stated that it was very important to get the balance right between the finance and quality concerns the Trust was experiencing.

Mr Wilkie sought assurance regarding the Trusts CIP. Mr Cullinan advised that the CIP had not been deliverable for a few months and the issue had been escalated to the Board previously. d) Governance Action Plan

Mr Burrow drew attention to the Governance Action Plan and advised that work was in progress to

have all actions from regulatory bodies in one place. It was noted that the principle behind this was that each Board Committee would have an area to keep action and focus on.

It was noted that the Governance Action Plan would be a standing agenda item on the Board

Committees.

Mr Hearty noted that he recognised all the actions but he was not sure they had all been to the Audit Committee. Mr Burrow advised that the Trust had been working reactively and not all reports had been received corporately. Mr Hearty requested that Mr Burrow present a report to the next meeting on how the new system was working and how reports were received.

ACTION That the Governance Action Plan would be a standing agenda item and therefore be added

to the workplan.

That Mr Burrow present a report to the next meeting on how the new system was working and how reports were received.

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6. Review of Internal Audit Progress (KPMG)

a) Internal Audit Progress Report Miss Fisher drew attention to the Internal Audit Progress Report and advised that work had commenced on the 2019/20 reviews.

The Committee agreed to the proposed changes and plan for the year.

. Mr Hearty felt uneasy around the ICP/ICS and the Trusts position. It was agreed that Mr Bennett and Miss Fisher would liaise outside of the meeting regarding the possibility of a review being commissioned.

ACTION That Mr Bennett and Miss Fisher would discuss the possibility of a ICP/ICS review being commissioned.

b) Internal Audit Technical Update

The Internal Audit Technical Update was noted by the Committee for information.

7. Items for Focus and Discussion a) Health Informatics Strategy – EPR Update

This item was deferred to the October meeting and Mr Bloor was not present.

b) Workforce Strategy Update Mr Hearty welcomed Mrs Meek and Mr Tarren to the meeting. Mrs Meek drew attention to the Workforce Transformation Strategy update report which was noted by the Committee. The Strategy highlighted a number of key strategies that were being developed to support the implementation of all key deliverables, with timelines, culminating in papers being submitted to the Board for approval regularly over the time period.

. c) Self- Review Tool (SRT) Quality Assessment Report Security Annual Mr Hearty welcomed Mr Heath to the meeting. The Committee noted the positive assurance on Trust security arrangements. There were improvements to be made regarding induction training, a regional alert system of known risk patients and support for staff.

d) Counter Fraud Progress Report Mr Marsden drew attention to the Counter Fraud Progress Report which was noted by the Committee.

e) 2018/19 Counter Fraud Survey (Trust Wide) Mr Marsden drew attention to the Counter Fraud Survey results, it was noted that there were some actions that needed to be undertaken but overall it had been a positive piece of work. f) Trust Reference Costs Mr Hearty welcomed Mr Cunday to the meeting. Mr Cunday drew attention to the Reference Costs update report and advised that the Trust was working towards delivering the 10 recommendations arising from the Ernst and Young Review of the 2017/18 Submission. It was noted that the 2018/19 cost collection had been submitted and a dedicated costing team had been implemented.

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Mr Cunday requested that costing be included in the Internal Audit Plan.

ACTION That Miss Fisher include Cost Collection to the Internal Audit Plan.

g) Waivers The Committee expressed significant concern regarding the 12 waivers that have been approved since 1st April 2019. The Committee has taken the view that single tender waivers should be exceptional and comply with the Trust Standing Financial Instructions.

h) Supplier Compliance Appraisal Mr Hearty welcomed to Mr Donovan to the meeting. Mr Donovan advised that he had undertaken an audit within the Clinical Support Division regarding the number of waivers submitted and all spend over £10,000. There had been 4 contracts identified where waivers should have been in place. Lancashire Procurement Cluster were working with the division to educate and to ensure that all contracts became compliant with the Trusts SFIs.

Mr Bennett asked Mr Donovan to come back to a future Audit Committee to provide assurance that all contracts were compliant. Mr Hearty stated that the Audit Committee did not support the use of single tender waivers. The Trust had SFIs in place and if the criteria for a single tender waiver was met this would be visible. Mr Hearty advised that the Audit Committee had a role to write to their Chief Executive to report this issue. Mr Wilkie queried if the SFIs were fit for purpose. It was noted that the Audit Committee reviewed the SOs and SFIs 2 yearly. Mr Marsden expressed concern as to whether it was the same company/member of staff that was intentionally leaving the contract renewal until the last minute so it would become a waiver. It was agreed that Mr Donovan and Mr Marsden would liaise outside of the meeting. Mr Hearty felt that further investigation work over the last 12 months was required. It was agreed that Mr Donovan would review the waiver register for the previous 5 years and identify any repeat offenders. Mr Hearty also encouraged a review of SFIs.

ACTION That Mr Hearty would write to the Chief Executive to advise that the Audit Committee were

concerned about the increasing use of single tender waivers and encourage the CEO to take a personal interest in ensuring they were tightly monitored, their use kept to an absolute minimum and utilised in the most exceptional of circumstances

That Mr Marsden and Mr Donovan would liaise outside of the meeting regarding repeat offenders.

