AB/JJP/SC
19 September 2014
Dear Colleague
You are invited to a meeting of the Board of Directors which will be held on Thursday 25
September 2014 at 1.15pm in Lecture Theatre A, Pinewood House, Stepping Hill Hospital.
An agenda for the meeting is detailed below.
Yours sincerely
GILLIAN EASSON
CHAIRMAN
****************************************************************
AGENDA ITEM
TIME
1.15pm –
1.20pm
1.
Apologies for Absence.
2.
Opening Remarks by the Chairman.
“
3.
Declaration of Amendments to the Register of Interests.
“
4.
Carbapenemase – Producing Enterobacteriaceae (CPE) – Ward M4 (Presentation by
Moira Taylor, Consultant Microbiologist and Infection Control Doctor)
1.20pm –
1.40pm
5. OPENING MATTERS:
5.1 To approve the minutes of the previous meeting of the Board of Directors held on 24
July 2014 (attached).
1.40pm –
1.45pm
5.2 Matters Arising.
“
5.3 Board Action Tracker (attached).
“
5.4 Patient Story (Report of Director of Nursing and Midwifery attached).
1.45pm –
1.55pm
5.5 Report of the Chairman.
1.55pm –
2.00pm
6. TRUST ASSURANCE / GOVERNANCE:
6.1 Progress report Annual Improvement Objectives – quarter 1 (Report of Director of
Finance attached).
2.00pm –
2.10pm
6.2 Integrated Performance Report (attached).
2.10pm –
2.40pm
6.2.1 High Profile Report (Report of Director of Nursing and Midwifery attached).
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AGENDA ITEM
TIME
6.3 Unscheduled Care Programme Report (Report of Chief Operating Officer and Medical
Director attached).
2.40pm –
2.50pm
6.4 Strategic Risk Register (Report of Director of Nursing and Midwifery attached).
2.50pm –
3.00pm
6.5 Nurse Staffing (Report of Director of Nursing and Midwifery):
3.00pm –
3.20pm
6.5.1 Maintaining Safe Staffing Levels (attached)
6.5.2 Nursing and Midwifery Staffing Review (attached).
6.6 Deloitte’s Review of Trust Governance Arrangements
3.20pm –
3.35pm
6.6.1 Governance Review Highlight Report (Report of Chief Executive attached)
6.6.2 Key Issues Reports from Assurance Committees:
6.6.2.1 Building a Sustainable Future (attached and John Schultz to report)
6.6.2.2 Finance, Strategy & Investment Committee (attached and Malcolm
Sugden to report)
6.6.2.3 Quality Assurance Committee (attached and Mike Cheshire to report)
6.6.2.4 Workforce and Development Committee (attached and Carol Prowse to
report).
6.6.3 Draft Quality Improvement Strategy 2014-19 (Report of Director of Nursing and
Midwifery and Medical Director attached).
6.7 CQC Consultation Briefing (Report of Director of Nursing and Midwifery attached).
7
3.35pm –
3.50pm
3.50pm –
3.55pm
STRATEGY AND DEVELOPMENT:
7.1 Report of Chief Executive (attached).
3.55pm –
4.10pm
7.2 “Healthier Together” Consultation (Chief Executive to report).
4.10pm –
4.30pm
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CLOSING MATTERS:
8.1 Any Other Urgent Business.
8.2 Date of Next Meeting: 27 November 2014, 1.15pm, Lecture Theatre A, Pinewood
House, Stepping Hill Hospital.
“
“
JJP/SC/Notes/BoD/2014/Sept/Public/Public BoD agenda – 25.09.14
19 September 2014
2
Agenda Item: Public ( 5.1 )
MINUTES OF THE PUBLIC MEETING OF THE BOARD OF DIRECTORS HELD ON
THURSDAY 24 JULY 2014 AT 1.15PM IN LECTURE THEATRE A, PINEWOOD HOUSE,
STEPPING HILL HOSPITAL
Present:
In
attendance:
Gillian Easson (Chairman)
Ann Barnes (Chief Executive)
Mike Cheshire (Non Executive Director)
Bill Gregory (Director of Finance)
Judith Morris (Director of Nursing and Midwifery)
Carol Prowse (Non Executive Director)
John Sandford (Non Executive Director)
John Schultz (Non Executive Director)
Jayne Shaw (Director of Workforce and Organisational
Development)
Malcolm Sugden (Non Executive Director)
James Sumner (Chief Operating Officer)
Leslie Wilcock (Non Executive Director)
John Pierse (Trust Secretary)
ACTION:
160/2014
APOLOGIES FOR ABSENCE
An apology for absence was received from James Catania, Medical
Director.
161/2014
OPENING REMARKS BY THE CHAIRMAN
The Chairman welcomed Directors and members of the public to the
meeting and reported upon:
a) The retirement on 31 July 2014 of John Pierse, Trust Secretary, after
nearly 40 years NHS service. John would be returning for a short
period whilst arrangements were put in place to appoint his
replacement. The Chairman thanked John for his commitment,
knowledge and support over the years. Whilst she congratulated him
on his retirement she was pleased he was to return to support the
Trust and help with the changes, largely resulting from the
Governance Report actions.
b) The approval by the Council of Governors of the appointment of
Deloitte as External Auditors for the Trust for a period of three years
with the option to extend for a further two periods of 12 months.
c) The outcome of the recent Governor elections. In Tame Valley and
Werneth, there were two new Governors – David White and Roy
Driver – who would be appointed until the Annual Members’ Meeting
in 2015.
In Heatons and Victoria, Lesley Auger, Eve Brown and Gerry Wright
had been elected until the Annual Members’ Meeting in 2017.
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d) The proposal that the Foundation Trust Governors’ Association
should join with the Foundation Trust Network. The Council of
Governors had offered their support to the proposal and the Board of
Directors similarly supported the proposal and requested the
Chairman to vote in support on behalf of the Trust.
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e) The approval by the Council of Governors of the new Constitution
and Code of Conduct which had been approved by the Board of
Directors at their previous meeting on 26 June 2014.
f)
The continuing hard work of staff in all areas of the hospital in
support of the Trust’s plans to sustainably achieve the Emergency
Department four hour 95% target.
g) The signing up by the Trust to the Making Safety Visible Programme.
Judith Morris circulated a briefing document with regard to Making
Safety Visible.
It was noted that the Board would be required to attend three two-day
learning sessions and these would take place on:

11 and 12 February 2015

6 and 7 May 2015

29 and 30 July 2015.
h) The hugely successful open day held on 19 July 2014 which had
been attended by over 1,000 people.
i)
162/2014
National and local publicity following the Trust’s recent appointment
of three Youth Ambassadors.
DECLARATION OF AMENDMENTS TO THE REGISTER OF
INTERESTS
John Schultz declared his senior advisory role to the local government
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(but not healthcare) sector of a management consultancy, Newton
Europe. He said that he would not be involved in any potential discussion
with the Trust with regard to bed allocation modelling.
163/2014
MINUTES OF THE PREVIOUS MEETING
The minutes of the previous meeting of the Board of Directors held on 26
June 2014 were agreed as a correct record subject to one amendment to
the first line of the third paragraph of minute number 147/2014 to replace
the word “Trust” with “hospital site”.
164/2014
BOARD ACTION TRACKER
The Board of Directors noted the status of the actions on the Board
Tracker.
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165/2014
PATIENT STORY
The Chairman reminded the Board that the purpose of the patient stories
was to ensure that the focus of the Board was on its core purpose to
place the patient at the centre of everything it did.
The Director of Nursing and Midwifery circulated a paper giving details of
a posting on the patient opinion website. The posting on behalf of a
patient of the Trust’s maternity services praised the care provided by the
Trust during the individual’s pregnancy. The story was listened to and
noted.
166/2014
INTEGRATED PERFORMANCE REPORT
The Board of Directors considered the Integrated Performance Report
for July 2014.
Specific reference was made to:
a) Cancer Waiting Times
Performance against the breast two-week target continued to be
below the expected level. The issue related to the short notice period
being provided to referrals.
The Chief Executive said that the target now related to cancer and
non-cancer patients. John Schultz suggested that it might therefore
be appropriate to change the heading of the section.
In reply to a question from Carol Prowse, James Sumner said that a
capacity and demand review had been undertaken and he was
confident that the service was resilient enough for an improvement in
performance in quarter 2.
b) Accident and Emergency Department
Performance continued to struggle against the 95% target. James
Sumner described the actions that had been taken during the month
to improve the position, including extended senior manager on-call
working, Associate Directors chairing bed meetings and the
extension of the Emergency Nurse Practitioner minor injuries service.
Discussions continued with the Clinical Commissioning Group with
regard to winter planning initiatives with further meetings scheduled.
The report also provided details of the Trust’s performance against
the Monitor trajectory and the details of average attendances per day
which in common with other Trusts had seen a considerable
increase.
During the previous seven days, the performance had been above
98% which meant that the Trust was meeting the Monitor trajectory.
The Board of Directors noted the ongoing position with regard to the
availability of Emergency Department Consultants.
The Board of Directors asked James Sumner to pass on their
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appreciation to all staff who were involved in the ongoing efforts to
sustainably achieve the target.
Malcolm Sugden said that it was helpful that information with regard
to the quality of clinical care had been included within the report and
asked that this information be included in future reports.
c) Cancelled Operations
The Trust had experienced an unusually high number of cancelled
operations not treated within 28 days in April and May 2014. Whilst
the number of patients affected was low, this was disappointing from
a patient experience perspective.
As requested at the previous meeting, the report provided details for
each of these cancellations.
It was likely that poor performance in April and May was linked to the
increased number of cancelled operations experienced over the
winter months. The position would continue to be closely monitored
by the business group.
d) Staff Appraisals
The Board of Directors noted the improvement in all business groups
bar one.
The Estates directorate had achieved the 95% target and the Board
offered their congratulations to the directorate for doing this.
e) Mandatory Training
The Board noted the improvement in compliance in this area. The
Executive Team, in June 2014, had discussed a detailed review of all
mandatory training. It was anticipated that the changes being made
in booking, delivery and recording activity would improve compliance
and accurate monitoring of all mandatory training across the Trust.
f) Staff Sickness and Absence
June had seen an increase in sickness and absence from 3.98% to
4.26%. The Trust target remained at 4% or less. Jayne Shaw said
that work was being undertaken to review the reasons for this
increase and a report would be made to the Workforce and
Organisational Development Committee on 31 July 2014.
g) Finance
Bill Gregory said that the Trust was reporting a deficit of £1,425K as
at the end of June 2014. This positon was £458K favourable against
the planned deficit of £1,883K.
Performance against the Trust’s Savings Plan had improved during
June and was £0.1million below plan cumulatively which represented
an improvement in month of £0.6million.
The continuity of services risk rating remained unchanged from the
previous month as ‘3’ and was on plan.
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John Sandford made reference to the effect of the D-Block scheme
on the liquidity of the Trust.
It was agreed that liquidity and longer term cash issues should be
reviewed regularly at meetings of the Board’s Finance, Strategy and
Investment Committee.
BG
A more detailed line by line forecast with regard to the end of year
position would be provided to the Board of Directors in September
2014.
BG
h) Discharge Summary
The Board noted and welcomed this new addition to the Integrated
Performance Report which provided details of the Trust’s
achievement against the target of 95% of discharge summaries being
published within 48 hours by December 2014.
i)
Referral to Treatment
The Board noted that this section of the report now included, as had
been requested, details of performance by specialty.
j)
Nursing Dashboard
It was confirmed that Carol Prowse and Judith Morris had met to
discuss the content of the nursing dashboard.
Additional narrative with regard to “red” wards would be included
within the next report.
167/2014
HIGH PROFILE REPORT
The Board of Directors received and discussed the High Profile Report
for July 2014.
The report provided information on the outcome of high profile inquests
held in the preceding month together with the details of those planned for
the next month. Areas of concern were highlighted to assist in the
identification of patterns and trends across the Trust to allow lessons
learned to be shared.
The Trust also provided information on learning outcomes from any
Serious Untoward Incidents, Serious Adverse Events, inquests,
complaints and claims which were for discussion and cascade
throughout the Trust as appropriate.
The report also detailed any external investigations / recommendations
from the Parliamentary and Health Service Ombudsman and any reports
to prevent future deaths from HM Coroner. This would include any
changes to practice as a result of these reports.
John Sandford made reference to the Serious Untoward Incident
(W81993) and the care and service delivery problems identified.
Judith Morris said that she did not believe that in this incident there was
5
JM
a systems issue but rather an individual failure.
Carol Prowse said that she believed the issue came down to a lack of
leadership in the area involved.
John Sandford said that there were a number of pressure ulcer events
described in the Serious Adverse Events section and yet this was an
area that had been green rated in the Integrated Performance Report.
Judith Morris said that this was an area in which good progress had been
made but agreed that more work was required with regard to those
acquired in the community. A project with the Clinical Commissioning
Group and nursing homes was just beginning.
Les Wilcock said that any education programme on pressure ulcers
needed to include carers and partners.
The Board of Directors noted that the High Profile Report would in future
be considered at the new Board Quality Committee.
168/2014
UNSCHEDULED CARE PROGRAMME
James Sumner presented a report updating the Board on progress with
regard to the Unscheduled Care Programme.
The report detailed the key actions completed during the month, updated
on the action tracker and provided an update on key performance
indicators.
The Unscheduled Care Programme Director had commenced in post.
The Clinical Decision Unit, GP front of house model and triage plus
model were scheduled to go live by the end of July 2014. It was intended
that these projects would address the evening and overnight
performance issues.
Three further ACU pathways in acute headache, anaemia and asthma
had been agreed and were in development.
In response to questions from John Sandford, James Sumner updated
the Board with regard to the position on the expanded space for the
Clinical Decision-making Unit and the Older Persons’ Short Stay Unit.
John Sandford also made reference to the Unscheduled Care
Programme risk log and the four areas identified as being high risk and
the actions being put in place. It was agreed that further versions of the
risk log should include details of any new target dates.
The Unscheduled Care Programme, particularly the issue of a GP-led
assessment unit, would also be on the agenda for the Board to Board
meeting with the Clinical Commissioning Group on Thursday 18
September 2014.
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169/2014
STRATEGIC RISK REGISTER
The Board received the Strategic Risk Register which reported on the
distribution of risk across the Trust and presented in greater detail those
risks which had an impact upon the stated aims of the Trust.
With regard to risk 2130 which related to capacity issues in endoscopy,
Malcolm Sugden suggested that it would be helpful for future versions to
include a target date for the resolution of the issue.
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John Sandford suggested that risk 1881 relating to ED waiting times
required updating given there were no actions open. James Sumner to
action this.
170/2014
MAINTAINING SAFE STAFFING LEVELS
Judith Morris presented a report which provided an overview by
exception of actual versus planned staffing levels for the month of June
2014. Staffing levels were split between day and night duty and between
registered staff and assistants.
The Board noted the contents of the report which highlighted areas of
improvement. There remained pressures on the provision of safe staffing
at times which the inclusion of a Minimum Staffing Escalation Policy was
intended to resolve in a consistent manner. Provision of additional staff
for winter was key with simultaneous and ongoing proactive recruitment
of student nurses and other clinical staff.
171/2014
DELOITTE’S REVIEW OF TRUST GOVERNANCE ARRANGEMENTS
a) Independent Review of Governance Arrangements
The Board of Directors approved the summary of the final Deloitte’s
report for sharing with stakeholders and the wider public.
AB / JJP
b) Governance Review Highlight Report
The Chief Executive presented a report which provided an overview
to the Board of progress against the action plan produced to deliver
the recommendations that came out of the Deloitte’s governance
review. The report highlighted the key milestones achieved and
future milestone targets.
The report was intended to assure the Board on the status of the
delivery of the plan against agreed targets.
c) Reports from Assurance Committees
i.
Building a Sustainable Future
The key issues report from the meeting held on 16 July 2014
was circulated by John Schultz, Chair of the Committee.
Draft terms of reference for the Committee were also circulated
and Board members asked to forward any comments to either
John Schultz or Ann Barnes.
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All
ii.
Finance, Strategy and Investment Committee
Malcolm Sugden, Chair of the Committee, reported that the
Finance, Strategy and Investment Committee would meet on 30
July 2014.
iii.
Quality Committee
Mike Cheshire, Chair of the Committee, reported that the
Quality Committee would hold its first meeting during August
2014.
iv.
JM
Workforce and Organisational Development Committee
Carol Prowse, Chair of the Committee, reported that the
Workforce and Organisational Development Committee would
meet on 31 July 2014.
172/2014
BG
JSh
PLANNING AND STRATEGY UPDATE
Bill Gregory presented a report which updated the Board on the progress
with planning and strategy development.
John Sandford asked whether the process had been over-engineered.
Bill Gregory said that he thought the methodology proposed would be
useful and that a lot of what was proposed already existed. The report
was designed to show how all of the work would be brought together.
Carol Prowse said that she thought the proposal would bring clarity to
the planning process.
Malcolm Sugden said that he thought it was a good paper which filled
some of the existing gaps in this area.
John Schultz said that the key issue would be to ensure proportionality in
the use of the proposed process.
The Board of Directors approved the recommendations within the report
and the proposed future planning cycle, timescales and process set out
to produce business group / corporate function plans.
It was agreed that the newly introduced process should be reviewed after BG
December 2014 in the Finance, Strategy and Investment Committee.
173/2014
MONITOR COMPLIANCE FRAMEWORK ASSESSMENT
The Board considered the quarter 1 2014/15 Monitor declarations. ED
performance would be flagged as ongoing risk.
Cancer two-week wait (breast) was considered to be a quarter risk only
and not declared going forward.
62-day cancer not to be declared.
8
RTT not to be declared.
Reference within the governance section to be made to the ongoing
implementation of the Deloitte’s governance review.
A finance declaration to be made confirming a COSRR of 3.
Executive Directors to review the return and supporting commentary
prior to its submission to Monitor.
174/2014
BG / AB /
JSu
REPORT OF THE CHIEF EXECUTIVE
The Chief Executive reported upon:
a) Strategic Planning
The Board of Directors received a briefing paper upon Healthier
Together, Southern Sector including the Challenged Health Economy
exercise and Stockport Integrated Care.
The Healthier Together consultation closed on 30 September 2014.
The Trust’s response to the options would make the case for
specialist designation for the Stepping Hill site.
Information about Healthier Together, the consultation and the
Trust’s position were being publicised widely in the Trust and a series
of internal meetings and events were planned. The Trust was also
engaging external parties and the public through various channels to
promote the hospital’s view and encourage a response.
The Trust had focused on the impact for patients of not being
designated a specialist site, particularly in relation to access to
emergency care and visitor travel times from the High Peak area.
The Trust’s response would be shaped by the further views of staff,
