COUNCIL OF GOVERNORS - Aintree University … University Hospital NHS Foundation Trust Minutes:...

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COUNCIL OF GOVERNORS 15 March 2017

5pm – 7pm Board Room, Aintree Lodge

AGENDA

d = document v = verbal p = presentation

No Item Reference

Preliminary Business – Chairman

1. Apologies for Absence

To note the apologies

CG16-17/033 (v)

2. Declarations of Interest

To receive declarations of interest in agenda items and/or any changes to the register of governors’ declarations of interest pursuant to Standing Orders

CG16-17/034 (v)

3. Minutes from the last meeting (8 December 2016)

To approve the minutes from the last meeting and discuss any matters arising:

Exit Interviews (Director of People & Corporate Affairs)

CG16-17/035 (d)

CG16-17/036 (d)

Overview

4. Strategic Update

Chairman/Chief Executive

To note

CG16-17/037 (p)

5. Lead Governor Report

To note

CG16-17/038 (d)

Quality & Performance Management

6. Emergency & Acute Care Programme

Deputy Chief Operating Officer

CG16-17/039 (p)

7. Assurance on Key Indicators:

Quality & Safety

Finance & Performance

Non-Executive Directors

CG16-17/040 (p)

Internal System of Control

8. Key Issues & Assurances

Audit

Non-Executive Director

CG16-17/041 (p)

Governance

9. Appointment of External Auditor

Non-Executive Director & Governor Representative

To approve

CG16-17/042 (d)

10. Governor Committees:

Committee Chairs

Membership Committee (1 February 2017) for noting

Quality of Care Committee (9 February 2017) for noting

Nominations Committee (15 March 2017) for approval

CG16-17/043 (d/v)

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Aintree University Hospital NHS Foundation Trust

Agenda: Council of Governors’ Meeting15 March 2017 2/2

Concluding Business

11. Any Other Business

Chairman

CG16-17/044 (v)

12. Date and Time of Next Meeting:

Thursday 15 June 2017 at 12:30pm – 2.30pm

Council of Governors – Objectives 2016/17

To further develop skills and knowledge base in order to collectively understand and constructively challenge and support the quality of care agenda provided by the Trust

To improve communication and engagement with members of the Trust in line with the membership strategy objectives

To monitor the performance of the Board of Directors through holding the Non-Executive Directors individually and collectively to account

To deliver its statutory duties in line with regulatory requirements

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Council of Governors

Wednesday 8 December 2016 12:30pm

Board Room Aintree Lodge

MINUTES

Present: Neil Goodwin - Chairman

Pamela Peel - Lead Governor

Sharon Bird - Public Governor

Mike Bowker - Public Governor

Tony Byrne - Public Governor

Gerry Hill - Public Governor

John Johnson - Public Governor

Tony Kneebone - Pubic Governor

Julie Naybour - Public Governor

Stephen Thornhill - Public Governor

Rose Milnes - Public Governor

Helen Frankland - Staff Governor (Nursing)

Lorraine Heaton - Staff Governor (AHPs)

Kerry McManus - Staff Governor (Other)

Paul Cummins - Appointed Governor (Sefton Council)

In Attendance:

Steve Evans - Medical Director

David Fillingham - Non-Executive Director

Michael Games - Corporate Governance Manager

Sue Green - Director of People & Corporate Affairs

Tim Johnston - Non-Executive Director

Ian Jones - Director of Finance & Business Services

Caroline Keating - Associate Director of Corporate Governance/Board

Secretary

Emily Kelso - Corporate Governance Officer

Kevan Ryan - Non-Executive Director

Angie Smithson - Deputy Chief Executive/Chief Operating Officer

Apologies: Tracey Barnes - Public Governor

Mike Booth - Public Governor

Brian Lawless - Public Governor

Rosemary Urion - Public Governor

Andrew Swift - Staff Governor (Medical)

Barbara Hunter-Douglas - Appointed Governor (Edge Hill University)

John Wilding - Appointed Governor (University of Liverpool)

Joanne Clague - Non-Executive Director

Paul Fitzpatrick - Director of Estates & Facilities

Juliet Herzog - Non-Executive Director

Andrea Thomas - Acting Director of Nursing & Quality

Steve Warburton - Chief Executive

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Minutes: Council of Governors’ Meeting 8 December 2016 2/6

Ref Minute

Preliminary Business

CG16-17/023 Apologies for Absence

The apologies were noted as above.

CG16-17/024 Declarations of Interest

There were no declarations of interest.