That Mr Donovan would review the waiver register for the previous 5 years and identify any repeat offenders. A report would then be presented to the Audit Committee.

That Mr Burrow, Mr Donovan and Mr Patel would undertake a review of the SFIs.

i) Losses and Special Payments

The Losses and Special Payments report was noted for information.

8. Procedural Items/Information

a) Findings from the Audit Committee Self-Assessment

Mr Burrow drew attention to the findings from the Audit Committee Self-Assessment.

Mr Hearty requested that a policy of no late papers be adhered to and any exceptions must be agreed by the chair.

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It was agreed to add the potential areas for improvement to the end of future agendas.

ACTION That the potential areas for improvement be added to the end of future agendas. 9. Minutes/Actions from reporting Committees

a) Minutes of Quality Committee 18th June 2019 The minutes of the Quality Committee were noted for information. b) Minutes of Finance Committee 19th June 2019 The minutes of the Finance Committee were noted for information.

c) Minutes of Strategic Workforce Committee 17th April 2019

The minutes of the Strategic Workforce Committee were noted for information. d) Minutes of Risk Committee 15th April 2019

The minutes of the Risk Committee were noted for information. 10. Reference Folder

a) Local Counter Fraud Communications Strategy Document The Committee noted the Local Counter Fraud Communications Strategy document for information.

11. Items Recommended for Discussion/Decision by the Board of Directors –

Advice/Assurance/Alert

The challenges of balancing quality, performance and finance in the Trust

Mr Hearty to write to the Chief Executive regarding waivers 12. Attendance Monitoring

The Committee noted the Attendance Monitoring chart.

13. Any Other Business


14. Declaration of Confidentiality

Agenda item 7h - Supplier Compliance Appraisal was declared confidential and, as such, may be exempt from disclosure under the Freedom of Information Act 2000 or the Environmental Information Regulation.


The next meeting would be held on Tuesday 29th October 2019 at 12.30pm in the Boardroom, Trust Headquarters.

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Minutes of the Finance Committee Meeting

Held on Wednesday 18th

September 2019 at 9.30am in the Boardroom

Members Present: Mr Mark Cullinan Non- Executive Director (Chair) Mr Tim Bennett Deputy Chief Executive/Director of Finance Mrs Janet Barnsley Director of Operations – Scheduled Care (for item 6b onwards) Mr Keith Case Non-Executive Director (for item 5a onwards) In Attendance: Mr Paul Cunday Assistant Director of Finance: Financial Management Mr Feroz Patel Deputy Director of Finance Mr Steven Bloor Chief Information Officer

Mr Simon Raffaelli Head of Transformation Miss Jane Rowley Head of Performance, Planning and Contracting Mr Ian Owen Governor Observer Mr Chris Clark Associate Director of Business Planning – left after break Miss Judith Oates Corporate Assurance Manager/Foundation Trust Secretary Mr Jamie Sweet Transformation Manager - for item 6a Mrs Patricia Butcher Data Protection Officer - for item 6a Mr Kristian Heaton Head of Information Management – for item Miss Loie McNeill Financial Information and Costing Manager – for item Miss Kayleigh Briggs Executive Assistant (Committee Secretary)

1. Declarations of Interests

It was noted that Mr Case would declare an interest in his capacity as the ATLAS Chair once he joined the meeting.


Apologies for absence were received from Mrs Berenice Groves, Director of Operations – Unscheduled Care.

3. Minutes of the Previous Meeting

It was noted that the Committee was not quorate until Mr Case arrived and therefore this item would be discussed later in the agenda.

4. Matters Arising

a) Action Log from the previous meeting The Committee discussed the actions from the previous meeting and the action log would be updated accordingly.

b) Action Tracking Document

The Committee noted the action tracking document. c) Workforce Requirement Forecast : Clinical Vacancy Rate This item would be discussed later in the agenda when Mr Tarren joined the meeting.

At this juncture Mr Case joined the meeting.

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5. Governance

a) Board Assurance Framework The Board Assurance Framework was noted by the Committee. The Committee noted that the EDMS business case was going through the governance approval system for presentation to the Board of Directors in November 2019. Mr Bennett advised that the BAF 10 - Length of Stay required input from Mrs Groves and Mrs Barnsley who were not present at the meeting. Miss Rowley advised that a weekly meeting had been organised regarding Length of Stay which had met and agreed the objectives and the way in which Length of Stay should be reporting across the Trust.

Mr Bennett requested that BAF 6 be discussed and considered once the other items on the agenda had been discussed.

RESOLVED That Mrs Barnsley and Mrs Groves provide an update regarding BAF 10 – Length of Stay

outside of the meeting. 3. Minutes of the Previous Finance Committee

The minutes of the previous meeting held on 24th July 2019 were agreed as a correct record of the proceedings and signed by the Chair.

b) Governance Action Plan The Committee noted the Governance Action Plan and accepted that changes would be made to reflect the changes which were being made to the Committee structure.

6. Strategy

a) Business Case for Electronic Document Management System This item would be discussed later in the agenda when Mr Sweet and Mrs Butcher joined the meeting. b) Forecast Financial Position 2019/20 Mr Patel drew gave a brief presentation on the Forecast Financial Position 2019/20.

