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BOARD OF DIRECTORS

30 MARCH 2017

PUBLIC MEETING

http://www.stockport.nhs.uk/

www.stockport.nhs.uk Corporate Services | Stockport NHS Foundation Trust


Board of Directors - PUBLIC MEETING - 30 March 2017 - meeting pack_2

Document Page

1 Public BoD Agenda - 30.03.17 32 Item 4.1 - Public Board Minutes 23.02.17 53 Item 4.2 - Patient Story 214 Item 5.1 - Performance Report 255 Item 5.1 - Attach to Performance Report 336 Item 5.2 - Agency Report 717 Item 5.3 - N M Staffing Review march 17 (2) 758 Item 5.4 - Safe Staffing Report 839 Item 5.5 - BoD Strategic Risk Register March 2017 9110 Item 5.6 - Budget Setting Report 11311 Item 5.7 - Going Concern Declaration 2017-18 BoD 300317 12312 Item 5.8 - Staff Survey Results 13313 Item 5.9 - Registration Authority Report 14514 Item 5.10.1 - F&P Key Issues Report 15 Mar 17 16315 Item 5.10.2 - AC Key Issues Report 14 Mar 17 16516 Item 5.10.3 - QAC Key Issues Report 21 Mar 17 16917 Item 5.10.4 - PPC Key Issues Report 23 Mar 17 17118 Item 6.1 - Chief Executive's Report 17319 Item 6.2 - Board Assurance Framework 17920 Item 6.2 - Attach to Board Assurance Framework 185

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1

March 2017

Dear Colleague

You are invited to a meeting of the Board of Directors which will be held on Thursday 30 March 2017 at 1.15pm in Lecture Theatre B, Pinewood House, Stepping Hill Hospital.

An agenda for the meeting is detailed below. Yours sincerely

GILLIAN EASSON CHAIRMAN

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

AGENDA ITEM TIME

1. Apologies for Absence. 1.15pm – 1.20pm

2. Opening Remarks by the Chairman. “

3. Declaration of Amendments to the Register of Interests. “

4. OPENING MATTERS:

4.1 To approve the minutes of the previous meeting of the Board of Directors held on 23 February 2017 (attached).

1.20pm – 1.25pm

4.2 Patient Story (attached). 1.25pm – 1.35pm

4.3 Report of the Chairman.

1.35pm – 1.40pm

4.4 New Models of Care (Presentation by Mrs M Malkin, Director, Community Business Group)

1.40pm – 1.55pm

5. TRUST ASSURANCE / GOVERNANCE:

5.1 Performance Report (Report of Chief Operating Officer attached). 1.55pm – 2.25pm

5.2 Agency Utilisation Report (Report of Director of Workforce & OD attached). 2.25pm – 2.35pm

5.3 6-Monthly Safe Staffing Report (Report of Director of Nursing & Midwifery attached). 2.35pm – 2.45pm

5.4 Maintaining Safe Staffing Levels (Report of Director of Nursing & Midwifery attached). 2.45pm – 2.55pm

5.5 Strategic Risk Register (Report of Director of Nursing & Midwifery attached). 2.55pm – 3.05pm

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AGENDA ITEM TIME

5.6 Budget Setting 2017/18 (Report of Director of Finance attached). 3.05pm – 3.15pm

5.7 Going Concern Assessment (Report of Director of Finance attached). 3.15pm – 3.25pm

5.8 Staff Survey Results (Report of Director of Workforce & OD attached) 3.25pm – 3.35pm

5.9 Registration Authority - Annual Report (Report of Director of Support Services attached).

3.35pm – 3.45pm

5.10 Key Issues Reports from Assurance Committees:

5.10.1 Finance & Performance Committee (attached and Malcolm Sugden to report)

5.10.2 Audit Committee (attached and John Sandford to report)

5.10.3 Quality Assurance Committee (attached and Mike Cheshire to report)

5.10.4 People Performance Committee (attached and Angela Smith to report).

3.45pm – 3.55pm

6 STRATEGY AND DEVELOPMENT:

6.1 Report of Chief Executive (attached).

3.55pm – 4.05pm

6.2 Board Assurance Framework (attached). 4.05pm – 4.15pm

7 CLOSING MATTERS:

7.1 Any Other Urgent Business. “

7.2 Date of next meeting:

Thursday 27 April 2017, 1.15pm, in Lecture Theatre A, Pinewood House, Stepping Hill Hospital.

“

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STOCKPORT NHS FOUNDATION TRUST

Minutes of a meeting of the Board of Directors held in public on Thursday 23 February 2017

1.15pm in Lecture Theatre B, Pinewood House, Stepping Hill Hospital Present: Mrs G Easson Chairman Mrs C Anderson Non-Executive Director Mrs C Barber-Brown Non-Executive Director Dr M Cheshire Non-Executive Director Mr J Sandford Non-Executive Director Mr M Sugden Non-Executive Director Mrs A Barnes Chief Executive Mr P Buckingham Director of Corporate Affairs Mrs D Lynch Acting Director of Strategy, Planning & Transformation Mr H Mullen Director of Support Services Mrs J Morris Director of Nursing & Midwifery Mr F Patel Director of Finance Mrs J Shaw Director of Workforce & OD Ms S Toal Acting Chief Operating Officer In attendance: Dr G Burrows Deputy Medical Director Dr J Catania Chief Clinical Information Officer Mrs S Curtis Membership Services Manager

39/17 Apologies for Absence

Apologies for absence were received from Ms A Smith and Dr C Wasson.

40/17 Opening Remarks by the Chairman

Mrs G Easson welcomed members of the Board to the meeting and in particular welcomed Dr G Burrows who was deputising for the Medical Director. She noted that there were two presentations on the agenda regarding the Hospital Electronic Patient Record and the Elective Care Rapid Testing Programme.

41/17 Declaration of Amendments to the Register of Interests

There were no interests declared.

42/17 Minutes of the previous meeting

The minutes of the previous meeting held on 27 January 2017 were approved as a true and accurate record of proceedings. The action log was reviewed and annotated accordingly.

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43/17 Patient Story

Mrs J Morris presented a patient story about a lady who had felt that she had not received all relevant information into the circumstances of her husband’s death. Mrs J Morris advised that a productive face to face meeting had been held during which the lady had been able to discuss her husband’s case and consequent concerns with the Cardiology Clinical Lead. She noted that the patient story highlighted the importance of information sharing with patients and their families. In response to a question from Mr M Sugden, Mrs J Morris advised that anyone raising an issue with the Patient & Customer Services department was offered an opportunity of a face to face meeting. The Board of Directors:

Received and noted the Patient Story Report.

44/17 Report of the Chairman

Mrs G Easson advised that earlier that morning, Board members had undertaken a whiteboard round for the third time across the hospital. She noted that Board members had consequently gained assurance with regard to the rigour of addressing issues around delayed transfers of care and she wished to thank everyone involved for undertaking the valuable exercise. Mrs G Easson also advised that she had attended a memorial service for Mr S Mycio OBE, former Deputy Leader of Manchester City Council and Chairman of Central Manchester University Hospitals NHS Foundation Trust, who had sadly passed away in December 2016. She paid tribute to Mr S Mycio OBE who would be sadly missed.

45/17 Hospital Electronic Patient Record (EPR) Update

Dr J Catania, Chief Clinical Information Officer, delivered a presentation on the Electronic Patient Record (EPR) Programme which covered the following subject areas:

The Clinician’s Vision – Translated

Programme Objectives

EPR Governance Structure

EPR Programme Implementation Plan

Rollout 1 – Laying the Foundations

Communication & Engagement

EPR Programme Finance Position

EPR Benefits Delivery

EPR Programme Risks and Clinical Hazards Management

EPR Key Messages.

Dr J Catania advised that an update on EPR Benefits Delivery would be provided to the EPR Programme Board and the Finance & Performance Committee in March 2017. Mrs C Barber-Brown commended the positive progress made with regard to connecting EPR with transformation and wished to congratulate all staff involved. Mr M Sugden commented on the ‘messy period’ referred to in the presentation with regard to the early days post-implementation and queried whether the Trust would take a measured step change approach. Dr J Catania noted that the approach would

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be informed by a better understanding of the system and consequent knowledge of early warnings and advised that the ‘messy period’ was envisaged to last between two to six months. In response to a question from Mr M Sudgen, Dr J Catania acknowledged the Stockport Together developments since the approval of the original EPR business case and advised that work was ongoing to establish the ‘end state’ of Stockport Together to facilitate appropriate alignment of EPR. He also noted that benefits, such as patient portal contribution, would be easier to articulate following the establishment of a single organisation. Mrs A Barnes noted that the Community EPR system shared the same lead as the Hospital EPR. Mr J Sandford raised a concern with regard to the potential disruption of six months and commented on the need for careful planning and management of the switch over period. He also commented on EPR being a transformation project and noted his concern about the replication of current systems and ways of working. Dr J Catania acknowledged Mr J Sandford’s concern and noted that ideally the end state would have been established before the preparation of the business case but that had not been possible. He noted, however, that processes would be reviewed and changed where possible and gave as an example the changing of RTT forms from paper to electronic. He advised that some processes would not able to be changed before the ‘go live’ date but that each process would be reviewed and revised as part of the transformational agenda. In response to a follow up question from Mr J Sandford who queried a definition of the ‘messy period’, Mr F Patel advised that following feedback received from other organisations who had implemented the EPR programme, it appeared that the disruption was not related to the day to day usage or the patient care element of the programme but to the submission of data to commissioners and regulators. In response to a question from Mrs G Easson, Mrs A Barnes advised that business continuity and the patient care element had been risk assessed by the EPR Programme Board. It was noted that if any risks associated to the EPR programme became significant, the Board would be sighted on them via the Strategic Risk Register. The Board of Directors:

Received and noted the presentation on the EPR Project Update.

46/17 Trust Performance Report – Month 10

Ms S Toal presented the Performance Report which summarised the Trust’s performance against the NHSI Single Oversight Framework for the month of January 2017, including the key issues and risks to delivery. She advised that the report also provided a summary of the key risk areas within the Integrated Performance Report which was attached in full in Annex A. Ms S Toal briefed the Board on the content of the report and whilst noting one area of non-compliance in month 9 which was the non-achievement of the Accident & Emergency (A&E) 4-hour target, she was pleased to report compliance of all other metrics. It was noted that the Referral to Treatment (RTT) and Cancer 62-day standard performance were compliant with the national standard for the third consecutive month. Ms S Toal advised that the Respiratory Outpatient Waiting List (OWL) had increased in month due to medical staffing challenges and noted that there had been five breaches of the 28 day cancelled operations standard.

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With regard to the Emergency Department (ED) performance, Ms S Toal advised that attendances in January had been lower than preceding months but noted that average total admissions per day remained steady. She noted, however, an increase in admitted activity to assessment areas and commented on the high acuity of patients who had presented at ED. Ms S Toal advised that after an initial improvement in delayed transfers of care (DTOC) in November and December, DTOC levels had significantly increased again in January. She noted that the Stockport system remained extremely challenged with a DTOC rate of 11% against a target of 3.3% and advised of a local trajectory which was to achieve 4% by August 2017. Ms S Toal noted that the Urgent Care and Stockport Together plans to reduce admissions and expedite discharge continued to be implemented but that the full benefits would not be realised during Quarter 4. She advised that home based capacity was being expanded to support care at home to enable discharge to assess. She also advised that until fully established, the Stockport Urgent Care system was rapidly exploring additional community bed based capacity to enable assessment and discharge processes to be undertaken in a non-acute hospital bed and noted that a fully integrated discharge team should be fully established by April 2017. Ms S Toal advised with regret that there had been seven reported 12 hour trolley wait breaches in January 2017, categorised as follows:

Long wait for a bed due to surge in demand – three breaches

High level of dependency in the Emergency Department – two breaches

Administrative error – two breaches. In response to a question from Mrs G Easson, Ms S Toal provided further clarity with regard to the number of 12 hour trolley waits and reminded the Board that at the previous meeting, one breach had been reported for December and five breaches for January. She noted that since the previous Board meeting, there had been a further two breaches in January which meant that the total number of breaches for January was seven. Ms S Toal advised the Board that the Trust had been called to attend a Greater Manchester DTOC event on 13 February 2017 as the region’s ED performance was worse than in other parts of the North of England. She noted that the Trust, South Manchester and Salford were collectively reviewing how to reduce levels of DTOC to 3.3% by the end of March 2017. Ms S Toal advised that many examples of good practice had been shared at the event but noted that these had not included anything new that the Trust had not already considered or implemented. In response to a question from Mr M Sugden, Ms S Toal acknowledged that the Trust did not currently have an oversight of bed capacity for private homes and commented on the importance of bringing private providers into the discharge team to improve the position and ownership across the system. In response to a question from Mrs C Barber-Brown, Ms S Toal advised that the Stockport trajectory was to reduce levels of DTOC to 4% by August 2017 but noted that Greater Manchester was aiming for 3.3% by April 2017. Ms S Toal noted a presentation which Ms M Malkin, Interim Director of Community Business Group, had given to Emergency Department Consultants on the development of new models of care as part of the Stockport Together Programme and it was proposed that Ms M Malkin be invited to deliver the same presentation at the Board meeting in March 2017.

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Mrs C Anderson noted that at the earlier whiteboard round, an issue had been raised with regard to the discharge of patients who lived out of area. Ms S Toal noted that the focus was to get the discharge system right in Stockport first whilst acknowledging the importance of ensuring efficient discharge arrangements in all areas. In response to a question from Mr J Sandford, Ms S Toal advised that approximately 85% of DTOC patients were from Stockport. Ms S Toal advised the Board of future risks to the compliance against the Single Oversight Framework. With regard to other key risks from the Integrated Performance Report (IPR), Ms S Toal and Mrs J Morris provided an overview of issues and mitigating actions in the areas of Discharge Summary, Clinical Correspondence, Patient Experience, Pressure Ulcers, Outpatient Waiting Lists, Emergency Readmissions and the 28-day cancelled operations standard. In response to a question from Mrs G Easson who queried the five breaches of the 28-day cancelled operations standard, Ms S Toal advised that four of them were attributable to winter pressures and the reduced routine elective programme, particularly in Orthopaedics. Mr F Patel briefed the Board on the Finance section of the report and noted a favourable position of £1.2m against the planned deficit as at 31 January 2017. He advised, however, that as the NHSI control total excluded Sustainability & Transformation Fund variances and impairments, the consequent variance was £0.1m favourable to plan. Mr F Patel provided an overview of performance against the Trust’s Cost Improvement Programme (CIP) and advised that as at 31 January 2017, the Trust was £3.3m behind the profiled plan. He advised that there was a significantly higher element of recurrent CIP compared to previous years but noted that strategic level transformation change projects had not delivered as planned and remained central to the financial viability of the Trust in the medium term. Mr F Patel briefed the Board on expenditure variance and noted the effect of agency spend due to service pressures. With regard to financial sustainability, he reported that the Trust’s overall Finance Use of Resources score was 3 which was in line with the Trust’s 2016/17 Operational Plan. Mr F Patel advised that the cash in the bank position was £23.4m which was £3.3m ahead of plan. He noted, however, that this was due to continued lower than planned capital cash payments, invoice queries and the receipt in month of additional income of £1.6m from Stockport CCG. He further advised that the deferred CNST premiums referred to in last month’s report had now been made with £3.5m paid in January 2017. Mr F Patel advised the Board that the Trust would receive £2.2m funding from Greater Manchester with regard to the 2016/17 winter pressures and Community EPR. In response to a question from Mrs C Barber-Brown who queried whether the Trust would still access a loan following the receipt of additional funding from Greater Manchester, Mr F Patel confirmed that this was likely but noted that the additional funding would possibly delay the requirement for the loan. Mrs J Shaw briefed the Board on the Workforce section of the report and provided an update on metrics relating to essentials training, appraisals, turnover, induction and efficiency. She noted that service pressures continued to impact on workforce metrics, particularly with regard to essentials training and sickness absence. She advised the Board that the Trust was undertaking many innovative pieces of work with regard to recruitment and associated systems and processes and noted that a separate report

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on agency expenditure would be considered later on the agenda. Mr M Sugden noted that staffing in the Medicine business group was 17% below establishment and queried processes in place to achieve a more sustainable position. Mrs J Shaw advised the Board of mitigating actions in place and commented on the positive impact recently recruited health care assistants would have on the position. She also wished to commend the efforts of staff who had worked extremely hard in the demanding circumstances. In response to a question from Dr M Cheshire who queried the downward position of essentials training compliance, Mrs J Shaw advised the Board of mitigating actions in place, including promotion of e-learning, but also noted that the Trust’s position was above national average. Mrs G Easson noted the effect of the severe service pressures on training but also reminded Board members of the need to ensure their own training compliance. In response to a question from Mrs C Barber-Brown who sought assurance with regard to planning for winter pressures going forward, Mrs A Barnes advised that of the number of targets the Trust was measured against, the only one the Trust was non-compliant with was the ED target. Whilst noting the favourable position compared with many other organisations in Greater Manchester, she noted that Stockport Together would be the solution to a more sustainable ED position. The Board of Directors:

Received and noted the contents of the Trust Performance Report

Noted the position for Month 10 compliance standards

Noted the future risks to compliance and corresponding actions to mitigate

Noted the key risk areas from the Integrated Performance Report.

47/17 Maintaining Safe Staffing Levels

Mrs J Morris presented a report which provided an overview, by exception, of actual versus planned staffing levels for the month of January 2017. She briefed the Board on the content of the report and made particular reference to the following points:

Average fill rates for Registered Nurses and care staff remained above 90%.

A significant increase on the reliance of bank and agency staff was noted in the month of January 2017. Seven wards within the Medicine Business Group were reporting <90% sub-optimal Registered Nurse levels. Surgery & Critical Care were reporting three areas and Child & Family one area below 90%.

Vacancy rate in Medicine Business Group: 82 whole time equivalents (WTE) substantive (18.9%) and 17 WTE on maternity leave or long-term sick. In Surgery & Critical Care business group Registered Nurse vacancies were 16 WTE and 18 WTE on maternity leave or long-term sick.

Bank and agency staff support has been crucial in ensuring safe staffing. Off-framework nursing agency has been required to support safe staffing in escalation areas and the Community Unit.

Mrs J Morris briefed the Board on work around recruitment and retention and advised that a successful recruitment day had been held on 11 February 2017. She also noted that the Communications Team was supporting the nursing directorate with a comprehensive plan to support a social media campaign and improve the Trust’s profile in attracting recruits. Mrs J Morris provided an overview of ongoing

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international recruitment, including an adaptation assessment programme. In response to a question from Dr M Cheshire, Mrs J Morris acknowledged the retention issue with regard to European nurses and advised the Board of associated mitigating actions. In response to a question from Mr J Sandford, Mrs J Morris confirmed that the Trust was working closely with colleges and that posts had been offered to individuals who were due to qualify as nurses in 2018.

The Board of Directors:

Received and noted the Safe Staffing Report.

48/17 Strategic Risk Register

Mrs J Morris presented the Strategic Risk Register and advised that one strategic risk had been mitigated and managed to below a risk score of 15, two risks had actions completed and risk scores reduced from 20 to 16, there were currently a total of three entries with a risk score of 20 and one with a risk score of 25 and one new strategic risk had been added this month. Mrs C Anderson made reference to risks 1881, 3031 and 3019 which at the last Board meeting had been highlighted as requiring review but had not been amended on the Register. It was noted that this was a timing issue and that the risks would be reviewed in time for the next Board meeting.


Received the Strategic Risk Register and noted the content.

49/17 External Review of Never Events

Dr G Burrows presented a report which detailed progress made with actions identified to address recommendations from the External Review of Never Events. She briefed the Board on the content of the report and noted that all three remaining actions were under way. In response to a question from Mrs G Easson who sought assurance with regard to the effectiveness of the actions, Dr G Burrows advised that such matters were routinely reviewed as part of the Serious Incident Review process. In response to a question from Mrs C Anderson who queried action 14, Dr G Burrows advised that the CCG had agreed to the reduction of the number of never events from six to three although it was noted that only one never event had been identified by Professor B Toft. The Committee:

Received and noted the External Never Events Review Report.

50/17 Trust Agency Utilisation Update

Mrs J Shaw presented a report which provided the Board of Directors with an update on the Trust’s agency utilisation and assurance with regard to mitigation plans and actions. She briefed the Board on the content of the report and noted that while expenditure remained within the agency ceiling at Month 10, the forecast cumulative year-end position had deteriorated from £1.1m to £1.5m above the agency ceiling. Mrs J Shaw then referred the Board to s4 of the report which provided an overview of

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changes to IR35 arrangements coming into effect on 6 April 2017. She advised that a report detailing measures to ensure compliance with the revised arrangements would be presented to the Board of Directors at the meeting on 30 March 2017. Mr M Sugden noted that the Finance & Performance Committee was also following up on the revised IR35 arrangements. The Board of Directors:

Received and noted the Trust Agency Utilisation Update Report and noted the forthcoming changes to IR35 arrangements.

51/17 Corporate Objectives 2016/17 & 2017/18

Mrs D Lynch presented a report which provided an update on progress towards the achievement of 2016/17 corporate objectives and sought Board approval for the proposed 2017/18 corporate objectives. She briefed the Board on the content of the report and noted that of the 2016/17 corporate objectives, 15 were green and the remaining three were red. She advised that the current status of the 2016/17 corporate objectives had been included in Annex A to the report and that the proposed strategic objectives and associated corporate objectives for 2017/18 had been included in Annex B to the report. The Board of Directors conducted a review of the corporate objectives during which the following points were noted:

C10 (2016/17) and C12 (2017/18) – Rephrase the objectives to read: “We will identify and deliver CIP savings for the Trust to reduce the deficit”.

C11 (2017/18) – Rephrase the objective to read: “We will implement and monitor a revised performance management framework in order to foster a culture of high performance”.

C16 (2017/18) – Mrs J Shaw to review the objective to include staff involvement in transformation.


Received and noted the Corporate Objectives 2016/17 & 2017/18 report

Approved the 2017/18 Corporate Objectives for cascade throughout the Trust as part of the Start the Year, subject to the amendments noted above.

52/17 Key Issues Reports

Finance & Performance Committee Mr M Sugden briefed the Board on matters considered at a meeting of the Finance & Performance Committee held on 15 February 2017. He noted the busy agenda and advised that the Committee had considered in detail a comprehensive Month 10 Finance Report. Mr M Sugden advised that the Committee had considered the financial performance of Business Groups and noted the continuing financial challenges for the Medicine and Surgical & Critical Care Business Groups which had been exacerbated as a result of operational pressures impacting on elective activity and levels of agency expenditure. He advised that the Acting Director of Medicine Business Group had presented a report which detailed progress against the Business Group’s Financial Recovery Plan. The Committee had acknowledged progress made in recovering the

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position and commended the Business Group’s efforts in managing expenditure over the previous six months with underlying variance against control total at Month 10 reduced to £108k. Mr M Sugden advised that the Director of Nursing & Midwifery had presented a report on forecast position for CQUIN delivery in 2016/17 and the Committee noted the forecast that the Trust would earn circa £5.1m from the overall CQUIN value of £5.8m. The Committee had also considered current Finance-related risks and noted a general need for formal risk assessment of the MCP development and Contract Review process in 2017/18. Finally, Mr M Sugden advised that at its previous meeting, the Committee had requested a report to compare the current benefits realisation position for the EPR project with benefits identified in the original business case which would be presented at the next meeting on 15 March 2017. While the Committee had raised concern that the information had not been available for the February meeting, Mr M Sugden noted that he felt more assured following today’s EPR presentation. People Performance Committee Mrs J Shaw briefed the Board on matters considered at a meeting of the People Performance Committee held on 16 February 2017. She noted the busy agenda and advised that the Committee had approved an Internal Communications & Engagement Plan 2017/18 and had noted the pivotal role of line managers in sharing relevant information with their teams. The Committee had consequently requested that a structure approach be established for identifying any communication training needs for line managers. Mrs J Shaw noted that the Committee had also considered a Workforce Planning Transformation Tracker and had received assurance that workforce changes were being captured to enable identification of gaps in skills and capacity to assist in the identification of future workforce requirements. Mrs J Shaw advised that the Trust had not met the medical staff appraisal target for Quarter 3 but the Committee had noted that mitigating actions were in place to ensure future compliance. Dr G Burrows advised, however, that the Trust performed favourably compared to other Trusts. Finally, Mrs J Shaw advised that the Guardian of Safe Working Hours had presented a Quarter 3 exception report and the Committee had considered and consequently approved a local Equality Impact Analysis with regard to the implementation of the 2016 Junior Doctors Contract. Mrs G Easson invited Board members to read the Equality, Diversity & Inclusion Annual Report which had been published on the Trust’s website. In response to a question from Mr J Sandford who queried workforce planning in the context of Stockport Together developments, it was agreed that workforce planning would be considered in detail at the Board strategy session in April 2017.

53/17 Chief Executive’s Report

Mrs A Barnes presented a report which detailed matters relating to NHS Improvement Quarterly Review Meetings. She advised that in late January 2017, the Trust had received correspondence from Mrs A Gibbs, Delivery & Improvement Director, NHS Improvement, relating to working arrangements for NHS Improvement in the Greater Manchester & Lancashire area and implementation of Quarterly Review Meetings (QRM) in accordance with the Single Oversight Framework. She noted that a copy of the correspondence was included for reference at Annex A to the report. Mrs A Barnes advised that the first QRM would be held on 6 March 2017 and the Board would

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consequently receive an update at the meeting on 30 March 2017. In response to a question from Mr M Sugden, Mrs D Lynch provided an overview of 2017/18 cost improvement schemes. Mrs A Barnes also noted that the Trust had received a petition from Stockport NHS Watch with regard to concerns over actions taken by the Trust to respond to operational and financial challenges. She noted that the petition, which had been supported by 3,000 signatures, would be acknowledged and the Trust would share the level of concern raised with commissioners.


Received and noted the Report of the Chief Executive.

54/17 Operational Plan 2017-19

Mrs D Lynch presented a report seeking approval for the public version of the Operational Plan 2017-19. She provided an overview of the Plan document and noted that the content was consistent with the Trust’s final operational plan narrative but excluded any information which was commercial in confidence. She noted that once approved, the public version of the Plan would be published on the Trust’s website. In response to a question from Mr M Sugden, Mrs J Morris advised the Board of the national requirement to reference care hours per patient day in the Plan. Mrs C Barber-Brown noted that some of the terminology used in the Plan, such as ‘spells’ and ‘deflections’, might not be easily understood by the public. Mrs D Lynch agreed to review the terminology used in the Plan and provide additional clarity if appropriate.


Approved the content of the public version of the Operational Plan 2017-19 subject to the comments noted above.

55/17 Elective Care Rapid Testing Programme

Mrs D Lynch delivered a presentation on the Elective Care Rapid Testing Programme which covered the following subject areas:

Background

100 day approach

Rapid Testing Programme (100 days)

Focus of the challenges and team goals

Trauma & Orthopaedics

Gastroenterology

Cardiology & Respiratory

Phase One – Outcomes

Emergent impact – the views of the participants

What Next.

Mrs D Lynch advised the Board that a Sustainability Review for the second 100-day cycle would take place on 1 March 2017, coinciding with the launch of phase 2. She noted that based on the positive emerging results of the programme, NHS England

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were planning to partner with four to five Vanguard sites to form an Elective Care Development Collaborative. She advised that Stockport was the only site to be chosen to be part of the NHS England programmes and was considered as a ‘trailblazer’ for this work. Mrs D Lynch noted that Board members were invited to attend the launch event on 1 March 2017 and joining instructions would be circulated to the Board. Dr G Burrows commended the commitment of staff and the subsequent success of the programme. In response to a question from Mr J Sandford who queried how the resultant outcomes would be embedded in patient pathways, Mrs D Lynch advised that this would be an area of focus at the launch event on 1 March 2017. She further noted that any implemented changes arising from the Elective Care Rapid Testing Programme would continue and would not be stopped. Mrs G Easson thanked Mrs D Lynch for the informative presentation and wished to thank all staff who had been involved in the programme. The Board of Directors:

Received and noted the Elective Care Rapid Testing Programme presentation.

56/17 Any Other Urgent Business There was no other urgent business.

57/17 Date, time and venue of next meeting

There being no further business, Mrs G Easson closed the meeting and advised that the next meeting of the Board of Directors would be held on Thursday 30 March 2017 at 1.15pm in Lecture Theatre B, Pinewood House, Stepping Hill Hospital. Signed:______________________________Date:______________________________

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BOARD OF DIRECTORS: ACTION TRACKING LOG

Ref. Meeting Minute

Ref Subject Action Responsible

4/16 30 June 16 188/16 Trust Performance Report – Month 2

Mr J Sumner made reference to an Outpatient Waiting List national pilot and noted the innovative work that was being led by this Trust’s staff. It was proposed that this be explored further either at the next Board meeting or the deep dive session.

Update on 4 Aug 2016 – This action was carried forward. Update on 29 Sep 2016 – Mr J Sumner would provide a presentation to the Board either at the October Away Day or at the Board meeting in November 2016. Update on 27 Oct 2016 – Mr J Sumner would provide a presentation at the Board of Directors meeting on 24 November 2016. Update on 24 Nov 2016 – Mr J Sumner made reference to a 100 day model of care Vanguard and advised that Mrs D Lynch would provide a presentation at the Board of Directors meeting on 26 January 2017. Update on 27 Jan 2017 – Mrs D Lynch advised that a presentation would be provided to the Board of Directors on 23 February 2017. Update on 23 Feb 2017 – Presentation on agenda. Action complete.

J Sumner

D Lynch

7/16 30 June 16 190/16 External Review of

Never Events

It was noted that in order to ensure appropriate closure of the process, a report would be considered by the Quality Assurance Committee in September followed by the Board of Directors in October 2016.

Update on 4 Aug 2016 – A report would be considered at the Board meeting in October 2016. Update on 29 Sep 2016 – Dr C Wasson advised that this would be further considered at the Quality Assurance Committee in three months’ time and noted the good progress being made in this area. Update on 27 Oct 2016 – A report would be considered at the Board meeting in January 2017. Update on 27 Jan 2017 – The Board noted that a report had been considered by the Quality Assurance Committee and would be presented to the Board on 23 February 2017. Update on 23 Feb 2017 – On agenda. Action complete.

C Wasson

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8/16 24 Nov 16 339/16 Corporate

Objectives 2016/17

In response to a question from Mr J Sandford, it was agreed that reporting arrangements with regard to the delivery of the corporate objectives would be clarified. Update on 27 Jan 2017 – A report on corporate objectives 2017/18 will be presented to the Board on 23 February 2017. Update on 23 Feb 2017 – On agenda. Action complete.

D Lynch

9/16 24 Nov 16 340/16 Strategic Risk

Register

Mrs J Morris advised that all risks would be transferred to the new Datix system by the end of December 2016 and suggested that once implemented, Ms C Marsland would provide a presentation to the Board with regard to the new system.

Update on 27 Jan 2017 – A presentation would be provided to the Board in April 2017.

J Morris

11/16 24 Nov 16 342/16 Key Issues Report –

Audit Committee

With regard to the EPR Project Review, Mr J Sandford advised that the Committee had noted a lack of visibility at Board level on progress with the EPR Project. It was proposed that a report on this subject be considered at the Board meeting in January 2017 and Mrs A Barnes agreed to invite the Chief Clinical Information Officer and Senior Project Director to the meeting.

Update on 27 Jan 2017 – It was noted that the Chief Clinical Information Officer and Senior Project Director had been unable to attend the Board meeting due to the date change and would therefore be attending the meeting on 23 February 2017. Update on 23 Feb 2017 – Presentation on agenda. Action complete.

A Barnes

1/17 27 Jan 17 18/17 Breaches of the 12 Hour Decision to Admit Standard

In response to a comment made by Mr M Sugden with regard to Board assurance, it was agreed that the Quality Assurance Committee would review the outcomes of the actions and that the Board would receive a further update in February’s Performance Report.

Update on 23 Feb 2017 – Action complete.

S Toal

2/17 27 Jan 17 23/17 Key Issues Report – People Performance

Committee

Ms A Smith advised that the Committee had considered a Workforce Equality Monitoring Report 2016 and the Chairman consequently requested that a copy of the report be circulated to the Board for

S Curtis

18 of 200

- 15 -

information.

Update on 23 Feb 2017 – Report circulated to the Board. Action complete.

3/17 27 Jan 17 26/17 Charitable Funds Annual Report &

Accounts

In response to earlier comments from Mrs G Easson regarding accounting of a donation from MedEquip4Kids for the Treehouse play equipment, Mr F Patel advised that he was confident that any donations had been fully taken into account within the relevant Financial Year. He noted that there had been a number of donations from MedEquip4Kids in recent years and agreed to provide Mrs G Easson with appropriate assurance on the treatment of the donation in question outside the meeting.

Update on 23 Feb 2017 – Mr F Patel had provided assurance to Mrs G Easson with regard to the accounting treatment. Action complete.

F Patel

4/17 23 Feb 17 46/17 Trust Performance Report – Month 10

Ms S Toal noted a presentation which Ms M Malkin, Interim Director of Community Business Group, had given to Emergency Department Consultants on the development of new models of care as part of the Stockport Together Programme and it was proposed that Ms M Malkin be invited to deliver the same presentation at the Board meeting in March 2017.

S Toal

5/17 23 Feb 17 50/17 Trust Agency

Utilisation Update

Mrs J Shaw noted that a report detailing measures to ensure compliance with the revised IR35 arrangements would be presented to the Board of Directors at the meeting in March 2017.

Mrs J Shaw

6/17 23 Feb 17 52/17 Key Issues Reports – People Performance

Committee

In response to a question from Mr J Sandford who queried workforce planning in the context of Stockport Together developments, it was agreed that workforce planning would be considered in detail at the Board strategy session in April 2017.

J Shaw

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Report to: Board of Directors Date: 30th March 2017

Subject: Patient Experience: Story of Care

Report of: Director of Nursing and Midwifery Prepared by: Assistant Director of Nursing

REPORT FOR APPROVAL

Corporate objective ref:

Patient Experience

Summary of Report

The purpose of a patient story at the Board of Directors’ meetings is to bring the patient’s voice to the Board, providing a real and personal example of the issues within the Trust’s quality and safety agendas. It may also help to share the experiences of front-line staff and enhance understanding of the human factors involved in episodes of harm.

It is not intended to revisit the specific details of the story but rather to acknowledge that lessons have been learned where necessary and improvements to practice and care made.

Board Assurance Framework ref:

-----

CQC Registration Standards ref:

-----

Equality Impact Assessment:

Completed √ Not required

Attachments: None

This subject has previously been

reported to:

Board of Directors

Council of Governors

Audit Committee

Executive Team

Quality Assurance

Committee

FSI Committee

Workforce & OD Committee

BaSF Committee

Charitable Funds Committee

Nominations Committee

Remuneration Committee

Joint Negotiating Council

Other

21 of 200

- THIS PAGE IS INTENTIONALLY BLANK -

22 of 200

“It’s like going in for a loaf of bread and coming out with two bags of shopping” Comment from patient, Mrs J, 2017

This story is from a lady who was admitted for an elective hip replacement in February 2017. Feedback was given whilst the lady was an inpatient. She wanted to share her story with others and to pass on her overall praise for the staff.