CG16-17/025 Minutes from the last meeting (18 October 2016)

The minutes from the previous meeting held on 18 October 2016 were approved as an

accurate record. There were no matters arising.

Overview

CG16-17/026 Strategic Update

Prior to the strategic update, the Chairman advised that the Council of Governors had

met earlier and approved the appointment of Mandy Wearne to the post of Non-

Executive with effect from 3 January 2017 to replace Juliet Herzog who was leaving the

Trust on 31 March 2017.

The Chairman and Deputy Chief Executive then advised the meeting of the following

matters:

Aintree/Royal Merger – it was confirmed that the target date for the proposed merger

was 1 April 2018. A Programme Board had been established to oversee the process

with the Chairs, Chief Executives and Medical Directors of both Trusts in attendance.

Further consultancy support was being sought for high level strategic and tactical advice.

Regular updates will be provided to Governors through the formal Council meetings and

Board feedback sessions hosted by the Chairman.

Sustainability & Transformation Plan (STP) – the proposed merger with the Royal

Liverpool formed a significant part of the Trust’s Local Delivery Plan in North Mersey for

the Cheshire & Merseyside STP. It was acknowledged that STP’s both locally and

nationally had received negative media coverage but the local delivery plan was

considered to be credible and the proposed merger had broad political support locally.

Liverpool Community Services – the contract for services in Liverpool had been

awarded to the consortium led by Bridgewater, which included Aintree, with the contract

for South Sefton being awarded to Mersey Care. Overall, there were 13 transactions to

be undertaken before 1 April 2017. Whilst there was expected to be challenges with

having two different providers, the Trust would continue to work closely with them going

forward.

Members of the Council then sought and received clarification in relation to the following

matters:

The Trust continued to work with NHS Improvement on the detail of the merger

process for a Foundation Trust and an NHS Trust. As RLBUHT only had a shadow

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Ref Minute

Council of Governors in place there was no necessity for a joint meeting for the time

being and the Trust’s Lead Governor would continue to meet with the Royal’s

shadow Lead Governor.

The proposed merger makes reference to three Trusts coming together, including

Liverpool Women’s Hospital (LWH). However, LWH was currently going through an

options appraisal process with the Commissioners which will require consultation on

the future location of services. Once this process was concluded a decision would be

made about the best way for LWH services to be merged into the one entity.

There would be a single budget for the merged organisation with effect from April

2018. The costs associated with the merger would be borne by both Trusts and had

been included in the Trust’s annual plan. The merger would seek to sustain services

going forward whilst also creating efficiencies and savings without compromising the

quality of care.

If strong political views emerged that meant that the STP would be difficult or

impossible to achieve it may have an impact on the timetable for merger. The Trust

had raised its concerns on the governance arrangements for the STP particularly in

relation to the financial commitments for a review of services and whether the Trust

could contribute given the costs associated with the merger.

CG16-17/027 Lead Governor Report

The Lead Governor made reference to the report issued at the meeting and highlighted

the following matters:

Board Feedback Sessions – Governors were encouraged to attend these sessions

hosted by the Chairman. The next session was Monday 12 December 2016

Governor Activity – there had been positive involvement by Governors at recent events

including the Fazakerley Health and Wellbeing Forum, monthly Aintree Volunteer

Inductions, the Proud of Aintree Excellence Awards, Quality Conversation hosted by the

Patient Experience Team, Catering Food Quality Group and the Aintree/Edge Hill return

to Practice Nurse Interviews.

Governor Issues Log – the key themes arising from Governor queries had been

included for information purposes.

Lead Governor Activity – the Lead Governor continues to meet informally with the

shadow Lead Governor at RLBUHT and would feed back further on the development of

the Lead Governors’ Network. The national Lead Governor network had been working to

get more recognition from NHSI, some progress had been made with this and a

conference call had been set up to discuss ways to work alongside each other. Further

progress would be reported on in due course.

The Council noted the update.

Quality & Performance Management

CG16-17/028 Assurance on Key Indicators

Quality & Safety

Kevan Ryan (Non-Executive Director), member of the Quality & Safety Committee, gave

a presentation on assurance on key indicators relevant to quality and safety which

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covered the key areas of focus, where on-going assurance was received and where

assurance was sought on areas of concern. He highlighted the main areas of Committee

focus including serious incidents together with the main themes and trends, the Quality

Strategy delivery plan, infection prevention & control, mortality and the risk register. He

also referred to the on-going assurance relating to workforce and patient experience as

well as the areas of concern in respect of the Trust’s response to the CQC report and

ophthalmology. An overview was also provided on the Trust’s performance against the

main quality indicators.