At this juncture Mrs Barnsley joined the meeting. The Committee noted the risks to the financial performance and reporting timeframes, it was agreed

that essential actions needed to be identified and agreed. Mr Cullinan requested that the Forecast Financial Position 2019/20 presentation be presented to the

Informal Board of Directors meeting in October including the following additional slides:- • CIP • Cost pressures that have been approved by the Board • Cost pressures that have not been approved by the Board • Evidence on achievement of quality and performance by investment

It was requested that the risk and concern of the Committee be reflected in the Chairs Board Assurance Report. It was noted that the Committee had no confidence that the Trust would achieve the plan.

Mr Cunday stated that the Board was aware of most of the items which would be discussed although some had not been formally signed off. Mr Bennett emphasised the importance that all staff follow the Trusts Standing Orders and Standing Financial Instructions and comply with legal obligations.

ACTION That the Forecast Financial Position 2019/20 presentation be presented to the Informal Board of Directors meeting in October including the additional slides which had been requested.

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4c. Workforce Requirement Forecast: Clinical Vacancy Rate

Mr Cullinan welcomed Mr Tarren to the meeting. Mr Tarren highlighted the vacancies across the Trust which were noted by the Committee. It was noted that a plan to recruit 15 nurses a month and a round of recruitment from the Philippines was underway. The Committee expressed concern regarding the current and future resource implications. Mr Tarren advised that he was drafting a recruitment plan which would be presented to the Informal Board of Directors in October. Mr Cunday requested that input from the financial team was included.

ACTION That Mr Tarren would present a recruitment plan to the Informal Board of Directors meeting

in October. 6a. Business Case for Electronic Document Management System

Mr Cullinan welcomed Mr Sweet and Mrs Butcher to the meeting. Mr Bloor gave a presentation on the Business Case for Electronic Document Management System. Mr Bloor advised that the clinicians had been engaged throughout the planning process. The Committee supported the investment and recommended approval by the Board of Directors. Mr Bennett requested that a benefits realisation report be presented to the Finance Committee on a quarterly basis. Mr Cullinan stated that he supported a firmer approach in terms of pulling out productivity savings when efficiency gains had been realised.

Mr Owen advised that he was very supportive of the business plan and that the governors would be happy to see this implemented. Miss Oates advised that Mr Butler had requested this item be presented to the Board of Directors on 5

th November 2019.

ACTION That the Committee supported the investment and recommended approval by the Board of

Directors via Chair’s action to avoid waiting until the formal meeting on 5th

November 2019.

That a benefits realisation report be presented to the Finance Committee on a quarterly basis.

Post Meeting Note:-

Mr Holden and Mr Burrow have advised that the Business Case for EDMS should follow the Standing Financial Instructions, Reservation of Powers and Scheme of Delegation policies in regard to contracts over £1m and therefore should be formally presented to the Board of Directors on 5

th

November 2019.

c) NHS Long Term Plan Update Mr Clark gave a brief presentation on the NHS Long Term Plan which was noted by the Committee.

ACTION That an update on the NHS Long Term Plan Update be given to the Board of Directors. 7. Performance

a) Integrated Performance Report i) Financial Performance The consolidated Trust incurred a deficit of £2.9m in August which was £2.4m worse than the budget. The year to date actual was a deficit of £8.7m which was £3.9m worse than the budget.

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The key drivers of the worse than planned performance were investments to address quality, safety and regulatory concerns and CIP being behind budget. The reported position assumes full receipt of MOU and other monies due from the CCGs. There remained a risk around the remainder of the MOU funding. The consolidated Trust cash balance was £9.0m which was £8.9m worse than the plan. The current cash forecast indicates that the Trust will not require support in the next 3 months.

The Committee received limited assurance on the financial position of the Trust.

Based upon the Chair’s Assurance Repot – Assurance Ratings, limited assurance would be equivalent to partial assurance. ii) Operational Performance

Mrs Barnsley gave a brief presentation on Operational Performance. The 4 Hour A&E target was not achieved in August. The Trust did not achieve the Open pathway performance. The Trust did not achieve the 62 day urgent referral to treatment standard in July. The 62 day screening target was not achieved in July. It was noted that a Cancer Board meeting had been established, the first meeting was scheduled for October and it would report to the new Performance Committee. It was noted that there had been a 0.5% improvement in non-elective length of stay. Mr Patel expressed concern regarding the ‘none triangulation’ of performance targets. It was noted that there had been a reduction in length of stay but the benefits had not been realised in the other areas. It was requested that Mrs Groves would investigate this and report back to the next meeting.

ACTION That Mrs Groves would look into the benefits realised from the reduction of length of stay and report back to the next meeting.

b) Development Proposal for the Integrated Performance Report including Accountability

Framework Miss Rowley drew attention to the Development Proposal for the Integrated Performance Report which had been approved by the Board of Directors on 3

rd September 2019. The Finance Committee

supported the proposal and welcomed the new style report. It was noted that the proposals would be submitted to the Executive Directors meeting on 24

th

September 2019. Miss Rowley reported that the team was aiming to have the new style report ready for the Board of Directors meeting on 7th January 2020.

c) Fylde Coast Financial Position Mr Patel advised that there was £7.3m of delayed payments which were due to take place in the coming weeks. It was noted that the 2018/19 payment to the trust had been reduced by £0.5m. The Committee noted that the Trust had needed to agree credit in order to minimise the risk. The Committee requested updates on the £17.5m non-recurrent support as part of the normal financial reporting process.