Mrs J lives with her daughter and suffered from osteoarthritis which resulted in reduced mobility. She was a planned admission for hip replacement under the ERAS (Enhanced Recovery after Surgery) programme. The surgery had been cancelled for 4 weeks due to winter pressures within the Trust.

Following surgery she had been catheterised and the nurses had noticed that there appeared to be blood in her urine. She had been reviewed by a doctor and a referral made to the urology team who had seen her within 24 hours and arranged follow-up. She had suffered with incontinence for over 30 years following previous treatment for cancer. She had been discharged from follow-up over 10 years ago. For a number of years she had suffered worsening urinary incontinence and more recently her urine had appeared at times to be blood stained. She had not wanted to bother anyone with her symptoms as she had felt ashamed of her incontinence hoping that it might just stop. She was relieved that she was to be investigated and that she could have a long term catheter.

She praised all members of the multidisciplinary team and said she felt that the staff took great care to ensure that she was well looked after.

Less positively, she suffered hallucinations which had disturbed her sleep one night and had been very frightening. Her medication was reviewed and changed and the hallucinations had stopped.

Also she found the hospital food unappetising but again remarked that the staff had offered to change the meal.

Her overall comments were that staff worked hard and she would recommend the hospital to her friends and family.

Her daughter was pleased that her mother’s ongoing health needs were being addressed and commented that the nurses had shown her how to care for her mother’s catheter. This she felt was important as she now felt confident to help look after her mother when she was discharged from hospital.

Learning points: team working and the importance of timely review of medication.

Comments have been shared with the staff involved.

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Report to:

Board of Directors

Date:

30th March 2017

Subject: Trust Performance Report – Month 11

Report of:

Chief Operating Officer

Prepared by: Joanne Pemrick

Head of Performance

REPORT FOR APPROVAL


-----

Summary of Report

Key operational points to note:

ED was the only area of non-compliance against the Single

Oversight Framework metrics.

There was 1 reportable 12 hour trolley wait in ED in month.

RTT performance was compliant with the National standard for

the 4th consecutive month.

Cancer 62 day standard is predicted to achieve in month 11

Respiratory OWL increased in month due to medical staffing

challenges.

There was a high number of electives cancelled on the day due

to non-clinical reasons, mainly due to bed pressures.

Cancer 62 day target underachieved in month, and challenges remain

for November.

Cardiology OWL increased in month as expected dutinicesoenterology

OWL has again significantly reduced in month.


Completed

Not required

Attachments:

Appendix 1

Monitor score card


reported to:

Board of Directors


Audit Committee

Executive Team

Quality Assurance

Committee

FSI Committee


BaSF Committee





Other

25 of 200

1. Introduction This report provides a summary of performance against the NHSI Single Oversight Framework for the month of February 2017, including the key issues and risks to delivery. It also provides, in section 4, a summary of the key risk areas from the Trust Integrated Performance Report which is attached in full in Annex A.

2. Compliance against Single Oversight Framework The table below shows performance against the indicators in the Single Oversight Framework that came into effect 1st October 2016. The forecast position for March is also indicated by a red (non-compliant) or green (compliant) box.

3. Month 11 Performance against Single Oversight Framework There was one area of non-compliance against the regulatory framework in month 11: i) A&E 4hr target

A) 4hr standard

Attendances in February were higher than January but lower than the same month in the

preceding year. Admissions rates were similar to the same month last year.

Patients who’s ongoing care is delayed and remain in hospital still presents a significant

barrier to flow within the hospital. Home based capacity is being expanded to support care

at home to enable discharge to assess. Until fully established, the Stockport Urgent Care

system is rapidly exploring additional community bed based capacity to enable assessment

and discharge processes to be undertaken in a non-acute hospital bed.

There was 1 reportable 12 hour trolley wait breach in February which was due to a long wait

for a bed during surge in demand.

StandardMonitoring

PeriodOct-16 Nov-16 Dec-16 Q3 Jan-17 Feb-17

Mar-17

(f.cast)

Maximum time of 18 weeks from point of referral to

treatment (RTT) in aggregate: Patients on an incomplete

pathway

92% Monthly 91.50% 92.40% 92.10% 92.00% 92.10% 92.50%

A&E maximum waiting time of four hours from arrival to

admission/ transfer/ discharge: 95% Monthly 77.60% 78.90% 69.40% 75.30% 70.50% 75.20%

All cancers: Maximum 62-day wait for first treatment

from: urgent GP referral for suspected cancer 85% 81.42% 85.11% 89.10% 86.00% 85.40% 87.30%

All cancers: maximum 62-day wait for first treatment

from: NHS Cancer Screening Service referral 90% n/a n/a n/a n/a n/a n/a n/a

Maximum 6-week wait for diagnostic procedures

99% Monthly 99.70% 99.80% 99.60% 99.70% 99.80% 99.70%

Monthly

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B) Average attendances: 244 per day in February

C) Admission rates of patients: 76 per day in February

D) DTOC levels were an average of 70 per day in February

However, the back end of the month saw a steeper increase in DTOC, with numbers rising to 80 per day.

E) Emergency admissions via A&E > 1day LOS: average 55/day in February

27 of 200

Future risks to compliance against the new Single Oversight Framework Future risks to compliance with the new framework are:

ED o Dependent on mobilisation of the Home based capacity and how quickly additional

community bed based capacity can be secured.

RTT o Dependent on the delayed impact of winter on the admitted backlog.

Cancer 62 day o Dependent on the delayed impact of patient initiated postponement of

appointments during the festive holiday period.

4. Key Risks/hotspots from the Integrated Performance Report

4.1 Quality

Discharge Summary The percentage of discharge summaries published within 48 hours was 88.1% in February. The volumes of patients coming through the acute assessment areas and staff vacancies

within Acute Medicine are the significant factors for trajectory below performance. These

vacancies within Acute Medicine have meant that the doctors working in these areas have

not been rotated to have specific days for HCR completion. Recruitment within Acute

Medicine has started to improve the performance.

Clinical Correspondence The overall Trust performance for February was 61%. Outsourcing is now underway in Ophthalmology and agency typists are in post in the Medicine Business Group.

Patient Experience Overall in February, the trust scored 93% extremely likely or likely to recommend. The ED score improved to 89%.

Pressure Ulcers Acute Trust The number of new pressure ulcer incidents and the severity being reported within the acute trust has decreased significantly this month by more than 50%, new Pressure Ulcer incidents reduced from 30 to 14. The peaks seen in previous months correlate directly to the impact of winter pressures.

4.2 Performance

Outpatient Waiting Lists: Gastroenterology Reduction is still continuing as planned and further progress expected whilst the locum support is in place. Cardiology Cohorting of patients by diagnosis code continues to inform the most appropriate follow-up pathway for each patient. High risk surveillance patients are monitored and given priority Respiratory Additional capacity is being provided by switching current clinic models. Clinical validation of the waiting list continues. High risk surveillance patients are still being monitored and given priority.

28 of 200

Ophthalmology Post-op cataract follow-ups will commence to be being undertaken by Optometrist from April. A service review is planned for the end of March will fully explore the opportunities for further follow-up pathway redesign; virtual clinics/out of hospital follow-up.

Assurance has been provided that there is minimal clinical risk in this backlog, as high risk surveillance patients are monitored separately and given priority.

Emergency Readmissions General surgery: The redesign regarding hot clinics for lap chole patients will now move into Business as usual. Urology : Urology are incorporating the hot clinic scenario for nephrostomy patients business as usual. Further readmission projects for next year are being are in the process of being worked up.

Cancelled Operations: Last minute cancellations due to non-clinical reasons There were a total of 32 cancellations on the day for non-clinical reasons. 14 of these were due to no bed availability.

4.3 Finance

Financial Performance In the eleven months to February 2017 the Trust has made a £11.0m loss. The planned deficit was £14.1m, so this is £3.1m better than plan. However as covered in previous reports, the NHSI control total excludes Sustainability & Transformation Fund (STF) variances and impairments. Therefore, compared to the issued control total the variance is £1.4m favourable to the profiled plan.

Excluding the STF, total income is better than plan by £4.2m to date, but expenditure is worse than plan by £3.6m giving an EBITDA favourable variance to plan of £0.6m which is unchanged from last month. Compared to the control total the Trust is £1.4m favourable to date. This is due to the agreed injection of funds for Urgent Care from Greater Manchester, paid via Stockport CCG, in relation to the increased costs within the system. Elective income is in line with plan in month, as in-patient procedures cancelled are being offset by increased day-case throughput and varying levels of out-sourcing. The forecast out-turn position remains unchanged from last month, which is £0.4m favourable to the bottom line forecast, but in line with the control total. As covered in previous reports, this improvement is due to on-going dialogue with partners in Stockport, the local Devolution Manchester representatives and the regional NHS Improvement teams to explore all available opportunities to improve the forecast financial position.

CIP In total to February 2017 CIP is £5.4m behind the profiled plan; £17.5m (68%) was expected by this stage in the year and £12.2m (47%) has been transacted. £13.8m of savings (54%) of the £25.7m annual savings target has been achieved, of which the recurrent effect in 2017/18 is unchanged at £8.0m. There is a significantly higher element of recurrent CIP than in previous years, along with £5.8m of non-recurrent savings and transactional CIP. Although in-year achievement of CIP has improved during February by £0.2m, these continue to be in-year savings and have not improved the Trust’s underlying financial position recurrently. Strategic level transformation change projects have not delivered as planned and remain central to the financial viability of the Trust in the medium term.

29 of 200

To improve the forecast and offset the shortfall in CIP the Trust has been extremely well supported by GMH&SCP and NHSI in the delivery of the control total. The achievement of the control total for the Stockport NHS FT remains a significant challenge and is the key focus of the Trust to explore all potential avenues and improve the financial sustainability of the organisation.

Expenditure variance

The expenditure budgets are now £3.6m adverse to plan, including the shortfall in CIP. Some of these increased costs are covered by additional income invoiced to Stockport CCG and Stockport MBC as part of Stockport Together and in support of the Stockport urgent care system. Pay costs in February were £17.4m, in line with planned costs. Agency expenditure in January was £1.3m, increasing the year-to-date total costs to £12.0m. This is now at a level above the profiled NHSI agency ceiling to date. The agency expenditure forecast for the full financial year has remained static in month at £13.6m. The annual agency cap from NHSI is £12.1m, so with expenditure of £12.0m to the end of February this will definitely be exceeded at the year end. As referred to above under Elective Income, there have been significant amounts of in-sourcing and out-sourcing which have cost £1.4m to date; £0.6m orthopaedics, £0.2m ophthalmology, £0.4m endoscopy, £0.2m general surgery, ENT and urology. To achieve the required year end forecast and the control total agreed with NHSI, the Trust must improve by £4m in March 2017. This recovery is due to the strategic level actions agreed with Greater Manchester and NHS Improvement, as well as one-off technical financial adjustments, rather than any improvement in the underlying run-rate. There are therefore likely to be irregular variances between income and expenditure categories in the March financial position, but the Trust is still expected to mitigate the fluctuating risks and achieve the required control total position.

Financial sustainability Under the Single Oversight Framework the Trust’s Use of Resources (UOR) finance score is a 3, classified by NHSI as triggering significant concerns. The Trust’s operational plan for 2016/17 predicted a score of 3 for February 2017 and actual performance is in line with this. Cash in the bank on 28th February 2017 was £23.6m, which is an increase of £0.2m from last month and £6.2m better than planned. In the main this is due to continued lower capital cash payments than planned, receipt of £2.2m urgent care support from Greater Manchester via Stockport CCG, and advance payments from SMBC for Q4. The Sustainability & Transformation Fund (STF) cash for Q3 and Q4 has not yet been received

4.4 Workforce

Essentials training In February 2017 compliance was the same as the January 2017 position, at 87.7%. This is likely to be as a result of the winter pressures and the difficulty in releasing staff to attend training. From April 2017, mandatory training will only be available via e-learning for the majority of staff. The exception will be for facilities staff who do not have regular access to IT facilities.

Appraisals

The Trust’s total appraisal compliance for February 2017 is 91.71%, a decrease of 1.6% since January 2016 (93.31%). Although there has been a drop in compliance this month, the compliance rate compares favourably when compared with similar Trusts throughout Greater Manchester and is one of the Trusts top five rankings in the 2016 staff survey

30 of 200

Turnover The Trust staff in post for February 2017 is 88.96% of the establishment, which is a slight decrease of 0.19% from 88.77% in January 2017. Medical and Dental staff group have the highest vacancy percentage rate of 31.99% (161.88 FTE), however Registered Nursing and Midwifery have the highest vacancy FTE at 175.70 FTE in February 2017. Work continues to look to recruit to vacancies from international routes as well as the recent launch of a nursing recruitment campaign and ongoing recruitment days.

Induction

Corporate Welcome attendance is 94.23% in February 2017 with 3 people failing to attend Corporate welcome (2 Healthcare Assistants and 1 Telephonist). Non-attendance at Corporate Welcome is unusual and the Learning and Development are addressing this issue in conjunction with the Recruitment Team.

Efficiency Bank & Agency costs Bank and agency costs in February 2017 of £2.03m account for 11.7% of the £17.41m total pay costs. This is an increase of 0.3% from the position reported in January 2017 (£1.91m). Medicine business group has the highest spend on bank and agency across the Trust at £1.14m which equates to 56% of the bank and agency spend and 7% of the Trust total paybill. Agency expenditure has increased from the lowest 5.0% in October 2016 to 7.7% in February 2017. Bank costs have increased from the lowest 2.9% in April 2016 to 4.0% of costs in February 2017, and are reflective of winter pressures and hard to recruit posts in Nursing and Medical Staffing. Agency shifts above cap February 2017 shows an increase of 88 in the number of shifts above the agency cap, from 1,954 in January 2017 to 2,042 in February 2017. January’s reporting period was 4 weeks. A total of 2,042 shifts above wage or agency cap were worked between 30th January and 26th February, an increase of 88 shifts from the previous month. The majority of these shifts were within Medicine, of which 1,012 shifts were for medical staff. Throughout all business groups, a total of 1,118 shifts were worked by agency medical staff above cap. In an effort to reduce agency spend, NHSI have instructed Trusts not to allow workers with other substantive NHS employment to cover shifts via an agency. Discussions have begun regarding the creation of an internal bank to address this, including the development of a collaborative bank with other GM Trusts.

Sickness Absence The in-month unadjusted sickness absence figure for February 2017 is 4.02%. This is a decrease of 0.10% compared to the January 2017 adjusted figure of 4.12%. The sickness rate for comparison in February 2016 was 4.65%.

The unadjusted cost of sickness absence in February 2017 is £379,448, a decrease of £96,279 from the adjusted figure of £475,727 in January 2016. This does not include the cost to cover the sickness absence. Surgical & Critical Care Business Group are below the 3.5% target in February 2017.

31 of 200

The continued high absence level in Estates & Facilities is attributed to a spike in long term conditions within domestic services, and has reduced from 6.25% in January 2017.

5. Recommendations The Board is asked to:

Note the current position for month 11 compliance against standards.

Note the future risks to compliance and corresponding actions to mitigate.

Note the key risks areas from the Integrated Performance Report.

32 of 200

Integrated Performance Report

March 2017

IPR 1

www.stockport.nhs.uk Stockport | High Peak

Outer ring; Year-to-date performance. Middle ring, latest quarter. Inner ring, latest month.

Mortality is assessed on the latest 12 months, CIP (Cost Improvement Programme) on the year-to-date.

3.Finance

CIP

Financial Sustainability

Income Variance

Capital

Financial

Performance

Expenditure Variance

1.Quality 2.Performance

4.Workforce

Key to wheels:

Patient experience

Dementia FAIR

Falls

Pressure ulcers

C. diff.

Mortality

Discharge summary /

clinic letters

RTT 18 weeks

A&E

4 hours

Diagnostic

tests

Cancelled operations

Cancer

Emergency

Readmission

Outpatient Waiting

List

Appraisals

Turnover

Essentials

Training

Engagement Efficiency

Induction

Sickness

Absence

33 of 200



March 2017

IPR 2


Changes to this month’s report March 2017

Cancelled operations:28 day rebook standard - figure for January amended, 4 incidences reportable, not 5 as show in last months report.


Monitor indicators (in Risk Assessment Framework): Monitor indicators for which we have made forward declaration:

Corporate Strategic Risk Register rating (current or residual): Risks rated on severity of consequence multiplied by likelihood, both based on a scale from 1 to 5. Ratings could range from 1 (low consequence and rare) to 25 (catastrophic and almost certain), but are only shown for significant risks which have an impact on the stated aims of the Trust, with an initial rating of 15+.

Data Quality: Kite Marking given to each indicator in this report This scoring allows the reader to understand the source of each indicator, the time frame represented, and the way it is calculated and if the data has been subject to validation. The diagram below explains how the marking works.

M M15

Key to indicators:

Filled Blank Automated Not Automated

Filled Blank Trust Data National Data

Filled Blank Validated Unvalidated

Filled Blank Current Month Not Current Month

34 of 200



March 2017

IPR 3


Chart 1

Chart 2

Chart 3

Chart 4

Overall in February, the trust scored 93% extremely likely or likely to recommend:

Feedback Themes (acute): ED (adult) Positive comments were again received relating to staff attitude, the care and treatment received. Many comments noted how busy the department was. Negative comments again related to long waiting times and having to wait in corridor areas.

Inpatients (adults) Positive themes related to excellent care and treatment, approachable/ friendly staff. Several negative comments related to poor communication.

Maternity Positive comments included friendly supportive staff in both antenatal and post-natal feedback. Comments such as “caring” and “helpful” were often stated.There were no negative comments received.

Paediatrics (inpatients)Similar to last month – all comments received were positive and related to staff attitude and care.

Day case: Positive comments again related to staff attitude, with several stating they found staff to be “helpful” and “polite”. Negative comments included cancelled operations on the day.

Out Patients Positive comments this month highlighted staff showing compassion, while negative comments although relatively few related to waiting times to see the doctor.

IPad Inpatient Surveys In February 259 inpatient iPad surveys were undertaken, which is an increase of 20 compared to the number completed in January. Overall, the trust scored 85% positive responses in February, which is a 1% decrease on January. February has seen a slight increase

93%

89%

95%

98%

92%

89%

3%

5%

2%

1%

3%

4%

20% 0% 20% 40% 60% 80% 100%

Combined (4,221)

A&E (902)

Inpatient & D.C. (1,894)

Maternity (310)

Outpatient (523)

Community (592)

Friends and Family Test % recommend by type of service (90% KPI target for highlighted services):

February 2017

wouldn't would recommend

service (no. of responses)

93% would

3% wouldn't20%

0%

20%

40%

60%

80%

100%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Q4 Q1 Q2 Q3 Q4

2015/16 2016/17

% would/n't recommend

Friends and Family Test % recommend(combined responses from all services)

21%

0%

10%

20%

30%


Q4=21% Q1=20% Q2=22% Q3=20% Q4=21%

2015/16 2016/17

% of eligible patients

A&E Friends and Family Test response rate (2016/17 KPI target >=20%)

38%

20%

30%

40%

50%


Q4=35% Q1=35% Q2=37% Q3=31% Q4=34%

2015/16 2016/17

% of eligible patients

Inpatient & Day Case Friends and Family Test response rate (2016/17 KPI target >=40%)

AREA

Response rate

February

Variance on

previous month (RR)

% extremely

likely / likely to recommend

February

Variance on

previous month (% Rec)

ED inc children’s ED

21% same 89% +2%

Inpatients 30% +5% 94% -1%

Maternity (Birth)

50% -7% 99% +1%

Outpatients 40% -2% 92% same

Daycase 38% same 96% +1%

Community 27% same 88% -3%

Patient Experience

35 of 200



March 2017

IPR 4


in positive responses from patients being asked about having found some to talk to about worries and fears (2%) and getting enough emotional support (2%) however less positive reposes were seen n questions relating to noise at night from other patients (12%) and assistance with eating a meal was also down (5%).

Return to FRONT page Chart 5

Chart 6

Chart 7

Charts 5 to 7 show performance against the dementia standards. Compliance with standard is expected to continue.

97%

50%

60%

70%

80%

90%

100%


Q4=96.8% Q1=96.6% Q2=98.3% Q3=97.6% Q4=96.7%

2015/16 2016/17

% relevant patients

Patients asked Dementia Finding question within 72hrs (KPI target >=90%)

92%

50%

60%

70%

80%

90%

100%


Q4=98.9% Q1=96.8% Q2=97.2% Q3=92.9% Q4=92.3%

2015/16 2016/17

% relevant patients

Patients receiving Dementia Assessment & Investigation (KPI target >=90%)

100%

50%

60%

70%

80%

90%

100%


Q4=100.0% Q1=98.2% Q2=100.0% Q3=100.0% Q4=100.0%

2015/16 2016/17

% relevant patients

Patients receiving Dementia Referral (KPI target >=90%)

Dementia

36 of 200



March 2017

IPR 5


Return to FRONT page

Chart 8

Chart 8 shows compliance with discharge summary completion within 48hrs. The percentage of discharge summaries published within 48 hours was 88.1% in February. Recuritment in Acute Medicine has started to improve performance in the Acute areas.


Chart 9

Chart 10

Chart 9 shows the performance against the clinical correspondence standard of 95% of Outpatient letters to be typed within 7 days. The overall Trust performance for February was 61%. Chart 10 details the longest wait for those specialties not achieving the 7 day turn-round in February. Outsourcing is now underway in Ophthalmology and agency typists are in post in the Medicine Business Group.

88.1%

70%

80%

90%

100%


Q4 Q1=87.2% Q2=87.7% Q3=87.4% Q4=87.9%

2015/16 2016/17

% of discharges

Discharge summary published within 48 hours, admitted patient care (KPI target >= 95%)

% waiting within 7 days

% typed within 7 days , 61%

0%

20%

40%

60%

80%

100%


Q4=92.6% Q1=95.5% Q2=82.7% Q3=74.6% Q4=65.5%

2015/16 2016/17

Overall Score

waiting 14 days or less (target up to Aug-16)

% within KPI target

Clinical Correspondence (Outpatient Letters) % typed in 7 days or less (KPI target >=95%)

Department Longest wait (days)

Cardiology 28

Chest 21

DMOP 23

Gastroenterology 16

Maxfax 19

Ophthalmology 26

Paediatrics 21

Rheumatology 15

Clinical correspondence (typing backlog)

Discharge Summary Discharge summary (published within 48 hours)

37 of 200



March 2017

IPR 6



Chart 11

This year’s target is 19 or below avoidable falls. In February there was 2 patients who had a fall. One of these falls is still under investigation Year to date:

There have been 44 falls graded major and

above April – end of February

37 have occurred in Medicine, 7 in Surgery

and 0 in Child and family.

There have been 7 avoidable falls, these

have occurred on B2, E2, C2, A11, AMU1, TU

and A10.

31 falls out of the 44 were deemed

unavoidable.

7 are still under investigation

To date the Trust is on target to meet its

trajectory for 2016/17.

New guidelines from the Royal College of Physciains have been circulated for taking Lying and standing BP. These will be incorporated into the revised training programme.

The Trust has registered for the National audit of inpatient falls (NAIF) for 2017. Data will be inputted between 15th – 2nd June 2017

Chart 12

The stretch target for Stockport Acute services is zero tolerance of avoidable pressure ulcers grade 3 and 4 by the end of 2017. In February, there have been 2 category 3 and above pressure ulcers reported for acute services, both of which have been deemed avoidable. The total avoidable pressure ulcers this financial year is 21.

The number of new pressure ulcer incidents and the severity being reported within the acute trust has decreased significantly this month by more than 50%, new Pressure Ulcer incidents reduced from 30 to 14. Which reinforces the previous

00

10

20

30

40

50


Q4=7 Q1=5 Q2=2 Q3=0 Q4=0

2015/16 2016/17

falls, major and above

Falls incidence (causing major harm

and above) 2016/17 target<=19YTD Unavoidable YTD Under review

YTD Avoidable annual cum. target

Stockport Acute - Total Avoidable

20

5

10

15

20

25

30

35

40

45

50


Q4=5 Q1=3 Q2=3 Q3=9 Q4=6

2015/16 2016/17

pressure ulcers

Stockport Acute Pressure Ulcer incidence (grade 3 and above) 2016/17 target =0

YTD Unavoidable

YTD Under review

YTD Avoidable

annual cum. target

Stockport Acute - Total

Avoidable

Falls

Pressure Ulcers 16

16

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March 2017

IPR 7


Chart 13

explanation that the peaks in harm seen in December and January, correlated directly to the impact of the recent winter pressures.

The stretch target for Stockport Community is 50% reduction in grade 3 and 4 avoidable pressure ulcers by end of 2017. The target is 6 avoidable pressure ulcers for the year. In February there have been 3 new grade 3 or 4 pressure ulcers reported, one of which is still under review, and 2 have been deemed unavoidable. Bringing the total avoidable severe pressure ulcers this financial year in the community to 16.

The Trusts improving Wound Care DIP has now been devised and agreed by the newly formed Wound Care Steering Group, chaired by the DNS. This group will oversee the implementation of the trusts 3 year pressure ulcer prevention and management strategy plan that has now also been agreed.

Return to FRONT page Chart 14

There has been 5 cases of Clostridium difficile in February, the total number YTD is 35. Of these 35 cases 25 have been reviewed with the other 10 cases still under review. We have been advised by the CCG that fifteen cases reviewed by them do not have significant lapses in care and do not reach the threshold for reporting; however 10 cases do have significant lapses in care and do reach the threshold for reporting. Therefore 15 cases would not count towards the trajectory of 17 significant lapses in care but 10 cases will.

00

10

20

30

40

50

60


Q4=5 Q1=8 Q2=4 Q3=3 Q4=1

2015/16 2016/17

pressure ulcers

Community Pressure Ulcer incidence (grade 3 and above) 2016/17 target <=3

YTD Unavoidable

YTD Under review

YTD Avoidable

annual cum. target

Community - Total

Avoidable

00

10

20

30

40

50

60


Q4=7 Q1=3 Q2=5 Q3=1 Q4=1

2015/16 2016/17

number of infections

C. diff. infections (2016/17 objective <=17 due to lapses in care )

YTD Not lapses in care YTD Under review

YTD Lapses in care annual cum. target

Total C-diff cases Due to lapses in care

Clostridium difficile (C. diff.) infections M

39 of 200



March 2017

IPR 8



Summary Hospital-level Mortality Indicator (SHMI) This is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there. It covers all deaths reported of patients who were admitted to non-specialist acute trusts in England and either die while in hospital or within 30 days of discharge. Data source: Health and Social Care Information Centre Chart 15

Mortality analysis now includes 3 measures, SHMI, RAMI, and HSMR (not Dr Foster HSMR but a proxy provided by the CHKS software). Where possible data is shown to represent performance over time, against peers and with weekend/week comparisons. Whilst overall mortality profile is good and reported as Green, investigation is needed into the varying mortality at the weekend compared to the week. This would be in tandem with the Trust 7 day services action plan

Chart 16

Chart 17


0.96

0.6

0.8

1.0

1.2

1.4

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

2015/16 2016/17

SHMI value (baseline = 1)

End of rolling 12 month period

Trend of Summary Hospital-level Mortality Indicator (SHMI) for Stockport NHS FT

expected range

0.6

0.8

1.0

1.2

1.4

0 1000 2000 3000 4000 5000


expected number of deaths for each trust

Summary Hospital-level Mortality Indicator July 2015 - June 2016

all non-specialist acute trusts Greater Manchester trusts Stockport

exp

ecte

d

range

weekday, 0.94

weekend, 1.04

0.6

0.8

1.0

1.2

1.4

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

2015/16 2016/17



Trend of calculated SHMI value for Stockport NHS FT weekend and weekday admissions,

emergency admissions only

Mortality

40 of 200



March 2017

IPR 9


Risk Adjusted Mortality Index (RAMI) The main differences in calculation from SHMI are: RAMI only includes in-hospital deaths; it excludes patients admitted as emergencies with a zero length of stay discharged alive, and patients coded with receiving palliative care; the estimates of risk used to work out the number of expected deaths are calculated once per year (“rebasing”), data is shown here using latest 2014 benchmarks; RAMI includes data from the whole patient spell rather than just the first two admitting consultant episodes. Data source: CHKS Chart 18

Chart 19

Chart 20


0.750.6

0.8

1.0

1.2

1.4

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2015 2016

RAMI 2016 value


Trend of overall RAMI (CHKS) for Stockport NHS FT (against constant benchmark)

0.6

0.8

1.0

1.2

1.4

1.6

0 500 1000 1500 2000 2500 3000 3500

RAMI 2016 value

expected number of deaths for each trust

RAMI (CHKS) Jan-16 to Dec-16with value and expected range for all trusts shown

all non-specialist acute trusts Greater Manchester trusts Stockport

expected range

weekday

weekday, 0.74

weekend

weekend, 0.76

0.6

0.8

1.0

1.2

1.4


2015 2016

RAMI 2016 value


Trend of RAMI value for Stockport NHS FT weekend and weekday admissions, non-elective

admissions only

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March 2017

IPR 10


Hospital Standardised Mortality Data (HMSR) The main differences in calculation from SHMI are: HSMR only includes in-hospital deaths; the factors used in estimating the number of patients that would be expected to die includes whether patients are coded with receiving palliative care, and socio-economic deprivation; the estimates of risk used to work out the number of expected deaths are calculated once per year (“rebasing”), data is shown here using latest benchmarks. Data source: CHKS (using Dr Foster Intelligence methodology) Chart 21

42 of 200



March 2017

IPR 11



Chart 22

Chart 23

Chart 24

Chart 25

Chart 22 shows performance against the RTT Incomplete standard. The Trust achieved 92.5% against the National standard in February. Two specialties remain non-compliant; ENT and Oral Surgery. However, both specialties have again improved their level of performance from the previous month. Service reviews are planned to take place for both of these specialties to understand future requirements and options. Charts 24 and 25 show the number of patients waiting beyond 18 weeks split by admitted and non-admitted pathways. The total number of patients waiting beyond 18 weeks at the end of January was 1496. The number of admitted pathways > 18 weeks reduced to 500 at month end.

92.5%

85%

90%

95%

100%


Q4=91.8% Q1=91.2% Q2=91.2% Q3=92.0% Q4=92.3%

2015/16 2016/17

% within 18 weeks

Referral to Treatment: Incomplete pathways (quarterly Monitor target

>=92%)monthy performance NHSI trajectory

92.3%

92.4%

92.0%

88.5%

97.2%

93.1%

92.9%

94.7%

92.4%

93.9%

96.9%

←84.7%

85% 90% 95% 100%

General Surgery (2714)

Urology (1912)

Trauma & Orthopaedics (3201)

ENT (1723)

Ophthalmology (2011)

Oral Surgery (1309)

Neurosurgery (0)

Cardiothoracic Surgery (29)

General Medicine (3616)

Rheumatology (319)

Geriatrics (446)

Gynaecology (1200)

Other (1469)

% within 18 weeks

Incomplete pathways by specialty: Feb-2017

Specialty (number of pathways)

Admitted

500

0

250

500

750

1000


2015/16 2016/17

number over 18 weeks

RTT: Incomplete pathways (2016/17 KPIs target <=200 admitted)

Non-admitted

996

0

500

1000

1500


2015/16 2016/17

number over 18 weeks

RTT: Incomplete pathways (2016/17 KPIs target <=1000 non-admitted)

Referral to Treatment (RTT) waiting times

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March 2017

IPR 12



Chart 26

Chart 27

Chart 28

Chart 26 shows compliance against the 4hr A&E standard. Performance against the 4hr standard in Febraury

was below trajectory but improved from the

previous 2 months. Attendances in Febraury were

higher than January but lower than the same month

in the preceding year. Admissions rates were

similar to the same month last year.

Patients who’s ongoing care is delayed and they

remain in hospital still presents a significant

barrier to flow within the hospital. Home based

capacity is being expanded to support care at home

to enable discharge to assess. Until fully

established, the Stockport Urgent Care system is

rapidly exploring additional community bed based

capacity to enable assessment and discharge

processes to be undertaken in a non-acute hospital

bed.

There was 1 reportable 12 hour trolley wait breach

in February which was due to a long wait for a bed

during surge in demand.

75.2%

65%

75%

85%

95%


Q4=73.0% Q1=82.1% Q2=76.7% Q3=75.3% Q4=72.8%

2015/16 2016/17

% within 4 hours

A&E time from arrival to admission/ transfer/ discharge (quarterly Monitor

target >=95%)

monthy performance

NHSI trajectory

244(-5.8%)

200

220

240

260

280

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Q1 Q2 Q3 Q4

average attendances per day

Trend of A&E attendances 2016/17. Year-to-date change on 2015/16 = +1.2%

2015/16

2016/17

Accident & Emergency, Urgent Care & Flow

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March 2017

IPR 13


Chart 29

Source: Greater Manchester Academic Health Science Network.


83.7%

91.0%

72.4%

79.8%

84.7%

80.7%

90.2%

86.8%

70% 80% 90% 100%March 2017 to date

80.8%

81.7%

73.8%

72.2%

78.9%

74.9%

83.7%

82.0%

70% 80% 90% 100%

Bolton

Bury

North Manchester

Oldham

Salford

Stockport

Tameside

Wigan

Qtr 4 2017 to Date

A&E department (Major, Type 1)

'UM Gold' A&E performance, total time in dept. within 4 hours

Chart 30

Chart 31

Chart 32

Chart 33

250218

0

100

200

300

400

500

600


Q4=369 Q1=217 Q2=355 Q3=563 Q4=250

2015/16 2016/17

number Ambulance handovers - NWAS only, financial exclusions applied (KPI target = 0 per month)

Handovers > 30 mins

Handovers > 60 mins

7

977

0

500

1000

1500

2000

2500


Q4=1772 Q1=1121 Q2=1574 Q3=2237 Q4=977

2015/16 2016/17

number >12 hour ED trolley waits & >=8 hour total time in ED (KPI targets = 0)

ED total time >=8 hours

12 hour trolley waits (DTAto admission time)

00:29

00:00

00:15

00:30

00:45

01:00


Q4=0:28 Q1=0:21 Q2=0:26 Q3=0:32 Q4=0:31*

2015/16 2016/17

Time to Initial Assessment

Time to Initial Assessment (95th percentile)Arrivals by Ambulance

*latest quarter includes current month’s data

00:36

00:00

00:15

00:30

00:45

01:00


Q4=0:47 Q1=0:40 Q2=0:50 Q3=0:52 Q4=0:43*

2015/16 2016/17

Time to Initial Assessment

Time to Initial Assessment (95th percentile)Walk in attendances


45 of 200



March 2017

IPR 14


Chart 37

The following charts (37 to 45) are the high level KPIs to measure progress realized through the implementation of the Urgent care 90 day plan.