patients, Governors, public and partners over the coming weeks and
a proposed response will be submitted to the Board of Directors at its
meeting on 25 September 2014.
AB
b) Southern Sector Pathology
James Sumner said there had been little movement since the
previous report to the Board of Directors.
An update with regard to the heads of terms discussion would be
provided to the Finance, Strategy and Investment Committee at its
meeting on 30 July 2014.
c) Winter Pressures
James Sumner updated the Board of Directors on the approach
being taken within the local health economy and the availability of
£1.9million resilience monies to the Stockport economy.
Bill Gregory said that a bid had also been made against funding
available for RTT specialty by specialty targets.
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d) Francis “Listening to You” Events
The findings and recommendations from this activity would be
presented to the Board at their away days in October 2014.
e) Monitor Meetings
The most recent Progress Review Meeting with Monitor had taken
place on 1 July 2014. Discussions had focused on governance, ED
performance, finance and complaints. The next meeting was
scheduled for 5 August 2014.
175/2014
DATE OF NEXT MEETING
The next public meeting of the Board of Directors would take place on
Thursday 25 September 2014 at 1.15pm in Lecture Theatre A, Pinewood
House, Stepping Hill Hospital.
JJP/SC/BoD/2014/Sept/Public/Public minutes 24.07.14
17 September 2014
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Agenda Item No: Public ( 5.3 )
ACTION TRACKER – PUBLIC
a) ITEMS BROUGHT FORWARD
MEETING
ACTION
ACTION
BY
Board of
Directors –
27
February
2014
Report of the Chief Executive
Board of
Directors –
27 March
2014
Report of the Chief Executive
Board of
Directors –
27 March
2014
Performance Assessment Summary
a)
STATUS
DUE
DATE
Meeting with Stockport CCG
It was proposed that a Board to Board
should also be arranged with Tameside and
Glossop Clinical Commissioning Group.
JJP
Under review
Nov
2014
AB / JJP
Under review
23/24
October
2014
BG
Finance,
Strategy &
Investment
Committee
25 Sept
2014
JSh
Workforce &
OD Committee
25 Sept
2014
a) Regulation in the NHS
It was suggested that the briefing note from
Mersey Internal Audit Agency and the key
questions included should be included on the
programme for future Board development
sessions.
a) Working Capital Facility
The Board of Directors agreed:
i)
BG
That the Trust should not renew the
Working Capital Facility with Barclays
PLC.
ii) That a further report reviewing the
position be brought to the Board of
Directors in September 2014.
b) Human Rights Equality and Diversity
Strategy 2014-18
The Board of Directors approved the
strategy and asked for a further update at
the Board meeting in September 2014.
Board of
Directors –
26 June
2014
Integrated Performance Report
Board of
Directors –
26 June
2014
D-Block Business Case
a) Mandatory Training
Update to be provided to the Board of
Directors in September 2014.
The Board of Directors agreed that a monthly
report on progress be submitted to the Board of
Directors.
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BG /
PHo
Sept
2014
b) MEETING OF THE BOARD OF DIRECTORS HELD ON 24 JULY 2014
ITEM
ACTION
ACTION
BY
STATUS
1. Apologies for
Absence
An apology for absence was received from
James Catania.
JJP
Completed
2. Declaration of
Amendments
to the Register
of Interests
John Schultz declared his senior advisory
role to the local government (but not
healthcare) sector of a management
consultancy, Newton Europe. He said that
he wouldn’t be involved in any potential
discussion with the Trust with regard to bed
allocation modelling.
JJP
Completed
3. Minutes of the
Previous
Meeting
The minutes of the previous public meeting
of the Board of Directors held on 26 June
2014 were agreed as a correct record.
JJP
Completed
4. Proposal for
Merger of
Foundation
Trust
Governors’
Association
with
Foundation
Trust Network
The Board of Directors supported the
merger proposal and authorised the
Chairman to vote on their behalf to that
effect.
JJP
Completed
5. Integrated
Performance
Report
a) Breast Patient Information
Change of title of section suggested
given that the target referred to cancer
and non-cancer referrals.
DUE
DATE
25 Sept
2014
JSu
b) Accident and Emergency Waiting
Times
It was agreed that it would be helpful in
future reports for any comments on
quality of care to be included.
JSu
Completed
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Completed
BG
Refined
forecast in
month five
report
c) Staff Sickness and Absence
New Deputy Director of Human
Resources undertaking a piece of work
to interrogate sickness and absence
data. Report to Workforce and
Organisational Development Committee
on 31 July 2014.
d) Finance Report
More detailed line by line forecast with
regard to the end of year position to be
2
25 Sept
2014
ITEM
ACTION
ACTION
BY
STATUS
DUE
DATE
BG
Delegated
to FSI
30 July
2014
JM
For next
Board
meeting
25 Sept
2014
JJP
Completed
AB / JJP
Completed
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Completed
provided to the Board in September
2014.
Liquidity and longer term cash issues to
be reviewed at Finance and Investment
Committee.
e) Nursing Dashboard
Additional narrative with regard to “red”
wards to be included within the next
report.
6. Unscheduled
Care
Programme
Update
To be added to the agenda for the Board to
Board meeting with the Clinical
Commissioning Group on Thursday 18
September 2014.
7. Deloitte’s
Review of
Governance
Arrangements
a) Summary Report
The Board of Directors approved the
summary of the final Deloitte’s report for
sharing with stakeholders and the wider
public.
b) Building a Sustainable Future
Committee
Key issues report from meeting on 16
July 2014 circulated to the Board.
Draft terms of reference for the
Committee were also circulated. Any
comments to be forwarded to either
John Schultz or Ann Barnes.
8. Planning and
Strategy
Update
The Board of Directors approved the
proposed future planning cycle, timescales
and process to produce Business Group /
corporate function plans and supporting
strategies that would result in a full set of
strategies being signed off by the Board in
December 2014.
Process to be reviewed after December
2014 in the Finance and Investment
Committee.
The Board of Directors reviewed the Monitor
Compliance Framework declarations for
Quarter 1 2014/15.
ED performance to be flagged as an
ongoing risk.
Cancer two-week wait (breast) to be
regarded as a quarter risk only in the
commentary and not declared.
3
BG
Ongoing
ITEM
ACTION
ACTION
BY
STATUS
DUE
DATE
62-day cancer not to be declared.
RTT not to be declared.
Attention to be drawn to the Deloitte’s
Governance Review.
Finance declaration to be made confirming
COSRR of 3.
Executives to review further before
submission.
9. Report of the
Chief
Executive
BG / AB / Completed
JSu
a) South Sector Pathology
Further information to be provided to the JSu
Finance and Investment Committee at
its meeting on 30 July 2014.
Completed
b) Francis Listening Events
Board of Directors informed of the
development of “have your say”
discussion rooms.
The findings and recommendations
from this activity to be presented to the
Board of Directors at the away day on
23 October 2014.
JJP/SC/Notes/BoD/2014/25.09.14/Public/Public Action tracker for BoD 25.09.14
18 September 2014
4
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Scheduled
23 Oct
2014
Board of Directors
Date
25th September 2014
Title of Report
Patient Story
Judith Morris
Director of Nursing &
Midwifery
Presented by:
Name & Title
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Item
No.
Part
Public/Private
Public
Prepared by:
Name & Title
Margaret Gilligan
Matron for Patient
Experience
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.
Patients’ health and well-being is supported by high quality, safe and timely
care
Patients and their families feel cared for and empowered
Is this on the
No
√
Yes
Trust’s risk
register?
Confirm that Datix and the BAF reflect this risk
and assurance information. Or state the date
when they will be updated.
Board action
Approve
Ratify so
sought (X)
as fit for
comes
purpose
into force
Points to note re the
Nil
Trust’s CQC registration
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for Nil
Consideration:
If Yes,
Score
Endorse
management
action
Note
√
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
Patient Story
This story is taken from written feedback received by a patient who stayed as an inpatient on
wards A3 (one night), A15 (two weeks) and A12 (one week) from May - June 2014. Having
spoken with the patient she gives both positive and negative feedback around her stay and
described the following experiences.
In the feedback the patient described ward A3 as ‘noisy chaos all the time’.
A15 was described as clean and tidy with most staff being pleasant and the doctors being
excellent and caring. However, the patient discussed in her feedback, and with me, her
inability to have a good night’s sleep due to the “machines constantly alarming” in the ward,
and how the nursing staff did not always silence them. The patient stated staff used to enter
the ward early morning when arriving on duty greeting each other loudly, and although
pleasant in manner this was very loud. She also stated the ward managers did not introduce
or make themselves known and she had to ask who was in charge of the ward.
The patient described how some staff would compare their own hospital experience with the
patients, and even though she is a retired nurse, she felt this was inappropriate as
experiences are not the same and she found this upsetting.
She found that none of the staff asked her what she was eating, and due to her diagnosis of
a liver problem, she found the fat free, diabetic diet she was given to be “inedible”. The
patient stated because she felt unwell she wrote comments on the diet sheet which she felt
were ignored. However, she did manage the diabetic part of the diet. The patient had a poor
experience of the food she was given and stated there was no taste and it was not cooked
well. She commented “tell the chefs to look at what they are eating at home and out, note the
taste and texture etc. and replicate – it’s not hard”.
The patient asked in her feedback if there is a “named nurse” for each patient as she felt she
had more attention from the health care assistants than the trained nurses.
I was able to tell the patient about the work we have done on trying to reduce noise at night
and the changes planned for the role of ward manager; I also assured her that her comments
about the food would be reported to Catering.
Following her stay on A15 she was moved to ward A12, which she also described as clean
and tidy but with all staff pleasant and caring. By comparison with the previous wards, she
described a more restful environment on A12 especially at night, where alarms on machines
were attended to immediately. The patient stated that the ward had a calm, peaceful
atmosphere and described it as “wonderful”.
The patient wrote to the Patient Experience Team on 4th July 2014 about her stay and this
was forwarded to the Patient and Customer Services Department so that her concerns could
be investigated. A response has now been sent. However, I have spoken with the patient
and she is happy to give her consent for her experiences to be shared with the Board of
Directors.
Margaret Gilligan
Matron for Patient Experience
Board of Directors
25th September 2014
Title of Report
Part
Public Item
No.
Public/Private
Progress report Annual Improvement Objectives – quarter 1
Presented by:
Name & Title
Bill Gregory
Director of Finance
Date
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Prepared by:
Name & Title
Karen Lees
Head of Planning
The Annual Plan 2014/15-2015/16 sets out the Trust Priorities and Improvement
Objectives.
This paper provides the Board with summary information for quarter one 2014/15,
detailing progress and any remedial action required, to address progress against
planned delivery trajectories.
The Trust Annual Improvement Objectives cover all strategic and corporate
objectives
Is this on the
No
X
Yes
If Yes,
Trust’s risk
Score
register?
Confirm that Datix and the BAF reflect this risk
and assurance information. Or state the date
when they will be updated.
Board action
Approve
Ratify so
Endorse
Note
sought (X)
as fit for
comes
management
X
purpose
into force
action
Points to note re the
The Trust Annual Improvement Objectives include national service and
Trust’s CQC registration
quality standards
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for
Consideration:
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce
& OD
Committee
Exec Team
16/09/2014
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
Trust Annual improvement objectives for 2014-15
1. Background
The Annual Plan 2014/15-2015/16 sets out the Trust’s four priority areas: Quality,
Partnership, Integration and Efficiency. The difference we want to make for our patients
for each priority is described by the Strategic Outcomes, which translate the Priorities
into the tangible benefits we want to achieve.
The Trust is focusing its efforts on these Strategic Outcomes over the next two years.
The Improvement Objectives are the actions the Trust intends to take to deliver these
benefits, and these are broad-based and ambitious, as many require partnership
working.
As part of good governance arrangements, there is a named lead Executive Director for
each Improvement Objective.
Through one-to-one discussions with the Chief Executive and Executive Directors, the
Head of Planning has gathered the progress information for each Improvement
Objectives as at quarter one, together with a judgement on whether or not the progress
is ‘on or off track’. This information was collated, and then validated by the Executive
Team on 16th September 2014.
2. Improvement Objective quarterly progress report
The Annual Plan is delivered through the day-to-day work of the business groups and
corporate functions. The Board on a quarterly basis undertakes the monitoring of the
overall delivery of the Plan. This paper provides the Board with summary information for
quarter one 2014/15, detailing progress and any remedial action taken, to ensure
progress against planned delivery trajectories.
The progress report is presented in a tabular format, and includes the Strategic Priority
and Outcome, together with details of each Improvement Objective. For each
Improvement Objective a key performance indicator has been selected by the Lead
Executive. Where possible the indicator is a national or local measure, such as the
national standard A&E 4 hour wait, or a local CQUIN target.
The table includes the progress as at the end of quarter one, together with a judgement
on whether or not, the progress in delivering the objective is ‘on or off track’. Where
progress is ‘off track’, details of the planned actions to improve performance is included.
3. Action required
The Board is asked to note progress, and approve the planned actions to ensure the key
performance is achieved.
Karen Lees
Head of Planning
18th September 2014
Trust Annual improvement objectives for 2014-15
Quarterly progress report for Q1 April - June 2014
Key performance indicator
Strategic
Outcome
In 2014-15 we will:
Completion
date
On track
or
off track
at Q1
Planned actions if
delivery is not following
plan
Lead
Executive
91.2%
Off track
Unscheduled care phase
2 programme actions are
being implemented and
having an impact on
performance
JS
91.3%
On track
Q1
Progress
Quality priority
Patients
health and
well-being is
supported by
high quality,
safe and
timely care