ACTION That updates on the £17.5m non-recurrent support would be provided as part of the normal

financial reporting process.

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d) Cost Improvement Programme and Turnaround Update

Mr Raffaelli drew attention to the CIP report which was noted by the Committee. It was noted that the Trust was £2m behind target and therefore there was a significant risk that the Trust would not achieve the overall target. Mr Bennett stated that attendance at the CIP Board was still poor. Mr Bennett advised that some good work had been undertaken in the way community services were provided and this would deliver significant savings next year.

ACTION That the Finance Committee request that the Chief Executive present some

recommendations and direction at the next Board of Directors meeting.

e) Commercial Development and Investment Committee Terms of Reference

Mr Cullinan requested that the membership be updated to reflect that Non-Executive Directors need not attend the Commercial Development and Investment Committee.

ACTION That Mr Bennett update the membership and bring back to a future meeting.

f) Health Informatics Committee Terms of Reference Mr Bloor drew attention to the Health Informatics Committee Terms of Reference which had been updated post the annual review.

RESOLVED The Finance Committee approved the Terms of Reference. 8. Items for Focus and Discussion

a) National Costing Collection Process 2018/19 Mr Cullinan welcomed Mr Heaton and Miss McNeil to the meeting. An update on the National Costing Collection process was noted by the Committee. b) Siemens Contract Renewal Mr Cullinan welcomed Mr Wrigley to the meeting. Mr Wrigley drew attention to the Siemens Contract Renewal, it was noted that the delay was entirely due to the process and not the actual decision. It was noted that ATLAS had not been used to procure something like this before and lessons had been learnt from the experience.

RESOLVED The Finance Committee approved the Siemens Contract renewal and recommended

Chairs urgent action. Post Meeting Note:- Mr Holden and Mr Burrow have advised that the Siemens Contract should follow the Standing Financial Instructions, Reservation of Powers and Scheme of Delegation policies in regard to contracts over £1m and therefore a formal Board Resolution will be issued to the Board of Directors to expedite approval.

c) Pharmacy Contracts i) Lloyds Out-Patient Contract ii) HIV Medicines Contract

This item was deferred to the next meeting as there was no Pharmacy representative available to attend.

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Mrs Barnsley queried whether the extension had already been enacted as the contract ended in June 2019.

ACTION That the Pharmacy Contract be deferred to the next meeting which would be held on 23rd

October 2019.

9. Minutes from Committees Report to the Finance Committee

a) Cash Committee – 30

th August 2019

The notes from the Cash Committee held on 30

th August 2019 were noted by the Committee.

b) Health Informatics Committee – 9

th July 2019

The minutes from the Health Informatics Committee held on 9

th July 2019 were noted by the

Committee. Mr Bloor advised that the business case for the PAS and Theatre Replacement system would be presented to the Finance Committee in October and the Board of Directors in November.

c) Cost Improvement Programme Board – 1st

July 2019, 17th

July 2019 and 29th

July 2019 The notes from the CIP Board held on 1

st July 2019, 17

th July 2019 and 29

th July 2019 were noted

by the Committee. The Committee had previously acknowledged the poor attendance earlier in the meeting.

d) Commercial Development and Investment Committee – 10th

July 2019 The minutes from the Commercial Development and Investment Committee held on 10

th July 2019

were noted by the Committee. e) Lancashire Procurement Cluster Board – 12

th July 2019

The minutes from the Lancashire Procurement Cluster Board held on 12

th July 2019 were noted

by the Committee.

10. Items Recommended for Decision or Discussion by Reporting Committees

The following items were recommended for decision or discussion by the Board:-


Forecast Financial Position presentation be sent to Board members

EDMS – Chairs action was requested

Siemens Contract – Chairs action was requested

Workforce Requirement Forecast : Clinical Vacancy Rate

NHS Long Term Plan Update

ACTION That Mr Bennett would distribute the Forecast Financial Position presentation to Board members along with the additional slides requested by Mr Cullinan by Friday 20

th

September 2019. 11. Attendance Monitoring

The attendance monitoring form identified that committee members were achieving the required attendance performance target.

12. Any other Business

Replacement of CT2 Scanner Mrs Barnsley distributed a report on the Replacement of the CT” Scanner and apologised for the latest of the paper. Mr Cullinan advised that the Finance Committee would have preferred the report in a timelier manner.

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The Committee considered the report and supported the need to replace the scanner. Mr Cullinan requested that Mrs Barnsley liaise with Mr Patel to ensure the correct process is met.

ACTION That Mrs Barnsley would liaise with Mr Patel to ensure that the correct procurement process

was adhered to. 14. Declaration of Confidentiality

Agenda items 5a BAF and 7a IPR were declared confidential and, as such, may be exempt from disclosure under the Freedom of Information Act 2000 or the Environmental Information Regulation.