29%

10%

20%

30%

40%

50%


Q4=32% Q1=35% Q2=31% Q3=30% Q4=29%

2015/16 2016/17

% of GP init. adms.

GP initiated emergency admissions, % who arrive via ED (Trust total)

previous year monthy performance

Chart 34

Chart 35

Chart 36

00:41

00:30

00:45

01:00

01:15

01:30


Q4=1:30 Q1=1:03 Q2=1:09 Q3=1:03 Q4=0:47*

2015/16 2016/17

Time to seen for treatment

Time from Arrival to Seen for Treatment (median time)


2.9%

0%

2%

4%

6%

8%


Q4=5.1% Q1=3.8% Q2=5.2% Q3=5.0% Q4=3.2%

2015/16 2016/17

% of ED attendances

% Left ED without being seen

6.6%

0%

2%

4%

6%

8%


Q4=6.5% Q1=6.8% Q2=6.9% Q3=7.0% Q4=7.0%

2015/16 2016/17

% of ED attendances

ED Unplanned Re-Attendance Rate (within 7 days)

46 of 200



March 2017

IPR 15


Chart 38

Chart 39

Chart 40

31%

27%

0%

10%

20%

30%

40%


Q4=30% Q1=29% Q2=29% Q3=31% Q4=32%

2015/16 2016/17

% of ED attendances

% ED attendances admitted (conversion rate)

previous year ED conversion rate

monthy ED conversion rate

conversion excluding ED admissions to ACU

18%

0%

10%

20%

30%

40%


Q4=24% Q1=23% Q2=23% Q3=17% Q4=17%

2015/16 2016/17

% of ACU activity

ACU conversion to "full" ward admission (all specialties)

33%

0%

10%

20%

30%

40%


Q4=31% Q1=32% Q2=33% Q3=32% Q4=31%

2015/16 2016/17

% of AMU activity % patients on AMU discharged from AMU

47 of 200



March 2017

IPR 16


Chart 41

Chart 42

Chart 43

SAFER - is intended to improve the patient journey by ensuring an efficient pathway from admission to discharge by delivering timely appropriate care at the right time in the right place. Key metrics have been agreed to measure SAFER performance which includes discharges before 12md and 16:30hrs as shown in chart 33 and 34. All wards are invited to attend monthly performance meetings to report compliance against these key metrics and actions plans developed as appropriate. A team from the Emergency Care Improvement Programme (ECIP) is supporting further implementation of SAFER. Work has commenced on three wards, namely: A1, A11 and E2 for an 8 week period until the end of Jan 2017.

5.2

0

1

2

3

4

5

6


Q4=4.9 Q1=4.9 Q2=4.9 Q3=4.8 Q4=5.1

2015/16 2016/17

days Average emergency Length of Stay (Trust total)

previous year monthy performance

58

0

20

40

60

80

100

120


Q4 avg.=41 Q1 avg.=64 Q2 avg.=80 Q3 avg.=69 Q4 avg.=77

2015/16 2016/17

patients delayed

Total inpatients with Delayed Transfers of Care (snapshot at last Thursday in month, includes

delays attributable to Local Authorities)

KPI target (10)

monthly snapshot

19%

0%

10%

20%

30%

40%


Q4=19% Q1=22% Q2=23% Q3=25% Q4=19%

2015/16 2016/17

% of discharges

Discharges before 12:00 (time left last ward, trust total, excludes deaths in hospital, emergency

admissions staying overnight)

48 of 200



March 2017

IPR 17


Chart 44

Chart 45

Identifying patients for discharge at the weekend is just as important as weekday discharges to continue flow and create capacity. An action plan has been developed to strengthen roles and responsibilities’ of the on call team at weekend in order to ensure robust plans are in place and adhered to.


Chart 46

Chart 46 shows performance against the diagnostic standard.


44%

30%

40%

50%

60%

70%


Q4=44% Q1=42% Q2=43% Q3=42% Q4=44%

2015/16 2016/17

% of discharges

Discharges between 12:00 and 16:30 (time left last ward, trust total, excludes deaths in hospital,

emergency admissions staying overnight)

59%

0%

20%

40%

60%

80%

100%


Q4=18% Q1=18% Q2=18% Q3=19% Q4=19%

2015/16 2016/17

chance of discharge on weekend

Weekend discharge rate (trust total emergency admissions, excludes deaths in hospital, target

rate 80% of weekday average)

99.7%

95%

96%

97%

98%

99%

100%


Q4=99.9% Q1=99.2% Q2=99.7% Q3=99.7% Q4=99.8%

2015/16 2016/17

% waiting <6 weeks

Patients waiting at month end for one of 15 diagnostic tests (Monthly KPI >=99%)

monthy performance

NHSI trajectory

Diagnostic tests (6 week wait) 16

49 of 200



March 2017

IPR 18


Chart 47

Chart 47 shows no breach of standard in month.

Chart 48

Chart 48 shows failure to meet standard in February. There were a total of 32 cancellations on the day for non-clinical reasons. The top reasons for cancellation were:

14 due to no bed / no HDU bed 8 due to lack of theatre time 3 due to urgent case taking priority 3 due to surgeon sickness on the day


00

1

2

3

4

5


Q4=4 Q1=4 Q2=2 Q3=2 Q4=4

2015/16 2016/17

number of patients

Patients not treated within 28 days of last minute elective cancellation

(monthly KPI target =0)

0.97%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%


Q4=1.68% Q1=0.79% Q2=0.70% Q3=0.99% Q4=0.80%

2015/16 2016/17

% of elective admissions

Last minute elective operations cancelled for non clinical reasons

(shown against threshold <=0.85%)

Cancelled Operations 20

50 of 200



March 2017

IPR 19


The Outpatient Waiting List (OWL) is where patients are placed when awaiting a future follow up appointment. When capacity and demand are mismatched, the numbers of patients who are overdue their follow up by a certain date will increase and delay these patients. There are four specialties within the Trust where this is a current problem. This situation is being monitored by the Quality Assurance Committee (a sub-committee of the Board of Directors). This committee requested that the data should be shared with the Board through the Integrated Performance Report. The Trust has been issued a First Exception Report based on performance against the original clearance trajectories and is now required to provide a refreshed plan for each of the four specialties in addition to completed Quality Impact Assessments to confirm patient care is not being compromised. Chart 49 Ophthalmology OWLs past due date

Ophthalmology Post-op cataract follow-ups will commence to be being undertaken by Optometrist from April. A service review is planned for the end of March will fully explore the opportunities for further follow-up pathway redesign; virtual clinics/out of hospital follow-up. Assurance has been provided that there is minimal clinical risk in this backlog, as high risk surveillance patients are monitored separately and given priority.

Chart 50 Gastroenterology OWLs past due date

Gastroenterology Chart 50 shows the number of Gastroenterology patients on the Outpatient waiting list beyond their due date. Reduction is still continuing as planned and further progress expected whilst the locum support is in place.

699

0

500

1,000

1,500

2,000


Q4=333 Q1=515 Q2=721 Q3=706 Q4=724

2015/16 2016/17

number past due date

OWL overdue - Ophthalmology excluding Glaucoma and Diabetic Retinopathy

recovery plan monthy performance

1,372

0

500

1,000

1,500

2,000


Q4=2095 Q1=2199 Q2=2205 Q3=1605 Q4=1396

2015/16 2016/17


OWL overdue - Gastroenterology

Outpatient Waiting List (OWL) Outpatient Waiting List (OWL)

20

51 of 200



March 2017

IPR 20


Chart 51 Respiratory Medicine OWLs past due date

Respiratory Medicine Additional capacity is being provided by switching current clinic models. Clinical validation of the waiting list continues. High risk surveillance patients are still being monitored and given priority.

Chart 52 Cardiology OWLs past due date

Cardiology Cohorting of patients by diagnosis code continues to inform the most appropriate follow-up pathway for each patient. High risk surveillance patients are

monitored and given priority.


Chart 53

Compliance with the urgent referral standard continues.

772

0

250

500

750

1,000


Q4=554 Q1=629 Q2=496 Q3=579 Q4=781

2015/16 2016/17


OWL overdue - Chestrecovery plan monthy performance

1,623

0

500

1,000

1,500

2,000


Q4=343 Q1=1078 Q2=1547 Q3=1545 Q4=1596

2015/16 2016/17


OWL overdue - Cardiologyrecovery plan monthy performance

97.2%

70%

75%

80%

85%

90%

95%

100%


Q4=97.5% Q1=97.1% Q2=96.8% Q3=96.7% Q4=96.9%

2015/16 2016/17

% within 2 weeks

Urgent Cancer: referral to date first seen (quarterly Monitor target >=93%)

Cancer waiting times 16M

52 of 200



March 2017

IPR 21


Chart 54

Chart 55

Chart 56

97.4%

70%

75%

80%

85%

90%

95%

100%


Q4=98.1% Q1=98.3% Q2=98.9% Q3=98.2% Q4=96.1%

2015/16 2016/17

% within 2 weeks

Breast patients: referral to date first seen (quarterly Monitor target >=93%)

96.9%

70%

75%

80%

85%

90%

95%

100%


Q4=98.3% Q1=97.9% Q2=98.8% Q3=98.1% Q4=97.0%

2015/16 2016/17

% within 31 days

All cancers: diagnosis to first treatment (quarterly Monitor target >=96%)

100.0%

70%

75%

80%

85%

90%

95%

100%


Q4=100.0% Q1=100.0% Q2=100.0% Q3=100.0% Q4=100.0%

2015/16 2016/17

% within 31 days

2nd or subsequent anti-cancer treatment: Surgery (quarterly Monitor

target >=94%)

53 of 200



March 2017

IPR 22


Chart 57

Chart 58

Chart 58 shows performance against the 62 day cancer standard. The current predicted performance for February is 87.3%

Chart 59 GP referral to first treatment with breach reallocation, by tumour group.

Chart 59 shows performance against the 62 day standard by tumour group.


100.0%

70%

75%

80%

85%

90%

95%

100%


Q4=100.0% Q1=100.0% Q2=100.0% Q3=100.0% Q4=100.0%

2015/16 2016/17

% within 31 days

2nd or subsequent anti-cancer treatment: Drug (quarterly Monitor target

>=98%)

87.3%

70%

75%

80%

85%

90%

95%

100%


Q4=86.8% Q1=90.2% Q2=85.5% Q3=86.0% Q4=86.4%

2015/16 2016/17

% within 62 days

Urgent GP cancer referral to first treatment - with breach reallocation

(quarterly Monitor target >=85%)

Monthly performance NHSI trajectory

Tumour Group

(Feb-17 data)

Performance

(85% target)

Monthly

trend

Urology 2 / 29

Haematology 1.5 / 2.5

Lung 1 / 2

Upper GI 0.5 / 5.5

Colorectal 0.5 / 3

Breast 0 / 10.5

Head & Neck 0 / 2.5

Gynaecology 0 / 2

Number of

breaches / cases

93%

40%

50%

91%

83%

100%

100%

100%

54 of 200



March 2017

IPR 23


Chart 60

Data source: CHKS / Health and Social Care Information Centre

Chart 60 shows the Emergency Readmission rate within 28 days of discharge. General surgery: The redesign regarding hot clinics for lap chole patients will now move into Business as usual. Urology : Urology are incorporating the hot clinic scenario for nephrostomy patients business as usual. Further readmission projects for next year are being are in the process of being worked up.


8.6%

0%

2%

4%

6%

8%

10%


Q3=8.7% Q4=7.8% Q1=7.9% Q2=8.4% Q3=8.6%

2015/16 2016/17

% rate Emergency Readmission rate within 28 days of discharge (shown vs. National rate)

Emergency Readmissions

55 of 200



March 2017

IPR 24


Chart 61

Chart 62

Chart 63

In the eleven months to February 2017 the Trust has made a £11.0m loss. The planned deficit was £14.1m, so this is £3.1m better than plan. However as covered in previous reports, the NHSI control total excludes Sustainability & Transformation Fund (STF) variances and impairments. Therefore compared to the issued control total the variance is £1.4m favourable to the profiled plan. Excluding the STF, total income is better than plan by £4.2m to date, but expenditure is worse than plan by £3.6m giving an EBITDA favourable variance to plan of £0.6m which is unchanged from last month. Compared to the control total the Trust is £1.4m favourable to date. This is due to the agreed injection of funds for Urgent Care from Greater Manchester, paid via Stockport CCG, in relation to the increased costs within the system. Elective income is in line with plan in month, as in-patient procedures cancelled are being offset by increased day-case throughput and varying levels of out-sourcing. The forecast out-turn position remains unchanged from last month, which is £0.4m favourable to the bottom line forecast, but in line with the control total. As covered in previous reports, this improvement is due to on-going dialogue with partners in Stockport, the local Devolution Manchester representatives and the regional NHS Improvement teams to explore all available opportunities to improve the forecast financial position. In total to February 2017 CIP is £5.4m behind the profiled plan; £17.5m (68%) was expected by this stage in the year and £12.2m (47%) has been transacted. £13.8m of savings (54%) of the £25.7m annual saving has been achieved, of which the recurrent effect in 2017/18 is unchanged from prior months at £8.0m (31%).

961

613

(879)

1,846

(673)

539

555

(1,126)

86

(1,000)

(500)

-

500

1,000

1,500

2,000

Pla

nn

ed

(D

efi

cit

)

ST

F

Clin

ica

l In

co

me

Oth

er

Inc

om

e

Pay

Co

sts

No

n P

ay C

osts

CIP

Fin

an

cin

gA

cti

vit

ies

Actu

al (D

efi

cit

)

£ 000s February 2017

Variance to Financial Plan

(14,106)

(11,031)

613

4,057

57

2,089

(2,265)

(3,387)

1,910

0

(14,500)

(13,500)

(12,500)

(11,500)

(10,500)

(9,500)

(8,500)

(7,500)

Pla

nn

ed

Su

rplu

s/

(Defi

cit

)

ST

F

Clin

ica

l In

co

me

Oth

er

Inc

om

e

Pay

Co

sts

No

n P

ay C

osts

CIP

Fin

an

cin

gA

cti

vit

ies

Actu

al (D

efi

cit

)

£ 000s

Year to Date Variance to Financial Plan 2016/17

(£16M)

(£14M)

(£12M)

(£10M)

(£8M)

(£6M)

(£4M)

(£2M)

-


2016 2017

Cumulative Trust Financial Position

Actual deficit (greenif favourable to plan)

Actual deficit (red ifadverse to plan)

Planned deficit

Financial Performance

56 of 200



March 2017

IPR 25



Chart 64

£7.5m capital costs have been incurred to date, against a plan of £9.4m so is £1.9m behind the profiled plan. This is due to a reduction in estates non-backlog maintenance, IT hardware and medical equipment purchases, in line with actions linked to protecting cash earlier in the year. Purchase of a new fluoroscopy machine for the radiology department has been delayed, so to compensate for this various items of medical equipment have been brought forward from the 2017/18 capital programme where goods can be delivered by 31st March 2017. IT spend has also been fast tracked for PC replacement and wireless access points totalling £0.7m. NHSI have not allowed a capital to revenue transfer of underspend within the financial year, but discussion is underway regarding the capitalisation of staff time associated with key capital projects. The above actions will bring the final out-turn capital spend within the NHSI tolerance of +/- 15% of the original plan.

Plan 2016/17 Year to Date February 2017

Description Year Plan Actual Variance

£'000 £'000 £'000 £'000

Surgical & Medical Centre - Building 3,740 3,740 3,343 397

Surgical& Medical Centre - Furniture & Fittings 600 600 97 503

Surgical& Medical Centre - Medical Equipment (partly donated) 660 660 1,392 (732)

Medical Ward Refurbishments 250 250 - 250

Emergency Department Expansion - - 219 (219)

Electronic Patient Records - Purchased Software 598 250 6 244

Electronic Patient Records - Estates Enabling scheme b/f 55 55 134 (79)

Facilities Equipment b/f 60 60 - 60

Medical Equipment b/f 52 52 - 52

Aspen House Server Room b/f - - (4) 4

MRI Estates Enabling works b/f - - 7 (7)

6,015 5,667 5,193 473

Medical Equipment 1,290 1,345 695 650

Facilities Equipment 75 - (5) 5

IT Hardware 503 496 277 218

IT Software 297 259 154 105

Estates -Backlog Maintenance 125 115 43 72

Estates - Non Backlog Maintenance 710 665 157 508

3,000 2,880 1,322 1,558

9,015 8,546 6,515 2,031

Revenue to Capital - - 179 (179)

Capital to Revenue - - (13) 13

TOTAL (excluding Finance leases) 9,015 8,546 6,681 1,865

New Finance Lease Contracts

I M & T - Intersystems EPR Software 1,006 862 862 0

I M & T - EMIS Community EPR Software - - - -

1,006 862 862 0

TOTAL including new Finance Lease Contracts 10,021 9,408 7,543 1,865

Capital Programme

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March 2017

IPR 26


Chart 65


In total to February 2017 CIP is £5.4m behind the profiled plan; £17.5m (68%) was expected by this stage in the year and £12.2m (47%) has been transacted. £13.8m of savings (54%) of the £25.7m annual savings target has been achieved, of which the recurrent effect in 2017/18 is unchanged at £8.0m. There is a significantly higher element of recurrent CIP than in previous years, along with £5.8m of non-recurrent savings and transactional CIP. Although in-year achievement of CIP has improved during February by £0.2m, these continue to be in-year savings and have not improved the Trust’s underlying financial position recurrently. Strategic level transformation change projects have not delivered as planned and remain central to the financial viability of the Trust in the medium term. To improve the forecast and offset the shortfall in CIP the Trust has been extremely well supported by GMH&SCP and NHSI in the delivery of the control total. The achievement of the control total for the Stockport NHS FT remains a significant challenge and is the key focus of the Trust to explore all potential avenues and improve the financial sustainability of the organisation.

£0M

£5M

£10M

£15M

£20M

£25M


2016 2017

Cumulative CIP Achievement

Red Plans

Amber Plans

Bold Actions Achieved

BAU Achieved

FIP Achieved

Target

Cost Improvement Programme

58 of 200



March 2017

IPR 27


Chart 66

Chart 67

Under the Single Oversight Framework the Trust’s Use of Resources (UOR) finance score is a 3, classified by NHSI as triggering significant concerns. The Trust’s operational plan for 2016/17 predicted a score of 3 for February 2017 and actual performance is in line with this. Cash in the bank on 28th February 2017 was £23.6m, which is an increase of £0.2m from last month and £6.2m better than planned. In the main this is due to continued lower capital cash payments than planned, receipt of £2.2m urgent care support from Greater Manchester via Stockport CCG, and advance payments from SMBC for Q4. The Sustainability & Transformation Fund (STF) cash for Q3 and Q4 has not yet been received.


Chart 68

Elective income was in line with plan in February; although in-patient activity continues at a reduced level this continues to be countered by increased day-case throughput. Year-to-date elective income is £1.1m favourable to plan, but this must be considered in line with the high cost of delivering this additional capacity.

Rating Trigger Excellent Poor Weight Weighted

Finance & Use of Resources Metrics Override 1 2 3 4 score

Financial sustainability Capital service cover 4 Yes 2.50 1.75 1.25 < 1.25 20% 0.8

Financial sustainability Liquidity (days) 2 No 0 -7 -14 < -14 20% 0.4

Financial efficiency I&E margin (%) 4 Yes 1.0% 0.0% -1.0% <-1.0% 20% 0.8

Financial controls Distance from financial plan (%) 1 No 0.0% -1.0% -2.0% <-2.0% 20% 0.2

Financial controls Agency spend 1 No < 0% 0% 25% 50% 20% 0.2

Finance Use of Resource Metric (UOR) - Calculated 3

OVERRIDE TRIGGERED? Yes Yes

Finance Use of Resource Metric (UOR) - Final Reportable 3

£23.6m

£3m loan October 2016

£9m loan August 2016

£0M

£10M

£20M

£30M

£40M


Q4 Q1 Q2 Q3 Q4

2015/16 2016/17

Cash Position by Month

Actual

Forecast

£25m minimum, equivalent to 30 days cash

-

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000


Elective Income - £sDay Case actuals Inpatients actuals Plan

Financial Use of Resources Rating

Elective Income vs. Plan

59 of 200



March 2017

IPR 28


Chart 69

Surgery have in-sourced 599 cases, in orthopaedics and ophthalmology, and out-sourced to non-NHS providers a further 281 cases. In addition, the Surgical & Critical Care business group has seen 1,443 patients as part of waiting list sessions above standard sessions. This is to deal with increased demand and tackle RTT backlogs, particlularly in Ophthalmology. Within the Surgery business group 12% of overall elective activity to date has been delivered at these premium rates. This is in excess of the over-performance against plan, meaning that both additional and planned capacity is being provided at premium cost which is not sustainable. This is not isolated to with the Surgery business group, as within Diagnostics & Clinical Support Endoscopy are 609 cases ahead of plan, but have spent £0.5m on in-sourcing and waiting list initiatives in year. Work with Four Eyes Insight on theatre productivity and scheduling continues, and the 6-4-2 scheduling system is now in place. A key risk to delivery is uncovered sessions in March due to annual leave booked, but utilisation benefits should be felt from April 2017. This is linked to the Trust’s transformation projects and the need to release additional internal capacity to enable the Trust to meet demand and undertake additional work more cost effectively.

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000


Elective Income - Activity

Day Case activity Inpatients activity Plan

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March 2017

IPR 29


Chart 70

The expenditure budgets are now £3.6m adverse to plan, including the shortfall in CIP. Some of these increased costs are covered by additional income invoiced to Stockport CCG and Stockport MBC as part of Stockport Together and in support of the Stockport urgent care system. Pay costs in February were £17.4m, in line with planned costs. Agency expenditure in January was £1.3m, increasing the year-to-date total costs to £12.0m. This is now at a level above the profiled NHSI agency ceiling to date. The agency expenditure forecast for the full financial year has remained static in month at £13.6m. The annual agency cap from NHSI is £12.1m, so with expenditure of £12.0m to the end of February this will definitely be exceeded at the year end. As referred to above under Elective Income, there have been significant amounts of in-sourcing and out-sourcing which have cost £1.4m to date; £0.6m orthopaedics, £0.2m ophthalmology, £0.4m endoscopy, £0.2m general surgery, ENT and urology. To achieve the required year end forecast and the control total agreed with NHSI, the Trust must improve by £4m in March 2017. This recovery is due to the strategic level actions agreed with Greater Manchester and NHS Improvement, as well as one-off technical financial adjustments, rather than any improvement in the underlying run-rate. There are therefore likely to be irregular variances between income and expenditure categories in the March financial position, but the Trust is still expected to mitigate the fluctuating risks and achieve the required control total position.

394K

51K

11K

154K

557K395K

523K

866K

130K303K

27K

20K

729K

183K385K

53K 35K

548K

1,408K1,362K

382K

59K

(£800K)(£600K)(£400K)(£200K)

0£200K£400K£600K£800K

£1000K£1200K£1400K£1600K


2016 2017

Trust Expenditure Variance (above axis is worse than plan)

Pay Non-Pay

Expenditure Variance

61 of 200



March 2017

IPR 30


Chart 71

In the eleven months to the end of February the Trust is £4.2m ahead of plan on income, excluding the Sustainability & Transformation Fund income. This is due to the agreed injection of funds for Urgent Care from Greater Manchester, paid via Stockport CCG, in relation to the increased costs within the system, as agreed to support the year end forecast position. There is also a further £1.2m of income invoiced to Stockport CCG and Stockport MBC as part of Stockport Together transformation projects and in support of the Stockport urgent care system. Non-elective income continues to be effected by the growing number of patients with delayed transfers of care (DTOCs) and increased length of stay, as explained in previous reports. DTOCs peaked at nearly 100 beds, and this has been a contributory factor in the launch of the Trust’s “Home for Easter” campaign in early April. The adverse position on Other Income shown in the above graph is due to the shortfall in planned revenue generation CIP projects, including the bold scheme intentions around sale of land. The financial position on the Stockport CCG block is being closely monitored and discussed with the CCG as part of the reconciliation of the overall financial position and as part of planning for 2017/18. It is likely that a full and final settlement will be reached with Stockport CCG to limit the impact of any differences in March activity levels hitting the next financial year. See also Financial Income and Expenditure table

495K

765K

163K 173K 258K

480K174K

1,182K

539K183K

1,896K

49K

18K 8K 61K 1K

153K 92K

641K912K

1,075K

668K

(£1500K)

(£1000K)

(£500K)

0

£500K

£1000K

£1500K

£2000K

£2500K


2016 2017

Trust Income Variance (above axis is better than plan)

Clinical Income Other Income

Income Variance

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March 2017

IPR 31


Chart 72

Chart 73

The Trust’s total appraisal compliance for February 2017 is 91.71%, a decrease of 1.6% since January 2016 (93.31%). Although there has been a drop in compliance this month, the compliance rate compares favourably when compared with similar Trusts throughout Greater Manchester and is one of the Trusts top five rankings in the 2016 staff survey. Efforts continue to support business groups to achieve the Trust’s 95% target.

The medical appraisal rate for February 2017 is 92.83%, a decrease of 2.03% from January 2017 (94.86%). The compliance rates and the importance of the completion of Appraisals continue to be presented at the Trust’s monthly Team Briefing sessions.


92%

50%

60%

70%

80%

90%

100%


Q4=82% Q1=87% Q2=93% Q3=95% Q4=93%

2015/16 2016/17

% staff appraised

Staff having annual appraisal(target >=95%)

93%

50%

60%

70%

80%

90%

100%


Q4=88% Q1=88% Q2=93% Q3=94% Q4=94%

2015/16 2016/17

% staff appraised

Medical appraisals(target >=95%)

Workforce Appraisals

63 of 200



March 2017

IPR 32


Chart 74

Chart 75

The Trust staff in post for February 2017 is 88.96% of the establishment, which is a slight decrease of 0.19% from 88.77% in January 2017. Medical and Dental staff group have the highest vacancy percentage rate of 31.99% (161.88 FTE), however Registered Nursing and Midwifery have the highest vacancy FTE at 175.70 FTE in February 2017. Work continues to look to recruit to vacancies from international routes as well as the recent launch of a nursing recruitment campaign and ongoing recruitment days.

89.0%

50%

60%

70%

80%

90%

100%


Q4=92% Q1=89% Q2=89% Q3=88% Q4=89%

2015/16 2016/17

% staff posts (WTE)

Staff in post(target >=98%)

Workforce Turnover

64 of 200



March 2017

IPR 33


Chart 76

Chart 77

The Trust’s adjusted permanent headcount turnover figure for the 12 months ending February 2017 excluding retire and return and TUPE transfers is 13.19% (green line on chart 5) against a national average rate of 13.93%. This is an increase of 1.83% compared to the adjusted January 2017 figure of 11.36%. The unadjusted permanent headcount turnover figure is 28.24% for the 12 months ending February 2017. The unadjusted turnover rate for comparison to February 2016 was 11.66%. Community Healthcare has the highest turnover rate at 31.49%, attributed to the TUPE transfer of several services. Medicine Business Group remains high at 17.58% in February 2017. Allied Health Professionals have the highest turnover percentage which is predominantly due to the community service TUPE transfers; followed by Registered Nursing & Midwifery. In support of the exit interview process the Corporate Nursing team provide staff, who have tendered their resignation, or are considering in doing so with the opportunity to meet and discuss any issues / alternatives. This has had a positive impact in a number of areas


Chart 78

Pay is overspent by £0.027m in February 2016, decreasing the year-to-date variance to a £1.524m favourable position.

16.2%

1.0%

0%

5%

10%

15%


Q4=11.5% Q1=11.5% Q2=12.9% Q3=15.9% Q4=16.1%

2015/16 2016/17

% Permanent headcount

Workforce Turnover(target <=10%)

forecastrolling 12-month turnoverin-month turnoverAdjusted excluding R&R

(£27k)

(£ 1,000)

(£ 500)

-

£ 500

£ 1,000

£ 1,500


Q4=£1,029k Q1=£354k Q2=£1,106k Q3=(£213k) Q4=£276k

2015/16 2016/17

£ 000s Trust Pay Variance(shown with cumulative quarters)

Workforce Efficiency

65 of 200



March 2017

IPR 34


Chart 79

Chart 80

Chart 81

Bank and agency costs in February 2017 of £2.03m account for 11.7% of the £17.41m total pay costs. This is an increase of 0.3% from the position reported in January 2017 (£1.91m). Medicine business group has the highest spend on bank and agency across the Trust at £1.14m which equates to 56% of the bank and agency spend and 7% of the Trust total paybill. Agency expenditure has increased from the lowest 5.0% in October 2016 to 7.7% in February 2017. Bank costs have increased from the lowest 2.9% in April 2016 to 4.0% of costs in February 2017, and are reflective of winter pressures and hard to recruit posts in Nursing and Medical Staffing.

February 2017 shows an increase of 88 in the number of shifts above the agency cap, from 1,954 in January 2017 to 2,042 in February 2017. January’s reporting period was 4 weeks. A total of 2,042 shifts above wage or agency cap were worked between 30th January and 26th February, an increase of 88 shifts from the previous month. The majority of these shifts were within Medicine, of which 1,012 shifts were for medical staff. Throughout all business groups, a total of 1,118 shifts were worked by agency medical staff above cap. In an effort to reduce agency spend, NHSI have instructed Trusts not to allow workers with other substantive NHS employment to cover shifts via an agency. Discussions have begun regarding the creation of an internal bank to address this, including the development of a collaborative bank with other GM Trusts.

11.7%

0%

5%

10%

15%


Q4=11% Q1=10% Q2=9% Q3=9% Q4=12%

2015/16 2016/17

% pay costs Bank and Agency pay costs(target <=5%)

Bank & Agency costs

Bank Staff

Agency Staff

2042

0

1000

2000

3000

4000

5000

6000


Q4=1133 Q1=3441 Q2=4494 Q3=5009 Q4=3996

2015/16 2016/17

number of shifts

Agency Shifts Above Captarget zero above cap, based on weekly data

66 of 200



March 2017

IPR 35



Chart 82

Corporate Welcome attendance is 94.23% in February 2017 with 3 people failing to attend Corporate welcome (2 Healthcare Assistants and 1 Telephonist). Non-attendance at Corporate Welcome is unusual and the Learning and Development are addressing this issue in conjunction with the Recruitment Team. Local induction has remained at 100% in February 2017 with all business groups achieving the 100% compliance with the local induction target.

Chart 83


To be developed

100%

0%

20%

40%

60%

80%

100%


Q4=76% Q1=52% Q2=58% Q3=69% Q4=100%

2015/16 2016/17

% staff inducted

Local Induction(target 100%)

Workforce Induction

Staff Engagement

67 of 200



March 2017

IPR 36


Chart 84

Chart 85

The in-month unadjusted sickness absence figure for February 2017 is 4.02%. This is a decrease of 0.10% compared to the January 2017 adjusted figure of 4.12%. The sickness rate for comparison in February 2016 was 4.65%. The unadjusted cost of sickness absence in February 2017 is £379,448, a decrease of £96,279 from the adjusted figure of £475,727 in January 2016. This does not include the cost to cover the sickness absence. Surgical & Critical Care Business Group are below the 3.5% target in February 2017. The continued high absence level in Estates & Facilities is attributed to a spike in long term conditions within domestic services, and has reduced from 6.25% in January 2017. The top 3 known reasons for sickness in February 2017 are back problems and other musculoskeletal problems including injury/fracture at 28.56% (a 2.29% increase from 26.27% in January 2017, stress at 26.56% (a 3.66% increase from 22.90% in January 2017), and cough, cold, Influenza, chest, respiratory problems at 11.61% (a 7.78% decrease from 19.39% in January 2017). This is reflective of the picture nationally. Staff Health & Wellbeing remains high on the Trust agenda and attendance management is monitored within business groups and monthly through performance meetings.


4.0%

0%

1%

2%

3%

4%

5%

6%


Q4=4.7% Q1=3.8% Q2=3.7% Q3=4.3% Q4=4.1%

2015/16 2016/17

% staff absent (FTE)

Staff with Sickness Absence (<=3.5% Full Time Equivalent basis from Sep-16)

Sickness Absence

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March 2017

IPR 37


Chart 86

In February 2017 compliance was the same as the January 2017 position, at 87.7%. This is likely to be as a result of the winter pressures and the difficulty in releasing staff to attend training. Non-compliance within specific departments and wards is currently being identified and addressed through the Business Group specific Quality and Governance Boards.

All staff receive regular notifications to remind them of forthcoming mandatory training sessions they are booked onto in addition to the monthly reminders as they are about to or are non-compliant.

Mandatory training compliance is a key component in successful incremental pay progression. In addition, external training will only be approved if a member of staff is fully compliant with their mandatory training. From April 2017, mandatory training will only be available via e-learning for the majority of staff. The exception will be for facilities staff who do not have regular access to IT facilities.


87.7%

75%

80%

85%

90%

95%

100%


Q4=89.4% Q1=88.3% Q2=87.2% Q3=89.1% Q4=87.7%

2015/16 2016/17

% staff trained

Staff attending "Essentials" Mandatory Training in last 3 years (target >=95%)

Essentials Training

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March 2017 Financial Table

IPR 38


Trust

Income and Expenditure Statement Annual

Plan Plan Actual Variance

£k £k £k £k

INCOME

Elective 41,627 37,787 38,875 1,088

Non Elective 76,163 69,538 68,734 (804)

Outpatient 34,459 31,314 31,147 (167)

A&E 12,130 11,110 11,118 8

Total Income at Full Tariff 164,379 149,749 149,874 125

Community Services 30,081 27,706 27,984 278

Non-tariff income 62,143 55,519 59,956 4,437

Memo line: Sustainability & Transformation Fund (STF) 8,400 6,300 6,913 613

Clinical Income - NHS 256,604 232,974 237,814 4,840

Private Patients 698 640 194 (445)

Other 959 879 1,107 228

Non NHS Clinical Income 1,656 1,518 1,301 (217)

Research & Development 474 426 421 (5)

Education and Training 7,277 6,680 6,879 199

Stockport Pharmaceuticals/RQC 5,517 5,061 4,711 (350)

Other income 19,276 17,226 17,524 298

Other Income 32,544 29,393 29,534 141

TOTAL INCOME 290,804 263,885 268,649 4,764

EXPENDITURE

Pay Costs (205,688) (191,986) (190,462) 1,524

Drugs (18,104) (16,866) (17,648) (782)

Clinical Supplies & services (19,099) (17,782) (20,570) (2,788)

Other Non Pay Costs (39,577) (37,807) (39,360) (1,553)

TOTAL COSTS (282,468) (264,442) (268,041) (3,599)

EBITDA 8,336 (556) 608 1,165

Depreciation (9,094) (8,297) (8,004) 293

Interest Receivable 63 57 63 5

Interest Payable (936) (859) (833) 26

Other Non-Operating Expenses (708) (649) (163) 486

Fixed Asset Impairment Reversal - - 1,184 1,184

Unwinding of Discount (30) - - -

Profit/(Loss) on disposal of fixed assets - - (84) (84)

Donations of cash for PPE 540 - - -

PDC Dividend (4,160) (3,802) (3,802) (0)

RETAINED SURPLUS / (DEFICIT) FOR PERIOD (5,988) (14,106) (11,031) 3,075

Trust

CONTROL TOTAL POSITION Annual

Plan Plan Actual Variance

£k £k £k £k

RETAINED SURPLUS / (DEFICIT) FOR PERIOD (5,988) (14,106) (11,031) 3,075

Add back:

Profit/(Loss) on disposal of fixed assets - - (84) (84)

Depreciation - donated/granted assets (24)

Donations of cash for PPE 540 - - -

Fixed Asset Impairment Reversal - - 1,184 1,184

STF 8,400 6,300 6,913 613

CONTROL TOTAL SURPLUS/ (DEFICIT) FOR PERIOD (14,904) (20,406) (19,043) 1,362

Year-to-date

Year-to-date

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Report to: Board of Directors Date: 30 March 2017

Subject: Trust Agency Utilisation Update

Report of: Director of Workforce & OD Prepared by:

Deputy Director of Workforce

REPORT FOR NOTING


N/A

Summary of Report

The purpose of this paper is to provide the Board of Directors with an update on the Trust’s agency utilisation and expenditure. At month 11 there is an adverse position against the planned ceiling trajectory of £0.6m. Actions are in place to look to address spend above the ceiling trajectory continue; however this is impeded by the increasing need for additional staffing requirements in response to the increasing service demand.