Meet national service
standards:
 A&E 4 hour
 Referral to
treatment times 18
weeks
 Cancer treatment
times
Qtly
Qtly
Qtly
A&E time from arrival to
admission/transfer/discharge 95% of
patients within 4 hours - quarterly
monitoring target for Monitor.
Percentage of admitted service users
starting treatment within a maximum of
18 weeks from referral. 90% at
speciality level.
JS
RTT- the Trust has a
potential of up to £1.4m of
extra monies through the
economy system
resilience group, to
reduce overall waits and
improve sustainability
Percentage of non-admitted service
users starting treatment within a
maximum of 18 weeks from referral.
95% at specialty level.
95.6%
On track
Percentage of service users on
incomplete RTT pathways waiting no
more than 18 weeks from referral. 92%
at specialty level.
94.2%
On track
JS
Percentage of service users referred
urgently with suspected cancer by a GP
waiting no more than two weeks for first
outpatient appointment. Operating
standard 93%
94.8%
On track
JS
Percentage of service users referred
urgently with breast symptoms waiting
no more than two weeks for first
outpatient appointment. Operating
standard 93%
91.7%
Off track
Page 1 of 11
Breast patients, referral to
date first seen 92.4% actions are recruitment of
a middle grade doctor to
mitigate referral increase
and sustain target.
JS
JS
Key performance indicator
Strategic
Outcome
In 2014-15 we will:
 Hospital acquired
infections (MRSA, C
diff)

Develop revised quality
strategy with
stakeholders
Q1
Progress
On track
or
off track
at Q1
Percentage of service users waiting no
more than 31 days from diagnosis to
first definitive treatment for all cancers.
Operating standard 96%
97.5%
On track
JS
Percentage of service users waiting no
more than 31 days for subsequent
treatment where that treatment is
surgery. Operating standard 94%
100%
On track
JS
Percentage of service users waiting no
more than 31 days for subsequent
treatment where that treatment is an
anti-cancer drug regime. Operating
standard 98%
100%
On track
JS
Percentage of service users waiting no
more than two months (62 days) from
urgent GP referral to first definitive
treatment of all cancers. Operating
standard 85%
86.7%
On track
Minimise rates of Clostridium difficile.
Centrally set trajectory of 39.
0 reportable
infection
On track
Zero tolerance MRSA
1 reportable
infection
On track
Completion
date
Qtly
Q2
Adoption of strategy by the BoD. Senior
clinicians and managers explicitly use
the strategy to drive service
improvement.
Page 2 of 11
Drafting
underway
On track
Planned actions if
delivery is not following
plan
Note - this includes GM
breach reallocation
Lead
Executive
JS
JM
Note – confirmed to be
attributable to a third party
and NOT SFT
JM
JC and
JM
Key performance indicator
Strategic
Outcome
In 2014-15 we will:
Reduce hospital related
mortality:
 Implement
Patientrack, a vital
signs monitoring
system, to enhance
use of early warning
signs indicators
 Reduce incidence
of ventilator
acquired
pneumonia
 Increase presence
of senior clinicians
24/7