The next meeting of the Finance Committee will be held on Wednesday 23rd

October 2019 in the Boardroom, Trust Headquarters. Mr Cullinan advised that the new Committee structure would be in place in time for the next meeting and therefore performance colleagues need not attend. Mr Cullinan thanked performance colleagues for the hard work they had undertaken on behalf of the Finance Committee.

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Minutes of the Quality Committee

held on Monday 23rd

September 2019 at 9.00am In the Boardroom, Trust Headquarters

Members: Mr Michael Hearty – Non-Executive Director, Chair Mrs Mary Whyham – Non-Executive Director Mr Peter Murphy – Director of Nursing In Attendance: Mr Matthew Burrow – Head of Corporate Assurance Mrs Simone Anderton – Deputy Director of Nursing and Quality

Mrs Nicola Parry – Associate Director of Nursing for Families / Head of Midwifery Ms Lisa Horkin – Associate Director of Nursing – Unscheduled Care Mr Derek Quinn – Head of Communications

Mrs Tracy Crumbleholme – Interim Director of Quality Improvement Dr Steve Wiggans – Divisional Director Scheduled Care Dr Graham Goode – Divisional Director Unscheduled Care Mr Stefan Verstraelen - Deputy Director of Quality Governance Mrs Jo Lickiss - Associate Director of Nursing – Scheduled Care Mr Zacy Hameed – Deputy Governor Observer Mrs Liz Holt – Director of Adult Community Services Mr Andrew Heath – Assistant Director of Nursing – Quality (for items 10a and 10b) Mrs Lesley Anderson-Hadley– Chief Nurse – Fylde Coast CCG Mr John Mannion – Lead Infection Prevention Nurse (obo Sharon Mawdsley) - for item 9b Miss Kayleigh Briggs – Executive Assistant (minutes)

1. Declarations of Interest

There were no declarations of interest.


Apologies for absence had been received from Sue Crouch, Jane Rowley, Jim Gardner, Carole McCann, Alistair Gibson and Dr Sweeney.

3. Patient Story

The Committee was shown a DVD on the patient story of David Potts.

Mrs Holt advised that consultations should never be interrupted and this should be made a standard rule across the Trust. Dr Wiggans stated that the reason why consultations were being interrupted needed to be understood. Dr Goode stated that doctors did not receive any training in customer care. Dr Goode requested that the message be cascaded to the senior medical team as well as the nursing team.

4. Minutes of the Quality Committee held on 20th

August 2019

The minutes of the meeting held on 20th August 2019 were accepted as a correct record of

proceedings with the exception of updating Mr Murphy’s job title.

5. Matters Arising 5a) Action List from the Previous Quality Committee Meeting held on 20

th August 2019

The action list from the previous meeting held on 20

th August 2019 was noted.

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5b) Action Tracking Document

The action tracking document was noted by the Committee. 5c) Coroners Regulation 28 Notification Mr Murphy distributed the Coroners Regulation 28 report and apologised for the lateness.

Mr Murphy advised that the Trust would address the concerns raised within the Regulation 28 notice. 9c Harms Report

Mrs Crumbleholme drew attention to the Harms report. The Committee challenged the reliability of the data submitted and queried where assurance could be gained that all other items were being reported correctly. Mrs Crumbleholme stated that she could not provide any assurance on the patient safety items. Mr Hearty emphasised the importance of accurate data being available. It was agreed that a monthly report on the top four harms (pressure ulcers, falls, VTE and CAUTI) would be presented to future meetings.

The improvement in pressure ulcer data accuracy was noted. Mr Hearty stated from the report presented only partial assurance could be taken.

ACTION That a monthly report on the top four harms (pressure ulcers, falls, VTE and CAUTI) would

be presented to future meetings. 8b. VTE Report

The Committee expressed concern that the average Trust performance was 71% against the national requirement of 95%.

13c. Deep Dive VTE

Mrs Crumbleholme reported that concerns had been identified when undertaking the VTE Freedom of Information request, it had been highlighted that the Trust was not reporting VTEs to the required standard of compliance and there was no assurance on the reliability of the data. The Committee reviewed and approved the VTE risk assessment. It was agreed that divisions would undertake a risk assessment and report through the Divisional Board meetings and then to the Clinical Effectiveness Committee. It was agreed that coded VTEs would form part of the Divisional Performance Reviews. It was noted that a monthly cross reference of coded VTE will be undertaken by the Clinical Audit & Effectiveness Department to ensure all coded VTE are reported.

It was agreed that the Trust VTE policy be reviewed by the VTE Committee.

Mr Murphy stated that the Trust needs to ensure that the doctors understand the importance of VTEs. Mr Hearty stated from the report presented only partial assurance could be taken.

6. Governance 6a. CQC Report Update

The draft report has been received and an action plan was being developed which would be allocated to the Board Committees to gain assurance upon.

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6b. Quality Risk Register/Board Assurance Framework The Committee recommended a medical engagement risk be added to the Board Assurance

Framework.

Mrs Whyham queried how often the Board Assurance Framework was discussed within the divisions. It was noted that the risks within the document were discussed albeit not in the format of the document itself. Mr Hearty stated from the report presented only partial assurance could be taken.