The cumulative end of year position is predicting a £1.5m adverse position, above the agency ceiling. The Board of Directors are asked to:

Note the contents of this report


N/A


N/A


Completed X Not required

Attachments:

This subject has previously been reported to:

Board of Directors Council of Governors Audit Committee Executive Team Quality Assurance Committee

F&P Committee

PP Committee SD Committee Charitable Funds

Committee Nominations Committee Remuneration Committee Joint Negotiating Council Other - WEEF

71 of 200


72 of 200

Trust Agency Utilisation & Self-Assessment Assurance

1. Introduction The purpose of this paper is to provide an update on the Trust’s agency utilisation and expenditure. The position is presented as at month 10 and provides the updated forecast month 12 position.

2. Current Position

During 2015/16 the expenditure on agency staff was £18.5m. In accordance with the NHSI processes and arrangements previously outlined the Trust was allocated an agency ceiling of £12.1m. The month 11 position (February 2017) indicates that agency expenditure is £11.9m against a 2015/16 spend of £17.1 demonstrates a significant reduction.

The agency spend for month 11 is £11.9m against the forecast trajectory position of £11.3m. This is the first month in which spend is above the agency ceiling, an adverse position of £600k. The cumulative end of year position is predicting a continuing adverse position of £1.5m above the agency ceiling.

The Trust continues to require agency staff in order to meet its demand on clinical services. The following is included in this forecast:

Tiger Team requirements including Community Unit

Additional nursing in ED until March Paramedics in ED (HALO)

A12 additional 12 beds to March (A14 now returned to B5) Community AHPs for Stockport Together Extra theatre nursing based on current levels (since Surgical Block opened) Corporate agency staff (Deputy Chief Operating Officer / project assistant / PMO

resources) Extension of medical posts approved by ECP

The increase in spend is in line with the forecast reported at month 10. There has been no additional requirements which have impacted on the forecast reported last month..

-

£2,000,000

£4,000,000

£6,000,000

£8,000,000

£10,000,000

£12,000,000

£14,000,000

£16,000,000

£18,000,000

£20,000,000

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Agency Ceiling Trajectory by Month 2016/17 Expenditure 2015/16

Agency Ceiling 2016/17

Actual 2016/17

73 of 200

This increased service and therefore workforce demand is reflected in the business group expenditure, detailed in the graph below. There is a notable decrease in the expenditure within the medicine business group, with an increase for corporate services however, this is due to the re-allocation of expenditure from medicine business group to corporate services.

3. Actions to Reduce / Mitigate Utilisation of Agency Staff

The Trust continues with a number of actions to look to minimise the number of agency staff required, recruit to vacancies and re-negotiate agency rates. However, the impact of these actions has been reduced by the increasing demands on the Trust services.

4. IR35 (intermediaries Legislation)

As detailed in February’s committee report actions have been taken to address the changes to IR35 legislation. 161 ‘off-payroll’ providers have been written to, advising them of the changes and the implications. We are working through the responses and taking action to ensure that these individuals are paid via the payroll in accordance with the revised arrangements. All agency providers (160) have also been written to and advised of the expectation the Trust consider deductions to be due for all staff they provide without exception and expect them to deduct payments accordingly. To date we have not received any responses indicating objections to this position. Furthermore, we have not had any rate increases applied to accommodate this at this time; however the legislation does not come into effect until April. The temporary staffing team will be closely reviewing this are to ensure that no rate increases are applied to compensate for the required deductions.

5. Recommendation

The Board of Directors are asked to note the contents of this report.

(200,000)

(100,000)

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

April May June July Aug Sept Oct Nov Dec Jan Feb

Agency Expenditure by Business Group, by Month

Child & FamilyServicesCommunityHealthcareCorporate

Diagnostic &Clinical SupportEstates &FacilitiesMedicine

74 of 200

- 1 of 7 -


Subject: Safe Staffing

Report of: Director of Nursing and Midwifery

Prepared by:

Deputy Director of Nursing and Midwifery

REPORT FOR APPROVAL


-----

Summary of Report There is a national requirement for a Nursing and Midwifery staffing review to be presented to the Board every 6 months.

Recent changes to the requirement for Non EU and now EU staff to pass an international English language course has adversely impacted on our ability to recruit to sufficient levels to support our establishment.

There is an increased reliance on temporary workers, both

bank and agency.

Delayed transfers of care, patient numbers and winter pressures have meant that additional beds have needed to be opened, putting additional pressure on nurse staffing.

This report represents the interim strategic staffing review across the organisation. The Board of Directors is asked to note the contents of this report and to note the challenges to established staffing levels over the last 6 months.


-----


-----


Completed

Not required

Attachments:


reported to:

Board of Directors


Audit Committee

Executive Team

Quality Assurance

Committee

FSI Committee

Workforce & OD

Committee

BaSF Committee

Charitable Funds

Committee




Other

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- 2 -


76 of 200

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1 INTRODUCTION

1.1 National Quality Board (NQB) recommendations require that all NHS organisations will take an annual strategic staffing review to their Board of Directors on the Registered Nurse and Midwifery staffing levels within their organisation and confirm whether they are adequate to meet the acuity and dependency of their patient population. This is then followed by a further comprehensive review after 6 months. This report presents the interim strategic staffing review for March 2017.

2 BACKGROUND

2.1 There is a greater focus now on ensuring that organisations have the right size and shape of the Nursing and Midwifery workforce to meet the needs and expectations of their patients. The National Quality Board recommendations (June 2016) suggest that establishment reviews are underpinned by the following 3 expectations;

Expectation 1; Right staff – achieved through evidence based workforce planning, professional judgment and comparison of staffing with peers

Expectation 2; Right skills – achieved through mandatory training, development and education, working as a multi professional team and through effective recruitment and retention

Expectation 3; Right place and time – achieved through productive working time and eliminating waste, through efficient deployment and flexibility and minimizing agency

This report will subsequently provide assurance against these 3 expectations.

3 3.1

CURRENT SITUATION Expectation 1: Right Staff The NQB recommends that there is an annual strategic staffing review, with evidence that is developed using a triangulated approach (accredited tools, professional judgment and a comparison with peers). This should be followed with a comprehensive staffing report to the board after 6 months. The NQB recommends use of the Safer Nursing Care Tool (SNCT) (adult inpatient wards) and Birth-rate plus (Maternity) and Professional judgement. This organisation has used these tools for several years.

3.2

Our approach to assuring safe staffing levels on our adult wards and within the Emergency Department (ED)

i. The NQB recommends assessment incorporating evidence based tools and also: staff to patient ratios (CHPPD/NHPPD), patient to staff ratios, skill mix, whole time equivalents (WTE), head count and fill rates. All these measurements are currently used by the organisation.

ii. The Safer Nursing care Tool (SNCT) is deployed as the evidence based tool. It is recommended that changes to establishments are made based on a minimum of two sets of data across the calendar year. The wards undertook their audit in late February 2017; SAU and ED will undertake the BEST audit in April 2017. NICE guidance advocates implementation of acuity based tool recommendations in conjunction with RN to patient ratios. Significant changes due to the opening of the new wards and the reconfiguration of

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3.3 3.4 3.5

wards within Medicine has meant that for many areas year on year comparisons are not now available. Detailed analysis will be needed to triangulate data and therefore the outcomes will be presented in the April safe staffing monthly report and action plans developed accordingly.

iii. The Emergency Department has significantly increased its footprint, and staffing levels and skill mix have been altered in light of the changes and challenges to safe staffing.

Triangulation of Quality metrics and staffing outputs All wards are subject to a triangulation of data with each 6 monthly acuity review, including:

i. Red flag reporting – red flag events are used to report an issue which staff feel is due to reduced staffing levels and/or increased patient acuity and covers delays in administering pain relief to a reduction of staffing greater than 25%. During the period of this report (September 2016 to February 2017) a total of 131 incidents (compared to 110 in the previous 6 months ) were reported SSOP, ACU, A1, A10 were the top 4 wards reporting red flags.

ii. Safe staffing figures for the 6 month period since September 2016 show an overall average fill rate of RN days 92% , RN Nights 96%, care staff days 100% and care staff nights 116%, against funded establishments.

iii. Nurse sensitive indicators – nationally evidenced indicators which deteriorate in the absence of RN presence. These include falls, pressure ulcers and medication errors, measured per 1000 bed days. For this period, the data is not robust due to the ward reconfiguration.

Our approach to achieving safe midwifery levels

i. The workforce requirements for the maternity unit are currently being calculated using the nationally recognised Birth rate Plus assessment process. A full report is expected to be available by May 2017. We will also use this opportunity to scope out what staffing would be required if the Maternity service was to deliver additional births in the future.

ii. We currently use the Birth-rate Plus Intrapartum tool which is based upon the principle of providing one to one care during labour and delivery to all women, with additional hours being identified for more complex deliveries. This is updated by the Delivery Suite Co-ordinator every 4hrs.

iii. The Birth-rate Plus overall recommended ratio is 1:29.5. Our funded Midwife to Birth ratio is agreed at 1:30, taking into account the role of the Assistant Practitioners in our workforce. For the period of reporting, the Midwife to Birth ratio was 1:29.99, an improvement from the previously reported 1:29.40

iv. In the same way as for adult in-patient wards, Maternity services are recommended to triangulate staffing data as follows:

Red flag staffing events – 23 flag events were reported by Delivery suite and Birth centre and related to staff not being able to take breaks. These will be reviewed by the Head of Midwifery

Safe staffing – fill rates for the period report above 95% Our approach to achieving safe community nursing levels

i. The September 2016 Staffing Report updated the Board regarding the review of Greater Manchester (GM) district nursing services. The report noted that ongoing changes in both skill mix and staffing models due to the Stockport Together Vanguard needed to be acknowledged with the

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3.6

additional investment that this had secured. Subsequently, discussions with Stockport CCG have secured an extra 5.0 WTE band 5 posts which will be funded from April 2017.

ii. Band 6 District Nurse Caseload Holders with the Specialist Practitioner (SP) Qualification continue to be a challenge to recruit locally and nationally with the shortfall of 6.73 WTE in the day time service although in 2017/18 funding has been secured from Health Education England for five band 5 staff to be seconded on the student SP programme.

iii. As part of the Stockport Together service modelling, transformation and business case development, a five year workforce plan for Integrated Neighbourhood teams (GPs, Social Workers and District Nurses) has been agreed. This sees a significant additional investment in non-registered staff, band 3 and band 2, over the next two years.

iv. NHS Improvement published this March, for consultation, draft guidance regarding district nursing: ‘An improvement resource for the district nursing service’. This improvement resource for providers looks to support safe, sustainable and productive staffing ensuring the right staff with the right skills in the right place at the right time. The resource refers to ‘safe caseloads in the district nursing service’ rather than ‘safe staffing’, as this better reflects the complexity of determining the required staffing levels. The improvement resource outlines a number of principles that apply in setting safe caseloads in the district nursing service and emphasises that these will apply where services are reconfigured, such as in the development of new health and social care models as in Stockport Together.

Our approach to achieving safe and effective Paediatric and Neonatal staffing levels

Neonatal Unit ward staffing

Current staffing levels meet National guidance.

Paediatric Ward staffing establishment

A survey of our peers showed that against most of the guidance there was no unit

that was fully compliant. The headlines from this document are:-

Supernumerary shift supervisor on all shifts o We have a full time supervisory Ward Manager and a Matron post in

addition to a team of Band 6 team leaders

At least one RN on every shift be APLS trained o Over the past 2 years we have recognised that the HDU module and

the Paediatric AIMs course are much more appropriate and useful to nurses working on our unit – we maintain compliance by having all of our registrars and Consultant medical staff APLS compliant and this covers the 24 hour service.

Minimum staffing ratio of 70:30 Registered to Non-registered o Our current ratio of Registered to Non-registered is 80:20 with a high

proportion of the non-registered staff being Assistant Practitioners who are paediatric trained

From April 2017 we will have a full rota of 24 hour cover of Band 6 nurses on the Treehouse – this is an increase of 2.0 WTE post holders since 2016 in line with the CQC recommendations for increased leadership on the night shift.

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3.7 3.8 3.9

Expectation 2 – Right skills The NQB states that clinical leaders should be supported at a local level to deliver high quality, efficient services with a staffing resource that reflects a multi professional team approach. Specifically, the following is recommended;

Establishments should take into account the need for staff to undertake training and fulfil all professional development requirements. Leaders should also have supervisory time allocated

Organisations should commit to investing in new roles and skill mix

That effective recruitment and retention strategies are in place All in-patient wards and large departments (ED, ITU, and Theatres) have a minimum of 0.60 WTE supervisory status for the Senior Sister/Charge Nurse. Expectation 3 – Right place and right time The NQB recommends that in addition to the delivery of high quality care, Boards should ensure improvements in productivity. This will include effective management and rostering of staff, with clear escalation policies if concerns arise. Our approach to ensuring effective deployment of staff Effective recruitment – at present, the number of substantive vacancies has increased significantly from the last safe staffing report with medicine reporting 71 WTE band 5 vacancies. Surgery reports 34 WTE, with 17 of these recruited, awaiting start dates. The impact of the International English Language Test Standard (IELTS) has adversely impacted upon the current staffing levels with only 6 of the anticipated 60 WTE nurses from India on site as at March 2017. The number of European recruits has also declined dramatically. We have commenced an ‘adaptation’ course converting nurses registered in their own country living in the UK working as care staff. 16 have commenced the course with 40 places funded in 2017. This will hopefully be a new pipeline of Registered Nurses. Effective rostering – The organisation utilises ‘Health Roster’ for Nursing and Midwifery staff. Reducing the use of agency staff – The organisation is working in partnership with five neighbouring acute providers to reduce the use of agency staff. An additional pressure has been the requirement to safely staff additional beds opened in the last 6 months in the new Community Unit and on ward A12 to support patient flow. The agency rate is now 5.7 % for all areas with total wards reporting 6.9% agency usage in the month. Care hours per patient day (CHPPD) There is currently national work underway to explore how Care Hours per patient day (CHPPD) can be deployed successfully to enable both comparisons between peers and to help inform daily deployment of staff linked to changes in acuity and occupancy.

4.0 RISK & ASSURANCE

4.1 This paper demonstrates to the Board of Directors that every effort is being made to ensure safe nursing staffing levels within the current funded establishments. Challenges related to recruitment, retention and the covering of additional beds to support patient flow and DTOC patients and unforeseen absences requires at least daily reviews of staffing levels to ensure safe staffing levels are maintained. The

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experience level of the nursing establishment has declined with the majority of UK applications from newly qualified nurses. Also the EU nurses are often newly qualified, diluting the experience levels on the wards and departments.

5.0 CONCLUSION

5.1 The report presents an overview of Nursing and Midwifery staffing levels across the organisation. The report highlights the challenges faced due to the UK nursing shortage and difficulties recruiting from EU and Non EU countries. This has adversely impacted upon our vacancy rate. Reliance on temporary workers to ensure safe staffing levels has increased in the last 6 months and it is anticipated that the forthcoming 6 months will be as challenging. Nursing and Midwifery staffing levels are dynamic and need to be reviewed at least 6 monthly to respond to changes in acuity and dependency. A subsequent review will be presented in September 2017.

6.0 RECOMMENDATIONS

6.1 The Board of Directors is asked to:

note the contents of this report

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Subject: Safe Staffing report

Report of: Director of Nursing and Midwifery Prepared by: Deputy Director of Nursing and Midwifery (Acting)

REPORT FOR APPROVAL


-----

Summary of Report The report provides an overview by exception of actual versus planned staffing levels for the month of February 2017 Key points of note are as follows; Average fill rates for Registered Nurses (RN) and care staff remains above 90%. Medicine reports 6 wards with less than 90% Registered Nurse fill rate, down from 7 last month. Surgery and critical care has 1 ward below 90%. It is pleasing to note progress in respect of recruitment and retention initiatives in Medicine, Surgery and Critical Care. This has contributed to a significant reduction in vacancies at band 5. Medicine reports 70 whole time equivalent (WTE) vacancies (99 last month). Of note Emergency Department has only 3WTE Registered Nurse vacancies. Surgery and Critical Care has 29WTE vacancies (34 last month) 17 have been recruited to. Of note ICU will have no RN vacancies as at April 17. Child and family Neonates reports below 90% staffing, this is due to short term sickness not vacancy rates. The Boards is asked to note the contents of this report with assurance that safe staffing levels have improved in February 2017, although there are areas with sub optimal Registered Nurse levels. The Board of Directors is asked to note the contents of this report with assurance given that Safe Staffing was maintained during


-----


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Completed

Not required

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reported to:

Board of Directors


Audit Committee

Executive Team

Quality Assurance

Committee

FSI Committee


BaSF Committee





Other


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1 INTRODUCTION

1.1

As part of the ongoing monitoring of staffing levels, this paper presents to the Board of Directors a staffing report of actual staff in place compared to staffing that was planned, for the month of February 2017. Work-streams to support safe staffing continue, with a monthly Safe staffing group chaired by the Director of Nursing and Midwifery. The Board of Directors is asked to note the contents of this report.

2. BACKGROUND

2.1

NHS England is not currently RAG (Red, Amber and Green) rating fill rates. A review of local organisations shows that fill rates of 90% and over are adopted with exception reports provided for those areas falling under this level.

February 2017 DAY NIGHT

RN/RM Average Fill Rate 90.80% 96.1% ↔

Care Staff Average Fill Rate

101.7% 116.4%

3.

CURRENT SITUATION

3.1

Medicine

Medicine has started to show signs of recovery in respect of recruitment and retention.

Vacancy levels have decreased from 99 Registered Nurse whole time equivalents (WTE),

which includes maternity and long-term sick to 71WTE.

The number of wards reporting Registered Nurse (RN) staffing levels below 90% has

reduced from 7 to 6. Ward E1 is reporting reduced levels as this ward tends to be the ward

where an RN is transferred to another area at short notice if last minute sickness occurs,

placing another ward on red flag staffing (one staff nurse).

Ward B4 has shown significant turnover over the last two months and is a focus of support

by the Head of Nursing and the Matrons. An acting band seven has been appointed and

focused recruitment is on-going. C4 is also showing significant vacancy levels.

Within medicine, to ensure safe staffing, 40WTE band 2 care staff have been appointed

over establishment. With additional beds open in both medicine and surgery this has

placed additional workforce pressure and off framework agency has been required on A12

escalation and B4. It is anticipated this will need to continue in the near future.

Agency Care Staff has been required to support the wards, but it will be recommended

that as of end April 2017 the previous agency exclusion will be re-instated, as the new

recruits will have commenced in post.

The Emergency Department (ED) continues to be supported by agency RNs to ensure safe

staffing. The ED focus on recruitment is starting to improve the vacancy situation.

At band 2 there are no vacancies with 4 awaiting start dates

At band 3 there are 2 vacancies specifically to cover paediatrics and an advert is currently

in process

At band 5 there are 3 vacancies, 8 nurses are due to start in March and a further 2 are

awaiting start dates in April.

It is anticipated by the end of April ED will d be able to significantly reduce the use of

agency RNs as they will have a much more robust and established team

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3.2

3.3

3.4

3.5

3.6

Surgery and Critical Care

Surgery and critical care is also starting to show improve signs of recruitment and retention

in all areas. Specifically of note are recruitment levels in intensive care. The Head of

Nursing reports that within two months they will be at full RN staffing levels.

Theatres trajectory continues to show positive recruitment. Initiatives in anaesthetics an

recovery they have 6.78WTE band 5 vacancies which are 10.8%. 2 posts have been

recruited to which will mean when all staff have started they will be at a 7.6% vacancy rate.

Scrub theatres has 8WTE vacancies (9.17%) After all recruits commence this reduces to

3.6%, a significant improvement.

Surgery and T&O wards are reporting 11WTE vacancies which is 7% but after new

starters commence this reduces to 3.7%

Community

The community unit continues to cover some shifts with agency staff including off

framework agency. There has been a successful recruitment campaign for care staff and

they will be at full complement at band 2. They have had some interest at Registered

Nurse levels which is improving the position slightly but there continues to be significant

RN vacancies.

Child and Family

Neonatal day duty continues to report below 90% which is sub-optimal. This is due to

short term sickness and is being closely monitored by the Business Group. The activity in

February 2017 decreased ensuring the nurse to patient ratio was safe for the activity and

acuity levels, despite the absence levels.

Recruitment and Retention

There has been significant progress with the recruitment campaign in month. The video

campaign to support the social media platform has been completed. All of the new posters

and pop-ups have been delivered. The recruitment website for nursing has been updated.

The Communications and Marketing Department has been pivotal in all aspects of this

campaign which launched on 8 March. In March/April there will be a focus on streamlining

the process once an RN or theatre practitioner has contacted the Trust, to maximise our

recruitment potential.

We continue to on average retain 3 RN per month with the revised transfer options which

we must continue to support and indeed improve on.

A further cohort of nurses from India arrived and we continue to recruit EU staff via Skype

interviews.

Cohort 2 for the adaptation course sat their assessments and eight passed. Cohort 1 have

completed their two week intensive course.

Care hours per patient day (CHPPD)

Of note the care hours per patient day has decreased from an average of 7.7 to 7.3 in the

month which is a continued reflection of the vacancy levels that we are experiencing.

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3.7

The care hours calculate the total amount of nursing (Registered and care staff) available

during a month divided by the number of patients present on the inpatient areas at

midnight. This gives an overall average for the daily care hours per patient day.

Temporary Staffing

We continued to book off framework agency in February 2017 for the medical wards

specifically A12 and B4, The total wards percentage temporary staffing is 6.3% (6.6% last

month) The grand overall total which includes all nursing staff areas has decreased from

6.6% to 5.7%.

DEPARTMENT FEB 2017 JAN 2017 DEC 2016 NOV 2016

Medicine, ED and Wards Agency % 18% 17% 10.1% 10.7%

Surgery & Critical Care Agency % 11% 12% 8.0% 7.2%

Emergency dept ONLY 26% 23% 20% 19%

4

RISK & ASSURANCE

4.1

Sub-optimal Registered Nurse levels are reported with a continued but decreasing reliance on agency and bank staff, which has enabled a 90% overall coverage with some areas below optimum levels. The situation has been exacerbated by increased bed numbers to support patient flow and activity levels. Daily safety huddles and continuous support by the Heads of Nursing and Matrons, site managers, and Senior Nurse Managers and Executives continues to address the increased vacancy levels.

5. CONCLUSION

5.1

6.

6.1

There is continued pressure on the Registered Nurse staffing levels across the wards and in particular in Medicine. Every effort is being made by approving off framework agency, NHSP agency and care staff to provide sufficient numbers of staff to support the wards and departments. RECOMMENDATIONS The Executive Team are asked to note the contents of the report

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Appendix A – Previous months staffing fill rates

Jan 2017 DAY NIGHT

RN/RM Average Fill Rate 91.2% ↓ 96.1% ↑

Care Staff Average Fill Rate 100% ↓ 117.5%↑

Dec 2016 DAY NIGHT

RN/RM Average Fill Rate 93.3% ↓ 95.7 % ↓

Care Staff Average Fill Rate 100.5% ↑ 110.4% ↓

NOVEMBER 2016 DAY NIGHT

RN/RM Average Fill Rate 93.4% ↑ 97.3% ↑

Care Staff Average Fill Rate 99.3%↓ 115.4%↓

OCTOBER 2016 DAY NIGHT

RN/RM Average Fill Rate 93.0% ↑ 95.6% ↑

Care Staff Average Fill Rate 101.3%↓ 119.4%↑

SEPTEMBER 2016 DAY NIGHT

RN/RM Average Fill Rate 92.4% ↑ 95.5%↑


AUGUST 2016 DAY NIGHT

RN/RM Average Fill Rate 91.9% ↑ 95.3%↓


JULY 2016 DAY NIGHT

RN/RM Average Fill Rate 90.5% ↓ 96.6 % ↑

Care Staff Average Fill Rate 104.9% ↑ 117.9% ↑

June 2016 DAY NIGHT

RN/RM Average Fill Rate 91.1%↓ 95.7 % ↑


May 2016 DAY NIGHT

RN/RM Average Fill Rate 91.9% ↑ 95.2% ↓

Care Staff Average Fill Rate 106.3% ↓ 125.1% ↑

April 2016 DAY NIGHT

RN/RM Average Fill Rate 90.3% 95.7 % ↑

Care Staff Average Fill Rate 107.6% ↑ 122.9% ↑

March 2016 DAY NIGHT

RN/RM Average Fill Rate 90.3% ↑ 95.3 %

Care Staff Average Fill Rate 101.5% ↑ 116.2% ↓

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Fill rate indicator return

Staffing: Nursing, midwifery and care staffOrg: RWJ - Stockport NHS Foundation Trust

Period: February_2016-17

Site code Hospital Site name Specialty 1 Specialty 2

Total

monthly

planned

staff hours

Total

monthly

actual staff

hours

Total

monthly

planned

staff hours

Total

monthly

actual staff

hours

Total

monthly

planned

staff hours

Total

monthly

actual staff

hours

Total

monthly

planned

staff hours

Total

monthly

actual staff

hours

RWJ09 STEPPING HILL HOSPITAL - RWJ09 Neonatal Unit 420 - PAEDIATRICS 2100 1702.5 0 0 1470 1165.5 0 0 81.1% n/a 79.3% n/a 277 10.4 0.0 10.4safety assured as activity levels reduced therefore nurse

to patient ratio safe .

RWJ09 STEPPING HILL HOSPITAL - RWJ09 Tree House 420 - PAEDIATRICS 2940 2715 420 420 1960 1806 0 0 92.3% 100.0% 92.1% n/a 516 8.8 0.8 9.6

RWJ09 STEPPING HILL HOSPITAL - RWJ09 Jasmine Ward 502 - GYNAECOLOGY 840 835 420 420 560 560 0 0 99.4% 100.0% 100.0% n/a 221 6.3 1.9 8.2

RWJ09 STEPPING HILL HOSPITAL - RWJ09 Birth Centre 560- MIDWIFE LED CARE 501 - OBSTETRICS 1680 1680 420 420 1120 1076 280 280 100.0% 100.0% 96.1% 100.0% 48 57.4 14.6 72.0

RWJ09 STEPPING HILL HOSPITAL - RWJ09 Delivery Suite 501 - OBSTETRICS 2520 2370 420 397.5 1680 1601 280 269 94.0% 94.6% 95.3% 96.1% 194 20.5 3.4 23.9

RWJ09 STEPPING HILL HOSPITAL - RWJ09 Maternity 2 501 - OBSTETRICS 560- MIDWIFE LED CARE 1470 1470 840 840 560 560 280 280 100.0% 100.0% 100.0% 100.0% 452 4.5 2.5 7.0

RWJ09 STEPPING HILL HOSPITAL - RWJ09 ICU & HDU192 - CRITICAL CARE

MEDICINE4200 4032 700 700 3696 3597 0 0 96.0% 100.0% 97.3% n/a 281 27.1 2.5 29.6

Spare capacity within the unit throughout the month has

ensured safety on a daily basis

RWJ09 STEPPING HILL HOSPITAL - RWJ09 Short Stay Surgical Unit 100 - GENERAL SURGERY 101 - UROLOGY 1886 1761 720 650.25 792 792 616 627 93.4% 90.3% 100.0% 101.8% 581 4.4 2.2 6.6 Safe staffing assured

RWJ09 STEPPING HILL HOSPITAL - RWJ09 C6 101 - UROLOGY 100 - GENERAL SURGERY 1260 1224 1260 1296 616 616 616 825 97.1% 102.9% 100.0% 133.9% 621 3.0 3.4 6.4Additional Care Staff at night due to increase in patient

mix/acuity to support patient flow and capacity

RWJ09 STEPPING HILL HOSPITAL - RWJ09 D1110 - TRAUMA &

ORTHOPAEDICS1470 1381.5 1260 1314 616 616 616 969 94.0% 104.3% 100.0% 157.3% 619 3.2 3.7 6.9

Additional Care Staff at night due to increase in patient

mix/acuity to support patient flow and capacity


ORTHOPAEDICS1260 1206 1050 1008 616 616 616 616 95.7% 96.0% 100.0% 100.0% 468 3.9 3.5 7.4 Safe staffing assured


ORTHOPAEDICS846 857.75 906 882.5 616 616 440 446 101.4% 97.4% 100.0% 101.4% 421 3.5 3.2 6.7 safe staffing assured

RWJ09 STEPPING HILL HOSPITAL - RWJ09 D6 100 - GENERAL SURGERY 1260 1320 1050 1308 616 880 616 880 104.8% 124.6% 142.9% 142.9% 738 3.0 3.0 5.9

Additional beds opened to support patient flow and

capacity. Increase percentage in both Registered Nurses

and Care staff to support this temporary increase in

patient numbers. Safety assured .

RWJ09 STEPPING HILL HOSPITAL - RWJ09 M4110 - TRAUMA &

ORTHOPAEDICS1410 892 1512 1854.5 616 583 924 1232 63.3% 122.7% 94.6% 133.3% 744 2.0 4.1 6.1

8 beds have now been re-opened to support patient

flow/bed capacity. Increase in Care Staff to offset sub

optimal Registered Nurse levels . Daily assessment of

staffing by Matron and staff moved from one area to

another has ensured safe staffing. Recruitment has been

secured, awaiting start dates.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 SAU 100 - GENERAL SURGERY 101 - UROLOGY 1470 1392 1008 972 784 773 616 616 94.7% 96.4% 98.6% 100.0% 335 6.5 4.7 11.2 Safe staffing assured

RWJ09 STEPPING HILL HOSPITAL - RWJ09 A1 300 - GENERAL MEDICINE 1260 798 1092 810 924 808 616 583 63.3% 74.2% 87.4% 94.6% 894 1.8 1.6 3.4

Sub -optimal Registered Nurse and Care Staff .

Additional beds remain open due to seasonal pressures

. Recruitment is ongoing . Never less than 2 Registered

Nurses on duty. Ward is closely monitored and

supported by Matron.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 A3 320 - CARDIOLOGY 1285.25 1091.75 882 858 924 715 616 583 84.9% 97.3% 77.4% 94.6% 672 2.7 2.1 4.8

Sub optimal Registered Nurse establishment day shifts

due to sickness and movement of Registered Nurses to

support other areas. (Never less than 2 Registered

Nurses on duty)

RWJ09 STEPPING HILL HOSPITAL - RWJ09 A10 430 - GERIATRIC MEDICINE 1428 1120.5 1470 1770 616 605 616 1100 78.5% 120.4% 98.2% 178.6% 796 2.2 3.6 5.8Sub optimal Registered Nurse establishment on day

shifts (Never less than 2 Registered Nurses on duty)

RWJ09 STEPPING HILL HOSPITAL - RWJ09 A11 300 - GENERAL MEDICINE 1722 1557 1302 1294.5 616 616 616 1012 90.4% 99.4% 100.0% 164.3% 774 2.8 3.0 5.8

Slight under establisment on days. Recruitment is on

going. Over established on night duty with care staff to

support patients requiring 1-1 supervision.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 A12 300 - GENERAL MEDICINE 430 - GERIATRIC MEDICINE 672 672 336 281.75 616 616 336 336 100.0% 83.9% 100.0% 100.0% 380 3.4 1.6 5.0

Escalation ward - sub optimal care staff days. Care

Staff vacancies have been recruited to , awaiting start

date , unit is monitored by Matron for safety.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 AMU 300 - GENERAL MEDICINE 3696 3646.5 3024 2892 3360 3283 2772 2783 98.7% 95.6% 97.7% 100.4% 1533 4.5 3.7 8.2

RWJ09 STEPPING HILL HOSPITAL - RWJ09 B2 430 - GERIATRIC MEDICINE 1512 1158 756 1014 1232 924 616 638 76.6% 134.1% 75.0% 103.6% 415 5.0 4.0 9.0

Sub-optimal Registered Nurses due to vacancies and

sickness, additional Care Staff booked to support

Registered Nurses and patient care. Recruitment is on-

going.Never less than 2 Registered Nurses per shift.

Ward is closely monitored and supported by Matron.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 B4 300 - GENERAL MEDICINE 1092 754.5 546 744 616 627 616 616 69.1% 136.3% 101.8% 100.0% 444 3.1 3.1 6.2

Sub-optimal Registered nurse numbers during the day,

additional Care Staff booked to support Registered

Nurses and patient care. Never less than 2 Registered

Nurses per shift. Recruitment is on-going.Ward is

supported and monitored by Matron.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 B5 300 - GENERAL MEDICINE 756 768 756 672 616 638 616 550 101.6% 88.9% 103.6% 89.3% 376 3.7 3.3 7.0Slight reduction in Care Staff day and night due to

vacancy which has been recruited to.

RWJ88 STEPPING HILL HOSPITAL - RWJ09 B6 300 - GENERAL MEDICINE 1092 1092 966 966 616 616 616 616 100.0% 100.0% 100.0% 100.0% 588 2.9 2.7 5.6

RWJ09 THE MEADOWS - RWJ88 Bluebell Ward 318- INTERMEDIATE CARE 1092 857 1876 1612 616 616 616 616 78.5% 85.9% 100.0% 100.0% 680 2.2 3.3 5.4

Sub-optimal Registered Nurses and Care Staff during the

day shifts due to sickness and re-deployment of staff to

support other areas . Never less than 2 Registered

Nurses per shift.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 C2 430 - GERIATRIC MEDICINE 1152 972 672 537 616 616 616 924 84.4% 79.9% 100.0% 150.0% 445 3.6 3.3 6.9

Sub-optimal Registered Nurses during day shifts due to

vacancy and sickness.Sub-optimal Care Staff day duty

. Care staff recruitment successful .