Provide harm free care:
 Reduction in the
number and
severity of
pressures ulcers
acquired in hospital
and community
settings
Completion
date
Q1
Progress
Q4
Patient track implemented as per roll out
plan.
Q4
Target is 5 per 1000 ventilator days
compared to 5.45 per 1000 ventilators
days for 2013-14*
Q3
On track
or
off track
at Q1
Planned actions if
delivery is not following
plan
On track
JM
*increased vigilance and
revision of diagnostic
criteria may alter baseline.
To formulate a clinical service strategy
which identifies areas, where 7 day
working is required, supported by the
appropriate workforce
Lead
Executive
JC
On track
JC
Q4
Stockport acute and community
pressure ulcer grade 2-4 prevalence
(CQUIN target <3.7% for 5 consecutive
months).
3.6%
On track
JM
 Reduce incidence
of falls
Q4
Percentage of adults who receive a falls
risk assessment within 6 hours of
admission using an assessment tool
approved by the commissioner. Target
95%.
98.9%
On track
JM
 Reduce incidence
of urinary tract
Q4
Performance indicator is a 50%
reduction in device related bacteraemias
On track
JC
Page 3 of 11
Key performance indicator
Strategic
Outcome
In 2014-15 we will:
Completion
date
infections
 Reduce incidence
of venous
thromboembolisms
Patients and
their families
feel cared
for and
empowered

Friends and Family
 Rollout patient
survey to day-case,
outpatients and
community (DN)
 Increase response
rate above 20% in
all areas
 Develop strategy to
improve patient
experience from
feedback provided

Q1
Progress
On track
or
off track
at Q1
95.7%
On track
JC
On track
JM
On track
JM
On track
JM
JM
Planned actions if
delivery is not following
plan
Lead
Executive
associated with urinary catheters (7
cases in 2013-14 reducing to 4 in 201415)
Q4
Q3
Q1
Q2
VTE risk assessment; all inpatient
service users undergoing risk
assessment for VTE, as defined in
contract technical guidance. Target 95%
Start rollout from October 2014
Friends and family test combined
response rate (2014/15 Q1 CQUIN
target >= 15% for A&E and 25% for
inpatients).
Strategic vision adopted by the Board.
To be incorporated into the new Quality
Improvement Strategy.
28%
(combined
A&E and
inpatients)
Responding to Francis
and Keogh
 Increase the
proportion of ward
leader time
dedicated to
supervision
Q3
Supervisory status for ward managers
introduced as part of nurse staffing
review
On track
 Review nurse
staffing against
Q3
Appropriate staffing levels based on
activity and skills mix – Board
On track
Page 4 of 11
Paper is coming to the
Board in September 2014
JM
Key performance indicator
Strategic
Outcome
In 2014-15 we will:
Completion
date
standards and
acuity and make
necessary changes
 Develop and deliver
a programme to
embed our caring
values and
behaviours across
all services
 Publish ward
staffing numbers
outside each ward


Improving dementia
care focussing on
dignity and respect, but
also ensure 90% of
appropriate patients
are assessed for
dementia on admission
Focus on improving
communication by
Trust staff with patients
and their carers,
including electronic
discharge letters
Q1
Progress

Planned actions if
delivery is not following
plan
Lead
Executive
discussion will lead to delivery plan and
targets
Q4
Refreshed values adopted
Behavioural framework adopted
On track
JSh
Q4
Ward establishment reviewed and
staffing rations on external ward
information boards
On track
JM
Q4
Continued implementation of the Trust
Dementia Strategy 2014-18, by
milestones.
Patients asked Dementia Finding
question within 72 hours (quarterly
CQUIN target >= 90%).
On track
JC
Q3
Discharge summary published within 48
hours (to reach 95% by December
2014).
Partnerships priority
The Trust is
an effective
member of a
modern and
innovative
health care
On track
or
off track
at Q1
Take a leading role in
shaping the plans and
implementation of new
approaches to health
and community care in
conjunction with CCGs
Page 5 of 11
92.2%
On track
65.9%
Which
exceeds
planned
trajectory for
Q1
On track
Process in place, but
need to consider how to
make these more resilient
JC
JC
Key performance indicator
Strategic
Outcome
community
In 2014-15 we will:
and local authorities
 Support CCG in the
development of a
Stockport urgent
care strategy

Engagement with
Tameside and
Glossop, and
Stockport on
integration of
community service
 Work with Stockport
stakeholders through
the Joint
Transformation Board
to develop and agree a
Strategy for the shape
and development of a
new health and care
community for coming
years
 Delivery of CQUIN
measures
Effective and
efficiently
run services
across the
Southern
Sector
partnership
 Reduce costs of back
office functions,
including identified
internal efficiencies and
recently identified
opportunities for
collaboration with
Southern Sector
Completion
date
Q1
Progress
Q3
Strategy adopted, driving improvements
and setting agenda for Urgent Care
Board
Q3
Clarity on commissioning intentions to
allow the Trust to plan for the future
Q2
Q4
Q3
Off track
Stockport
confirmed
Tameside
uncertain
Gain recognition and understanding of
the operation and financial risk across
health economy and contribute to plans
to address the gap.
Trust plans on 85% achievement on
CQUIN and this should be viewed as
the minimum target
Identify as appropriate, financial and
non-financial benefits from collaboration
on procurement.
Page 6 of 11
On track
or
off track
at Q1
Planned actions if
delivery is not following
plan
A new governance
structure has been put in
place during Q2, within
the Stockport economy,
and the Trust is fully
engaged with this
Lead
Executive
JC and
JS
On track
JS
Off track
Monthly meetings with
COO, DoF and contracts
team
Off track
A new governance
structure has been put in
place during Q2, within
the Stockport economy,
and the Trust is fully
engaged with this
98%
On track
Joint
procurement
management
now in place
with UHSM
On track
BG and
JS
JM
BG
Key performance indicator
Strategic
Outcome
In 2014-15 we will:
partners
Completion
date
Q3
Q1
Progress
Evaluate the potential for collaboration
on Estates and Facilities
Being
explored as
part of option
for future
service
provision
Project
started
On track
or
off track
at Q1
Q4
 Scope and develop
clarity of future
objectives for further
clinical services for joint
working
Q4
Evaluate options as part of continuing
Challenged Health Economy, Southern
Sector and Healthier Together initiatives
Off track
 Implementation of
pathology services
shared service
Q3
Pathology service transferred to UHSM,
with clear financial and legal
agreements in place, and service levels
do not reduce.
Q4
Workforce plan developed and adopted,
and aligned to Business Planning.
Q4
Evaluate options as part of continuing
Challenged Health Economy work,
Southern Sector and Healthier Together
initiatives
Lead
Executive
On track
 Scoping of a sector
wide electronic patient
record system
 Agree approach and
begin implementation of
“single service” across
the Southern Sector for
at least two clinical
services
Selection of potential supplier to be
considered by the Board
Planned actions if
delivery is not following
plan
On track
Off track
JS
Action relates to both of
these improvement
objectives:
CE is discussing and
agreeing a potential way
forward with South Sector
partners.
Options will also be
considered at the
Challenged Health
Economy Board
JC
Off track
Turnaround process being
led by programme
manager
JS
Off Track
Will form part of Trust
workforce plan
JSh
Integration priority
Patients’
lives are
easier
because
they receive
their
 Begin to develop a
strategy and associated
workforce plan for
community services that
improves care closer to
home
Page 7 of 11
Initial
scoping
Key performance indicator
Strategic
Outcome
treatment
closer to
home
Patients’
receive
better quality
services
through
seamless
health and
social care
In 2014-15 we will:
 Implement initial
elements of the Strategy
which will reduce
admissions to hospital,
including:
 Integrated IV therapy
service
 Hospital at home
 Outreach services
Completion
date
Q1
Progress
On track
or
off track
at Q1
Planned actions if
delivery is not following
plan
Lead
Executive
Q1
To put in place with the CCG a number
of integration schemes in line with the
Trust priorities
In place
On track
 Develop a business
case for a community
electronic patient record
system
Q3
Business case and decision reached by
Board in agreement with CCGs.
Scoping in
progress
On track
 Implementation of phase
2 of the child and family
services integration
Q4
Establishment of a single allocation
system across the four localities and
specialist hub
On track
Q2
Assertive in reach service reduces LOS
and admission rate for highest risk
patients who use emergency care
regularly.
Off track
Difficulties in recruiting
staff, service has not yet
commenced, however
through agency aim to
start Oct 14
JS
Identify and agree Trust involvement in
main initiatives:
 Smoking cessation (pre op)
 Smoking cessation (general)
 Detection and management of
problem drinking
 Public health standards
(Healthier Together)
 Healthier catering
On track
Director of Public Health
has funded 1.5 PA of
Consultant in Public
Health time
JC
 Implement enhanced
assertive in reach for
highest risk patients who
use emergency care
frequently

Support the Public
Health Prevention
Strategy
Page 8 of 11
JS
Interim Senior IM&T
Director in place
JS
JS
Key performance indicator
Strategic
Outcome
In 2014-15 we will:
Completion
date
Q1
Progress


On track
or
off track
at Q1
Planned actions if
delivery is not following
plan
Lead
Executive
Prevention and Health Literacy
Staff health
Efficiency priority
The Trust is
able to
demonstrate
to
Governors,
local
residents,
partner
organisation
s and
regulators
that it makes
the best use
of its
resources
 Safely reduce costs and
embed transformation
ethos across the Trust.
Q1
The PMO is developing the high level
KPI’s for inclusion in this plan, drawing
on the current work in BaSF
 Roll out at least two
transformation projects
in-year
Q2
Identification of projects at BaSF
Q4
Monitor CoS risk rating of 3 or above.
 Achieve a Monitor
Continuity of Service
Risk Rating of ≥3
 Strengthen holistic
approach to managing
performance including
horizon scanning and
the integrated
performance reporting
framework
Q2
Integrated performance framework in
place.
Examples of where horizon scanning
has led to prompt management action,
and maintenance of performance.
 Strengthen the process
for approving investment
decisions
Q2
Business case panel established
Finance, strategy and investment
committee established.