Finance & Performance

David Fillingham (Non-Executive Director), member of the Finance & Performance

Committee, then gave a similar presentation on assurance on key indicators relevant to

finance and performance which covered the key areas of focus including the operational

plan for 2017-19, the financial outturn for 2016-17, performance against cancer targets

and divisional deep dives. He also highlighted the areas of on-going assurance in

relation to emergency & acute care, transformation and the progress against the annual

business plan priorities. Reference was also made to the areas of concern in relation to

stroke services and agency staffing. An overview was also provide on performance

against the financial and activity indicators, including access to services and workforce

targets.

Members of the Council then sought and received clarification in relation to the following

matters:

The steady increase over the last three quarters in the mortality rates for the

Standard Hospital Mortality Indicator (SHMI) and the maintenance of a watching brief

over the coming months

The increase in the number of Serious Incidents reported and the value of the

lessons learned arising from these cases to improve systems and processes to

minimise further cases arising

The work being undertaken through increased staff training to reduce the level of

pressure ulcer cases whilst also reviewing the key trends

The continued efforts being exerted on recruitment of staff to make the Trust

attractive for potential employees as well as focussing on compliance with mandatory

training and further development of current staff to enhance retention.

The capacity and resourcing issues being dealt with within Ophthalmology to clear

the backlog and tackle the demand for the service

The Trust’s AED performance in comparison to others locally and nationally and the

support being provided to the Trust by Emergency Care Improvement Programme

(ECIP) hosted by NHS Improvement. Also, the improvements made to systems and

processes arising from the establishment of the Purple to Gold (Added Value)

Scheme

The improvements made by the Trust in conjunction with NWAS on reducing

ambulance handover times

The concerns with the stroke service not achieving its prescribed standards and the

continued work being undertaken to address staffing levels

The analysis of exit interviews to determine any themes in relation to turnover of staff.

A report was to be provided to the next Council meeting in regard to this matter.

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Ref Minute

The Council noted the presentations.

Internal System of Control

CG16-17/029 Key Issues & Assurance (Audit)

Tim Johnston (Non-Executive Director), Chair of the Audit Committee, gave a

presentation which covered the key areas of assurance gleaned from the Committee’s

deliberations which included internal audit reports on A&E Data Quality and Equality &

Diversity together with the assurance sought on areas of concern relating to sickness

absence management and additional clinical activity sessions.

Members of the Council then sought and received clarification in relation to the following:

The Trust’s internal systems and controls in place to combat cyber-attacks and the

continued work with the Counter Fraud Team on raising awareness amongst staff.

Governance

CG16-17/030 Reports of Governor Committee Chairs

Membership Committee – 10 November 2016

The Council of Governors received the report of the Committee which was taken as read

and noted.

Quality of Care Committee – 16 November 2016

The Council of Governors received the report of the Committee which was taken as read

and noted.

Reference was made to the Purple to Gold (Value Added) scheme and Governors were

encouraged to get involved where appropriate with the initiative as well as attending the

MADE events to be arranged during the festive period.

Nominations Committee –8 December 2016

The Council of Governors received the verbal report of the Committee relating to the

approval of the appointment of Mandy Wearne to the post of Non-Executive.

CG16-17/031 Governors Elections

The Associate Director of Corporate Governance presented the report which provided

and update on forthcoming Governor elections which will take place January to March

2017. NHSI had been consulted on the necessity for elections to take place given the

merger discussions and confirmation had been received that the Health & Social Care

Act required the elections.

The Council noted that 1 staff post (AHP/Scientists) and 8 public posts were to be

advertised. Three Governors would not be eligible to stand for election as they had

completed two consecutive terms of office. Prospective governors would be invited to

attend a prospective Governors event and full details would be circulated in due course.

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Concluding Business

CG15-16/032 Any Other Business

No further business was raised

Date and Time of Next Meeting:

Wednesday 15th March 2017 in the Board Room Aintree Lodge at 5.00pm

The meeting closed at 2.15pm Chair’s Signature: Date:

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Agenda Item (Ref) CG16-17/036 Date of Meeting: 15 March 2017

Report to Council of Governors

Report Title Exit Interviews

Executive Lead Sue Green, Director of People and Corporate Affairs

Lead Officer Steven Richardson, HR Business Partner

Action Required To review & agree any actions arising

Substantial assurance

High level of confidence

in delivery of existing

mechanisms / objectives

Acceptable

assurance

General confidence

in delivery of existing

mechanisms/

objectives

Partial assurance

Some confidence in

delivery of existing

mechanisms /

objectives

No

assurance

No

confidence

in delivery

Key Messages of this Report (2/3 headlines only)

A Trust-wide approach to exit interviews is being developed to enable trends and themes to be

more easily identified and remedial action to be initiated in a more timely way.