RWJ09 STEPPING HILL HOSPITAL - RWJ09 C4 300 - GENERAL MEDICINE 1092 822 546 894 616 616 616 616 75.3% 163.7% 100.0% 100.0% 411 3.5 3.7 7.2

Sub-optimal Registered Nurses during the day shifts due

to vacancy and sickness.Ward supported with additional

care staff . Recruitment is ongoing and ward is closely

monitored by Matron.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 Coronary Care Unit 320 - CARDIOLOGY 756 762 420 427.5 616 616 308 319 100.8% 101.8% 100.0% 103.6% 145 9.5 5.1 14.7

RWJ03 STEPPING HILL HOSPITAL - RWJ09 Clinical Decisions Unit 300 - GENERAL MEDICINE 336 336 336 336 308 308 308 308 100.0% 100.0% 100.0% 100.0% 171 3.8 3.8 7.5

RWJ09 CHERRY TREE HOSPITAL - RWJ03Devonshire Centre for Neuro-

Rehabilitation314 - REHABILITATION 966 918 1806 1554 616 616 616 880 95.0% 86.0% 100.0% 142.9% 519 3.0 4.7 7.6

RWJ09 STEPPING HILL HOSPITAL - RWJ09 E1 430 - GERIATRIC MEDICINE 1758 1398 2086 1658.5 924 825 1232 1309 79.5% 79.5% 89.3% 106.3% 889 2.5 3.3 5.8

Sub-optimal Registered Nurse and Care Staff during the

day and at night due to vacancies and movement of staff

across the business group to support other areas. Never

less than 2 Registered Nurses on duty.Care Staff now

fully recruited to.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 E2 430 - GERIATRIC MEDICINE 2058 2036.83333 1428 1761.33333 924 924 924 1232 99.0% 123.3% 100.0% 133.3% 933Additional Care Staff on day and night shifts to support

1-1 patient care.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 E3 430 - GERIATRIC MEDICINE 2058 1983 1428 1408.5 924 902 924 1375 96.4% 98.6% 97.6% 148.8% 972 3.0 2.9 5.8Additional Care Staff on the day shifts to support 1-1

patient care.

RWJ09 STEPPING HILL HOSPITAL - RWJ09 Short Stay Olders People's Unit 430 - GERIATRIC MEDICINE 1050 960 714 1044 616 583 616 671 91.4% 146.2% 94.6% 108.9% 545 2.8 3.1 6.0Slight reduction of Registered Nurses day and night,

supported by an over establisment of Care Staff .

Total 53445.25 48541.8333 34428 35017.8333 33230 31927.5 20712 24107 90.8% 101.7% 96.1% 116.4% 19098 4.2 3.1 7.3

Day Night

Head of Nursing Comment

Registered

midwives/nursesCare Staff Average fill

rate -

registered

nurses/mid

wives (%)

Average fill

rate - care

staff (%)

Average fill

rate -

registered

nurses/mid

wives (%)

Average fill

rate - care

staff (%)

Care Hours Per Patient Per Day (CHPPD)

Cumulative

count over

the month of

patients at

23:59 each

day

Registered

midwives/

nurses

Care Staff Overall

Please provide the URL to the page on your trust website where your staffing information is available

www.stockport.nhs.uk/112/safe-staffing

Hospital Site Details

Ward name

Main 2 Specialties on each wardRegistered

midwives/nursesCare Staff

Day Night

89 of 200


Subject: Strategic Risk Register

Report of: Director of Nursing & Midwifery Prepared by: Risk & Customer Services Team Manager

REPORT FOR APPROVAL


Summary of Report

The strategic risk register reports on distribution of risk across the Trust and presents in greater detail those risks which have an impact upon the stated aims of the Trust. The headlines for this report are:

Two strategic risks have been mitigated and either closed or managed to below a risk score of 15.

Currently there are 2 severe strategic risks scoring 20 and two unacceptable scoring 25.

There have been no new strategic risks added this month The Board of Directors is asked to note the contents of the risk register




Not required

Attachments: Strategic Risk Register


reported to:

Board of Directors


Audit Committee

Executive Team

Quality Assurance

Committee

FSI Committee


BaSF Committee





Other

91 of 200


92 of 200

Trust Wide Risk & Severity Distribution

1.1 There are currently 364 live risks recorded on the Trust Risk Register system. 1.2 Trust wide distribution of risk is shown below.

Low Significant High

Very High

Severe Unacceptable

1 2 3 4 5 6 8 9 10 12 15 16 20 25

March 2017 1 8 20 69 3 42 41 38 6 89 6 32 7 2

1.2 Top Five Sources of Risk across the Trust

93

89

49

20 12

Equipment

Compliance (with standards/mandatory orlegislative)

Staffing

Financial

IT Systems

27%

60%

13%

Severity Distribution Trust Wide

Low Significant/High V High/Severe/ Unacceptable

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2.1 Corporate Risk (approved) Distribution across Business Groups

Very High Severe Unacceptable

15 16 20 25 Total

Medicine

0 4 3 0 7

Child and Family

2 3 0 0 5

Community Healthcare

0 0 0 0 0

Surgery and Critical Care

2 6 3 0 11

Estate and Facilities

1 1 0 0 2

Corporate Risk (Nursing, Finance, I.T. Executive Team, HR.)

0 11 1 2 14

Diagnostics and Clinical Support

1 7 0 0 8

Total Corporate Risks Trust wide (score 15 and above)

6 32 7 2 47

2.2 Severity Distribution in Business Groups

0

10

20

30

40

50

60

70

80

Diagnostics andClinical Support

Medicine Child and Family CommunityHealthcare

Surgery andCritical Care

Estate andFacilities

CorporateNursing

Low Risk

Significant-High

Very High -Severe-Unacceptable

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of 22

3.1 Closed Risks & Mitigated Risks The strategic risks below have been reviewed and either closed or mitigated to a lower risk rating.

3019 Current pressures in ED have the potential to impact upon Patient Safety has been combined with 2970 ED Overcrowding

2990 Emergency Department - Registered Nurse staffing has a reduced rating from 16 to 12. 3.2 New Strategic Risks

There have been no new strategic risks added this month

3.3 Changes in Risk Rating

All strategic risks are reviewed monthly. Currently there are 15 strategic risks on the register with a rating of 15 or over, 2 of these have a current risk rating of 20 and so are considered severe:

2889 7 day working

3066 Reduction of In-patient Elective Activity One Risk has been reviewed and the rating increased to 25 therefore there are 2 Risks with a score of 25 which is considered unacceptable:

2896 Delivery of 2016/17 CIP

1881 Failure to deliver 4 hour Performance Target within ED

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Strategic Risk Register

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Mitigating actions to be completed

Ta

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Key Indicators

Risk Journey 2016/17

Fin

ance

2896

Fin

ancia

l

26-J

an

-2016

Kay W

iss

FS

&I

FP

Delivery of 2016/17 CIP The Annual Plan of the Trust for 2016/17 needs to deliver a break-even position and in order to achieve this significant transformational savings needs to be realised.

As part of the Board Assurance Framework Structure performance (including finance and standards) are reported through the committees. This has been enhanced by a second tier of performance and CIP escalation meetings.

20 5 5 25

Development of a Recovery Plan Ensure internal and external

stakeholders are kept informed of recovery plan

Engage with clinical and service leaders to share current financial

pressures

15 CIP delivery

June 2016

20

Sept 2016

20

October 2016 25

Key for Committees: QAC – Quality Assurance Committee WOD – Workforce & Organisational Development Committee FS&I – Finance, Strategy & Investment Committee

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Key Indicators


Tru

st E

xecutive team

1881

Com

plia

nce

23-J

un

-2011

Sue T

oal

QA

C

JS

Failure to deliver 4 hour Performance Target within ED Failure to achieve this target would represent a significant corporate risk to the Foundation Trust both financially and reputation.

Existing internal escalation processes

Daily monitoring of staffing rotas in ED and on-call

The trust Unscheduled Care Plan- monthly meetings Whole health economy

collaboration to deliver this target

20 5 4 25

Ownership of longer term issues DTOCs - Ownership of longer

term issues. DTOCs - Formalised outputs with clear escalation where required. Clear escalation where required.

DTOCs - 11:30 Meeting Structure/ Agenda.

CAIR - Leadership/ Presence? CAIR - Daily processes.

CAIR - Clarity of Roles and Responsibilities.

Clarity of Roles and Responsibilities.

Junior Doctors Batching of jobs e.g. TTO's

Acutes entering EDD into Advantis.

Surgery escalation - SOP (Co-ordination/ Leadership) Surgery

escalation - SOP (Roles and responsibilities).

RAT Model - 1hr from arrival to consultant (95th Centile).

Triage Plus Model - 15 min to Triage (95th Centile)

10

Achieving 95% in the 4

hour Performance Target within

ED

Jan 2016

20

Dec 2016

20

Feb 2017

25

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Key Indicators


Surg

ery

& C

ritical C

are

3066

Com

plia

nce

20-J

an

-2017

Kare

n H

atc

hell

QA

C

KH

Reduction of In-patient Elective Activity

Daily operational capacity meetings, with full information feeding into the Trust Capacity Meeting Daily assessment of staffing and use of temporary workers to ensure safe staffing

20 4 5 20

Ongoing tracking of cases lost on a daily basis

Highlight any issues regarding review with medical outliers that

will ensure safety or expedite discharge

Daily board round focus on discharge, escalating any issues

to resolve to expedite where possible

Daily operational capacity and flow meeting with full information to

feed into the Trust capacity meeting

Daily staffing overview, with deployment of agency staff as

required

16

Increase Performance

Improve Patient

Experience

Jan 2017

20

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ial

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Key Indicators


Tru

st E

xecutive T

eam

2889

Com

plia

nce

13-J

an

-2016

Colli

n W

asson

QA

C

CW

7 day working The Keogh Review has recommended 10 standards to support the NHS in improving clinical outcomes and patient experience at weekends. 4 of these standards have been prioritised and there is a risk that at present the trust cannot achieve them in the given timeframes:

Extending palliative care team support for community and hospital over Saturday and

Sunday, 8am to 430pm. Rota changes of consultants in

Medicine Business Group to provide Consultant Physical

presence on AMU from 8am to 5pm on Saturday and Sunday; to provide Consultant delivered ward rounds on B2/E1 (stroke unit) on Saturday and Sunday; to provide in reach Consultant Cardiology input to AMU and CCU on Saturday and Sunday Radiology staff on site 24/7 to

provide plain film x rays, mobile x rays, theatre imaging and CT

scans. There is now continuous CT provision on site providing swifter patient access to CT

scanning for trauma and stroke patients out of hours.

20 4 5 20 All actions to be taken through

Stockport Together Transformational Project

12 Achievement

of standards in 7/7 working

Jan 2016

20

Jan 2017

20

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Key Indicators


Fin

ance

3000

Fin

ancia

l

12-A

ug

-2016

Kay W

iss

FS

&I

FP

Delivery of Sustainability and Transformation Fund

As part of the Board Assurance Framework Structure performance (including finance and standards) are reported through the committees. This has been enhanced by a revised committee structure and performance meetings as part of the Financial Improvement Programme. Monthly regulatory reporting to NHS Improvement is in place.

16 4 4 16

The Trust to explore the possibility to appeal against the A&E

trajectory because of the growth in A&E attendance and DTOCs

Forecast of Achievement of STF in future months to be undertaken on a monthly basis and submitted to

NHSI Monitoring of Agency costing through Workforce Efficiency

Group Completion of Phase 3 of Financial Improvement

Programme

12 Achieve STF requirement

Aug 2016

16

Nov 2016

20

Feb 2017

16

Mar 2017

16

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isk S

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Key Indicators


Tru

st E

xecutive team

2977

Com

plia

nce

28-J

un

-2016

Sue T

oal

QA

C

JS

Compliance with RTT 92%

Incomplete Monitor

Standard. Failure to achieve the

RTT 92% Incomplete

standard at the end of March 2016, as such

failing the standard for Q4 of

2015/16.

Weekly Trust-wide PTL meeting – captures performance

overview and tracks progress against recovery trajectory

20 4 4 16

ENT/Oral Surgery-Address residual capacity & demand deficit

for both specialties following impact analysis of previous

actions. -Review pathway for micro-

suctioning with CCG and further review of agreed pathway.

GS/Urology-Address residual capacity & demand deficit for both

specialties. Theatres-Extending staff mode for theatres/wards to be explored to

maximise weekend theatre capacity.

Diabetes/Endocrinology-Temporarily increase consultant

PA for on-call to 1.4 both substantive consultants to offer increase in PM clinics when on-

call. Gastro-6th Consultant appointed

to commence. Gastro-Prioritise booking of new

patients>18wks. ENT/Oral Surgery-Continue to

offer choice of alternative provider to new ENT referrals. T&O-

Implement longer term service redesign for spinal pathway.

12 Achieve the RTT target

Jun 2016

20

Dec 2016

16

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Key Indicators


Corp

ora

te N

urs

ing

2806

Com

plia

nce

23-O

ct-

2015

Head o

f R

isk a

nd C

usto

me

r S

erv

ices

QA

C

JM

Non Compliance with the Trust Alert & Hazards SOP

Trust process in place to circulate alerts through Risk & Safety Team

16 4 4 16 Introduction of new datix module to monitor alerts

8

Staff compliance

with Alert and Hazard

notices SOP

Jan 2016

16

June 2016

16

Sept 2016

16

Feb 2017

16

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Key Indicators


Corp

ora

te N

urs

ing

2969

Fa

lls

9-J

un

-2016

Cath

y G

ibson

QA

C

JM

Reduce the number and harm of Major to Catastrophic Patient Falls-2016–2017 A number of major to catastrophic falls has increased in 2015-2016. Target of avoidable falls was not met.

Hospital falls group Unavoidable Severe and catastrophic falls managed as SI = full RCA Policies and procedures in place regarding falls prevention and management. Specialised falls prevention and management training mandatory every three years for nursing and therapy staff.

16 4 4 16

Complete Trust Falls Alarm Programme, to include purchase of additional alarms Post falls action chart for medical staff to be developed Trust falls SOP to be reviewed and launched

12

To have less than 19

avoidable falls in a year.

June 2016

16

Sept 2016

16

Dec 2016

16

Feb 2017

16

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Key Indicators


Corp

ora

te N

urs

ing

3015

Infe

ctio

n P

reventio

n a

nd C

ontr

ol

30-S

ep

-2016

Rebecca B

ark

er

QA

C

JM

Year on year reduction of

single rooms. Inappropriate use of single rooms across the Trust

Bed management team maintaining single room

database SOP for isolation of patients

Ongoing training around usage of single rooms

16 4 4 16

Require an effective bed utilization database which is accessible and

up to date. Require an effective and efficient

bed utilization process. Effort should be devoted to

changing the negative culture that exists around single rooms across

the whole site. New D-Block is on track for opening in October 2016, this will slightly increase the number of side rooms available across the acute Trust

8

A robust system is in

place to ensure

patients are appropriately managed in single rooms

Dec 2016

16

Jan 2017

16

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Key Indicators


Hum

an R

esourc

es

2879

Fin

ance

7-J

an

-2016

Em

ma C

ain

WO

D

JS

h

Use of Temporary Staffing Risk to patient care through ongoing or increasing use of temporary staffing

Twice yearly train the trainer updates at the CPF workshops Bi monthly report to the medical devices committee regarding compliance New RNs being taught at clinical induction from September 2015

20 4 4 16 All actions completed. Risk assessment to be reviewed.

12

Reduction in cost and use of Temporary

Staffing

Jan 2016

20

Aug 2016

16

Sept 2016

16

Oct 2016

16

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ial

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Key Indicators


Dia

gnostic &

Clin

ical S

upport

2130

Clin

ical pro

cedure

s

22-A

ug

-2012

Sara

Wils

on

QA

C

JS

Insufficient capacity in Endoscopy to meet the current demand

Flexible use of existing staff to cover as many unused lists as possible. A plan to review the utilisation of the unit and the changes needed to meet demand. Mediscan have been commissioned to conduct 10 additional weekend lists per month. Close monitoring of the breaching of targets Introduced new role of Inpatient coordinator to manage all inpatient referrals to prioritise referrals and maximise use of capacity. Endoscopy Cancellation escalation procedure developed.

20 4 4 16

Develop agreement with other business groups on the

deliverable endoscopist sessions. Improve sessional productivity,

adding 1 unit to each list by developing case pre-assessment and additional nurses allocated to

procedure rooms. Continue to support estates/procurement in

establishing plans for unit expansion.

Develop process to feedback incomplete and inappropriate

referrals to evidence issue and inform future improvement.

Identify data required to support utilisation and performance

management, explore potential for report development.

Confirm last year's activity and project anticipated demand.

Use department staffing model to anticipate impact of increased

medical endoscopist workforce. Progression of unit infrastructure

change as directed by exec board. Continue to support

estates/procurement in establishing plans for unit

expansion Efficiently recruit to vacant posts.

12 Endoscopy target to be achieved

Jan 2016

16

March 2016 20

June 2016

20

Sept 2016

20

Nov 2016

16

Jan 2017

16

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Key Indicators


Tru

st E

xecutive team

2644

Com

plia

nce

4-N

ov-2

014

Colin

Wasson

QA

C

CW

Upper GI Bleed Service Provision (Non Compliance with NCEPOD Gastrointestinal Haemorrhage (Time to Get Control) published in 2015 and NICE Guidance 141) NICE Clinical Guidance 141 has Quality standards at present the Trust is fully compliant with 2 standards, partially compliant with 3 standards and non-compliant with 4 (claim of breach of duty).

There is guidance for the management of those patients

who are haemodynamically unstable to receive endoscopy this plan is different for in hours and out of hours (Standard 2). Endoscopy within 24 hours can be offered to patients with the

exception of those being admitted on Saturdays and on

Sundays preceding bank holidays In hours, the

appropriate endoscopic treatment for non variceal bleeding can be offered.

Aspirin and antibiotic therapy advice is a given as per

guidance

20 4 4 16

Identify a Clinical Lead for GI Bleeding

Training of theatre staff in the management of bleeding upper GI patients to ensure a 24/7 7 days a week service or 2. Separate rota

for endoscopy staff and organisation of Endoscopy list to

prioritise blood. Development of a separate

"bleeder rota" to provide 24/7 provision of endoscopic diagnostic

and treatment service

8

Full compliance

with the NICE/NCEPO

D guidance

Nov 2015

20

Jan 2016

16

Nov 2016

16

Jan 2017

16

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isk S

co

re

Key Indicators


Corp

ora

te N

urs

ing

3031

Tis

sue V

iabili

ty

8-N

ov-2

016

Joanne C

onvey

QA

C

JM

Reducing the Incidence of Avoidable Pressure Ulcers

Integrated Tissue Viability Service advises/disseminates evidence based guidelines Trust wide on pressure ulcer prevention and management strategies to support staff in clinical practice. Equipment contract to supply pressure relieving mattresses, cushions and bedframes (Hillrom/Nightingale contract in acute and Ross Care contract in the community) Static mattress audit within acute hospital. Monthly nursing indicator audits which includes pressure area care, Monthly data collection for safety thermometer survey across hospital and community sites. Safety cross completed on all wards for grade 2 and above hospital acquired pressure sores (incidence) which is reported externally each month via open and honest reporting. All organisationally acquired category 2 and above ulcers are reported locally as a clinical incident. All organisational acquired pressure ulcers have a pressure ulcer ProForma completed to identify any lapses in care. RCA and investigation of all avoidable organisational pressure ulcers meeting the criteria of an SI Training database maintained of all staff who have attended PU prevention and equipment training who are employed by SFT

16 4 4 16

Work streams within key aress to be established (1) Critical Care and Surgery (2) Theatres (3)

Community (4) Urgent Care (5) Women and Children's (6)

Medicine including elderly care and rehab

Annual pressure ulcer study day Standardised wound care

formulary and promotion of direct purchasing to minimise dressing

spend and standardisation of wound care practice

React to Red to be disseminated to care homes

All organisational avoidable pressure ulcers to be raised as a

safeguarding concern Introduce pressure ulcer reporting

process that enables determination of

avoidable/unavoidable within 48 hours for (1) Acute

Quarterly trends/changes in practice report to commissioners.

Care homes to commence PU proforma completion

DATIX/TV referrals to include photograph of pressure ulcer,

DATIX software to be updated and community media systems

improved to facilitate this action Introduce pressure ulcer reporting

process that enables determination of

avoidable/unavoidable within 48hrs for (2) Community

Introduce a minimum of 90% electric beds across inpatient

services to ensure HSE compliance and reduce the risk of

pressure ulcer development

12

Reduction in pressure

ulcers incidents

Aug 2016

16

Jan 2017

16

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Bu

sin

ess G

rou

p

ID

So

urc

e

Date

Ris

k F

irst

Rep

ort

ed

Ris

k O

wn

er

Execu

tive C

om

mit

tee

Execu

tive O

wn

er

Risk

Existing Controls

Init

ial

Rati

ng

Cu

rren

t C

on

seq

uen

ce

Cu

rren

t L

ikelih

oo

d

Cu

rren

t R

ati

ng


Ta

rge

t R

isk S

co

re

Key Indicators


Tru

st E

xecutive T

eam

3003

Com

plia

nce

17-A

ug

-2016

Joanne P

em

rick

QA

C

JS

RTT Pathway Recording - Compliance

RTT training - however very limited resource to deliver and sustain regular update training

across all staff groups. Pathway validation - limited due to resource required to sustain

16 4 4 16

Review and improve internal processes that support RTT

delivery Secure Provider to implement

bespoke e-learning for RTT to all applicable staff roles within the

organization Submit RTT data quality audits to

F&P Committee and Audit Committee as programmed to

provide assurance on improved RTT recording

9

Compliance with RTT Pathway recording

Aug 2016

16

Jan 2017

16

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sin

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rou

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ID

So

urc

e

Date

Ris

k F

irst

Rep

ort

ed

Ris

k O

wn

er

Execu

tive C

om

mit

tee

Execu

tive O

wn

er

Risk

Existing Controls

Init

ial

Rati

ng

Cu

rren

t C

on

seq

uen

ce

Cu

rren

t L

ikelih

oo

d

Cu

rren

t R

ati

ng


Ta

rge

t R

isk S

co

re

Key Indicators


Dia

gnostics &

Clin

ical S

upport

1555

Com

plia

nce

28-A

pri

l-2010

Caro

line C

ulv

erw

ell

Failure to meet the 62 day Cancer target standards

Monthly Cancer Board chaired by Trust Lead Cancer Clinician There is an established team of experienced Cancer Trackers and Cancer MDT Coordinators who are tracking all cancer patients to ensure they are treated within 31 and 62 days. Cancer Services Manager monitors performance on a daily basis using the 'Predictor tool' Cancer Access Manager undertakes weekly Tumour specific PTL meetings with Business Manager and Cancer Pathway Tracker. Weekly Trust-wide PTL chaired by the Director of Operations An escalation policy is in place to alert business groups of any issues causing delay to patient pathways

12 4 4 16

Ensure attendance at PTL's Weekly performance Meetings Breast - Flexibilty of additional

sessions with new locum Consultant.

Urgent Lung capacity accommodated (additional

capacity put in place dependent on the volume of proforma

requests. Haematology patient activity

monitored and Consultant staff can accommodate additional patients if close to breaching.

8 Compliance with National

Standards

Jan 2016

12

Oct 2016

16

Feb 2017

16

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6. RISK ASSESSMENT SCORING/RATING MATRIX

LIKELIHOOD OF HAZARD

LEVEL DESCRIPTER DESCRIPTION

5 Almost certain Likely to occur on many occasions, a persistent issue - 1 in 10

4 Likely Will probably occur but is not a persistent issue - 1 in 100

3 Possible May occur/recur occasionally - 1 in 1000

2 Unlikely Do not expect it to happen but it is possible - 1 in 10,000

1 Rare Can’t believe that this will ever happen - 1 in 100,000

The risk factor = severity x likelihood By using the equation, a risk factor can be determined ranging from 1 (low severity and unlikely to happen) to 25 (just waiting to happen with disastrous and widespread consequences). This risk factor can now form a quantitative basis upon which to determine the urgency of any actions.

CONSEQUENCE

LIKELIHOOD

1 2 3 4 5

Low Minor Moderate Major Catastrophic

5 - Almost Certain AMBER

(significant) AMBER (high)

RED (very high)

RED (severe)

RED (unacceptable)

4 - Likely GREEN

(low) AMBER


RED (very high)

RED (severe)

3 - Possible GREEN

(low) AMBER


AMBER (high)

RED (very high)

2 - Unlikely GREEN

(low) GREEN

(low) AMBER

(significant) AMBER


1 - Rare GREEN

(low) GREEN

(low) GREEN

(low) GREEN

(low) AMBER

(significant)

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QUALATIVE MEASURE OF CONSEQUENCE

Impact Score 1 2 3 4 5 Domains / Description

NEGLIGIBLE / LOW

MINOR MODERATE MAJOR CATASTROPHIC

Impact on the safety of patients, staff or public (physical / psychological harm)

Minimal injury requiring no intervention or treatment. No time off work

Minor injury or illness, requiring minor intervention Requiring time off work for <7 days Increase in length of hospital stay by 1-3 days

Moderate injury requiring professional intervention Requiring time off work for 7-14 days Increase in length of hospital stay by 4-15 days RIDDOR / agency reportable incident An event which impacts on a small number of patients

Major injury leading to long-term incapacity / disability Requiring time off work for >14 days Increase in length of hospital stay by >15 days Mismanagement of patient care with long-term effects Fatality Multiple permanent injuries/irreversible health effects

An event which impacts on a large number of patients Multiple Fatalities

Quality / complaints / audit

Peripheral element of treatment or service suboptimal Informal complaint / inquiry

Overall treatment or service suboptimal Formal complaint (stage 1) Local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved

Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) complaint Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Major patient safety implications if findings are not acted on

Non-compliance with national standards with significant risk to patients if unresolved Multiple complaints / independent review Low performance rating Critical report Inquest / ombudsman negative finding

Totally unacceptable level or quality of treatment / service Gross failure of patient safety if findings not acted on Gross failure to meet national standards

Human resources / organisational development / staffing / competence

Short-term low staffing level that temporarily reduces service quality (< 1 day)

Low staffing level that reduces the service quality

Late delivery of key objective / service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Poor staff attendance for mandatory / key training

Uncertain delivery of key objective / service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Very low staff morale No staff attending mandatory / key training

Non-delivery of key objective / service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training / key training on an ongoing basis

Statutory duty / inspections

No or minimal impact or breech of guidance / statutory duty

Breech of statutory legislation Reduced performance rating if unresolved

Single breech in statutory duty Challenging external recommendations / improvement notice Register concern

Enforcement action Multiple breeches in statutory duty Improvement notices Low performance rating Critical report

Multiple breeches in statutory duty Prosecution Complete systems change required Zero performance rating Severely critical report

Adverse publicity / reputation

Local Press >1 Potential for public concern

Local media coverage >1 Elements of public expectation not being met

Local media coverage – long-term reduction in public confidence

National media coverage with <3 days service well below reasonable public expectation

National media coverage with >3 days service well below reasonable public expectation. Full Public Inquiry MP concerned (questions in the House) Total loss of public confidence

Business objectives / projects

Insignificant cost increase / schedule slippage

<5 per cent over project budget Schedule slippage

5–10 per cent over project budget Schedule slippage

Non-compliance with national 10–25 per cent over project budget Schedule slippage Key objectives not met

Incident leading >25 per cent over project budget Schedule slippage Key objectives not met

Finance including claims / cost

Small loss Risk of claim remote < £2k

Loss of 0.1–0.25 per cent of Trust budget Claim / cost less than £2- 20k

Loss of 0.25–0.5 per cent of Trust budget Claim(s) / cost between £20k -£1M

Uncertain delivery of key objective / Loss of 0.5–1.0 per cent of Trust budget Claim(s) / cost between £1m and £5m Purchasers failing to pay on time

Non-delivery of key objective / Loss of >5 per cent of Trust budget Failure to meet specification / slippage Loss of contract / payment by results Claim(s) >£5 million

Service / business interruption Environmental impact

Loss / interruption of >1 hour Minimal or no impact on the environment

Loss / interruption of >8 hours Minor impact on environment

Loss / interruption of >1 day Moderate impact on environment

Loss / interruption of >1 week Major impact on environment in more than one critical area

Permanent loss of service or facility Catastrophic impact on environment

Project related Insignificant impact on planned benefits

Variance on planned benefits <5% and <£50k

Variance on planned benefits >5% or >£50k Variance on planned benefits >10% or >£500k Variance on planned benefits >25% or >£1m

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- 1 of 9 -


Subject: Annual Budget Approval for 2017/18

Report of: Director of Finance Prepared by: Deputy Director of Finance

REPORT FOR APPROVAL


-----

Summary of Report To request approval of 2017/18 financial plan including planned cost improvements and capital expenditure. The Board are asked to approve for 2017/18

Opening Annual Budgets

CIP plan

Capital Programme Board Assurance Framework ref:

-----


-----


Completed

Not required

Attachments:


reported to:

Board of Directors


Audit Committee

Executive Team

Quality Assurance

Committee

F&P Committee


BaSF Committee





Other

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- 3 of 9 -

1. INTRODUCTION

1.1

The Trust submitted a 2 year operational plan covering the financial years 2017/18 and 2018/19 in

December 2016; this plan was approved by the Trust Board on the 20th December 2016 and was

subsequently presented to the Board of Directors in February 2017. This plan is then operationalised

into departmental budgets, a Cost Improvement Programme (CIP) plan and a capital programme.

Each of these needs to be approved by the Board of Directors for the upcoming financial year.

2. BACKGROUND

2.1

The Trust has prepared its two year Operational Plan in accordance with the planning guidance set

out in the “NHS Operational Planning and Contract Guidance 2017-19”. This is part of the NHS Five

Year Forward View. The timetable which has been followed for this is set out in Table 1 as follows:

Table 1

Timetable Date

Publication of planning guidance 22nd September 2016

Publication of planning tariff 31st October 2016

First submission of full draft 16/17 Operational Plan 24th November 2016

Publication of final tariff 22nd December 2016

Trust Board approval of Operational Plan By 23rd December 2016

Submission of final 16/17 Operational Plans, aligned with contracts 23rd December 2016

The tariff published covers two financial years and providers were required to sign two-year contracts

with commissioners.

2.2 The Operational Plan 2017/18 is presented under International Financial Reporting Standards.

3. 2017/18 and 2018/19 DRAFT OPERATIONAL PLAN

3.1

3.2

3.3

3.4

The Trust is forecast to have a deficit of £14.9m (excluding Sustainability & Transformation Fund and

impairments) at the end of 2016/17 and meets the control total agreed with NHSI in order to receive

the first year of the Sustainability & Transformation Fund (STF). If the Trust is able to deliver better

than control total forecast the Trust will benefit from additional STF funding, matched pound for

pound.

The Trust has achieved a higher level of recurrent CIP in 2016/17 than previous years at £8m, but has

not met its overall CIP target of £25.7m. The Trust has participated in a financial improvement

programme during the year with KPMG but not all of the bold schemes have delivered the

anticipated values in the year. The Trust has achieved its control total by non-recurrent solutions and

this therefore carries a further challenge into the coming financial year.

As part of the Operational Planning process the Trust was offered £7.6m of STF for each of the next

two financial years to deliver a £4.4m deficit for 2017/18 and £1.0m deficit for 2018/19.

At the Board of Directors on 27th October 2016, the NHSI offer was considered and rejected. The

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3.5

3.6

3.8

3.9

Board of Directors concluded that the financial risks including the level of CIP required poses too

great a challenge and therefore the control total is not achievable. This was after taking into

consideration the findings of the Financial Improvement Programme and the guidance from NHSI on

the level of CIP being no greater than 5% of operating income.

The draft Operational Plan was submitted on the 24th November 2016 on this basis and no changes

were made to overall total when the final Operational Plan was submitted on the 23rd December

2016.

Table 2 shows the detail of the Operational Plan and the level of CIP that would need to be delivered

to accept the control total and receive the STF. This has been reconciled from the latest 2016/17

financial forecast. The table also shows the main movement between the 2016/17 financial forecast

and the Operational Plan for 2017/18 and then 2018/19, removing non recurrent items and adding

expected increase in cost.

Table 2

Explanations of key components of the Operational Plan

In “normalising” the financial position from 2016/17, non-recurrent items need to be removed and

this year these have included the non-recurrent achievement of CIP, costs of the Financial

Improvement Programme, non-recurrent income and the release of unutilised provisions from the

balance sheet. The Trust has also received benefit from a change in impairments and donated asset

income, which fall below the EBITDA line within the income and expenditure statement but are all

part of the overall Trust position. The Trust also in rejecting the control total will not receive support

of the STF and this has also been removed as a non-recurrent item.

The tariff for 2017-2019 recognises inflation and also introduces HRG4+, which changes the

contracting currency structure particularly with how excess bed days are accounted for and how co-

morbidities are recognised.

£m 2017/18 2018/19 2017/18 2018/19

Forecast out-turn 16/17 (5.6) (27.4) (5.6) (12.0)

Non-recurrent CIP (5.8) - (5.8) -

Consultancy spend reduction 2.5 - 2.5 -

STF (6.7) (6.7)

Donated assets / impairment (2.0) (2.0)

Non recurrent income / balance sheet (6.8) - (6.8) -

Inflationary pressures & developments (15.0) (11.0) (15.0) (11.0)

Acute & community EPR (3.0) (1.0) (3.0) (1.0)

Underlying position (42.4) (39.4) (42.4) (24.0)

RECURRENT CIP 15.0 15.0 30.4 15.4

CIP % 5% 5% 11% 6%

Position after CIP (27.4) (24.4) (12.0) (8.6)

STF - - 7.6 7.6

Operational Plan / control total (27.4) (24.4) (4.4) (1.0)

Reject STF Accept STF

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3.10

3.11

3.12

3.13

Whilst the tariff recognises inflation, the actual increase in pay costs to the Trust is £3.8m. This

includes a 1% pay award which has not yet been confirmed, the delayed impact of the national junior

doctors’ contract, as well as changes to pension and national insurance contributions. The apprentice

levy is an increased cost to the Trust of £0.7m.

The Trust is obliged to pay an increase in CNST premiums, which is the Trust’s clinical negligence

scheme. This will increase by £0.8m in 2017/18. The Trust also has a number of other contractually

obliged inflationary increases which total £1.4m.

The Trust has a number of other developments that have been approved and have a financial impact

in 2017/18 and these include the Acute and Community Electronic Patient Record (EPR) projects,

international recruitment for doctors and targeted programmes for nurse recruitment. There has

also been significant investment required in Emergency Department staffing, medical ward discharge

co-ordination and support costs for increased patient throughput. The new Surgical and Medical

Centre opened in October 2016, so the budgets also include the full year impact of this development.

The Trust took out an additional loan from the Independent Trust Financing Facility (ITFF) in October

2016 and the repayment of this is an additional £0.2m.

4.

4.1

4.2

4.3

4.4

5.

5.1

Updates from NHS Improvement on the draft plan and changes since the draft submission

NHSI visited the Trust on the 6th March 2017 to undertake the first of their new programme of

quarterly review meetings. The Trust discussed the Operational Plan components including the Cost

Improvement Programme and progress with schemes for the coming year.