Develop and implement
a comprehensive
Workforce Plan with the
aim of reducing
dependency on
temporary staff
Q4
Workforce plan adopted by Board.
Senior clinicians and managers
explicitly use the strategy to drive
service improvement.
Page 9 of 11
On track
AB
On track
AB
Rated 3 in
June 14
On track
In place
On track
JS
Completed
On track
BG
Off track
Detailed forecast will be
prepared in October
New deputy Director of
HR now working on this
BG
JSh
Key performance indicator
Strategic
Outcome
Trust staff
are enabled
to deliver
their best
care within a
high quality
environment
In 2014-15 we will:
 Delivery of the values
and behaviours and
clinical leadership and
workforce planning
elements of the
Organisational
Development strategic
work programme
 Refresh the staff
appraisal framework and
embed the Strategic
Objectives within staff
appraisals
 Complete the roll out of
the e-prescribing system
 Complete market
evaluation of the
Electronic Patient
Record system
 Commence construction
of the new surgical and
short stay medical
facility “D Block
Scheme”, subject to
Business Case approval
Completion
date
Q1
Progress
On track
or
off track
at Q1
Q4
Trust values reviewed and updated
values framework introduced
On track
Q4
Trust wide behavioural framework
introduced, linked to trust values
On track
Q4
New appraisal framework launched
Q3
Critical Care inpatients is the last area of
adult care to be completed
Q4
Q2
Cultural
diagnostic
underway
Planned actions if
delivery is not following
plan
JSh
JSh
JSh
On track
Off track
Lead
Executive
The rollout across
Paediatrics is under
review as there is
currently insufficient
functionality within the
system to accommodate
does adjustment for
paediatric patients
JC
Selection of a potential supplier to be
consider by the Board
Scoping
underway
On track
JS
Full business case approved by the
Board, and building work commences
Started build
On track
BG
Page 10 of 11
Key performance indicator
Strategic
Outcome
In 2014-15 we will:
 Development of improve
retail and café facilities,
including planning for a
new main entrance
concourse

Open retail pharmacy
premises, subject to
Business Case approval
Completion
date
Q4
Q2
Q1
Progress
Contractor to be appointed to operate a
retail unit in Child and Family
Retail pharmacy shop opens – out
patient dispensing. Progress on
financial and non-financial benefits to be
reported to Finance, Strategy and
Investment Committee.
Prepared by Karen Lees, Head of Planning, 18th September 2014
Page 11 of 11
Tendering
exercise
underway
Opened in
August
On track
or
off track
at Q1
On track
On track
Planned actions if
delivery is not following
plan
Lead
Executive
BG
BG
Board of Directors
25th September 2014
Part
Public/Private
Integrated Performance Report (IPR)
Date
Title of Report
 Chief Operating
Officer
 Director of Nursing &
Midwifery
 Medical Director
 Director of Finance
 Director of Workforce
& OD
Presented by:
Name & Title
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Prepared by:
Name & Title
Public
Item
No.
Simon Goff, Director of
Performance
The IPR covers the organisational performance against operational, quality,
safety, workforce and financial measures and give the Board the overview
of the organisation’s performance. Each Director outlines the Hotspot areas
which are underperforming against the target measures.
This September report has some additions which are highlighted on the
change log on the first page.




Quality strategy
Performance against national and local standards
Financial sustainability
Workforce and Organisational Development
Is this on the
Multiple areas –
No
Yes
x
If Yes,
risk scores are
Trust’s risk
contained in the
Score
report.
register?
Confirm that Datix and the BAF reflect this risk Risks ratings in the IPR are consistent with the
and assurance information. Or state the date
Trusts risk register
when they will be updated.
Board action
Approve
Ratify so
Endorse
Note
sought (X)
as fit for
comes
management
X
purpose
into force
action
Points to note re the
The items reported on in the Trust IPR contain the national standards
Trust’s CQC registration
which must be adhered to in order to maintain CQC registration and
or the Trust’s compliance Monitor licence
with the Monitor licence.
Other Material Issues for
Consideration:
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
Integrated Performance Report
September 2014
Quality: Clinical and Access
Patient
Mortality
(SHMI) experience
C. diff.
Dementia
FAIR
Pressure
ulcers
VTE
risk
assess
Falls
Discharge RTT 18
summary weeks
Cancer
CQUIN
A&E
4 hours
Cancelled
operations
Canc.
%
ops:
28 days
Partnership and Efficiency
Capital
In-year
financial
performance
Appraisals
Cost
Reduction
Prog.
Continuity
of services
Sickness
absence
Key:
Quarter to Date Performance
Essentials
training
www.stockport.nhs.uk
In Month Performance
Year to Date Performance
IPR
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Stockport | High Peak | Tameside and Glossop
INTEGRATED PERFORMANCE REPORT
Changes to this month’s report:

RAG rated position of all CQUIN indicators shown on page 33.

Mortality (SHMI) added, data are provided for latest 12 month period, available 6 to 9 months in
arrears.

Waiting times for key diagnostic tests has been removed from this report; we have been close to
100% seen within 6 weeks for 14 of the last 15 months. This measure continues to be monitored.

Mandatory training has been rebranded to Essentials training.
Key to indicators:
M
Monitor indicators (in Risk Assessment Framework):
Monitor indicators for which we have made forward declaration:
M
Corporate Strategic Risk Register rating (current or residual): 15
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 upon 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 way it is calculated.
Unvalidated; Manually Sourced; Not Current Month
Unvalidated; Automated; Not Current Month
Validated; Automated; Not Current Month
Validated; Automated; Current Month
Data source is Stockport NHS Foundation Trust unless stated.
www.stockport.nhs.uk
IPR
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Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Hot Spots
HOT SPOTS EXECUTIVE SUMMARY:
September 2014
This section highlights key areas of current under
performance:
Cancer Waiting Times M
16
Return to FRONT page
Chart 1
% within
2 weeks
100%
Breast patients: referral to date first seen
(quarterly Monitor target >=93%)
The year-to-date performance is 92.7% for April
to August.
96.2%
95%
Performance for symptomatic breast referrals
returned to required levels in July and August.
Work continues to ensure that performance
against target is maintained going forward.
90%
85%
80%
75%
70%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=94.3%
Q3=94.6%
2013/14
www.stockport.nhs.uk
Q4=94.7%
Q1=91.3%
Q2=94.5%
2014/15
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Integrated Performance Report
September 2014 Hot Spots
Accident & Emergency total time in dept. M
Chart 2
Return to FRONT page
A&E time from arrival to admission/
transfer/ discharge (quarterly Monitor
target >=95%)
% within 4
hours
100%
ED performance significantly improved in August
and has continued to do so in September. As a
result the monitor trajectory is being achieved.
95.4%
95%
Chart 4 shows the current quarter-to-date and
September-to-date performance position of
Stockport in relation to the other hospital sites in
Greater Manchester
90%
monthy performance
85%
20
Monitor trajectory
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Q4=91.1%
Q1=91.2%
Q2=94.5%
2013/14
Q3
Q4
The attendances are still higher than last year,
currently running at 5.9% year to date increase
(April to August).
2014/15
Chart 3
average
attendances
per day
280
Trend of A&E attendances
2014/15 and previous year
The key factors that are influencing the
performance improvement as reported last
month are:
260
238