By using the data provided and through close working between HR and the Divisions the Trust

can identify if there are particular actions required to improve retention in key areas.

Impact (is there an impact arising from the report on the following?)

Quality

Finance

Workforce

Equality

Risk

Compliance

Legal

Equality Impact Assessment (if there is an impact on E&D, an Equality Impact Assessment must

accompany the report)

Strategy Policy Service Change

Strategic Objective(s)

Deliver outstanding care

Achieve best patient outcomes

Promote research and education

Deliver sustainable healthcare to meet people’s needs

Provide strong system leadership

Be a well-governed and clinically-led organisation

Governance (is the report a……?)

Statutory requirement

Annual Business Plan Priority

Key Risk

Service Change

Other

rationale for Board submission required:

Next Steps (actions following agreement by Board/Committee of recommendation/s)

Review the outputs from the current Nursing Retention Review underway;

Engage key stakeholders in reviewing the Policy/toolkit

Submit proposed Policy and plan to Workforce Executive Led Group April 2017

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Exit Interviews: Council of Governors – 15 March 2017 2/6

REPORT HISTORY

Committee / Group Name

Agenda Ref

Report Title Date of submission

Brief summary of key issues raised and actions

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Exit Interviews

Executive Summary

1. The purpose of this report is to update the Council of Governors on progress made on exit

interviews and how the Trust uses these and will use these to gain an understanding of the

main themes of reasons for staff leaving the Trust.

Key Issues / Proposals

2. The Trust does not currently have a centrally managed Trust wide approach to exit

feedback/interviews. This is not unusual in NHS Trusts given the size and nature of services

and professional groups. Local managers are always encouraged to meet with staff

members submitting their resignation and to reflect on the feedback received when

considering replacement. In addition, staff members can contact another appropriate

manager or request an exit discussion if they do not feel comfortable discussing their reason

with their own manager.

3. Recruitment; retention and turnover information is reviewed by the HR teams in liaison with

Divisions. Any particular trends or themes are then highlighted and a bespoke piece of work

undertaken to understand if there are any underlying reasons within the organisations gift or

to spot any issues with the “competitor” organisations (i.e. other Trusts paying higher

banding for similar roles or offering different working patterns).

4. One example of work undertaken to inform recruitment activity and methodology was a piece

of work undertaken within the Medicine Division in 2015/16, and specifically with Acute and

Emergency Medicine and the Accident and Emergency Department to understand why staff

were leaving the Trust. This informed recruitment campaigns and as a result both nursing

establishments were fully recruited to.

5. As part of our planning for 2017/18 resource planning, a high level analysis has recently

been completed to identify the most common reasons for staff leaving the Trust during the

period 1 April 2016 to 28 February 2017. This analysis has primarily focused on the reasons

for leaving, as contained within Leaver Forms submitted by the Clinical Business Units, in

which they notify Human Resources that an employee is leaving the Trust.

6. Table One shows the top five reasons for leaving the Trust and the percentage this

represents of total leavers. During this period there were a total of 559 leavers; the top five

account for just over 92% of all leavers.

Table One: High Level Reasons for Leaving

Reason for Leaving Number of

Leavers % of Total

Leavers

Voluntary Resignation 340 60.82%

End of Fixed Term Contract 98 17.53%

Retirement 38 6.80%

Dismissal 27 4.83%

Retirement - Ill Health 12 2.15%

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7. The data shows that almost two thirds of staff left the Trust due to voluntary resignation.

Further analysis has been undertaken to identify the key reasons for voluntary resignation,

again as submitted on the Leaver Form.

8. Table Two shows a breakdown of the reasons given for resignation:

Reason for Resignation Number of

Leavers % of Total

Resignations

Other/Not Known 81 23.82%

Relocation 64 18.82%

Work Life Balance 63 18.53%

Promotion 58 17.06%

To undertake further education or training 22 6.47%

Better Reward Package 15 4.41%

Caring Responsibilities (Family) 14 4.12%

Health 10 2.94%

Lack of Opportunities 10 2.94%

Incompatible Working Relationships 3 0.88% Table Two: Reasons for Resignation

9. Almost a quarter of resignations are for reasons unknown. Of the other reasons given,

relocation and work-life balance make up around a fifth of all resignations with promotion

opportunities another factor worth noting.