On the 14th March 2017, all Trusts were notified by NHSI of the opportunity to amend their

Operational Plans for changes to profiling, correction of errors and to ensure that the plans reconcile

with what has been agreed by the Board. There are also a number of templates which require

further verification of capital, cash projections as well as activity and workforce triangulation tests.

As part of developing the Trust’s transformational CIP programme, there is further clarity of delivery

by category and profile. The Operational Plan will be updated to reflect this profiling change and will

be transacted within the NHSI parameters that the overall bottom line financial position does not

deteriorate.

As cash flow management will be critical in the coming financial year with the Trust requiring distress

funding in order to meet its financial obligations, it is crucial that the CIP plan delivers according to

the profile set. The overall CIP delivery target of £15m has not changed.

2017/18 Operational Plan

The initial opening budgets for 2017/18 can be shown in Table 3 overleaf.

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5.2

5.3

Table 3

The Trust will be measured against the revised Use of Resources rating in 2017/18, where a score of 1

is good. The scores which have been submitted as part of the operational plan are shown in Table 4:

Table 4

If the Trust scores a 4 in any rating then there are overrides which determine the overall score

available.

A reconciliation of the cash position from forecast out-turn for 2016/17 to closing cash balance in

2017/18 is shown in Table 5:

Underlying

TRUST ANNUAL Position Opening

PLAN 2017/18 Excluding CIP Budgets

CIP 2017/18

£k £k £k

INCOME

Clinical Income - NHS 247,243 - 247,243

Non NHS Clinical Income 1,014 - 1,014

Other Income 23,979 783 24,762

TOTAL INCOME 272,236 783 273,019

EXPENDITURE

Pay Costs (221,026) 9,994 (211,032)

Non-Pay Costs (78,283) 4,223 (74,060)

TOTAL COSTS (299,309) 14,217 (285,092)

EBITDA (27,073) 15,000 (12,073)

Financing Costs (15,327) - (15,327)

RETAINED SURPLUS / (DEFICIT)

FOR PERIOD (42,400) 15,000 (27,400)

Use of Resources Rating

Forecast

out-turn

2016/17

Plan

2017/18

Plan

2018/19

Capital service 4 4 4

Liquidity 1 4 4

I&E Margin 4 4 4

I&E Variance from plan 2 4 4

Agency 2 1 1

Use Of Resources Rating before overrides 3 3 3

4 Rating Trigger for Use Of Resources Rating TRIGGER TRIGGER TRIGGER

Use Of Resources Rating after override 3 3 3

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Table 5

Annual Plan Cashflow Summary 2017/18

£m

Opening Cash at 31st March 2017 23.9

Income 273.0

Expenditure (285.1)

EBITDA (12.1)

Movement in working capital (before support) (0.1)

Financing (6.9)

Revenue Financing Support 13.8

Finance Leases (1.5)

Capital Programme 1617 (including creditors) (12.1)

Closing Cash at 31st March 2018 5.0

5.4

5.5

5.6

5.7

The Trust’s operational plan assumes a minimum cash balance of £5.0m is maintained throughout

2017/2018. Additional support in 2016/17 has improved the year end cash balance and thus reduced

the initial annual plan submission for revenue financing (working capital support) to £13.8 million. As

mentioned above, the cash performance is sensitive to the delivery of the CIP programme and

controlling cost pressures.

The process for accessing revenue financing has now been communicated to all Foundation Trusts

and Trusts. Where a Trust identifies revenue financing is required in a particular month it must

submit a 13 week daily cash flow to the NHS Improvement Capital and Cash Team one month

previously.

Access to revenue financing will be subject to increased challenge and scrutiny, and the Trust will

have to provide analysis of all individual cash draws to show level of cash required to fund deficit,

revenue loan repayments and working capital. Working capital support will only be provided in

exceptional circumstances and additional information will also be required at the point of draw

including Better Payment Practice Performance (BPPC), aged debtors/creditors, creditors beyond

payment terms and suppliers threatening to put accounts on hold.

Revenue financing cannot be drawn to fund capital expenditure or to cover capital loan repayments.

The cash table above reflects capital cash expenditure (including finance lease payments for the EPR

commitments of £13.6 million which is £3.6 million above planned depreciation. Financing costs

include £1.6 million in capital loan principle repayments. The Trust has already been asked to provide

feedback on these assumptions in the annual plan as it has also assumed revenue financing.

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5.8

5.9

Capital Programme

The draft 2017/18 capital programme is summarised in Table 6.

Table 6

Capital Plan

Description 2017/18

£'000

Property & Estates Schemes

Healthier Together 4,130

Minor Projects 863

Backlog Maintenance/Site Infrastructure 335

Non backlog Maintenance 500

5,828

Equipment Schemes

Plant and Equipment Other 610

Medical Equipment 3,049

3,659

I M & T Projects

EPR Acute and Community Finance Lease 1,490

EPR Internal Capital 970

Other IM &T 1,680

4,140

Capital Programme 1718 13,627

This investment is funded by:

Funded By:

Depreciation 2017/2018 9,982

Less:

Capital Loan Repayments -1,551

Finance Lease Repayments -1,514

6,917

Cash reserve 6,710

Total Funding 13,627

The capital plan currently reflects £4.1 million in Healthier Together schemes for ED expansion, ward

refurbishments, an endoscopy building and critical care and IT equipment. Whilst the funding

sources for these have not been confirmed, the Trust has included them within the 2017/18 capital

programme and this approach has been agreed with the NHS Improvement local team. The ED

expansion scheme is currently being designed as a two storey building. Until the funding sources are

confirmed, however, these schemes are at risk as is the ability of the Trust to deliver the capital

programme over and above its depreciation less repayments funding, given the restrictions on

revenue financing support from NHSI.

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6. RECOMMENDATIONS

6.1

The Board of Directors is asked to:

(a) Approve the Operational Financial Plan and the initial opening budgets for 2017/18

(b) Approve the level of CIP target of £15m within the financial plan for 2017/18

(c) Approve the Capital Programme for 2017/18.

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Subject: Going Concern Declaration

Report of: Director of Finance Prepared by: Associate Director of Finance

REPORT FOR APPROVAL


-----

Summary of Report International Accounting Standard 1 (IAS 1) requires the Trust to assess its ability to continue as a going concern as part of preparing the Annual Accounts. The process for considering Going Concern is to assess the financial risks facing the organisation and then model the financial impact of the risks on the available resources to deliver our operational services. This report provides an analysis of the downside scenarios including the associated cash impacts and the point at which the Trust moves into a negative cash position on the unmitigated testing scenario. The report provides the mitigations that are available to the Trust and to enable the Directors to assess the short to medium term solvency of the Trust. Purpose of this paper The Board of Directors are asked to:

Discuss the baseline cash trajectory and downside

scenario modelling;

Note the requirement for a working capital/distress

funding facility with the ITFF;

Agree to the going concern declaration.


-----


-----


Completed

Not required

Attachments:

This subject has previously been reported to:

Board of Directors Council of Governors Audit Committee Executive Team Quality Assurance Committee F&P Committee



Nominations Committee Remuneration Committee Joint Negotiating Council Other

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1 Introduction

1.1 The “Going Concern” concept is one of the fundamental concepts that underpin the accounting regime in most developed economies. Essentially it means that an entity’s Directors believe it has the resources in place to remain viable for the foreseeable future. It is normal practice to assess the Going Concern at or around the balance sheet date and look forward at the financial prospects of the organisation for at least twelve months. The “Going Concern” principle is also a key part of NHSI/Monitor’s licence and regulatory arrangements.

1.2 Each financial year, the Trust has to explicitly consider its ability to continue as a Going Concern,

both as part of preparing the annual plan and drawing up the annual financial statements. The main element for the declaration is whether the Trust has the required resources available to provide Commissioner Requested Services for the upcoming 12 months.

1.3 International Accounting Standard 1 (IAS 1) requires the Trust to assess its ability to continue as a

going concern as part of preparing the Annual Accounts. The process for considering Going Concern should be proportionate in nature and depth to the risk being faced by the entity.

1.4 In making such an assessment the Trust is required to take into account all the information

available about the future prospects of the Trust, taking a forward look for a minimum of twelve months. The extent and nature of this assessment will be driven by the historical financial position of the organisation and the knowledge of the financial challenges it faces. These challenges are considered in turn below.

1.5 It is not intended for this document to reproduce all the evidence of controls that exists to

support its conclusion, but provides the sensitivity modelling undertaken and the mitigations that the Trust can pursue to be a going a concern.

2 Financial Planning 2.1 The Board of Directors have considered the 2017/18 financial plans at a number of meetings over

the last four months through the presentation of detailed Board papers and presentations leading to the Trust rejecting the Sustainability and Transformation Fund (STF) in December 2016. These have explained:

a) the 2016-17 forecast outturn; b) the normalised financial position; c) movements in the financial position between the two financial years; d) the status and outcomes of the contract negotiations; e) the current Sustainability Cost Improvement Programmes (CIP) status; f) other financial risks facing the organisation; and g) the proposed 2017/18 financial plan.

2.2 The Financial Planning process has been especially challenging for 2017/18 due to the compressed timescales to submit annual plans before Christmas 2016. The Board have taken the decision not to agree a control total for the next two years given that the scale of cost savings required would not be deliverable - £30M (11%) in 2017/18 and a further £15M (6%) in 2018/19 assuming the 2017/18 CIP is delivered recurrently.

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2.3 The Trust financial plan for 2017/2018 reflects the latest information in relation to: a) tariff inflation;

b) pay cost impacts including national insurance and pension changes;

c) contract discussions and agreements;

d) building the Sustainability Cost Improvement Programmes;

e) the formal feedback from NHS Improvement on the draft Annual Plan; and

f) the Trust’s rejection of the STF.

2.4 As in previous years, we have developed a “base” case, without any CIP benefits, and an assessment of the potential income and associated expenditure, based on known assumptions and information. The summary underlying case for 2017/18, prior to the delivery of any cost improvement plans, results in a deficit of £42.4M.

3. Contract Risk 3.1. The Trust agreed the activity and finance schedule with Stockport Clinical Commissioning Group

(CCG) and have assumed a mixture of PbR and block funding to enable the Trust to make

transformational changes to services without a negative income impact.

3.2. The Trust has agreed all CCG contracts and NHSE contracts for 2017/2018 which is an

improvement on the position compared with last year. The implications of Stockport Together

workstreams and business cases is in progress but will not have a significant bearing on the Trust

finances in the year ahead. However, Board members are reminded that the strategic ambition of

Stockport Together is to significantly remodel a number of key areas of service delivery into

neighbourhood locations which would impact in the medium term on the Trusts financial model.

3.3. Healthier Together business cases are also progressing as part of the wider Greater Manchester

work but the detailed timing and financial implications of proposed changes is still being firmed

up and is unlikely to have a significant financial impact in 2017/2018 as the intention is that the

GM Health Transformation Fund will support the transition to any new arrangements.

3.4. Whilst the Trust has not agreed to agree a control total linked to the STF this may change

dependent on external influences which in turn would alleviate any requirement for any penalty

provision. There are also recent announcements from NHSI advising that there will be no

penalties for not achieving RTT and cancer targets so long as there is a commitment to try and

achieve them.

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4. Cost Improvement Programme Risk

4.1. The Trust has planned for £15M of Cost Improvement projects to be delivered in 2017/18 to

mitigate the financial loss that is currently forecast. This will help the Trust cash balances to remain in a positive position for as long as possible in 2017/18 before accessing working capital/distress funding which is a prerequisite from NHSI before the Trust can access any ITFF funding.

4.2. There is an outline of £15M CIP programme set out below but the intention is that this needs to

be recurrent with a similar level required in 2018/2019. This is a significant challenge and cannot be underestimated given previous CIP performance. The Trust has improved the level of CIP delivered in 2016/2017 compared with previous years (including the recurrent elements) but will have to achieve a step change in 2017/2018 whilst containing all other cost pressures within the agreed budget envelope for 2017/2018.

CIP Plan 2017/18 £'000

CIP Plan 2018/19 £'000

Theatre Efficiency Projects 1,700

Theatre Efficiency Projects 63

Account Management - High Peak 50

Length of Stay Programmes 300

Environmental Schemes 271

Impact of introduction of EPR 192

Medicines Management 170

Pay (WTE reductions) 9,897

Non NHS Income Generation 95

Non pay 4,103

Procurement Savings 1,200

Income (Patient Care Activities) 300

Workforce Efficiencies 1,601

Income (Other operating income) 145

Impact of introduction of EPR 409 Review of Neonates 250 Review of Wound Care Usage 22 Pathology Services 99 Reduction in Agency usage 1,000 Unidentified Schemes 8,134

TOTAL 15,000

TOTAL 15,000

4.3 At this stage, the Trust has not evaluated any further benefits from the following:

Operational Productivity Report from Lord Carter;

Further benefits from the Stockport Together Program;

Any GM wide initiatives such as the Theme 4 Projects; and

Any further workforce benefits

5 Other Financial Risks 5.1 In addition to the CIP challenge, the other main financial risks to the organisation over the next

twelve months are:

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a) The use of locum and agency staff continues to provide significant pressure to the Trust’s

expenditure levels due to the levels of vacancies in key clinical posts. Whilst the Trust has

assessed and planned for the likely cost of the locum and agency usage in 2017/18, there is a

risk that further vacancies cannot be successfully recruited to. The Trust is planning to reduce

overall agency spend through a dedicated sustainability program led by the Deputy Director

of Workforce building on the work undertaken in 2016/2017 and forms part of the 2017/2018

CIP Plan set out above.

b) The Trust’s budgets for 2017/18, net of the CIP target (£15M), are extremely tight, and the

Trust has had discussions with the Business groups highlighting the risks of overspending and

the need to address any financial pressures from within their existing budget allocations in

the first instance. The Trust will need to operate tight financial controls, procedures and

robust performance management to ensure budgets do not overspend. There continues to

be an issue with overspends in the Medicine Business Group driven by a range of factors but

these need to be contained in the year ahead as the Trust’s cash position is deteriorating.

c) The Trust continues to experience significant operational pressures to meet the national

patient core standards. The Trust has continued to invest in front-line clinical services to

meet access targets with little progress on transformational cash saving work in clinical areas.

There needs to be an ongoing review of the expenditure to ensure it is delivering the

intended benefits.

d) Whilst the Trust is planning significant CIP programmes for 2017/18 and 2018/19, it is not

planned for there to be significant redundancy costs as the Trust will manage down the need

for contingent staffing. Substantive staff would be redeployed into vacant posts where

appropriate.

6 2017/18 and 2018/19 Financial Projections 6.1 As the going concern assessment relates to the twelve month period from the day of the

accounts, the Trust is required to undertake a high-level projection for 2017/18. 6.2 The underlying assumptions used for 2017/18 have been derived from NHS Improvement’s

Economic Assumptions 2016/17 to 2020/21 published on 23rd March 2016. The table below summarises the Annual Operational Financial Plan submitted to NHS Improvement in December 2016.

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Plan 2017/18

Plan 2018/19

£m £m

Income 273.0 271.9

Expenditure (285.1) (279.4)

EBITDA (12.1) (7.5)

Non-Operating Expenditure (15.3) (16.9)

Surplus / (Deficit) (27.4) (24.4)

Year-end cash balance 5.0 5.0

Recurrent CIP 15.0 15.0

Capital Expenditure 13.6 9.0

Finance Use of Resources Metric 3 3

7 Downside Scenario Modelling 7.1 Delivering a financial plan with a recurrent CIP requirement of 5% is a challenge to the

organisation given the inability to meet the previous stretching targets that have been set. The pressing key risk for the Trust is the availability of cash in order to fund its day to day operating requirements.

7.2 To assess the robustness of the operational plan, and therefore aid the going concern assessment,

the Trust has stress tested the cash forecast using a number of scenarios. The Trust has assessed each scenario and has project cash balances to May 2018 being twelve months from the Annual Accounts Sign-off. The table below summarises the March 2018 cash balance along with the lowest cash balance in the fourteen month period for each scenario. The fourteen month trajectory is illustrated in Appendix A.

Scenario Mar 2018 Cash Balance (£’m)

Lowest Cash Balance to May

2018 (£’m)

Baseline (8.8) (12.2)

CIP delivery at 75% (£11m) (3.8) (3.8)

Cash Balance before revenue financing (12.6) (16.0)

Revenue Support required 17.6 21.0

Combined Downside Scenarios 5.0 5.0

Table 4 – Downside Scenario Modelling 7.3 The downside scenario modelling illustrates that if the Trust experiences the combination of all

downsides, which is highly unlikely, and does not take mitigating actions then the Trust will experience negative cash balances from December 2017. However, the Trust has set a minimum cash balance of £5 million to ensure working capital security and this would be breached in November 2017.

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8 Mitigating Actions 8.1 As illustrated in the baseline and combined downside cash trajectory in Appendix A, the Trust

needs to undertake urgent action to ensure the Trust remains solvent in the short/medium term, namely:

a) The Cash Action Group continues to proactively improve the cash flow of the Trust and has

successfully negotiated early settlement terms with commissioners and extended credit terms with NHSLA, Stockport Council and largely continuing to operate on 60 day settlement terms with suppliers. The Group is also actively managing debtor day performance working closely with the Business Groups. These actions have improved the cash flow and cash balances position of the Trust along with external support from Stockport and GM partners.

b) To apply for working capital/distress funding from the ITFF to ensure the Trust has access to cash to maintain service delivery;

c) To continue to work closely with Stockport Partners to ensure penalties are not invoked and if re-invested at the Trust, do not have any conditions attached;

d) To review the final Operational Productivity Report from Lord Carter and expedite any savings that have not been included in the sustainability programs;

e) To prioritise the Capital Programme for 2017-18; f) To expedite any savings that have been planned for 2017-18 and 2018-19; and g) To consider the sale and leaseback of assets.

9 Recommendations

9.1 Whilst the above analysis identifies several significant business risks facing the Trust in the coming

year, these are consistent with those faced in previous years and similar to those faced by other Acute NHS Trusts. However due to the Trust’s deteriorating cash balance, the Board of Directors are asked to;

a) Discuss the baseline cash balance and the downside financial modelling; and

b) Agree for an application for revenue financing in 2017/2018 of at least £14 million to

ensure the Trust can maintain funding of day to day operations.

9.2 The Trust will experience negative cash balances from December in the combined downside

scenario, likely to occur and secondly, as it occurs in December 2017, the Trust has twelve months to undertake mitigating actions. On this basis, the Board of Directors are asked to confirm the following declaration:

“After making enquiries, the Directors have a reasonable expectation that Stockport NHS Foundation Trust has adequate resources to continue its operations on an on-going basis for the foreseeable future. For this reason, the Directors continue to adopt the going concern basis in preparing the accounts.”

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Appendix A Fourteen Month Cash Trajectory (without revenue support)

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Subject: Key Results of the 2016 Annual Staff Survey

Report of: Director of Workforce and Organisational Development

Prepared by:

Vanessa Trimble, Head of OD and Learning

REPORT FOR NOTING


-----

Summary of Report The purpose of this report is to provide the Board of Directors with an overview of the 2016 annual staff survey results. The report will outline the top five and bottom five rankings as compared with all NHS acute and community Trusts. It will also provide the Trust’s engagement score and additional key findings. The Board are requested to note the content of the report.


-----


-----


Completed

Not required

Attachments: 2016 Staff Survey Results Summary Report


reported to:

Board of Directors


Audit Committee

Executive Team

Quality Assurance

Committee

FSI Committee

People Performance Committee

BaSF Committee





Other

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3

1. Introduction The purpose of this report is to present the key findings of the 2016 Staff Survey. The annual staff survey is a vital component in finding out the views of staff and helping to identify where improvements can be made at corporate, business group and staff group levels to improve the staff experience and further enhance engagement and staff satisfaction. In order to improve the response rate for 2016, a number of measures were adopted including; all staff were invited to complete a survey, a blended approach was used for ways to complete the survey, either on-line or a paper copy. Once again, as in 2015, incentives for completing a survey were implemented. In total, 1976 staff completed the survey, a response rate of 39%. This is a 5% increase from 2015 and compares with a national average of 39% for acute and community Trusts. 2. Key Findings

Staff engagement has decreased from 3.82 in 2015 to 3.75 in 2016. The national average is 3.80.

There are 32 Key Findings in the staff survey, which are structured thematically so that Key Findings are group appropriately. There are nine key themes within the report:

Appraisals and support for development

Equality & diversity (more detailed results can be found in Annex 1)

Errors & incidents

Health and wellbeing

Working patterns

Job satisfaction

Managers

Patient care and experience

Violence, harassment and bullying

The results of the 32 Key Findings are shown in the table below.

Key Finding Change since 2015 Ranking compared with all acute & community Trusts

Appraisal & support for development

KF11 % appraised in last 12 months √ Increase (better than 15)

Above (better than) average

KF12 Quality of appraisals No change Average

KF13 Quality of non-mandatory training, learning or development

No change ! Below (worse than) average

Equality & diversity

KF20 % experiencing discrimination at work in the last 12 months

No change √ Below (better than) average

KF21 % believing the organisation provides equal opportunities for career progression/promotion

No change Average

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Errors & incidents

KF28 % witnessing potentially harmful errors, near misses or incidents in last month

No change Average

KF29 % reporting errors, near misses or incidents witnesses


KF30 Fairness and effectiveness of procedures for reporting errors, near misses and incidents

No change Average

KF 31 Staff confidence and security in reporting unsafe clinical practice

No change Average

Health and wellbeing

KF17 % feeling unwell due to work related stress in the last 12 months

No change Average

KF18 % attending work in the last 3 months despite not feeling well

No change Average

KF19 Org and mgmt. interest in and action on health and wellbeing


Working patterns

KF15 % satisfied with the opportunities for flexible working


KF16 % working extra hours No change Average

Job satisfaction

KF1 Staff recommendation as a place to work or receive treatment

! Decrease (worse than 15)

! Below (worse than) average

KF4 Staff motivation at work No change Average

KF7 % able to contribute towards improvements at work


KF8 Staff satisfaction with level of responsibility and involvement

No change Average

KF9 Effective team working No change Average

KF14 Staff satisfaction with resourcing and support

! Decrease (worse than 15)

! Below (worse than) average

Managers

KF5 Recognition and value of staff by managers and the organisation

No change Average

KF6 % reporting good communication between senior management and staff

No change Average

KF10 Support from managers No change Average

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5

Patient care and experience

KF2 Staff satisfaction with the quality of work and care they are able to deliver


KF3 % agreeing that their role makes a difference to patients

No change Average

KF32 Effective use of patient feedback

No change Average

Violence, harassment and bullying

KF22 % experiencing physical violence from patients, relatives or public in last 12 months

! Increase (worse than 15)

Average

KF23 % experiencing physical violence from staff in last 12 months


KF24 % reporting most recent experience of violence

No change Average

KF25 % experiencing harassment, bullying or abuse from patients, relatives or public in last 12 months

! Increase (worse than 15)

√ Below (better than) average

KF26 % experiencing harassment, bullying or abuse from staff in the last 12 months


KF27 % reporting most recent experience of harassment, bullying or abuse


The tables below provide an overview of the best and worst scores when compared to all acute and community Trusts. A copy of the CQC survey summary report is embedded at the end of this report.

Key Findings 2016 2015

Our Trust National Average

Our Trust

Care of patients is my organisation’s top priority

70% 75% 76%

My organisation acts on concerns raised by patients

68% 73% 73%

I would recommend my organisation as a place to work

53% 59% 61%

If a friend or relative needed treatment, I would be happy with the standard of care provided by the Trust

66% 68% 73%

Staff recommendation of the organisation as a place to work or receive treatment

3.63 (out of 5)

3.71 3.79

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Top 5 Ranking Scores for 2016

Five questions we scored BEST in 2016


Percentage of staff appraised in last 12 months. 89% 86%

Percentage of staff experiencing physical violence from staff in the last 12 months (the lower the score the better)

1% 2%

Percentage of staff experiencing discrimination at work in the last 12 months (the lower the score the better) 8% 10%

Percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months (the lower the score the better)

21% 23%

Percentage of staff experiencing harassment, bullying or abuse from patients, relative or the public in the last 12 months (the lower the score the better)

24% 26%

Bottom 5 Ranking Scores for 2016

Five questions we scored WORST in 2016


Staff satisfaction with the quality of work and patient care they are able to deliver

3.87 (out of 5)

3.92

Percentage of staff reporting most recent experience of harassment, bullying or abuse.

43% 45%

Staff satisfaction with resourcing and support. 3.25 (out of 5)

3.28

Organisation and management interest in and action on health and wellbeing.

3.55 (out of 5)

3.61

Percentage of staff satisfied with the opportunities for flexible working patterns.

49% 51%

Key Finding Comparisons with local Acute/Acute Community Trusts

Trust Response Rate

Engagement Score

Recommend as a Place

to Work

Appraisal Rate

Recognised & Valued

Care of Patient is Top Priority

Stockport

39% 3.53 53% 89% 3.44 70%

Salford

52% 3.80 59% 87% 3.42 74%

Tameside

39% 3.95 69% 91% 3.63 83%

Pennine Acute

45% 3.64 48% 82% 3.29 66%

UHSM

35% 3.79 64% 81% 3.42 74%

East Cheshire

39% 3.86 62% 85% 3.52 73%

National Average

39% 3.80 59% 86% 3.47 75%

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3. Conclusion The results of the 2016 staff survey are disappointing, but given the challenging times and

context in which the survey was completed (September to December 2016), are not

surprising. The results present the Trust with an opportunity to look at what lies beneath the

results and to fully understand and appreciate the feedback. This will be a priority for the

new Head of OD and Learning who will work with business group directors and other senior

leaders to gain a more in-depth understanding of the results. Once this has been achieved,

and in line with the Trust’s communication and engagement plan, measures will be put in

place to ensure a better workplace experience for staff, leading to an improved position in

the 2017 staff survey results.

4. Recommendations

The Board is asked to note the content of the report and the next steps to be taken in

response.

NHS_staff_survey_2016_RWJ_sum.pdf

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Annex 1 2016 Staff Survey Equality and Diversity Trends

ADDITIONAL THEME: Equality and Diversity

Key Finding Men Women Disabled Not Disabled

White Black and

minority ethnic

KF20. % experiencing discrimination at work in last 12 mths

11

6

12

6

5

26

Number of respondents

302 1474 214 1573 1676 136

Ratio of respondents

1:8 1:14 1:8 1:14 1:17 1:4

ADDITIONAL THEME: Equality and Diversity

Key Finding

16-30

31-40

41-50

51+

KF20. % experiencing discrimination at work in last 12 mths

13

8

7

8

Number of respondents

240 315 535 735

Ratio of respondents

1:8 1:13 1:14 1:12

KF20. % experiencing discrimination at work in last 12 months. Trust score 8% (top ranking score) national average is10%

Highest in Medical (14%)

Highest in Medicine (13%) and Estates (13%)

Highest in Directorate of Older People (18%) Breakdown according to grounds for discrimination: Ethnic background 2% Gender 1% Religion 0% Sexual Orientation 0% Disability 0% Age 1% Other reason 3%

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2. Workforce Race Equality Standard (page 25)

There is little improvement in our WRES results since 2015 and in some areas we have scored worse. Of particular concern is the result to Question 17b “ In the last12 months have you personally experienced discrimination at work from your manager/ team leader or other colleagues?” The 2015 results showed a result of 3% for White staff and 16% BME. The 2016 results show 4% White staff and 19% BME.

3. Key Finding - Age

No additional themes other than the KSF 20.

4. Key Finding - Gender

Gender

Male

Female

KF15 % satisfied with the opportunities for flexible working patterns

41 52

This may be due to how the question is phrased “satisfied or very satisfied with the opportunities for flexible working patterns.” 5. Key Finding - Disability

Disability

Disabled

Not Disabled

KF17. % suffering work related stress in last 12 mths

54

32

KF18. % feeling pressure in last 3 mths to attend work when feeling unwell

77

52

KF26. % experiencing harassment, bullying or abuse from staff in last 12 months

33

19

6. Key Finding - Ethnic backgrounds

Ethnicity

White

BME

KF23. % experiencing physical violence from staff in last 12 mths

1

3

KF26. % experiencing harassment, bullying or abuse from staff in last 12 mths

20

25

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7. Other findings The demographics of the respondents were fairly reflective of the patterns within the workforce as a whole. Although 14% of staff who completed the staff survey declared a disability compared to 3% on ESR. Of those who declared a disability 76% said that the Trust had made adequate adjustments to enable them to carry out their work. Therefore if 14% of those who completed the survey declared a disability (1976 x 14% = 277). Of those who disclosed 76% said the Trust had made adequate adjustments (277x76% = 210). This equates to 67 staff members who need adjustments but have been unable to get them in place.

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Subject: Registration Authority Annual Report 2016/2017

Report of: Hugh Mullen Director of Support Services/SIRO

Prepared by: S. Raisbeck Registration Authority Manager

REPORT FOR BOARD APPROVAL


N/A

Summary of Report

Contents of this report demonstrate compliance with the requirements against the Information Governance Toolkit (IGT) and National Registration Authority (RA) Policy. National Registration Authority Policy states: “The Board/EMT individual must report to the Board annually on RA activity and must sign off on RA IG Toolkit submissions.” Trust compliance is submitted in March as part of the IG Toolkit.

Stockport FT is required to complete the Registration Authority IGT Requirements for RA and Smartcards. These requirements ensure that organisational processes and procedures are in place to meet an organisation's responsibility to be a Registration Authority and to ensure that NHS Smartcard users comply with the Terms and Conditions of use.

Board members are requested to;

Note the content of this report for reporting year 2016 to 2017.


N/A


N/A


Completed

Not required

Attachments: Appendix A – Access Positions

Appendix B – RA Sponsor Log

Appendix C – Summary of Sponsor Audit November 2016

Appendix D– Summary of Individual User Audit


reported to:

Board of Directors


Audit Committee

Executive Team

Quality Assurance

Committee

FSI Committee


BaSF Committee





Other

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1.

Registration Authority Annual Report 2016/2017

INTRODUCTION

The Registration Authority (RA) manages Smartcards and the registration and access control processes. The role of the RA is to ensure all users of National Programme applications are provided with the appropriate levels of access through the Smartcard system and have their identity rigorously checked.

2. BACKGROUND

The registration process applies nationally and must meet the current Government requirements.

The Director of Strategy, Planning & Transformation is the Board level individual who has overall

accountability in Stockport NHS Foundation Trust for RA activity; and in line with national policy must

report annually to the organisation on this activity. This report has been submitted to also meet

evidence requirements of the IG toolkit.

3. CURRENT SITUATION

3.1 NHS Digital published a revised National Registration Authority (RA) Policy 02/09/2014 in

preparation for the new Smartcard registration system in 2015, Care Identity Service (CIS). Stockport

NHS Foundation Trust’s local policy has subsequently been reviewed and updated in line with the

National RA Policy and is available on the Intranet.

3.2 The Registration Authority comprises of the RA Manager, Agents and Sponsors.

3.3 This Trust operates under Position Based Access Control (PBAC). PBAC simplifies how access rights

are granted to a user and builds on the existing Role Based Access Control (RBAC) security model. This

provides access to NHS CRS (Care Records Service) compliant systems appropriate to the job that staff

have been employed to do.

3.4 Access positions are under constant review and any changes are agreed with Caldicott Guardian, Information Governance lead and RA Manager with sign off at board/ET level in this report. There are currently 56 Access positions in the Trust and details are shown in Appendix A. The inclusion of this appendix is a requirement of the information Governance Toolkit. 3.5 There are currently 89 registered sponsors in the Trust and it is mandatory that they all must complete RA Sponsor training when registered. Sponsors are set at a senior level to authorise correct access to systems. The Training for Sponsors is via the Registration Authority Manager in accordance with National Policy requirements. Sponsor details are shown In Appendix B. The inclusion of this appendix is a requirement of the information Governance Toolkit. In Summary, currently Trust Sponsors are Split across the Business Groups as follows:

28 in Stockport Community Health

21 in Diagnostic and Clinical Support

19 in Surgical and Critical Care

12 in Corporate Services

6 in Child and Family

3 in Medicine

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3.6 Integration with HR – There is a robust, assured process in place within HR to ensure all new

starters are RA ID checked and registered when they present their documents to the recruitment

team. All HR ID Checkers are trained and complete RA e-learning.

3.7 Introduction of new systems and applications: Community EPR – EMIS Web has been successfully rolled out to the majority of Community staff.

Once the system is live for all services, before the end of March 2017, the iPM system access will be

closed.

Hospital EPR – Trakcare. The RA team are currently in the process of Identifying, registering and training appropriate Sponsors who will in turn authorise staffs access to Trakcare. All staff needing access to the system will require a smartcard.

3.8 Two annual audits have been conducted. The first was sent to a selection of individuals and the

second was the Sponsor Audit. Summary details are shown in Appendix C & D. The inclusion of these

Appendices is a requirement of the Information Governance Toolkit.

3.9 Statistics:

Currently maintain smartcards and access for 2047 users.

1051 new registrations to *e-GIF level 3 in last 12 months (this includes HR registrations for some staff

that have yet to have cards printed)

672 new smartcards issued in the last 12 months

112 smartcards reissued in last 12 months

606 cards refreshed in last 12 months (certificates renewed)

*e-GIF stands for e-government interoperability framework. It is a set of policies and

standards to enable information to flow seamlessly across the public sector. As part of the

framework, four confidentiality levels were set (zero to three) representing degrees of impact

of disclosure of private information. The levels are layered according to the severity of

consequences that might arise. Level 3 which imposes the most stringent security

requirements around confidentiality has been adopted for the NHS CRS.

4. RISK & ASSURANCE

The Board can be assured that our existing processes and procedures are comprehensive and robust. Our detailed approach to the management of RA meets the requirements of national standards surrounding registration and ID checking to the government standard e-GIF level 3.

5. CONCLUSION

As the Hospitals EPR project will require approximately another 3000 staff to be issued with NHS

Smartcards and detailed access control, the continued support of RA by the Trust Board and all

registered sponsors will be intrinsically important. Some changes to local processes may be required

but always within the set boundaries required by the IG toolkit and National Policy.

6. RECOMMENDATIONS

That the content of this report be noted.

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APPENDIX A

Position name Position description

1. Acceptance of

Terms and

Conditions

Temporary Job Role to allow smartcard user to accept terms and conditions

before sponsor approval of required PBAC.

CAB Admin Choose and Book access for Call Centre Staff

CAB Admin Manager Choose and Book access for CAB Admin Managers

CAB Consultant Choose and Book access enabling Consultants to receive referrals

CAB Medical Records Choose and Book access for Medical Records staff

CAB Sponsor Choose and Book Manager access with Sponsorship rights.