6c. Quality Improvement Action Plan

Mr Murphy noted that one single document including all risks from the CQC report would be presented to the Committee in the near future. Mr Hearty stated from the report presented only partial assurance could be taken.

7. Strategy

7a. Quality Improvement Strategy

The Committee noted the Quality Improvement Strategy was approved by the Board of Directors on 3 September and funding of £500,000 in Year 1 was approved.

At this juncture Mrs Crumbleholme left the meeting. 8. Performance – Effective 8a. Integrated Performance Report

The Committee received the IPR noting the data accuracy issues which are being addressed as part of the IPR review.

Mrs Whyham highlighted that the overall sickness rate had reduced again in August. It was noted that the overall assurance was partial.

8b. VTE Report

This item was discussed earlier in the agenda. 9. Performance – Safe 9a. Serious Incident/Duty of Candour Report

The Committee noted no never events, a reduction in StEIS incidents (from 10 to 3), however a deterioration in duty of candour compliance (from 87% to 67%) from the previous month. Mr Verstraelen advised that the report would be updated for the next meeting with a more collaborative approach with divisional ownership. Mr Hearty stated from the report presented only partial assurance could be taken.

9b. Infection Control Report Mr Hearty welcomed Mr Manning to the meeting.

The Committee noted zero MRSA’s and a continued reduction in C Diff incidents.

It was noted that a Clostridium difficile Infection reduction Action Plan had been agreed and shared with the Divisions. It was noted that Post Infection Reviews were now being completed by the Divisions instead of the Infection Prevention team and this process had been working well.

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The Committee were still concerned regarding Orthopaedic surgical site infections but noted the improvement actions that were underway. It was noted that Public Health England had agreed to undertake a review of the Trusts data and the Orthopaedic team had contacted their counterparts in Sheffield in order to arrange an external review of their clinical practice. Mr Hearty stated from the report presented only partial assurance could be taken.

9c. Harms Report This item had been discussed earlier in the agenda. 9d. Medicine Management Automation

The Committee supported the proposals and requested that the Finance Committee review once the Systems Improvement Board had agreed the next stage of the process.

10. Performance – Responsive

10a. Learning Disability Update

This item was deferred until Mr Heath joined the meeting. 10b. Complaints Report

This item was deferred until Mr Heath joined the meeting. 11. Performance – Staffing 11a. Safe Nurse Staffing Report

The Committee noted the increasing fill rate and that the Informal Board of Directors would consider the staff levels required to operate safe nursing services at its October meeting.

Mr Murphy drew attention to a report on ‘Nursing Leadership Structure Benchmarking and Ward Based Staffing Benchmarking’ which had been presented to the Board of Directors and agreed was noted by the Committee.

ACTION That staff levels required to operate safe nursing services would be considered at the

Informal Board of Directors meeting in October.

12. Procedural Items/Information 12a. Feedback from Formal Patient Safety Walkabouts

The feedback from the Formal Patient Safety Walkabout was noted for information. 12b. Emergency Preparedness Resilience and Response (EPRR) Assurance

The Committee noted the ‘substantial’ assurance and recommend the Board of Directors received and noted the assurance level. There were no areas of non-compliance with regard to the core standards however there were four areas of non-compliance with regard to adaptation to climate change in the deep dive section of the return. These non-compliance areas do not contribute towards the Trust’s overall rating. Mr Hearty stated from the report presented significant assurance could be taken.

ACTION That the Board of Directors received and noted the assurance level of the Emergency

Preparedness Resilience and Response Report.

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13. Committees Reporting to the Quality Committee 13a. Reports from the Reporting Committees by Exception Mrs Anderton advised that she was undertaking a review of the function of the Committees that

reported to the Quality Committee and an update would be provided at the next meeting. At this juncture Mr Heath joined the meeting. 10a. Learning Disability Report

The Committee were concerned with the statistical relevance of the report as only two patients had returned the survey and requested that the Board of Directors consider a patient story on learning disabilities to raise awareness across the Board. Mr Hearty stated from the report presented only partial assurance could be taken.

ACTION That the Board of Directors consider a patient story on learning disabilities to raise

awareness across the Board. 10b. Complaints Report

The Committee were concerned by the deteriorating response rates, however the Patient Experience Department presented several recommendations to address the issues and the Committee supported the department in developing a business case to address resourcing. Mr Hearty stated from the report presented only partial assurance could be taken.

At this juncture Mrs Holt left the meeting. 13b. Notes from the Systems Improvement Board The Quality Improvement Board minutes from 7

th August 2019 were noted by the Committee.

Mr Murphy advised that the Quality Improvement Board had been renamed and would now be called

the Systems Improvement Board. 13c. Deep Dive on VTE

This item was discussed earlier in the agenda. 14. Items Recommended for Discussion or Decision by the Board of Directors

The following items were recommended for discussion or decision by the Board: -


Integrated Performance Report

Learning Disability – Patient Story

Complaints Report

Emergency Preparedness Resilience and Response (EPRR) Assurance

Nurse Staffing Report

VTE Report

Infection Control Report 15. Attendance Monitoring

The attendance monitoring chart was noted and no issues were raised.