10. This information is useful as it clearly demonstrates that more work is required to engage

with our staff in order to better understand the reasons for leaving and to ascertain whether

other interventions may have been possible to affect the outcome.

11. Building on the high level data, work is underway to produce more detailed data to help

inform:

How many staff have left the Trust, broken down by Division, job role, and grade

What the reasons for leaving have been and whether or not the reason for leaving

was voluntary or as a result of action taken by the Trust

Where possible to identify the destination of the leaver, and to understand how

many of our leavers left the organisation to work elsewhere within the NHS; and

how this level compares to the number leaving to further their education and/ or

training and the number of leavers exiting the NHS altogether.

Review in detail the groups – Work Life Balance (anecdotally there is a suggestion

that this may be linked to the long shifts for nurses and Nursing Assistants); Better

Reward Package and the Other/Not Known

12. At the same time, work on an exit interview template and process is being undertaken by HR

to ensure that a consistent approach can be taken across the Trust.

13. Additionally, the Business HR Team working with the respective Divisions are analysing the

data to identify ‘hot spot’ areas where staff turnover is constant or where clear trends and

“peaks” can be identified. The Divisional HR Business Partner can then help individual

departments and Clinical Business Unit’s put strategies in place to begin to manage

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retention. Such initiatives may involve targeting recruitment for certain skills or specialties, or

over-recruitment into areas where high turnover is present.

14. Divisions will be encouraged to carry out exit interviews on every leaver, with the results fed

back to the HR in order for themes and trends to be identified. Such information can be

relayed and the themes presented through Divisional Workforce Group meetings on a

monthly basis and work with the Senior Leadership Teams of each Division to ensure that

feedback from exit interviews is acted upon and any changes or improvements identified can

be considered and, where practicable and possible, acted upon.

15. Any themes that are identified by exit interviews that cannot easily and practicably be

adopted by the Division / Clinical Business Unit will be escalated from the Divisional

Workforce Group to the Workforce Exec Led Group (WELG) in order for the organisation to

take a view and where appropriate, consider further action.

16. WELG receives notes of Divisional Workforce Group meetings on a monthly basis and will be

sighted on actions taken following analysis of exit interviews.

Implications / Impact

Quality

17. Retention of trained, qualification and professional staff will improve the quality of care our

patients receive.

Finance

18. It is widely acknowledged that the cost of retaining staff is much lower than the cost of

recruiting new staff, so improvements in retention rates will support effective use of

resources.

Workforce

19. Maintaining a stable, committed workforce is a key objective within the 2017 / 2018 strategic

plan. A reduction in staff turnover will likely have a positive impact on staff morale and

therefore staff survey results, and will likely have a positive impact of sickness absence rates

and ultimately will help the Trust develop a workforce capable of meeting the challenges

faced by the organisation over the coming years.

Equality & Diversity

20. The revised process and Policy will be subject to an Equality Impact Assessment. In

addition, Exit Interviews will include an assessment of any opportunities to promote Equality

and Diversity as well as ensuring no detrimental impact on people within the protected

characteristic groups.

Legal

21. The provisions of the Data Protection Act will apply in relation to data produced and stored

as a result of exit interviews.

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Conclusion

22. A more effective Trust wide approach and process is necessary in order to gain a better

understanding of why staff choose to leave the Trust; this will help to provide legitimate

intelligence around issues or interventions that can be deployed to change outcomes and

improve retention.

Recommendation

23. To note the contents of this report.

Author: Steven Richardson, HR Business Partner

Date: 9 March 2017

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Lead Governor Report


Date 15 March 2017

Committee Name Council of Governors

Chair’s Name & Title Pamela Peel, Lead Governor

Core Governor Activity

Attendance at Board meetings and Board Feedback sessions with the Chairman

Director Walkabouts – Governors participated in two walkabouts in January (Sharon Bird, Tony

Kneebone), one in February (Pam Peel)

Nominations Committee

Quality of Care Committee

Membership Committee

Quarterly Informal Council of Governors – the meeting on 7 March was chaired by John Johnson and

was preceded by a formal presentation of the Quality Account and Business Planning Process

Appointment of the external auditor – Tony Byrne and Gerry Hill served as Council of Governor

representatives on the tender process for the current appointment process.