Caldicott Guardian Restricted access for Caldicott Guardian only

Child Protection

Information Sharing

(CP-IS) in SCRa

Allows staff in unscheduled care, Summary Care Records access - can check if

a Child Protection Plan is in place or are classed as Looked After by Local

Authorities. Used to check the status of children and pregnant mothers due

to give birth

CSC access to

Lorenzo System

Access for CSC to both Tameside and Stockport's instances of LRC for

resolution of service calls and upgrade work

CSC Cluster System

Administrator

Access for CSC to support upgrades and deal with service calls.

Data Management

Sponsor

Restricted Specialist Role allowing access to SCR/PDS and SUS with

Sponsorship rights

Data Management

Team

Restricted Specialist Role allowing access to SCR (Summary Care Record) and

PDS

Emergency

Department Sponsor

Sponsor with access to CP-IS in SCRa - can check if a Child Protection Plan is

in place or are classed as Looked After by Local Authorities. Used to check

the status of children and pregnant mothers due to give birth.

Emis Web Admin

Authorised To

Manage

Appointment Slots -

Restricted

Restricted access authorised by the Information Team to manage

appointment slots - includes the standard EMIS Web Administrator access

Emis Web Admin

Manager and

Sponsor

Emis Web access for Community Admin Managers including NHS e-referral

codes and Sponsorship rights

Emis Web

Administrator

Emis Web access for Community Admin staff including NHS e-referral codes

Emis Web Clinician Emis Web access for Community Clinicians

Emis Web Clinician

Sponsor

Emis Web access for Community Clinician Managers with reporting &

Sponsor rights.

Emis Web Read Only Emis Web Read Only – Position under review

Emis Web Service

Lead

Emis Web access for Community Clinician Managers with reporting rights.

Emis Web SPCS

Clinician with B8029

Restricted access for SPCS Service enables the user to add to a patient record

after they are deceased. Includes the standard EMIS Web Clinician access.

Emis Web System

Admin - Restricted

Restricted position for EMIS Web System Admin only

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General Sponsor Allows the user to access & Sponsor staff for ESR, MOM, E-Learning ,ORMIS

and SSO (the user also requires a profile on the appropriate system & must

be authorised to use the system).

General User Allows the user to access ESR, MOM, E-Learning, ORMIS and SSO (the user

also requires a profile to be created on the appropriate system).

IT Manager Includes General User and IT Support access with ability to unlock

smartcards

IT Manager and

Sponsor

Includes IT Manager access with the rights to Sponsor staff

IT Support Includes General User access and ability to test access to both Stockport and

Tameside’s portal for the iPM systems.

Local Smartcard

Administrator

General user access with the ability to unlock smartcards and renew

certificates for non RA staff.

Midwife PDS Access Access to PDS Birth Notifications Application (Maternity)

Midwife Sponsor Access to PDS Birth Notifications Application (Maternity) with rights to

Sponsor staff

NCRS Trainer Specialist Role for NCRS trainer giving access in iPM and LRC for both

Stockport and Tameside & Glossop Communities.

Operational RA

Manager

RA Manager access including predecessor access to 5LH and 5F7 to enable

position management for IPM and LRC for community staff

Ormis Admin Administrator access in the ORMIS system with the right to unlock users

cards

Ormis Admin

Sponsor

Administrator access to the ORMIS system with the rights to Sponsor ORMIS

users

Overseas Visitor

Management

Restricted access to verify the surcharge status of overseas visitors in SCRa

used by the overseas visitor management team only.

Patient

Demographics view

only access (PDS)

User with access to Personal Demographic Service can view patient

demographic information and check patients NHS numbers and registered

GP.

RA Agent This is a standard position for RA Agents. Able to assign R8008 for

acceptance of T's and C's only.

RA Agent ID Checker HR staff able to check ID, upload photos and register details for smartcards.

No other RA activities included, cannot grant access or issue cards.

RA Manager &

Privacy Officer

Restricted to RA Manager and authorised Privacy Officer.

Senior Information

Analyst SUS access

Restricted Specialist role allowing access to SUS and SCR/PDS

Sponsor with access

to SCRa

View only access in Summary Care Record application (SCRa) with rights to

Sponsor staff.

Sponsor with PDS

access

Sponsor with access to Personal Demographic Service can view patient

demographic information and check patients NHS numbers and registered

GP.

Stockport

Community

Administrator

Standard IPM access for Stockport Community Admin staff also includes CAB

codes

Stockport

Community

Restricted access for Stockport Community Admin staff Authorised by

Information Team to Manage Clinic Setup includes the standard

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Administrator

Authorised to

Manage Clinic Setup

Administrator IPM access.

Stockport

Community Admin

Manager and

Sponsor

Restricted High level IPM access with Manage Clinic Setup, CAB and Sponsor

rights for Stockport Community Admin staff.

Stockport

Community Child

Health View Only

Access

View only access in Stockport's Child Health System. Used when no iPM

access is required.

Stockport

Community Clinician

Standard clinical access for Stockport Community staff in iPM

Stockport

Community Clinician

Sponsor

Clinician access in iPM and Sponsor for Stockport Community staff

Stockport

Community

Information and

Performance

Manager

Restricted specialist role for Manager of system administration in iPM and

LRC for Stockport Community. Includes Sponsor rights.

Stockport

Community

Information Team

Specialist role for system admin access to iPM and LRC for Stockport

Community.

Stockport

Community LRC

Administrator

LRC and IPM access for LRC trained Stockport Community Admin staff

Stockport

Community LRC

Clinician

LRC and IPM access for LRC trained Stockport Community Clinicians

Stockport

Community LRC

Clinician and Sponsor

Sponsor for LRC and IPM access for LRC trained Stockport Community staff

Stockport

Community

Safeguarding Nurse

Safeguarding Nurse iPM access for Stockport community staff

Stockport

Community

Safeguarding Nurse

and Sponsor

Safeguarding Team Sponsor with Safeguarding Nurse access in iPM for

Stockport Community staff

Summary Care

Record application

view only access

View only access in Summary Care Record application (SCRa)

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APPENDIX B

Trust Sponsors

Staff Group Job Title Area of Sponsorship Training

CHS Team Leader Adult Community Therapy Team CIS Trained

CHS Acting Head of Adult services (Stockport) Adult services Stockport CIS Trained

CHS Head of Performance and Business

Development

Business Unit and Community Admin CIS Trained

CHS CAIR Occupational Therapist CAIR Team CIS Trained

SFT Cancer Services Manager Cancer Services CIS Trained

SFT Cancer Services Access Manager Cancer Services CIS Trained

SFT Clinical Service Lead for patient access Centralised Library, Old Laundry

Building

CIS Trained

SFT Business Manager Child & Family Services CIS Trained

SFT Assistant Business Manager Child & Family Services CIS Trained

CHS Childrens Therapy Manager Children's Therapies + Early Attachment

Service

CIS Trained

CHS Speech & Language Therapist TL Childrens Therapy services CIS Trained

CHS Locality Administration Manager Community Services

Administration/School Health Admin

CIS Trained

CHS Continence Service Lead Continence Service CIS Trained

CHS COPD Team Leader COPD Team + Heart Failure Team CIS Trained

SFT Ward Manager D1 CIS Trained




CHS Diabetes Specialist Nursing Service Lead Diabetes CIS Trained

CHS Diabetes Specialist Nursing Service Lead Diabetes team CIS Trained

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SFT Business Manager Diagnostic and Clinical Support CIS Trained

SFT Gov & Quality Manager Diagnostic and Clinical Support CIS Trained

CHS Locality Lead for District Nursing District Nursing CIS Trained



CHS Pathway Lead Community Nursing DN's District Nursing CIS Trained

SFT Matron Emergency Dept. CIS Trained

SFT Endoscopy Sister Endoscopy Unit CIS Trained

SFT Endoscopy Manager Endoscopy Unit CIS Trained

CHS Clinical Lead Complex Care ENS/ONS and Werneth and Marple CIS Trained

SFT Head of EPR Clinical Deployment EPR Project team CIS Trained

SFT Head of EPR Technical Deployment EPR Project team CIS Trained

SFT Business Accountant Finance CIS Trained

SFT Assistant Business Manager - SCC business

group

General Surgery Medical Secs, Waiting

list teams

CIS Trained

CHS Advanced Physiotherapist and Physiotherapy

Team Leader

GP Direct Access Physiotherapy CIS Trained

CHS Advanced Physiotherapist and Physiotherapy

Team Leader

GP Direct Access Physiotherapy CIS Trained


group

Head & Neck Medical Secs, Waiting list

teams patient access/Rota team

CIS Trained

CHS Integrated Childrens Services Manager Health Visiting, School Nursing CIS Trained

CHS Service Manager Health Visiting, School Nursing CIS Trained

CHS Health Visiting Nurse Manager Health Visiting, School Nursing CIS Trained

SFT Recruitment Manager HR CIS Trained

SFT Workforce Team Leader HR CIS Trained

SFT Matron - ICU ICU CIS Trained

SFT Senior Infection Prevention Nurse Infection Prevention Team CIS Trained

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SFT AD of information Information CIS Trained

SFT Assistant Director of Information –

Information Governance & IT Security

Information Governance CIS Trained

CHS Information and Performance Manager Information Team CIS Trained

SFT Team Leader In-Patient Therapies CIS Trained

SFT Therapy Manager In-patient Therapies CIS Trained

SFT Acting Assistant Director of IM&T IT CIS Trained

SFT Service Manager IT CIS Trained

SFT Senior Sister Anaesthetics & Recovery Main Theatres CIS Trained

SFT Clinical Midwifery Manager Maternity CIS Trained

SFT Assistant Business Manager Medicine Business Group -

Gastroenterology, Diabetes &

Endocrinology

CIS Trained

SFT EPR Clinical Lead AHP Medicine for Older People Therapy

Team

CIS Trained

SFT EPR Clinical Lead AHP Medicine for Older People Therapy

Team

CIS Trained

SFT Head of Midwifery and Nursing Midwives CIS Trained


group

MSK and Pain Medical Secs, Waiting list

teams

CIS Trained

SFT Senior Clinical Research Nurse Oncology Research CIS Trained

SFT Research & Innovation Manager Oncology Research CIS Trained

SFT Eye Centre Manager Ophthalmology CIS Trained

SFT Sister Outpatients Department CIS Trained

SFT OPD Sister Outpatients Department CIS Trained

CHS Paediatric Physiotherapy TL + Manual

Handling Trainer

Paediatric Physiotherapy CIS Trained

SFT Advanced Nurse Practitioner Paediatrics - Tree House CIS Trained

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SFT Matron for Paediatrics and Neonates Paediatrics - Tree House CIS Trained

SFT Clinical Service Lead Laboratory Medicine Pathology CIS Trained

SFT Chief Technician Pharmacy CIS Trained

SFT Clinical Services Manager Pharmacy CIS Trained

CHS Podiatry Team Lead Podiatry CIS Trained

SFT Pre-op Service Manager Pre-op (Magnolia Suite) CIS Trained

SFT Clinical Services Manager Radiology CIS Trained

SFT Radiology Systems Manager Radiology CIS Trained

SFT Head of Risk & Customer Services Risk CIS Trained

CHS Named Nurse LAC Safeguarding children Stockport CIS Trained

CHS Macmillan Palliative Care Lead Nurse Specialist Palliative Care Team CIS Trained

SFT Ward Manager SSSU CIS Trained

SFT Stroke Therapy Team Lead Stroke Therapy Team CIS Trained

SFT Ward Manager Surgery and Urology (SAU) C3 CIS Trained

SFT Theatre Services Coordinator Theatres CIS Trained

SFT Matron Operating Theatres Theatres CIS Trained

SFT Senior Sister T&O Theatres Theatres CIS Trained

CHS AD of Nursing Tissue Viability CIS Trained

CHS Integrated Tissue Viability Lead Tissue Viability Service CIS Trained

SFT Business Manager Trauma and Orthopaedic Services CIS Trained


group

Urology CIS Trained

SFT = Hospital

CHS = Stockport

community

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APPENDIX C

1.1

SUMMARY of Sponsor Audit November 2016

Registration Authority Smartcard Usage Monitoring

The Information Governance Toolkit requires the Trust to put monitoring and enforcement procedures in place to ensure that NHS Smartcard users comply with the terms and conditions of use. This form is to be completed by the Registration Authority Manager, Sponsors or Agents to document that checks have been carried out on the appropriate use of Smartcards and associated applications. Where non compliance with the Terms & Conditions or other Stockport NHS Foundation Trust polices is identified a formal incident report should be completed on the Datix Risk Management System. The results of any spot checks undertaken should also be submitted to the Information Governance Team. Action must be taken in line with the Trust’s disciplinary procedures where any re-occurring issues are identified; where serious breaches are identified criminal prosecution may also be taken against the individual concerned.

Completed by:

Name: Sue Raisbeck

UUID: 61574076030

Location details:

Directorate / Business Group

Information Governance

Department:

Registration Authority

Location:

Cedar House

Area Uses Smartcards? Yes/No

Yes

Checklist (Part One):

Physical Security Checks

Question No. of users / pc’s checked (min 5)

Yes No

1. Are there any Smartcards left unattended in the readers?

Normal Working Hours

253

Out of Normal Working Hours

206

2. Are there any Smartcards left unattended elsewhere?

Normal Working Hours

247

Out of Normal Working Hours

190

3. Ask the user to show you their Smartcard to 229

Date: 30/11/2016

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confirm that it has not been lost / stolen.

4. Ask the user to confirm that when not in use their Smartcard is stored securely i.e. kept in a locked draw / handled like bank/credit cards.

237 235 2

5. Ask the user if their name remains the same as that printed on the card?

237

6. Is the user using their own Smartcard?

237

7. Are there any notes/stickers on the Smartcard or surrounding work station that show the users passcode?

237

8. Has the Smartcard been altered, defaced, tampered with or otherwise manipulated?

237

Issues and Actions: These details must be recorded for any issues identified:

Name UUID Question Number

Datix Incident Reference

Action Taken

M H

374*******16 4 N/A Left card in drawer, but drawer doesn’t lock **

S W 922*******37 4 N/A Card left in pencil case overnight in locked office, advised to lock in personal locker

Additional Comments / Observations:

Given a new card holder to put ID and also smart card in **

Use of smartcards quite limited at present but expect greater use over the next 12 months

Advised if they leave their desk/office for comfort break to ensure they take card out of

reader

Four smartcards kept in unlocked drawers, but office is locked (Safe Haven)

No issues to report as they had all heeded the advice from the last audit.

Summary Any/All issues addressed and resolved – checked completed by S. Raisbeck, RA Manager.

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APPENDIX D

1.2

SUMMARY Individual User Audit

Registration Authority Smartcard Usage Monitoring The Information Governance Toolkit requires the Trust to put monitoring and enforcement procedures in place to ensure that NHS Smartcard users comply with the terms and conditions of use. This form is to be completed by the Smartcard User to document that checks have been carried out on the appropriate use of Smartcards and associated applications. Where noncompliance with the Terms & Conditions or other Stockport NHS Foundation Trust polices is identified a formal incident report should be completed on the Datix Risk Management System. The results of any spot checks undertaken should also be submitted to the Information Governance Team. Action must be taken in line with the Trust’s disciplinary procedures where any re-occurring issues are identified; where serious breaches are identified criminal prosecution may also be taken against the individual concerned.

Name: Sue Raisbeck, RA Manager

UUID: 615744076030

Location details:

Directorate / Business Group

Community Healthcare, Diagnostics & Clinical Support, Child & Family, Corporate Services, Medicine, Surgical and Critical Care,

Departments:

Community Admin, Radiology, Outpatient Bookings, Health Records, Children’s Speech and Language Therapy, Vulnerable Children’s Team, Podiatry, Health Visiting, HR, Diabetes Service, Governance & Complaints, Orthopaedic Assessment Service, EPR, Audiology, Maternity, Central Booking Office, Urology, School Health, Adult Community Therapy team, Palliative Medicine, Ophthalmology, Orthotics, Information, Children’s Equipment and Adaptation Service, CAIR Team, Physiotherapy, District Nursing, IT Services, Training Dept. Trauma & Orthopaedics, Overnight Nursing Service, COPD Team, Infection Prevention, Stockport Heart Failure Service, Main Theatres

Locations:

SHH,X-ray A, Aspen House, Cedar House, Kingsgate, Beckwith House, Willow House, Hazel Grove Clinic, Abacus Centre, Ward D5, Regent House, Rowan Suite, OPB, Bramhall HC, Stopford House, Centralised Library, Gatley HC, Heaton Norris HC, Eye Centre, MAU, Heald Green HC, Beech House, Adswood Children’s Centre

System accessed with smartcards

iPM, Child Health, Lorenzo, ORMIS,ESR, E-learning, E-Referrals, EMIS Web

Date: Oct 2016

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Checklist (Part One):

Question

1. Where do you keep your smartcard when it’s not in use?

Keep it with me at all times

In my pocket/On my person

In my locker/ In a locked drawer

In my work bag.

At home

With my ID badge

Securely at work

In my purse/wallet

On my lanyard

2. Do you leave your smartcard unattended at any time?

No/Never

If the card is in the pc for the list & I have to leave theatre to collect extra co nsumables, have a break , etc card is leftactive. It would disrupt the smooth running of the theatre if staff permenantly removed their cards everytime they needed to leave theatre even for a couple of minutes due to low staffing levels and slow pcs to reboot

3. Do you use another person’s smartcard? No/Never

4. What must you do if your smartcard is lost or stolen?

Report it to my manager and Information Governance and submit an incident form

Inform RA/Contact the Smartcard office

Inform IG and complete DATIX

Report it to manager and smartcard team

Report it to the Choose and Book Manager

Notify Community EPR

Contact Registration Authority and complete Datix form

Report it to the Registration Authority Manager

Report immediately to line manager, Lorenzo team, complete Datix

Report it immediately to my Line Manager and Human Resources

Inform IT

Report to Sponsor

Report it to helpdesk

Inform relevant department

5. Do you allow anyone to share your smartcard?

No/Never

6. What must you do if your name changes? Inform HR

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Inform Lorenzo Team

Speak with Community EPR Officer

Inform line manager

Inform the Registration Authority/smartcard team

Inform the Registration Authority Manager

Inform my manager Log on to ESR learning and make changes.

Inform the Registration Authority Team and arrange to bring in evidence of the name change such as marriage certificate.

Report to Sponsor

Report it to helpdesk

Inform any changes to the relevant managers/staff who deal with Ormis

7. Are there any notes/stickers on your Smartcard or surrounding work station that show the passcode?

No

8. Has the Smartcard been altered, defaced, tampered with or otherwise manipulated?

No

9. Can smartcards be used for ID? No

Don’t know/Not sure

Yes

In NHS place of work

No , Need separate ID card

10. Does the photo on the smartcard clearly bear a true likeness to you and is the smartcard number clear?

Yes

No the picture has become blurred over time. The number is clearly displayed

Any Additional Comments:

“I do not take my smart card off site and it is stored in my desk in a locked room when the office is closed. I do not use it very often.” ----------------------------------------------------------------------------------------------------------------------------------------------- “I have recently had my smart card revalidated; it wasn’t made clear as to where I should keep it. I was told to treat it like a bank card. I carry it with my so if needed I can use it in other clinic areas.”

SUMMARY

The audit has raised a couple of issues that were clarified, by email with the audited users

and also highlighted to all by posting a Red Rules reminder on the Intranet. The issues

were:-

1. Leaving cards unattended -One user stated “If the card is in the pc for the list & I have to

leave theatre to collect extra consumables, have a break, etc. card is left active. It would

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disrupt the smooth running of the theatre if staff permanently removed their cards every time

they needed to leave theatre even for a couple of minutes due to low staffing levels and slow

pcs to reboot”. A DATIX was submitted and the user was requested to attend RA for a card

update and a short refresher training session around Terms and Conditions.

2. Clarity around the correct procedure for reporting lost cards.

3. Using smartcards as ID

The Red Rules were attached to the email and users asked to display them around their

teams. Also a reminder of the Terms and Conditions was attached to the email.

--------------------------------------------------------END------------------------------------------------------------------------

-

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1

Board of Directors’ Key Issues Report

Report Date: 30/03/17

Report of: Finance & Performance Committee

Date of last meeting: 15/03/17

Membership Numbers: Quorate

1. Key Issues Highlighted:

The Committee considered an agenda which included the following:

Month 11 Finance Report 2016/17

Agency Utilisation Report

PLICS Quarter 3 Report

Overseas Visitors - Income & Recovery

Month 11 Operational Performance Report

Financial Improvement Group - Update Report

EPR Benefits Report

EPR Progress Report

Strategic Planning Tool Update

Finance-Related Risks

With regard to matters to bring to the attention of the Board, the Committee’s emphasis during the meeting was on matters relating to the year-end financial and operational position and preparation for the new financial year. The Committee considered the Month 11 Finance Report which presented the Trust’s financial position as at 28 February 2017. The Committee noted a deficit position of £11m against a planned deficit position of £14.1m. However, following adjustments for Sustainability & Transformation Fund (STF) income and impairments, the overall position in relation to Control Total was a favourable variance of £1.4m against plan. With regard to year-end forecast, the Committee received positive assurance from the Director of Finance on delivery of Control Total but noted a risk relating to income from elective activity during February and March 2017. The Committee was advised that the position was being proactively managed but will be an area where the Board will need to seek assurance on 30 March 2017. The Director of Workforce & OD presented a report on the Trust’s agency utilisation and expenditure and the Committee noted that expenditure had exceeded the Agency Ceiling trajectory for the first time in 2016/17 resulting in a cumulative adverse variance of £600k as at 28 February 2017. The forecast year-end position had deteriorated from a negative variance of £1.2m to £1.5m as a result of initiatives to meet additional demand on clinical services. With regard to Operational Performance, the Committee noted positive results against Cancer and RTT standards with the latter standard being achieved for the fourth consecutive month. Less positive was performance against the 4-hour A&E standard although the Month 11 outcome of 75.2% was an improvement on performance in Month 10. The Committee noted that there had been a further two 12-hour trolley waits during the month.

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2

The Committee considered a report on the Financial Improvement Programme and noted a forecast savings total of £14.5m in 2016/17 which will be a significant achievement. The Committee then focused on progress with the identification of savings for the 2017/18 programme and noted identification of schemes with a value of £7.1m against a target for the year of £15m. A further 73 ‘pipeline schemes’ have been identified for validation to address the gap to target and it is imperative that this work is progressed as a matter of urgency. Following consideration, the Committee concluded that there is currently a low level of assurance in relation to the 2017/18 cost improvement programme. Dr J Catania and Mrs H Bennett attended the meeting to present reports on Electronic Patient Record (EPR) Benefits and EPR Project Progress respectively. The EPR Benefits report provided a comparison of the current position against the benefits set out in the original Business Case and the Committee noted a significant shortfall in the level of benefits expected to arise from Clinical Coding developments. In addition, a further sum of circa £13m aligned to benefits associated with length of stay and reduction in readmissions is currently amber-rated and the Committee noted work being undertaken in conjunction with the Transformation Team to complete further analysis of potential benefits in these areas. The Committee was assured that the assumed benefits had not been incorporated in the Trust’s financial plan for 2017/18. With regard to progress with the EPR Project, the Committee noted that good progress continues to be made and that the Trust remains on course to achieve the Rollout 1 go-live date of 24 June 2017. The Director of Finance presented a report which provided an update on procurement of a Demand & Capacity tool and the Committee noted a number of factors which had resulted in changes to the original requirement, including a shortage of reference sites where models were currently in use. The Committee noted a potential alternative approach based on enhancing the Trust’s access to appropriate business informatics resource. As a result of the discussion, the Committee agreed that it would be helpful for the wider Board to have an overview of the methodologies, as opposed to particular tools, currently being used for demand, capacity and workforce planning. Finally, the Committee received and noted reports relating to Patient Level Information Costing System (PLICS) and recovery of income from Overseas Visitors. With regard to the latter, the Board should note that income in this area is very modest with the level of income in 2015/16 equating to 0.01% of turnover. The Committee reviewed a register of Finance-related risks and noted that content would be updated to reflect commencement of a new financial year. Business was completed by validation of a Registration Authority Policy and a Secure Disposal of IT Assets Policy following periodic review.

2. Risks Identified Delivery of 2017/18 Cost Improvement Programme Achievement of the A&E 4-hour performance trajectory Delivery of EPR financial benefits.

3. Actions to be considered at the

Nil

4. Report Compiled by

Malcolm Sugden, Chair Minutes available from: Company Secretary

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1



Report Of: Audit Committee





Internal Audit Progress Report

Internal Audit Follow-Up Report

Draft Internal Audit Plan 2017/18

Draft Anti-Fraud Work Plan 2017/18

External Audit – Interim Audit Report

Key Issues - Annual Accounts & Report

Board Assurance Framework

Freedom to Speak Up

Evolve Project Review

RTT Audit Report

Losses & Special Payments

Waivers of Standing Financial Instructions

Compliance with FT Code of Governance

Committee Work Plan 2017/18

With regard to matters to bring to the attention of the Board, the Committee considered a Progress Report from Internal Audit which detailed outcomes of audit reviews as follows:

Combined Financial Systems Review - Significant Assurance Information Governance Toolkit - Significant Assurance

The Committee noted the positive outcomes of both reviews. The report also detailed findings of work relating to Consultant to Consultant referrals and the Committee requested that management assess the findings and provide a subsequent report to the Committee detailing outcomes and any associated actions. The Committee also considered a report which detailed outcomes from a Follow-Up of Audit Recommendations which provided positive assurance on progress with implementation of agreed actions. The only area where actions were outstanding related to Medical Appraisals and the Committee has requested an appropriate assurance report for its next meeting on 18 May 2017. The Committee then considered a draft Internal Audit Plan for 2017/18 and noted that plan content had been developed through engagement between Internal Audit representatives and both Executive and Non-Executive Directors. The Committee approved the plan but noted areas that were not included, such as; MCP

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2

Development, Workforce Planning and Emergency Department indicators, where alternative means of obtaining assurance may need to be considered. The Trust’s Local Anti-Fraud Specialist was present at the meeting and presented a draft Anti-Fraud Work Plan for 2017/18. The Committee approved the Work Plan and agreed that proactive work should focus on Overtime in High Use Areas and Pre-Employment Checks. External Audit representatives were in attendance at the meeting and presented an Interim Report on preliminary work associated with audit of the 2016/17 financial statements, the value for money conclusion and the Trust’s Quality Report 2016/17. The Committee noted progress to date and was advised that there had been no change to the significant risk areas which would be assessed during the audit. One of these areas, Going Concern, related to the next agenda item on Key Issues for the Annual Accounts & Report and the Committee noted the approach to this matter which would be adopted by both Trust and Audit representatives. The Committee noted a helpful briefing paper on this subject which had been produced by the HFMA which included a summary of areas to be reviewed as part of the Trust’s Going Concern assessment. A specific report on the subject of Going Concern will be prepared by the Director of Finance for consideration by the Board of Directors. The Committee approved recommendations made for the inclusion of key issues in the Annual Accounts & Report set out in the remainder of the report. The Committee received a report which detailed outcomes of the Evolve (Patient Record Scanning) Project which was undertaken over the period October 2013 – March 2017. While the Committee noted the benefits realised from the Project, which has included establishment of a firm foundation for EPR implementation, the scale of overall benefits from the project, particularly financial benefits, were significantly lower than those originally approved by the Board in the business case, partly due to a change in project approach initiated in 2014. Although this change was itself beneficial in terms of enhancing capacity, the Committee noted the need to ensure that all major investment / change projects include appropriate governance arrangements for consideration of project variations. The Committee was assured that such arrangements are in place for the EPR Project. The Committee also requested a report setting out the lessons learnt from the Evolve project and the mechanism by which they would be used to inform future projects. The Committee considered a report which detailed outcomes of an RTT audit. Board members will note that the RTT indicator has been the subject of a mandated audit as part of the annual review of the Trust’s annual Quality Report. In the two previous years, this audit has resulted in a qualified opinion on the Quality Report. The latest report considered by the Committee suggests that the outcome will be the same for the 2016/17 audit. The key measure to address weaknesses in this area, which primarily relate to the recording of start and end dates, is the introduction of mandatory training for all staff involved in the RTT pathway. An e-learning system has been procured and roll-out of the training to non-clinicians started during week commencing 6 March 2017. Roll-out to clinicians has been delayed pending revisions to the relevant e-learning package. Timely completion of the mandatory training by all relevant staff is imperative in order to mitigate the risk of a further qualified outcome in 2017/18 and the Committee has requested a further assurance report on this matter for its next meeting. Mr P Gordon commenced in the role of Freedom to Speak Up Guardian in January 2017 and was present in an observer capacity throughout the meeting. The

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3

Committee received a briefing from Mr Gordon on work completed in the role to date with a focus on the availability of relevant information for staff and promulgating the role of the Freedom to Speak Up Guardian. The Committee was happy to confirm to Mr Gordon that he had an open line of communication to the Chair of the Committee and other Committee members. The Committee reviewed the Board Assurance Framework entry for S05, which relates to financial sustainability, and noted that content of the entry would be updated to reflect transition to a new financial year. The Committee also noted a general need to ensure that measures identified as either ‘Controls’ or ‘Assurances’ in the BAF are accurate entries for these descriptors. Finally, the Committee noted reports on Losses & Special Payments and Waivers and took positive assurance from the outcomes of a 6-monthly review of compliance with the NHS Foundation Trust Code of Governance. These outcomes will be reflected in compliance statements which will be included in the Annual Report for consideration by the Board of Directors in May 2017. The Committee also considered and approved its Work Plan for 2017/18.

2. Risks Identified Qualified opinion on mandated audit of the RTT indicator

3. Actions to be considered at the Audit Committee

Nil


John Sandford, Chair Minutes available from: Company Secretary

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1



Report of: Quality Assurance Committee





Quality Governance Committee - Key Issues Reports

CQC Action Plan - Progress Report

Nursing & Midwifery Strategy – Progress Report

National Standards on Seven Day Services

Monthly Clinical Governance Report

Clinical Audit - Progress Report

Corporate Risk Register

With regard to matters to bring to the attention of the Board, the Committee considered Key Issues Reports from meetings of the Quality Governance Committee held in January and February 2017. The reports summarised a variety of items but, of particular note, was an item regarding the approval of Guidelines for Managing Poor Documentation. Accurate and legible documentation is a key element in the provision of good clinical care and the Guidelines document sets out red rules for the completion of case notes. The document also sets out a clear process for escalation of instances of poor record keeping. Board members should note that the Guidelines will remain valid until the EPR system is fully implemented. The Committee reviewed the CQC Action and noted good progress with 92% of actions now complete. Committee members sought and received clarification of matters relating to items yet to be completed and received assurance that appropriate monitoring arrangements are in place including monthly review by the Quality Governance Committee. The Committee also noted good progress with delivery of the Implementation Plan for the Nursing & Midwifery Strategy with current status as follows for the 25 actions:

16 actions complete

7 actions partially complete

2 actions not yet due. The Chief Executive presented a report which provided further information and associated actions to progress the four standards for Seven Day Services which have been prioritised by the Department of Health. The report was based on guidance jointly published by NHS Improvement and NHS England in December 2016 which provided clarification of these priority clinical standards. Board members should note that the main challenge for the Trust, and other providers, will

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be delivery of Standard 8 which relates to Ongoing Consultant-directed Review. Potential resource implications are significant and could involve the recruitment of an additional 22 full-time Consultants at a cost of circa £2.2m. The Trust will look to mitigate this risk through adoption of an alternative approach based on segmentation of the inpatient population with appropriate review arrangements being established for each segment. The Committee will receive periodic progress reports on this subject and noted that progress with actions is regularly reviewed by the Quality Governance Committee. The Committee considered the Clinical Governance Report and noted that presentations on matters relating to Pressure Ulcers and Falls, which are recurring themes of the report, will be provided at the Committee’s next meeting on 16 May 2017. The Committee also noted a Clinical Audit progress report, which identified an excellent completion rate, and reviewed the Corporate Risk Register. Finally, the Committee discussed means of enhancing future practice and agreed that Executive members would look to propose a discrete set of quality metrics for scrutiny at each Committee meeting.

2. Risks Identified

3. Actions to be considered at the (insert appropriate place for actions to be considered)

Nil


Mike Cheshire, Chair Minutes available from: Company Secretary

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Report of: People Performance Committee

Date of last meeting:

23/03/2017

Membership Numbers: Not Quorate



2016 Annual Staff Survey Results – Presentation

Staff Vacancies Update Report

Trust Agency Utilisation Update

Employee Relations Cases / Confidential Staff Matters


Post Graduate Education Monitoring Report

Policies for validation:

- Organisational Change Policy

- Smoke Free Premises Policy

Key Issues Reports from Sub-Groups

As the meeting was not quorate, any items requiring decision, including validation of policies, were carried forward to the next meeting. With regard to matters to bring to the attention of the Board, the Committee received a presentation from the Deputy Director of Workforce & OD with regard to the 2016 Annual Staff Survey results. The Committee expressed concern with regard to a number of questions which compared adversely to last year’s survey results. The Committee noted, however, that the timing of the survey had coincided with the announcement of a number of Financial Improvement Programme initiatives, such as increased car parking charges and voluntary redundancies, and consequently acknowledged the adverse impact this would have had on the results. The Committee was advised of a link between the Staff Survey results and the Communication & Engagement Plan and it was noted that the results would inform focus group discussions. The Committee acknowledged the need to integrate any actions arising from the Staff Survey results with Stockport Together work and it was noted that this would be further considered at the March Board Strategy session. It was also noted that a report on the Staff Survey results would be considered at the Board meeting on 30 March 2017. Following an action arising from the February meeting of the Committee, the Deputy Director of Workforce & OD presented a report on staff vacancies and noted that 40% of the Trust’s overall vacancies were in the Medicine business group. The Committee noted that information contained within the report would be incorporated in the revised Workforce & OD Quarterly Performance Report going forward. The Deputy Director of Nursing & Midwifery and the Head of Communications then briefed the Committee of an ongoing targeted campaign to encourage staff retention which was endorsed by the Committee. The Deputy Director of Workforce & OD presented a report on the Trust’s agency utilisation and

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expenditure and the Committee noted that expenditure had exceeded the agency ceiling trajectory for the first time in 2016/17, resulting in a cumulative adverse variance of £0.6m as at 28 February 2017. It was noted that the forecast year-end position had deteriorated from a negative variance of £1.2m to £1.5m as a result of initiatives to meet additional demand on clinical services. The Committee was also advised of a number of challenges relating to the changes to IR35 legislation which were coming into effect on 6 April 2017. The Committee considered a report on Employee Relations Cases / Confidential Staff Matters for a 12 month period to 28 February 2017. It was proposed that further analysis be undertaken to correlate the data with the results of the Staff Survey. The Committee also proposed that further consideration be given to the appointment of Investigating Officers (IOs) and establish whether there would be merit in employing full time IOs. The Committee reviewed the Corporate Risk Register and raised concerns with regard to a number of risks, some of which were out of date. It was agreed that following an update of the Corporate Risk Register, a detailed review of workforce-related risks would be undertaken at the April meeting. The Committee noted a monthly progress report of actions identified following a Post-Graduate Education Monitoring Visit by Health Education England North West (HEENW) in September 2016. The Committee noted that the Organisational Change Policy and Smoke Free Premises Policy would be deferred to the next meeting for validation as the meeting was not quorate. Finally, the Committee received key issues reports from the Joint Consultative Team Committee and the Workforce Engagement & Efficiency Forum.