240
220
200

2014/15
2013/14
Apr May Jun
Q1
Jul
Aug Sep Oct Nov Dec Jan Feb Mar
Q2
Q3

Q4
Chart 4
A&E department
(Major, Type 1)
Greater Manchester A&E performance,
total time in dept. within 4 hours
Bolton
Bury
Central Manchester
95.4%
Oldham
93.3%
93.1%
93.6%
96.6%
South Manchester
96.8%
94.6%
Stockport
98.0%
95.3%
98.5%
92.9%
Wigan
85%
85.7%
94.9%
Salford
Tameside
86.4%
90.8%
North Manchester
These are to be complemented in October with
the new Assertive In Reach community team
pilot.
93.7%
93.1%
94.2%
95.4%
90% 95% 100%
Quarter-to-date
The GP in ED pilot which commenced in
August
The minors ENP service running until
midnight instead of 10pm from July
Additional
management
input
at
weekends and evenings managing the
processes
98.0%
85%
90% 95% 100%
Month-to-date
Source: Greater Manchester Commissioning
Support Unit. Data includes 16th September.
www.stockport.nhs.uk
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Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Hot Spots
Cancelled Operations
Return to FRONT page
Chart 5
number of
patients
6
Patients not treated within 28 days of last
minute elective cancellation
(monthly KPI target =0)
There were two breaches of this standard in
August:
5
4
3

Orthopaedic patient cancelled twice due to
no High Dependency Unit (HDU) bed
availability