Wider Trust Activity

Aintree Volunteer Induction each month – this is an opportunity for Governors to recruit members

from amongst people who are already committed to the Trust, and also to engage with them, hear

their ‘stories’ and recognise the contribution they make to the smooth running of the hospital.

MADE – John Johnson, Tony Byrne, Sharon Bird, Gerry Hill and Pam Peel attended the sessions on

various dates

Workstream – Tony Kneebone continues to be involved in the Catering Food Quality Group

Well Led Governance Review (WLGR): Governor Focus Group, 8 December – Tony Byrne, Sharon Bird, Steve

Thornhill, Kerry McManus, Gerry Hill, Julie Naybour and Pam Peel participated

ACE Panel, 13 December – Pam Peel participated. Wards are accredited ACE (Aintree Champions

Excellence) status when they have had 3 consecutive green AAA assessments and are successful in

their application to obtain ACE standard. On that day the Panel awarded ACE status to Ward 4. The

Panel is currently looking at new ways of managing the accreditation process and it was interesting

to play a small part in that trialling.

WLGR Final Briefing at the Board of Directors’ Session, 21 December – Lorraine Heaton and Pam

Peel were invited to attend, this was an opportunity to get up to speed on the progress made by RSM

Consulting Services working with the Corporate Governance Team on the very detailed responses to

‘How is the Board assured (evidence)’ against a series of very specific questions, and how the Board

is addressing known gaps in the evidence.

Kidney Focus Event, 18 January – Sharon Bird attended

Prospective Governor Information Session, 31 January – Sharon Bird, Tony Byrne, Mike Booth,

Lorraine Heaton and Pam Peel met with potential governors and responded to questions

Staff Induction: Staff Governor Presentation, 6th February - Lorraine Heaton presented on staff

membership

Helipad Turf Cutting, 2 March – Tony Byrne participated in the traditional ceremony

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Lead Governors’ Report: Council of Governors 15 March 2017 2/2

World Kidney Day, 9th March – a number of Governors attended the free screening, advice and

information events as a way of supporting Aintree’s excellent Nephrology Team and also as an

opportunity to engage with patients and members of the public

Nutrition and Hydration Week, 13th – 18th March - A number of Governors attended the drop-in events

External Activity

Fazakerley Health & Wellbeing Forum, AGM, 12 January - Pam Peel was invited as guest speaker,

and was accompanied by Kerry Higham, Lead Nurse, Quality and Safety – Patient Experience, who

did a great job getting to know people present and answering their questions. The Forum is a small

but useful local arena for Governors to meet with, listen to and engage with members of the public.

Governor Issues Log

Issues added to the Log during the last trimester and currently in the process of receiving responses,

and where appropriate additional updates, concern the following:

The Trust’s reputation and obligations as a responsible landlord

Potential areas of development identified by the Reward and Recognition Survey

The status of Bank staff viz-a-viz job opportunities

How the Trust works with the CCGs regarding ‘revolving door’ patient data to seek alternative

solutions to hospital admission

Use of the Sefton Suite at times of increased pressure on the hospital, and how the current approach

might impact on the Trust’s reputation to offer good quality private care

Recommendation

The Council of Governors is asked to note the report.

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Page 35 of 41

1/3

Agenda Item (Ref) CG16-17/042 Date of Meeting: 15 March 2017


Report Title External Audit Service – Tender for Service from 2017/18

Executive Lead Ian Jones, Director of Finance and Business Services

Lead Officer Dawn Gerrard, Head of Corporate Finance

Action Required Approve

Strategic Objective(s)

Deliver outstanding care

Achieve best patient outcomes

Promote research and education

Deliver sustainable healthcare to meet people’s needs

Provide strong system leadership

Be a well-governed and clinically-led organisation

Governance

Statutory requirement

Annual Business Plan Priority

Key Risk

Service Change

Other

rationale for submission required:

Key Messages of this Report (2/3 headlines only)

The current contract for External Audit services ends on 31 March 2017 and a tender exercise

has been undertaken for a new service.

As it is the role of the Governors to appoint the Trust’s external auditor, with support from the

Audit Committee, an assessment panel consisting of governors and audit committee members

have undertaken the assessment of tenders and made a recommendation to the Council of

Governors.

The recommendation is to award a contract to PWC for 3 years, with an option to extend for a

further 2 years (subject to no penalty termination should the service no longer be required).