16. Any Other Business


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17. Declaration of Confidentiality

No items were declared as confidential. 18. Date and Time of Next Meeting

The next committee meeting will take place on Tuesday 22nd

October 2019 at 12.30pm in the Boardroom, Trust Headquarters.

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5th November 2019

Freedom to Speak Up Report Q2

Report Prepared By: Terri Vaselli, Freedom to Speak Up Guardian

Contact Details: [email protected] 01253 951185 or 51185

Date of Report: 30th October 2019

Purpose of Report: This report provides a summary of the last quarter’s Freedom to Speak Up activities and future plans for the service at Blackpool Teaching Hospitals.

1 For information

2 For Discussion

3 For Approval

Recommendations: It is recommended that the Board:

Continues to support the development of the Trust’s Freedom to Speak Up strategy

Supports implementing training on ‘how to raise and receive concerns’ for all staff (in line with national recommendations)

Notes the Trust’s results from the Freedom to Speak Up Index 2019 which monitors ‘speaking up culture’ in the NHS based on four questions from the annual NHS staff survey

Sensitivity Level:




X X

X

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1


5th November 2019

Freedom to Speak Up Report Q2

1. Introduction Freedom to Speak Up has continued to campaign and further develop activities at Blackpool Teaching Hospitals. This report outlines the accomplishments of the FTSU Service and provides a summary of the following:

Number of concerns raised, key themes and actions taken

National, regional and local Guardian updates

Evaluation of the service

Priorities for the next quarter

2. Blackpool Teaching Hospitals Raising Concerns Data 2.1 Concerns raised to date in Q2 2019 FTSU has continued to support staff that raise concerns via the FTSU Guardian and the FTSU Champions. This section highlights the numbers of concerns raised in the last three months. It also provides a summary of the types of concerns raised and an overview of who is raising those concerns. It is the responsibility of the FTSU Guardian to record and monitor all concerns raised and report them to the Trust’s Board of Directors and the National Guardian’s Office on a quarterly basis. The table below provides a summary of information provided by Blackpool Teaching Hospitals to the National Guardian’s Office, year to date.

Freedom to Speak Up Concerns raised to date in Q2 2019

2019/2020 Q1 Q2 Q3 Q4

Total number of concerns raised

37 32

Number of those raised anonymously

8 0

Cases with elements of patient safety/quality

25 16

Cases related to behaviours including bullying & harassment and poor attitudes & behaviour

16 14

Cases where people indicate that they are suffering detriment as a result of speaking up,

0 1

Received feedback from reporter *

5 4

Asked from feedback ‘Given your experience, would you speak up again?’* Yes = 5

5 4

* Feedback in this quarter may refer to concerns raised in previous quarters as not all concerns are completed within the reporting timeframe

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2

2.2 Concerns raised in Q2 Of the total number of concerns raised between June 19 and August 19, 30 were reported directly to the Freedom to Speak up Guardian and 2 reported to Freedom to Speak Up Champions 2.3 Types of concerns raised by staff It is clear from the information presented below that policies and procedures, poor attitudes and behaviours, patient experience and quality and safety are the dominate nature of concerns raised. Often, concerns will cover one or more of eight reportable categories listed below. Of the 32 concerns raised in Q2, 9 are still under investigation with 1 remaining under investigation from Quarter 1 2019. .

Types of concerns being raised – comparative data for Q1 and Q2 2019

Concerns raised continue to be dominated by clinical staff and this quarter, there has been an increase in the levels of concerns raised by admin colleagues including Senior Managers and in particular around policies and procedures not being followed. Colleagues have expressed their concerns around recruitment processes not being adhered to.

Who is speaking up at BTH – comparative data for Q1 and Q2 2019

0

5

10

15

20

25

30

Q 1 2019

Q 2 2019

0

2

4

6

8

10

12

14

16

18

Q1 2019

Q2 2019

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3

The majority of concerns are raised directly with the Freedom to Speak Up Guardian by e-mail

How concerns are raised at BTH – comparative data for Q1 and Q2 2019

Most concerns are raised within and about the Unscheduled Care Division this quarter.

Concerns raised by Division – comparative data for Q1 and Q2 2019

In summary, the main reasons for staff raising concerns are linked to policies and procedures not being adhered to, patient experience and quality and safety. Concerns have been predominantly raised by clinical staff directly with the Freedom to Speak Up Guardian and the majority of concerns raised are either from or about the Unscheduled Care Division. 2.4 Action Taken All cases presented to the Freedom to speak Up Guardian are signposted or escalated to the relevant level of management. With the majority of concerns being raised about Unscheduled and Scheduled Care, monthly meetings continue to take place with the Associate Directors of Nursing to discuss progress and ensure that timely action is taken to address concerns raised. Concerns around patient safety are also shared with Divisional Directors. Discussions with HR have taken place around policies and procedures not being adhered to across various Divisions with colleagues asking for more visibility of HR staff visiting departments to give them the opportunity to raise queries as soon as they occur.