2. Risks Identified 2016 Annual Staff Survey Results

IR35 and Agency Staffing



Angela Smith, Chair Minutes available from: Company Secretary

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Subject: Chief Executive’s Report

Report of: Chief Executive Prepared by: Mr P Buckingham

REPORT FOR NOTING


Summary of Report The purpose of this report is to advise the Board of Directors of

national and local strategic and operational developments which

include:

Implementation of Healthier Together in the South East

Sector

Carter Metrics

Breaking the Cycle – ‘Home for Easter’



N/A


Completed

Not required

Attachments:

Nil


reported to:

Board of Directors


Audit Committee

Executive Team

Quality Assurance

Committee

F&P Committee

PP Committee

SD Committee





Other

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1. INTRODUCTION

1.1

The purpose of this report is to advise the Board of Directors of national and local strategic

and operational developments.

2. IMPLEMENTATION OF HEALTHIER TOGETHER IN THE SOUTH EAST SECTOR

2.1

2.2

2.3

Background

As the Board will be aware, the Sector has, for the last twelve months, been working to

clarify the implications of implementing Healthier Together across Tameside and

Stockport. This has focused, particularly, on the service model and standards for

General Surgery, but has also included co-dependent specialties such as A&E, Acute

Medicine, Critical Care and Anaesthetics, Diagnostics and Paediatrics. Using full-year

activity data from 2015/16, and applying assumptions on the effect of achieving

Healthier Together standards, it has been possible to model the potential capacity and

financial impact of changed patient flows.

Within Sector programme governance structures, joint clinical and non-clinical sub-

groups continue to work on the detail of how the new models will be implemented. As

the Programme Plan stands, target implementation dates are:

Phase 1 (high risk elective procedures) – transfer – October 2017

Phase 2 (completion of transfers in respect of non-elective and other high risk

elective patients) – April 2018

These timescales have, within them, some key dependencies, particularly, for instance,

the timing of funding decisions and the initiation of recruitment, or completion of capital

developments supporting the new model of care. At present, all workstreams proceed

on the assumption that these timescales remain realistic.

Routes to Funding

The costs associated with implementation fall into three principal categories:

Transition funding – required to enable the initial changes and a period of “double-

running” in the early phases. A bid against Transformation funding held at Greater

Manchester level has been prepared for the Sector.

Recurrent Revenue – required to meet the on-going impact beyond transition. Local

providers and commissioners in Sectors are looking in detail at the elements of the

model which will involve higher costs. One such potential cost is the “stranded”

overhead at Tameside General Hospital when the tariff income associated with patients

who would previously have been treated locally, is no longer available to the Trust. The

resolution of stranded costs is acknowledged to be most appropriately handled under the

auspices of wider GM service strategies, beyond the scope of Healthier Together.

Capital funding – required to finance changes to buildings/equipment in order to support

the new models of care and/or patient flows. A single bid for capital to support Healthier

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2.4

2.5

Together across Greater Manchester is being co-ordinated at GM level for submission

against national capital funds.

Interdependencies in the Process to Secure Funding

There are clear interdependencies between each of the routes to funding. The Sector,

and partners within it, have previously agreed to the submission of Transitional Funding

bids on the understanding that this is conditional, pending satisfactory conclusion of

agreement on capital and recurrent revenue (including stranded cost) funding.

The Healthier Together Greater Manchester Full Business Case (FBC)

The Greater Manchester (GM) FBC will bring together the generic aspects of the case for

change with the specific plans and implications in each Sector. It is important that this

business case is scrutinised and approved in key GM bodies, as well as within Sectors and

partner organisations. Given the latest timetable provided at Greater Manchester level,

it is anticipated that GM bodies will be reviewing the various elements of the business

case in detail throughout April 2017, and that Boards and governing bodies in Sectors will

be asked to consider the FBC in their cycles of meetings in May 2017.

3. CARTER METRICS

3.1

3.2

Following the Carter Report, it was agreed that consistent metrics must be available for all

hospitals to bench mark the relative cost effectiveness of their services. The following

standard was set:

‘Trust boards being made accountable and mandated to review the dashboards for three

clinical or medical specialties each month, to benchmark themselves against the

established metrics and best practice, and routinely track progress by October 2016.’

Due to delays at a national level, the relevant metrics were only released earlier this month.

The Medical Director has reviewed the data and relayed a number of problems to ‘the

model hospital portal’, who manage this service. We should anticipate the need to start

reviewing metrics at board from April 2017.

4. BREAKING THE CYCLE – ‘HOME FOR EASTER’

4.1

4.2

The Home for Easter week is part of the Trust’s focus on wherever possible facilitating

patients discharge and allowing Clinical staff to concentrate more time on clinical duties.

There will be a command structure put in place with Bronze, Silver and Gold Control during

the week.

We are being supported by our Stockport partners with active engagement from the CCG,

Public Health and Social Care during the week. During the week the role of ward liaison

officer will be put in place with 1 person having responsibility for 2 wards for a half day

each reporting back to bronze and Silver any issues however minute that are affecting the

running of our wards. Our partners have nominated a range of people to fill this role and

it will also allow non-clinical staff to see services being delivered to patients first hand and

some of the unintentional barriers that can be in place.

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4.3

We want to enjoy the week and get a buzz across the hospital and put a smile on

everybody’s face whilst placing the Home for Easter within our overarching Urgent Care

/Better at Home plans. A short video which adds a bit more detail will be played at the

meeting. I am sure that the week will be a success and we will pick up many issues that we

can learn from and that will lead to improvements in our services to patients

5. RECOMMENDATIONS

5.1 The Board of Directors is recommended to:

Receive and note the content of the report.

Note the latest position in respect of finalising the business case supporting

implementation of Healthier Together.

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Subject: Board Assurance Framework

Report of: Chief Executive Prepared by: P Buckingham

REPORT FOR APPROVAL


N/A

Summary of Report Identify key facts, risks and implications associated with the report content. The purpose of this report is to present the current Board Assurance

Framework for consideration and approval by the Board of

Directors.


BAF Risk 2


N/A


Completed X Not required

Attachments:

Annex A – Board Assurance Framework


reported to:

Board of Directors


Audit Committee

Executive Team

Quality Assurance

Committee

FSI Committee


BaSF Committee





Other

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1. INTRODUCTION

1.1

The purpose of this report is to present the current Board Assurance Framework for

consideration and approval by the Board of Directors.

2. BACKGROUND

2.1

2.2

Assurance Frameworks vary across organisations and, in some instances, can be lengthy

documents that are not always well understood. This can prevent the Framework’s

effective use for managing the business and its strategic priorities. To be of real value to an

organization, the Board Assurance Framework must be clear, concise and tailored to the

organisation’s needs.

The format for the Trust’s current Board Assurance Framework was designed in partnership

with Mersey Internal Audit Agency (MIAA) with scope of content and presentation

informed by best practice identified by MIAA. In March 2016, the Board adopted a revised

approach based on formal closure of the Board Assurance Framework at year-end and the

opening of a new Board Assurance Framework from 1 April for the new financial year. This

approach provides the Board with the opportunity to formally review whether the strategic

objectives remain valid, and whether the principal risks to delivery of these objectives

remain appropriate. The approach enables the Board to take into account any changes in

either the strategic context or operating environment and ensure currency of the Board

Assurance Framework.

3. CURRENT SITUATION

3.1

3.2

The current Board Assurance Framework, which is included for reference at Annex A of the

report, has been reviewed by the relevant risk owners and updated accordingly. The only

significant movement in residual risk relates to Risk 5, delivery of CIP and Control Total,

which has reduced from 25 to 12.

As noted at s2.2 of the report, there is an opportunity for the Board to review currency of

strategic objectives and associated principal risks. At its meeting on 23 February 2017, the

Board approved the Corporate Objectives for 2017/18, all of which were based on the

Strategic Objectives, and no issues were raised as to the continuing validity of the Strategic

Objectives. Consequently, it is assumed that Board consideration will focus on currency of

the associated principal risks.

Detail of the current risks is reproduced below for ease of reference:

SO1

To achieve full implementation and delivery of the Trust’s Five Year Strategy 2015-20.

Risk 1 – Risk Owner: Chief Executive

Emphasis on day to day operational delivery, in response to environmental pressures,

results in lack of focus on strategic change programmes with consequent impairment or

failure to deliver the Trust’s Five Year Strategy.

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SO2

To achieve best outcomes for patients through full and effective participation in local

strategic change programmes including; Stockport Together, Healthier Together &

Greater Manchester Devolution.

Risk 2 – Risk Owner: Chief Executive

Failure to plan, resource and engage effectively with strategic change programme

impairs level of control and influence with a consequent detrimental impact on patient

services

SO3

To secure full compliance with requirements of the NHS Provider Licence through fit for

purpose governance arrangements.

Risk 3 – Risk Owner: Chief Operating Officer

Failure to achieve sustainable delivery of the 4-hour A&E target impairs quality of patient

care and results in further regulatory intervention.

SO4

To achieve, and maintain, a minimum ‘Good’ rating under the Care Quality Commission

inspection regime.

Risk 4 – Risk Owner: Director of Nursing & Midwifery

Inability to maintain and improve compliance with Care Quality Commission standards

impairs patient experience, damages Trust reputation and results in regulatory

intervention.

SO5

To achieve the level of financial sustainability necessary to ensure provision of good

quality services and facilitate delivery of the Trust’s Five Year Strategy

Risk 5 – Risk Owner: Director of Finance

Failure to deliver the required level of cost improvement to deliver the agreed control

total and receipt of STF with a consequent impact on patient services, increasing the

likelihood of regulatory intervention.

SO6

To develop, and maintain, a flexible, motivated and proficient workforce.

Risk 6 – Risk Owner: Director of Workforce & Organisational Development

Failure to prepare and deliver effective workforce plans supported by continuous

professional development impairs the availability of workforce resources with a

consequent impact on the delivery of patient services.

SO7

To implement and embed an Electronic Patient Record (EPR) system.

Risk 7 – Risk Owner: Director of Support Services

Failure to ensure efficient management of the EPR project results in data loss from

current systems and the inability to realise the benefits expected to accrue from

implementation of a comprehensive electronic system.

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3.3

In reviewing the principal risks, the Board should consider whether an amendment to Risk 5

is required to reflect a decision on STF funding. A suggested amendment would be as

follows:

Failure to achieve the required level of cost improvement to deliver the Trust’s financial plan

with a consequent impact on patient services, increasing the likelihood of regulatory

intervention.

4. LEGAL IMPLICATIONS

4.1 There are no legal implications arising out of the subject matter of this report.

5. RECOMMENDATIONS

5.1 The Board of Directors is recommended to:

Consider and approve the content of the current Board Assurance Framework at Annex A.

Consider the currency of the Principal Risks and agree any amendments as required.

Agree to close the current Board Assurance Framework and open a revised Framework based on principal risks, revised as necessary.

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SO1

To achieve full implementation and delivery of the Trust’s Five Year Strategy 2015-20.

Risk 1

Emphasis on day to day operational delivery, in response to environmental pressures, results in lack of focus on strategic change programmes with consequent impairment or failure to deliver the Trust’s Five Year Strategy.

Risk Owner: Chief Executive

Board Risk Rating

Initial 2 4 8

Current 3 4 12

L x C = Level

Opened Date 01/04/2016 Review Date 14/07/2016

Review Date 22/09/2016




RISK CONTENT The Board needs to spend time on ensuring delivery of the Five Year Strategic Staircase as described in the approved Strategy, ensuring congruence with other significant strategic partnerships programmes of Healthier Together, Stockport Together and GM Devolution.

BOARD RISK APPETITE

The Trust is not risk averse in this area and accepts that there may be exposure to reputation and staff engagement risks in pursuing service transformation. The communication and engagement of staff and key stakeholders is recognised as essential. However, the Trust remains risk averse to any negative quality, safety or patient experience issues and understands the balance required for financial efficiency. Reduction of 50% of strategic Board discussions would require immediate review.

CONTROLS BOARD ASSURANCE

Dedicated Board Strategy sessions.

Resources identified to ensure detailed work up of the Strategic Staircase and Innovation Programmes projects.

Assurance reports to the Finance & Performance Committee on financial delivery of the strategic projects.

Assurance reports to the Finance and Performance Committee on operational delivery of the strategic projects.

Regular CEO reports on progress with strategic programmes.

Quarterly review of progress against key organisational objectives.

Strategy 2016/17 presentation to senior managers and clinical managers 16 March 2016.

Start the Year: 3 & 5 May 2016 and rollout for all staff planned.

Increased capacity and focus at senior level on strategy delivery implemented from April 2016.

Increased capacity and focus through the Financial Improvement Programme to ensure financial improvement, efficiency and effectiveness of operational performance is managed robustly and does not impinge on strategic delivery focus

Director of Strategy, Transformation and Planning Executive position created from 1 December 2016 for an 18 month appointment which incorporates transformation, planning and strategy

Fix, Close, Transfer reports to Board / Finance & Performance Committee

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GAPS IN CONTROLS GAPS IN ASSURANCE

Risk that concurrent strategic programmes will impair senior management capacity. A

CTI

ON

PLA

N

Assigned to Action Detail Progress to Date Due Date

Chief Executive Deputy Chief Executive Acting Director of Strategy, Transformation and Planning Chief Executive

Board to be given dedicated time for strategic discussion Monitor engagement with staff and facilitate workshop with Child and Family Business Group Update on Strategic Staircase and strategy refresh 2017/18 to go to Board of Directors on 26/01/17 following work by the Executive Team Strategy refresh to be discussed with Medical, Business Group Directors and Nursing forums to be held in March and April to get operational leaders views and recommendations. Progress to be reviewed by Executive Team 28/03/17 and mid -April prior to Board paper in April. GM Devolution Theme 3 work programme on acute and specialist clinical services is being undertaken across GM and will result in changes to service provision over the next 1-4 years. This will need to be incorporated into the future Trust strategy as details develop. (Healthier Together is the most advanced of the service changes in Theme 3).

Board to hold monthly strategy sessions Workshops held x3 and Business Group advised this was now a GM Theme 3 priority and they should continue to work up a sector based medium term solution to service resilience for maternity and paediatrics. Executive Team have discussed on a number of occasions and will complete discussion on 16/01/17 Discussion forums being arranged Cases for change are being developed for a number of acute services which will then have workstreams on option development and co-design by commissioners and providers. New Theme 3 GM Chair has reset the timetable for all strategic services changes to be agreed within 12 months

Ongoing Ongoing Completed April Board Ongoing March 2018

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SO2

To achieve best outcomes for patients through full and effective participation in local strategic change programmes including; Stockport Together, Healthier Together & Greater Manchester Devolution.

Risk 2

Failure to plan, resource and engage effectively with strategic change programme impairs level of control and influence with a consequent detrimental impact on patient services.

Risk Owner: Chief Executive

Board Risk Rating

Initial 2 4 8

Current 2 4 8 L x C = Level

Opened Date 01/04/2016 Review Date 14/07/2016 Review Date 22/09/2016 Review Date 16/11/2016 Review Date 18/01/2017 Review Date 20/03/2017

RISK CONTENT The Board needs to spend time on ensuring delivery of the Five Year Strategic Staircase as described in the approved Strategy, ensuring congruence with other significant strategic partnerships programmes of Healthier Together, Stockport Together and GM Devolution.

BOARD RISK APPETITE

The Trust is not risk averse in this area and accepts that there may be exposure to reputation and staff engagement risks in pursuing service transformation. The communication and engagement of staff and key stakeholders is recognised as essential. However, the Trust remains risk averse to any negative quality, safety or patient experience issues and understands the balance required for financial efficiency. Reduction of 50% of strategic Board discussions would require immediate review.


Dedicated Board Strategy sessions.

Chief Executive and other Executives (especially Finance and HR) participation in Greater Manchester Devolution developments.

Chief Executive and Executive Director participation in the Stockport Together programme.

Deputy Chief Executive participation as member of the MCP Shadow Provider Board.

CEO, Chief Operating Officer, Medical Director and Clinical Lead attendance at South East Sector Healthier Together Planning Committee.

Director of Partnership designated as Programme Director for SE Sector Healthier Together implementation with consultancy resource support.

Locality plan for Stockport consistent with Trust Strategic Plan and planning assumptions.

Single MCP Providers report on recommended form of organisation going to all four organisations governance bodies in November 2016

Positive outcome of the Healthier Together Judicial Review.

Regular CEO reports on progress with strategic programmes.

Stockport Together adoption of the Trust’s patient segmentation approach.

Increased capacity and focus at senior level on Stockport Together programme implemented from April 2016.

Board approval of GM Devolution governance arrangements.

Appointment of interim Director of Provider MCP ( all providers)

Chief Executive, Deputy Chief Executive and Director of Finance are members of key Stockport Together governance meetings

Board involvement and agreements required on all strategic decisions relating to MCP including in scope functions and options for organisational form

Council of Governors to be kept informed of all strategic matters relating to the MCP and to be a key partner in decisions on organisational form

GM Health and Social Care Partnership agreed in principle to funding of £19M transitional monies over 3 years from the Transformation Fund – details tbc

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The Director of Corporate Affairs and the Director of Strategy, Transformation and planning are members of a new Stockport Together (ST) Governance meeting regarding organisational form discussions and other ST governance matters.

Regulators appraised on potential options for MCP function and form and discussions taking place as appropriate on regulatory change issues

Initial meeting of NHSI new models of care team and Trust senior managers to discuss the new “checklist” process for FBC process


Resource pressure associated with strategic change programmes.

Deputy CEO leaving in December will create a knowledge loss re the MCP proposals and a capacity gap.

New procurement regulation has resulted in the need to revisit some of the MCP procurement processes which could result in a delay or, if not successful the procurement could be stopped.

Risk that concurrent strategic programmes will impair senior management capacity.

Until the Theme 3 work programme is completed it is not possible to identify potential risks to service changes in the acute sector. The risk/gain share agreement between GM commissioners and providers is to be finalised in the next 2-3 months. Once details emerges it will be possible to calculate the effect and provide assurance or otherwise to the Board.

AC

TIO

N P

LAN


Chief Executive

Director of Finance / Director of Workforce & OD

Deputy Chief Executive

Board to be given dedicated time for strategic discussion

Information requirements from Trust as result of the Provider efficiency programmes Directors of Finance are undertaking at the request of the Provider Federation Board

Actively involved in the production of the options on form and recommended form which are to be taken to each of the Providers governing bodies for approval in November 2016

Board to hold monthly strategy sessions

The GM H&SCP at looking at two major financial initiatives: 1) To provide financial support to the 5 key provider projects (Corporate Services, Procurement, Radiology, Pathology and Pharmacy) with a view to increase the pace of the projects without impacting upon the lead Trusts’ financial performance. Each Director of Finance Lead are meeting with Jon Rouse to agree the scope and develop a case for funding; 2) To ensure the GM H&SCP receives the respective values of the STF from NHSI / NHSE, they are developing a financial flexibilities framework that would enable the GM STP meet the required control total and ensure resources are not lost from GM. Board to receive report on options on form and a single preferred form by all Providers.

Ongoing

Ongoing

Completed

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CEO/Company Secretary CEO/Acting Chief Operating Officer Executive Team Executive Team

Completion of FBC if the single recommended form is approved by all Providers and the CCG accept the outcome. Subject to approval of a new organisational form an interim structure needs updating and agreeing Executive team leads are supporting the CCG in navigating Checkpoint 1 and 2 in the new procurement regulations, including public consultation Working with partner providers on possible organisational form structures to provide optimal patient/client management and outcomes, including stakeholder consultation

Preparation of the initial Outline Business Case has commenced with joint leads from the Trust and SMBC. Development of OBC being progressed through the Governance Sub-Group of the Provider Board. Draft OBC to be finalised by end March by Providers for socialisation with stakeholders Preparatory work to develop revised structures commenced in December 2016 and is being coordinated by the Governance Sub-Group. Discussions are being held with NHS E and GM ST Provider Executive meetings held regularly and interface with the new Governance Sub-Group

Dec/Jan 2017 End March 2017 Ongoing Jan-July 17 Jan-July 17

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SO3

To secure full compliance with requirements of the NHS Provider Licence through fit for purpose governance arrangements.

Risk3

Failure to achieve sustainable delivery of the 4-hour A&E target impairs quality of patient care and results in further regulatory intervention.

Risk Owner: Chief Operating Officer

Board Risk Rating

Initial 4 4 16

Current 4 4 16

L x C = Level






RISK CONTENT Meeting national standards is key to maintaining the provider license. Failure to meet standards may adversely affect patient experience and have a negative impact on the Trust’s reputation. There may also be contractual penalties imposed by commissioners.

BOARD RISK APPETITE

The Board is prepared to take informed risks to resolve performance issues such as a period of planned underperformance against standard in order to resolve patient wait times more quickly.


Executive accountability and capacity enhanced with appointment of Acting Chief Operating Officer

Weekly Urgent Care Task & Finish Group implementing and tracking actions

Plans for Medicine Bed reconfiguration to enhance flow and ED capacity

Daily Breach validation

‘Hot Clinics’ pilot.

Key Issues Reports from Finance & Performance Committee

Escalation process to Board via Integrated Performance Report (IPR)

Monthly Business Group performance reviews

External reports on areas of underperformance, e.g. Cancer or ED through ECIST or other bodies

‘Deep Dive’ session on ED initiatives with Board members 18 July 2016

NHSI & NHS England support for medium/long term plans for Stockport Together as sustainable solution.

NHSI approval of revised trajectory for 4-hour standard in 2016/17.


Ability to maintain sustainable levels of DToC. Continuing increases impact on hospital flow during periods of high demand.

Emergency Department standard is still reliant on reduced demand which has not yet manifested despite actions taken by commissioners.

Matching capacity and demand within clinical services to best mitigate failure

Effectiveness of MCP in supporting long term sustainability against the 4 hour target; to avoid admissions and discharge to assess.

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Acting Chief Operating Officer, Chief Executive & Director of Finance Acting Chief Operating Officer

Continue to work with the Health and Social Care Economy leaders on the gaps in Urgent Care Provision across the health economy to enable achievement of the ED target Introduction of effective assurance reporting of outcomes from the monthly Performance & Planning meeting to the Quality Assurance Committee.

Systems Resilience Group in place and meeting monthly Action superseded by introduction of monthly Business Group performance reviews which are now fully established.

Ongoing

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SO4

To achieve, and maintain, a minimum ‘Good’ rating under the Care Quality Commission inspection regime.

Risk 4

Inability to maintain and improve compliance with Care Quality Commission standards impairs patient experience, damages Trust reputation and results in regulatory intervention.

Risk Owner: Director of Nursing & Midwifery

Board Risk Rating

Initial 4 4 16

Current 4 4 16

L x C = Level






RISK CONTENT If CQC outcomes are not met, then patient and family experience will be jeopardised. Closely linked to culture and values and issues arising from Francis, Keogh and Berwick reports. The ‘Requires Improvement’ rating received in August 2016 has the potential to impact adversely on public confidence and staff morale

BOARD RISK APPETITE

Risk averse with regard to all aspects of CQC compliance. Three or more wards or departments in a business group, which continue in ‘turnaround’ following CQC mock inspections and Nursing Dashboard escalation for longer than three months would trigger an immediate review and further action.


Mock CQC inspection proforma to be incorporated into development of accreditation process for clinical areas

Monitoring of performance with commissioners

Programme of activity forward to Board assurance through visibility and structured clinical activity for senior nursing staff

Nursing & Midwifery Dashboard and escalation process for agreed triggers, including action plans for ‘turnaround’ wards

Implementation of Trust Quality Improvement Strategy

Key Issues Reports from Quality Assurance Committee

Patient stories / complaints / incidents / patient experience quarterly report / High Profile Report – shared widely throughout organisation

Quality elements of Integrated Performance Report

Annual Quality Report

Infection prevention and control reports

Independent internal reviews of ongoing compliance

CQC inspection results and any resultant action plans

Twice yearly nursing and midwifery staffing reviews

Outcomes of patient surveys

Monitoring of CQC Action Plan 2016


Ongoing recruitment issues for some areas of nursing and medical workforce may jeopardise compliance with CQC standards

Overall rating for the Trust is ‘Requires Improvement’

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Director of Nursing & Midwifery

Lead the action planning required following the CQC inspection

Draft report received 12 July 2016; factual accuracy response returned 27 July. Action plan developed for all outstanding actions and presented to Board of Directors

Completed Completed


Lead on the implementation of the CQC action plan and monitoring progress against timescales. Monitoring will be through business group quality boards and regular updates to Quality Governance Committee and Quality Assurance Committee, with key issues to the Board of Directors Validation exercise for all actions under ‘Action Overdue but Progressing’category. Status as at 20 Mar 17: 92% actions completed, 12 actions ‘on track’ and 13 actions ‘overdue but progressing’.

As at 10/01/17 out of a total of 232 actions, 186 are completed, 11 on track, 167 overdue but progressing, and 1 overdue with some concern (Diagnostics – Imaging Services Accreditation Scheme). Monitoring as described has started; monitoring status report also shared with CQC, CCG and NHS England via urgent care meetings. Validation exercise undertaken during week commencing 27 Feb 17.

Various completion dates; latest 30/04/17 Completed


Establish preparation needed for return CQC inspection Commenced via regular monitoring of action plan.


Arrange bi-monthly engagement meetings with local CQC managers to update on progress with action plan and other relevant issues

In place.

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SO5

To achieve the level of financial sustainability necessary to ensure provision of good quality services and facilitate delivery of the Trust’s Five Year Strategy

Risk 5

Failure to deliver the required level of cost improvement to deliver the agreed control total and receipt of STF with a consequent impact on patient services, increasing the likelihood of regulatory intervention.

Risk Owner: Director of Finance, Director of Strategy, Transformation and Planning

Board Risk Rating

Initial 4 5 20

Current 5 5 12

L x C = Level






RISK CONTENT Failure to pay staff and suppliers to continue to provide safe and effective services. Triggering the need for distress financing which would increase the risk of regulatory intervention. Not being able to provide the range of services and failing respective access and contract targets / clauses leading to financial penalties. Not being able to support Strategic Development initiatives including the need to modernise the estate and replace aging medical equipment.

BOARD RISK APPETITE

Necessity to take risks to deliver the cost improvement and significantly challenging programmes to achieve financial resilience with a willingness to review core services with a view to third party delivery and/or outsourcing of corporate departments.


Detailed financial planning process including activity, workforce and capital planning

Operational Planning Guidance and Process

Implementation of a CIP Governance Framework with Executive-level monitoring

Business Group Finance and Performance Review Meetings

Establishment Control Panel & Staff Absence Panel

Detailed financial report to F&P Committee

Finance and CIP Performance reports

Budget and Plan approval

CQUIN update

Finance & Performance Committee review of progress reported to Board

Financial Improvement Group – monthly monitoring

Director of Strategy, Transformation and Planning Executive position created from 1 December 2016 for an 18 month appointment which incorporates transformation, planning, strategy and CIP

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Wider clinical ownership and accountability for programme delivery

CQUIN objectives need to be devolved to those charged with delivery

Prioritisation of capital investment for Medical Equipment replacement

Financial impact of final CQC report.

Performance Management Framework

Well defined and realistic efficiency programme for 2016/17

Appropriate targeting and deployment of additional resources to deliver savings and improvements – capacity and capability

Potential conflict between Trust plans and those of wider health economy

Programme management experience amongst senior managers across the Trust

Transfer of skills from KPMG personnel to substantive staff.

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Acting Chief Operating Officer / Director of Finance

Hold Business Group Directors to account for delivery of their financial and activity plans

Performance Review meetings established, supported by KPMG representatives. Through this process, the Trust has seen demonstrable successes in the appraisal and sickness rates.

On-going

Director of Workforce & OD Develop and deliver a clinical and non-clinical engagement programme to ensure that staff across the Trust understand the financial challenges facing the organisation.

Senior Clinical Leader Engagement event held on the 2

nd November to ensure ownership of

the financial and urgent care challenge

Ongoing

Director of Finance Progress application for a working capital facility to aid the external audit process.

Formal communication initiated between the Trust and ITFF for the application of a short-term working capital facility and a medium term loan. Further discussion to be initiated with the NHSI Regional Team on the required level of funding in 2017-18

Ongoing

Director of Finance Agree mitigating actions with Stockport CCG, NHSI and GMH&SCP and ensure all available resources are accounted for in the achievement of the Control Total

Utilise the NHSI Financial Improvement Checklist to ensure all possible actions are undertaken to mitigate any loss of CIP. Meetings are being held between Director of Finance for GM, NHSI (North), Stockport CCG and Stockport FT to develop all possibilities of financial flexibility to ensure achievement of the control total

Completed

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Acting COO / Director of Finance

Develop a demand and capacity model incorporating growth, impact of CIP/strategic programmes and impact of delivering agreed trajectories.

The Trust has engaged with 4 Eyes (recommended by NHSI and other Trusts) to review the utilisation of Theatres. As part of the project the company have agreed to review the utilisation of outpatients and radiology. Representatives from Finance, BIT and HR are due to undertake site visits where Trust have demand and capacity models with a view to replicating at Stockport

Completed

Director of Workforce & OD Preparation of a workforce plan which incorporates current and future vacancies in order to establish workforce requirements over the next 24 months.

Implementation of headcount tracker in conjunction with KPMG. Further development of future needs planning subject to development of demand and capacity plans and the workforce implications of the transformation programme.

Ongoing

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SO6

To develop, and maintain, a flexible, motivated and proficient workforce

Risk 6

Failure to prepare and deliver effective workforce plans supported by continuous professional development impairs the availability of workforce resources with a consequent impact on the delivery of patient services.

Risk Owner: Director of Workforce & Organisational Development

Board Risk Rating

Initial 3 4 12

Current 3 4 12

L x C = Level






RISK CONTENT An engaged workforce is critical during a period of transformation and associated uncertainty. Different staffing models will be needed resulting in different ways of working with an increased requirement for new roles, skill mix and role development. Key supply risks exist in relation to a number of roles including medical and nursing posts and other specialist roles.

BOARD RISK APPETITE

Risk averse given the necessity to engage successfully with the workforce to achieve change. Triggers for consideration:

1. >50% of the KPIs in the Integrated Performance Report are outside of a 15% threshold

2. The Trust’s staff engagement score in the annual staff survey falls below 3.0


Policies and procedures

Performance Appraisal Policy

Mandatory training

Establishment Control Panel

Quarterly Pulse Surveys, including Staff Friends & Family Test

Operational Plan 2016/17

Leadership plan

Staff focus groups

Business group performance meetings.

Pay Progression Policy

Recruitment and Retention Implementation Plan

Centralised temporary staffing processes

Absence and temporary staffing performance meetings

Workforce & OD Committee / People Performance Committee

Business Group assurance reporting

Assurance reporting on attendance, sickness, absence, mandatory training, turnover and medical appraisal & temporary staffing spend

Annual Staff Survey results and Friends & Family results (3 x per year)

Freedom to Speak Up Guardian to commence in post 1 January 2017

Health & Wellbeing Strategy & Workforce Group

Recruitment & Retention Strategy approved by Board of Directors

OD Strategy approved by Board of Directors

Leadership Strategy approved by Board of Directors

Talent management strategy approved by Board of Directors

NHS England Annual Organisational Audit – Comparator Report 2015/16

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Revised terms of reference for Establishment Control Panel

Learning & Development Plan

Clinical Skills Development Plan

Executive Emergency Resilience Plan


Staff Engagement Plan

Workforce Plan aligned to capacity and demand modelling.

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Head of Organisational Development and Learning

To ensure staff survey results are widely shared and robust action plans are developed in response to the annual staff survey and quarterly pulse surveys. Further information to be sought through focus group engagement.

Results shared. Business group action plans monitored via WEG. National annual survey results shared in line with communications plan

Ongoing March 2017

Director of Workforce and Organisational Development

Workforce KPIs reviewed for 2016/17 and approved by Workforce Organisational Development Committee.

Business group performance monitored in Performance meetings.

Ongoing

Deputy Director of Workforce

Workforce planning cycle to be aligned to business planning and workforce numbers monitored monthly.

Workforce planning update shared with People Performance Committee. HEE workforce planning return submitted and reviewed by PP Committee Sep 16. Business group planning template approved. Refreshed approach to workforce planning continues with the implementation of training and development with Business Groups.

Ongoing

Head of Organisational Development and Leadership

Engagement plan to be developed aligned to the internal communications plan.

Internal communications plan developed Engagement plan to be integrated into the Communications Plan.

Complete 31 January 2017

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SO7

To implement and embed an Electronic Patient Record (EPR) system.

Risk 7

Failure to ensure efficient management of the EPR project results in data loss from current systems and the inability to realise the benefits expected to accrue from implementation of a comprehensive electronic system.

Risk Owner: Director of Support Services

Board Risk Rating

Initial 3 4 12

Current 2 4 8

L x C = Level






RISK CONTENT Redesign of clinical and operational workforce will need to be enabled by IT both within the Trust and across GM to ensure a sustainable future.

Technology is key to delivering clinical services in terms of quality, safety and outcomes. The Board needs to be sighted on key projects.

BOARD RISK APPETITE

The Board is prepared to take decisions on investment at scale in IT provided that there is strong assurance that there is the ability to recover costs through efficiencies.


EPR programme board chaired by CEO

Programme and project governance

Policies and procedures

Audit programme

IG Toolkit

External and internal audit reporting of design and operation of plans

External ‘gateway’ review process prior to key stages of implementation

Approval of strategies and plans through Finance & Investment Committee

Data integrity assurance – through data quality strategy

IGT assurance – through HIS Board

Project and programme assurance – through HIS Board & Capital Programme Development Group

EPR Governance Assurance Report – Audit Committee 17 May 2016

Board presentation – 23 Feb 17

Quarterly Progress Reports to Finance & Performance Committee


Gaps in IT systems

Difficulty in recruitment of Benefits Analysts

Benefits realisation on large scale IT projects – further work required

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Deputy Chief Executive

Ensure Electronic Patient Record programme has suitable governance process in place Ensure a process for developing benefits realisation is in place

Benefits analyst recruitment has been unsuccessful. Need to look at alternative methods of recruitment through either different scope or terms and conditions.

Programme Board in place with terms of reference and executive leadership First two meetings held. Risk Register and programme reporting now in place. Internal Audit have looked at EPR programme governance and report states ‘significant assurance’ on this. Intersystems (strategic partner) have brought in Channel 3 to work with the EPR programme on benefits realisation process. Presentation on approach endorsed by July EPR programme Board. Acting Director of IM&T and EPR Programme Lead are reviewing this and talking to other sites. Also looking at recruitment agency support. Benefits realisation programme is underway and has been successful in identifying high level benefits as a starting point. This has been achieved through working with Channel 3 as partners. There is no delay in the programme associated with this.

July 2016 Nov 2016 Sept 2016 Oct 2016 Nov 2016

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