Impact (is there an impact arising from the report on the following?)

Quality

Finance

Workforce

Equality

Risk

Compliance

Legal

Equality Impact Assessment (if there is an impact on E&D, an Equality Impact Assessment must

accompany the report)

Strategy Policy Service Change

Next Steps (actions following agreement by Board/Committee/Group of recommendation/s)

To award a contract for external audit services to PWC for a period of 3 years with the option to

extend for a further 2 years. Due to the possibility of organisational restructure during that

timeframe, the contract will be capable of termination without penalty.

9. C

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042

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ntm

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f Ext

erna

l Aud

itor

Page 36 of 41


2/3

External Audit Service – Tender for Service from 2017/18

Executive Summary

1. The current contract for External Audit services with PwC covered 3 financial years (2012/13, 2013/14 and 2014/15) with the option to extend for a further 2 years (2015/16 and 2016/17). This extension option has been utilised in full, therefore, a new contract will need to be in place prior to the start of the financial year 2017/18, i.e. April 2017.

Background

2. The FT Governors are responsible for the appointing of auditors to the foundation trust. This includes ensuring that, as part of the process, their appointed auditors meet the criteria included by Monitor in The Audit Code for NHS Foundation Trusts updated in December 2014.

3. The Audit Committee Terms of Reference state that it is the role of the committee to assess

the auditor’s work and fees and to ensure that the work is of a sufficiently high standard and that the fees are reasonable. The Audit Committee shall then make a recommendation to the Council of Governors with respect to the re-appointment of the auditor. Monitor recommends that the foundation trust should undertake a market-testing exercise for the appointment of an auditor at least once every five years.

Procurement Process

4. The first stage of the procurement process included drafting a specification for the service and reviewing the Office of Government Commerce (OGC) framework agreement for external audit services. An OGC framework is a tender that has already been undertaken at a national level and which we can then draw from. As a procurement route, it ensures competition whilst reducing the burden of a full tender.

5. As a framework agreement exists for this service, the Audit Committee (including Gerry Hill

representing the Governors) decided to utilise this and invite those providers on the agreement to tender their prices. This exercise was undertaken during the autumn 2016 and in January 2017 an Assessment Panel (consisting of a mix of Audit Committee members and attendees plus Tony Byrne representing the Governors) was created in order to review both the qualitative and costing aspects of the tenders.

6. Despite using a framework agreement with 7 eligible companies who could provide this

service, only the incumbent supplier submitted a tender. This tender has be assessed using the criteria set for the exercise in assessing both cost and quality as follows:

7. The tendered prices compare to the current cost as follows:

FT Basic

Audit

£

Charitable

Fund

£

Quality

Account

£

Total

Cost

£

Days

Current Cost (2016/17) 57,784 3,296 (included) 61,080

PwC Tender (2017/18) 46,700 4,250 8,000 58,950 112

Page 37 of 41


External Audit Tender 2017/18: Council of Governors15 March 2017 3/3

8. The qualitative assessment resulted in the following combined weighted scores:

Assessment Criteria

Weight Combined

Weighted

Score

Experience 30 22

Methodology 30 21

Resources 20 14

Communication 20 14

Total 100 71

Conclusion & Recommendation

9. The Assessment Panel jointly agreed to recommend the re-appointment of PWC and to award a contract for 3 years with an option to extend for a further 2 years. Due to the possibility of organisational restructure during the contract term, this contract will include a provision to terminate without penalty.

10. The Council of Governors is asked to formally ratify this decision and accept the tender from PwC for External Audit Service for 3 years with the option to extend for a further 2 years, i.e. 2017/18, 2018/19 and 2019/20 with the option to extend for 2020/21 and 2021/22.

Author: Dawn Gerrard, Head of Corporate Finance

Date: 27 January 2017

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itor

Page 38 of 41

1/1

Membership Committee Report


Date 15 March 2017

Committee Name Membership Committee

Date of Committee Meeting 1 February 2017

Chair’s Name & Title Pamela Peel – Lead Governor

Summary of Meeting

A progress update was provided on the ‘Get Involved with Aintree’ concept. Three members of the

group had either submitted a Nomination Form for the Governor elections or were giving it serious

consideration. There was some concern that the remaining group members were not being nurtured

or regularly communicated with and the Committee had agreed to invite those members to attend the

Council of Governors’ meeting in March 2017. Furthermore, arrangements were to be made for an

event/coffee morning to meet with members who are interested in being involved with Aintree.