0

2

4

6

8

10

12

14

16

Intranet &App

Email Telephone ThirdPerson

Champion In Person Letter

Q1 2019

Q2 2019

0

5

10

15

20

25

Q1 2019

Q2 2019

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4

Whom concerns were escalated to – comparative data for Q1 and Q2 2019

3. Evaluation of the service The service continues to evaluate well. A quarterly audit will be undertaken by Kevin Moynes, Executive Director for HR & OD and also Michael Hearty, Non-Executive Director to ensure that the work provided by the service is in line with national policy and guidelines. Feedback from staff has been that people felt it was an easy and efficient service to use and staff felt listened to and appreciated. 4. FTSU service national and regional updates The National Guardian’s Office have published a report on a new FTSU index which monitors ‘speaking up culture’ in the NHS based on four questions from the NHS national staff survey. The index enables Trusts to see at a glance how their FTSU culture compares with other Trusts. An analysis of Blackpool Teaching Hospitals scores for the last four years has been undertaken. The results show that overall, the Trust fares well particularly in 2017 and 2018 where the Trust exceeded the average score by 1% (scores were calculated as the mean average of responses to the 4 questions). A breakdown of Freedom to Speak Up index information can be found on appendix 1. The National Guardian’s Office has issued guidelines on Freedom to Speak Up training in the health sector in England. In summary, the proposal is that all staff should be provided with training on how to speak up; that managers are trained in how to support people who speak up and that senior leaders are able to create a culture where people can speak up. The Trust is looking to adopt a collaborative approach to the training and conversations have taken place with other local Guardians as well as members of the Manchester Care Alliance in order to agree a regional approach. This will be further discussed at the FTSU regional meeting in October. The Trust has also contacted Skills for Health to identify if there are plans to include this training in the national Core Skills Framework. An update will be provided at the next Board meeting. FTSU service Trust update Blackpool Teaching Hospital hosted the regional network meeting in June which was well attended and supported by Russ Parkinson from the National Guardian’s Office in London. The Trust participated in October’s Freedom to Speak Up month activities. These included Executives and FTSU Champions visiting staff working on wards, in other clinical and nonclinical departments with the Trust and staff based in community. Staff were provided with information on how to raise concerns. A Twitter account has been launched to promote FTSU across the Trust and it is working as a positive platform to share FTSU news across BTH and the National Guardian’s Office. More Champions have been trained to support FTSU and their details are included in the FTSU section of the intranet page.

0

5

10

15

20

25

Q2 2019

Q1 2019

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5

Increased visits to wards and community continue with Champions supporting the Service during FTSU month. A monthly triage meeting between the Freedom to Speak Up Guardian and HR colleagues continue to ensure that themes and hot spots can be identified continue. This collaboration will be extended further starting in November with discussions taking place between FTSU and the Patient Liaison Team and Risk Management. 5. Priorities for next three months Continue to develop the training plan for the national Freedom to Speak Up training programme. In line with NHSi requirements, a Freedom to Speak Up strategy is being developed and should be ready to present to the Board on January 7

th 2020.

6. Conclusion This quarter, the Trust has received 32 concerns which demonstrates an average over the last year each quarter having spiked slightly before the CQC inspection. The trend in types of concerns raised has remained the same this quarter with quality and safety, patient experience and policies/procedures taking the lead for concerns being raised. The majority of these concerns are raised by our clinical colleagues. Policies and procedures not being adhered to has been demonstrated in various cases, however there has been an increase in colleagues raising concerns around this relating to recruitment processes and ‘regrades’ in pay and consultation processes not being adhered to for department restructure plans. Requests that HR colleagues are more visible across departments have been asked for by colleagues to allow staff the opportunity to speak to our HR colleagues informally when concerns such as these are first identified. All concerns raised are escalated to the relevant level of management and actions are put in place to address these concerns which are audited to ensure concerns are being taken seriously. Although the service continues to evaluate well with people citing the Service is accessible and easy to use and they feel supported and listened to, more work is needed to ensure that all staff know how to raise a concern. Discussions are taking place to develop this further following guidance from the National Guardian’s Office that all staff should receive training on how to respond to and raise any concerns. 7. Recommendations The Board of Directors is asked to:

Continue to support the development of the Trust’s Freedom to Speak Up strategy

Support implementing training on ‘how to raise and receive concerns’ for all staff (in line with national recommendations)

Note the Trust’s results from the Freedom to Speak Up index 2019 which monitors ‘speaking up culture’ in the NHS based on four questions from the annual NHS staff survey

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6

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Board of Directors

Attendance Monitoring

1st April 2019 – 31st March 2020

Attendance Apologies/Deputy No Apologies

Attendees (quorate) 7.5.19 2.7.19 3.9.19 5.11.19 7.1.20 3.3.20

Pearse Butler (Chairman) G G G

Michael Hearty Y G G

Mark Cullinan G G G

Mary Whyham Y G G

Keith Case G Y G

Dr Jim Gardner G G G

James Wilkie G G G

Mark Beaton G G G

Tim Bennett G G G

Professor Mark O’Donnell G Y N/A

Marie Thompson G N/A N/A

Kevin Moynes G G G

Kevin McGee G G G

Dr Grahame Goode N/A N/A G

Attendees (non-quorate) 7.5.19 2.7.19 3.9.19 5.11.19 7.1.20 3.3.20

Janet Barnsley G Y G

Berenice Groves Y G G

Peter Murphy G G G

R G A R

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