The promotion of membership to Staff at Corporate Induction had been reviewed with the new format

being rolled out with effect from 6 February 2017 which included information on the Board and the

Council of Governors. It was the intention for the Chairman and/or a Director to be present at all

future staff inductions to welcome staff. Furthermore, a Governor, preferably a staff Governor, would

be invited to attend the session to present slides on Trust Membership and the role of Staff

Governors. Lorraine Heaton was to attend the Induction session Monday 6 February.

A media awareness session was to be arranged with the Communications Team to develop

Governor understanding on Media and Social Media – A date would be arranged and circulated to all

Governors.

Targeting young people to become members of the Trust remains high on the membership priority

list. Governors will be invited to attend Edge Hill University Nursing Career Fairs to promote

membership to newly qualified nurses. Also, contact has been made within the Youth Parliament

through Paul Cummins to promote membership of the Trust to this group.

An overview of the discussions held at the meeting with the Patient Experience Manager and

Volunteers Manager was provided. It was agreed that the Corporate Governance Team, Volunteers

and Patient Experience would work together utilising the various contacts within the Trust to pull

together a calendar of all Trust events. Ultimately this calendar would be uploaded onto the Trust’s

website to allow the public, members and Trust staff the opportunity to access the information as well

as encourage attendance and engagement.

Recommendation


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Quality of Care Committee Report


Date 15 March 2017

Committee Name Quality of Care Committee

Date of Committee Meeting 9 February 2017

Chair’s Name& Title Mike Booth

Summary of Meeting

A presentation was provided on Infection Prevention and Control which included an overview of

the Trust’s Healthcare Associated Infections (HCAIs) Aspirations for 2016/17. The main points taken

from the presentation were:

The levels of CDifficile infection cases for 2016/17 compared to the last two years together

with the key actions taken following the post infection reviews

Comparisons of MSSA and MRSA cases for the last three years together with the key actions

taken following the identification of the main sources of infection

Details of central line associated infections (CLABSI) within the Trust together with

comparisons for the last two years and the key actions taken to improve surveillance and

better use of technology

An overview of the measurement of Ventilator Associated Pneumonia together with details of

the Trust’s case review against the network definition for lapses of care

The increase in carbapenemase-producing enterobacteriacese (CPE) cases together with

details of the toolkit for the early detection of CPE and the Trust’s processes in place in this

regard.

A report was received on the progress being made on the delivery of the Year 3 Quality Strategy

which highlighted that despite the operational pressures on the hospital a high number of the quality

goals were still being achieved which was a credit to the staff. The main areas discussed were:

a reduction in grade 2 pressure ulcers was currently being achieved

an increase in grade 3 pressure ulcers was being investigated and lessons learned were

being developed into action plans to help reduce levels going forward

the Trust was working with the Cheshire & Merseyside collaborative on reducing pressure

ulcers

an overall reduction in the levels of falls with harm with a deep dive to be undertaken on

moderate falls

significant progress had been made on compliance with the Modified Early Warning system

(MEWS) scoring for deteriorating patients

A review of the Trust Mortality report highlighted the following:

the Trust’s Summary Hospital Mortality Indicator (SHMI) had risen slightly but remained as

expected

the Hospital Standardised Mortality Ratio (HSMR) continued to be below that expected

the Trust was mid-table compared to its peers in the North West for SHMI and was third

lowest for HSMR

for crude mortality, the number of discharges had shown a downward trend but the number of

deaths remained fairly stable which reflected in the SHMI level increasing

a deep dive into Acute Kidney Injury revealed that good progress was being made as part of

the AQuA programme.

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Quality of Care Committee Report – 9 February 2017: Council of Governors 15 March 2017 2/2

A report was presented on the Aintree Assessment & Accreditation Framework Q2 2016/17

highlighted that every ward had now received at least two assessments under the AAA framework

and that it had also been rolled out to Theatres. At the end of Q3 there were 10 wards that had

achieved an Aintree Champions Excellence (ACE) rating meaning that they had sustained a Green

rating for over 12 months. A further eight wards had received a Green rating and one ward that had

been Red rated had been reassessed and recently achieved an Amber rating.

A complimentary letter had been received from a patient in respect of treatment and care they

received from the nursing staff whilst in Aintree hospital. The letter particularly mentioned one of the

nursing staff who stood out as being an exceptional individual.

Recommendation


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COUNCIL OF GOVERNORS - Aintree University … University Hospital NHS Foundation Trust Minutes:...

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