Surgical patient cancelled due to no HDU
bed availability.
2
2
1
0
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=0
Q3=2
Q4=1
Q1=5
Q2=2
2013/14
2014/15
Pressure Ulcers
Return to FRONT page
16
Chart 6
% surveyed
patients
10%
8%
There has been an increase in the Prevalence of
pressure sores to 4.1%. This percentage is a
combined total for acute and community but
when you consider the individual figures it
demonstrates a fall in the acute setting and a rise
in community. More focused work will take place
in the next 12 months within our community
working closely with nursing and care homes to
identify the burden and reduce the number of
developing pressure ulcers. A project manager
has been appointed to drive this initiative.
Stockport Acute & Stockport Community
Pressure Ulcer grade 2-4 prevalence
(CQUIN target <3.7% for 5 consecutive
months)
6%
4%
4.1%
2%
0%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=4.4%
Q3=3.2%
Q4=2.9%
Q1=3.6%
Q2=3.7%
2014/15
2013/14
Discharge summary (48 hours)
Chart 7
% of
discharges
100%
Return to FRONT page
Discharge summary published within 48
hours (to reach 95% by December 2014)
Thanks to a program of education and support
plus significant advances in the IT systems (as
part of the Building a Sustainable Future –
Service Transformation work stream); in July and
August of 2014 the Trust had the highest rates of
achievement yet suffering little effect from the
usual annual leave and change of junior medical
workforce. The Trust now expect to see a further
rise in achievement to reach a consistent level of
>95% for all discharge summaries to reach the
GP within 48hrs by December 2014
77.6%
75%
50%
Admitted patients only
25%
agreed trajectory
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Q4=63.2%
Q1=65.9%
2013/14
www.stockport.nhs.uk
Q2=78.3%
Q3
Q4
2014/15
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Integrated Performance Report
September 2014 Hot Spots
Return to FRONT page
Staff Appraisals
Chart 8
The Trust appraisal figure for August is 79.43%;
this has slowly decreased since it peaked at
80.52% in June 2014. This is most likely due to
this being peak holiday season and the staffing
capacity to undertake appraisals has been lower
than normal. We should see the figure rise again
once staffing levels return to normal. An interim
report will be presented to the Workforce and OD
Committee in October 2014
Staff having annual appraisal
(target >=95%)
% staff
appraised
100%
90%
80%
79%
70%
60%
50%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=76%
Q3=72%
Q4=71%
Q1=77%
2013/14
Q2=80%
2014/15
Chart 9
Essentials Training
Chart 10
% staff
trained
100%
Return to FRONT page
Staff attending "Essentials" Mandatory
Training in last 3 years (snapshot at end
of month, target >=95%)
August 2014 has seen a slight decrease from
92.93% to 91.83%. As with the appraisals, it is
most likely that this is due to staff capacity. We
should see this start to rise again from September
onwards
95%
90%
91.8%
85%
Changed from
needed in last
2 years
80%
75%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=n/a
Q3=83.8%
2013/14
www.stockport.nhs.uk
Q4=83.4%
Q1=86.8%
Q2=92.2%
2014/15
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Integrated Performance Report
September 2014 Hot Spots
Staff Sickness Absence
Return to FRONT page
Chart 11
% staff
absent (FTE)
5%
Staff with Sickness Absence
(<=4% Full Time Equivalent basis)
Since the start of year 2014/2015 sickness
absence rates have started to increase gradually
and the gap to target is now 0.25%. This is the
highest it has been since October 2013.
4.05%
4%
3%
2%
The August 2014 4.05% sickness percentage is
higher than the August 2013 figure of 3.73% but
lower than the August 2012 figure of 4.85%.
1%
0%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=3.9%
Q3=4.2%
Q4=4.4%
Q1=4.2%
2013/14
Q2=4.2%
As in July 2014 Community Healthcare has the
highest sickness absence rate closely followed by
Medicine, as seen in Chart 12. However both
Business Groups have seen a reduction in
sickness absence for August.
2014/15
Chart 12
The Trust target for 2014/15 remains at 4% or
less, and this will be reviewed as part of the
Workforce Health and Wellbeing Project of the
People and Policies Programme and which is
being led by the Deputy Director of Workforce.
Detailed analysis of sickness absence will form
part of the workforce report that is presented to
Workforce and OD Committee at each meeting
Financial Hot Spots
See Financial Report (page 23)
www.stockport.nhs.uk
IPR
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Integrated Performance Report
September 2014 Indicator Detail
INTEGRATED PERFORMANCE REPORT
INDICATOR DETAIL:
September 2014
This section includes data, definition and
commentary for each of the indicators
www.stockport.nhs.uk
IPR
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Integrated Performance Report
September 2014 Hot Spots
Return to FRONT page
Patient Experience 16
Chart 13
% of eligible
patients
40%
August Friends and Family Test (FFT) results
showed an overall response rate of 30%, slight
decrease on July result. Focused work needs to
continue if we are to hit the 40% response rate
required for acute inpatients by the quarter 4
CQUIN target. The combined FFT score was 59,
slight increase on 57.
Friends and Family Test combined
response rate (2014/15 Q1 CQUIN target
>=15% for A&E and 25% for inpatients)
30%
30%
20%
10%
0%
A&E response rate was 24.6% in August.
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=10%
Q3=21%
Q4=26%
Q1=28%
Q2=31%
2013/14
2014/15
Maternity show response down for antenatal and
post natal community handover but down in the
birth touch-point. Staff continue to promote FFT
in all areas of the service.
From the 261 maternity comments received, 95%
indicated they would either be likely or
extremely likely to recommend our services.
Chart 14
FFT Score
(NPS)
80
Friends and Family Test Score
(A&E and Inpatient combined)
70
We continue to implement the new guidance
issued by NHS England following a review of FFT,
which states that the net promoter scoring
approach will be replaced to a new but as yet
undisclosed approach, in the hope of improving
staff
and
patient
understanding
and
transparency.
59
60
Introduction of
SMS in A&E
50
England combined score
40
Stockport combined score
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=64
Q3=60
Q4=54
Q1=59
Q2=58
2013/14
2014/15
Source for England combined score: NHS England
The guidelines also give timeframes to extend the
roll out and ensure that by April 2015 any patient
accessing General and Acute Services; Mental
Health; Community Healthcare; General Practice;
Dentistry; Ambulance Services and those in
Secure Settings will be afforded the opportunity
to feedback using FFT methodology.
www.stockport.nhs.uk
IPR
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Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Hot Spots
Dementia
Return to FRONT page
16
Chart 15
% relevant
patients
100%
The Matron for Dementia continues to complete
the FAIR documents. Alternative solutions are
still being pursued and improved processes have
been introduced through IT system support.
Patients asked Dementia Finding question
within 72hrs (quarterly CQUIN target
>=90%)
99%
75%
Carers’ responses to the survey increased again
during August. Although CQUIN figures for
August are not yet finalized, no problems are
anticipated.
50%
25%
0%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=2.3%
Q3=7.0%
Q4=87.4%
2013/14
Q1=93.4%
Reports from the environmental walk-abouts are
being collated and will be fed back to the wards
and Estates for discussion/action.
Q2=99.2%
2014/15
Chart 16
% relevant
patients
100%
Dementia champions are in place on the wards
and regular meetings are taking place. Training
for the dementia skills/awareness is planned
through to the end of the financial year.
Patients receiving Dementia Assessment
& Investigation (quarterly CQUIN target
>=90%)
96%
75%
50%
25%
0%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=75.0%
Q3=83.9%
2013/14
Q4=75.6%
Q1=60.3%
Q2=95.7%
2014/15
Chart 17
% relevant
patients
100%
Patients receiving Dementia Referral
(quarterly CQUIN target >=90%)
100%
75%
50%
25%
0%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=75.0%
Q3=64.3%
Q4=79.1%
Q1=96.3% Q2=100.0%
2013/14
2014/15
www.stockport.nhs.uk
IPR
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Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Hot Spots
Venous Thromboembolism (VTE) Risk Assessments
Chart 18
% relevant
patients
100%
Return to FRONT page
Patients receiving VTE Risk Assessment
(monthly KPI target >=95%)
The Trust continues to achieve the 95% risk
assessment target. It is anticipated that this level of
performance would be sustained throughout 20142015.
98%
95.6%
96%
94%
This performance target is monitored and tracked
at the Thrombosis Committee
92%
90%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=95.8%
Q3=95.9%
2013/14
Q4=96.1%
Q1=95.8%
Q2=95.7%
2014/15
Falls Risk Assessments
Return to FRONT page
Chart 19
% surveyed
patients
100%
Compliance with falls risk assessment
documentation continues to remain over 95%.
The Trust target for 2014/15 is to reduce the
number of falls, major, severe and catastrophic by
10%
Acute patients having Falls Risk
Assessment (monthly KPI target >=95%)
99.3%
98%
96%
94%
A trial of an upgraded version of the bed and
chair alarms is due to take place beginning of
October 2014. This will provide data on usage
and response times to enable more accurate
monitoring of the use of alarms.
92%
90%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=98.8%
Q3=99.5%
Q4=99.6%
Q1=99.0%
Q2=99.5%
2013/14
2014/15
Clostridium difficile (C. diff.) infections M
Chart 20
number of
infections
40
Return to FRONT page
C. diff. infections (2014/15 Monitor target
<=39 due to lapses in care )
There has been one case of clostridium difficile in
July, the total number YTD is 3, with no cases
under review and with no cases due to lapses in
care.
YTD cumulative
annual cum. target
Total C-diff cases
Due to lapses in care
30
20
The Infection Prevention Team continues to
screen inpatient faeces specimens prior to
testing.
10
0
0
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=9
Q3=4
Q4=4
Q1=0
Q2=0
2013/14
2014/15
www.stockport.nhs.uk
IPR
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Integrated Performance Report
September 2014 Indicator Detail
Return to FRONT page
Pressure Ulcers 16
Chart 21
There has been an increase in the Prevalence of
pressure sores to 4.1%. This percentage is a
combined total for acute and community but
when you consider the individual figures it
demonstrates a fall in the acute setting and a rise
in community. More focused work will take place
in the next 12 months within our community
working closely with nursing and care homes to
identify the burden and reduce the number of
developing pressure ulcers. A project manager
has been appointed to drive this initiative.
Stockport Acute & Stockport Community
Pressure Ulcer grade 2-4 prevalence
(CQUIN target <3.7% for 5 consecutive
months)
% surveyed
patients
10%
8%
6%
4%
4.1%
2%
0%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=4.4%
Q3=3.2%
Q4=2.9%
Q1=3.6%
Q2=3.7%
2014/15
2013/14
Chart 22
Stockport Acute Patients having Tissue
Viability Risk Assessment (monthly KPI
target >=95%)
% surveyed
patients
100%
Compliance with tissue viability risk assessment
documentation continues to remain over
95%. This performance is measured via the
monthly audit of the nursing care indicators; a
review of these indicators is taking place in
October 2014
98%
97.3%
96%
94%
92%
90%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=99.3%
Q3=98.7%
Q4=98.7%
Q1=99.0%
2013/14
Q2=98.3%
2014/15
Chart 23
number of
patients
20
8
10
0
There has been a decrease in the numbers of new
hospital acquired pressure ulcers.
Figures continue to be reported monthly on the
Trust’s website via “Open and Honest Care” and
the Trust has been selected as a case study site to
evaluate this improvement programme.
Participants will be invited to complete a
questionnaire and to participate in a short
telephone interview.
Stockport Acute number of hospital
acquired Pressure Ulcers (Safety Cross)
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2
Q3
2013/14
www.stockport.nhs.uk
Q4
Q1
Q2
2014/15
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Integrated Performance Report
September 2014 Indicator Detail
Summary Hospital-level Mortality Indicator
Chart 24
Return to FRONT page
SHMI
(baseline = 1)
1.4
Summary Hospital-level Mortality
Indicator (SHMI) - Jan 2013 - Dec 2013
Chart 24 and Chart 25 show the 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.
1.2
Stockport,
expected
0.918
range
1.0
0.0
UHSM
Pennine Acute
0.2
Bolton
Tameside
WWL
0.4
CMFT
0.6
Salford
0.8
Non-Specialist Acute Trusts (England, GM highlighted)
Source: Health and Social Care Information Centre
Chart 25
A SHMI value is calculated for each trust and the
baseline SHMI value is 1. A trust would only get a
SHMI value of 1 if the number of patients who die
following hospitalisation there was exactly the
same as the number of patients expected to die
based on the SHMI methodology.
SHMI
Trend of Summary Hospital-level Mortality
(baseline = 1)
Indicator (SHMI) for Stockport NHS FT
1.4
1.2
1.0
expected
range
0.918
For any given number of expected deaths, a range
of observed deaths can be considered to be ‘as
expected’. If the observed number of deaths falls
outside of this range, the trust in question will be
considered to have a higher or lower SHMI than
expected.
0.8
0.6
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2012/13
2013/14
End of rolling 12 month period
Source: Health and Social Care Information Centre
Chart 26
Chart 26 shows the reduction of the gap in our
standardised mortality between weekend and
weekday admissions. This is calculated using a
slightly different methodology (CHKS’s Risk
Adjusted Mortality Index) which only looks at inhospital deaths.
RAMI index score,
weekend vs. weekday
RAMI Index
200
150
100
50
RAMI Weekday
RAMI weekend
Oct-13
Jan-14
Jul-13
Apr-13
Jan-13
Jul-12
Oct-12
Apr-12
Jan-12
Jul-11
Oct-11
Apr-11
Jan-11
Jul-10
Oct-10
Apr-10
Jan-10
Jul-09
Oct-09
Apr-09
0
Source: CHKS
www.stockport.nhs.uk
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Integrated Performance Report
September 2014 Indicator Detail
Referral to Treatment (RTT) waiting times M
Chart 27
% within 18
weeks
100%
Return to FRONT page
Referral to Treatment: Admitted pathways
(quarterly Monitor target >=90%)
In the summer of 2014 NHS England instigated a
plan to ensure the operational resilience of the
delivery of 18 Weeks. This plan included the
provision of additional funding for providers to
reduce the 18 week backlog, with a view to
recovering the national position to that achieved
in January 2013.
95%
90.8%
90%
85%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=92.1%
Q3=89.7%
Q4=91.0%
Q1=91.3%
2013/14
Stockport NHS Foundation Trust submitted plans
in July in a bid to obtain sufficient funding to
allow us to achieve a position of 92% of our
Incomplete Pathways waiting at or under 16
weeks. To be able to do this and to allow the
Trust to ensure we achieve a sustainable waiting
list position as we move forward, we are planning
to fail the Non-Admitted 95% and Admitted 90%
standards for the third quarter of 2014/15. This
will be a managed failure to ensure we take the
opportunity to treat those patients waiting
longest first, and continue to provide the same
high level of service to each patient on the
waiting list.
Q2=91.1%
2014/15
Chart 28
Admitted pathways by specialty: August 2014
General Surgery (225)
94.7%
Urology (206)
94.7%
Trauma & Orthopaedics (370)
ENT (97)
91.4%
←80.4%
Ophthalmology (300)
91.3%
Oral Surgery (120)
89.2%
General Medicine (41)
92.7%
Geriatrics (0)
Rheumatology (12)
Gynaecology (107)
100.0%
←81.3%
Other (38)
Specialty (number
85%
of pathways)
92.1%
90%
95%
% within 18 weeks
100%
Chart 29
% within 18
weeks
100%
Referral to Treatment: Non-admitted
pathways (quarterly Monitor target
>=95%)
The referral to treatment targets were achieved
at aggregate level in August for admitted care,
non-admitted care and incomplete pathways.
95.0%
95%
Specialty level performances for August are
depicted in Chart 27 (admitted care), Chart 29
(non-admitted care) and Chart 31 (incomplete
pathways) respectively.
90%
85%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=96.8%
Q3=95.9%
2013/14
Q4=95.5%
Q1=95.5%
Q2=95.4%
2014/15
RTT indicators continue on next page
www.stockport.nhs.uk
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Integrated Performance Report
September 2014 Indicator Detail
Chart 30
Return to FRONT page
Non-adm. pathways by specialty: August 2014
General Surgery (739)
Urology (294)
Trauma & Orthopaedics (728)
ENT (569)
Ophthalmology (681)
Oral Surgery (199) ←78.4%
Neurosurgery (3)
Cardiothoracic Surgery (6)
General Medicine (589)
Dermatology (438)
Rheumatology (91)
Geriatrics (110)
Gynaecology (357)
Other (542)
Specialty (number
85%
of pathways)
94.3%
96.9%
95.5%
92.8%
97.7%
100.0%
100.0%
92.7%
94.5%
97.8%
99.1%
98.9%
98.7%
90%
95%
% within 18 weeks
100%
Chart 31
% within 18
weeks
100%
Referral to Treatment: Incomplete
pathways (quarterly Monitor target
>=92%)
95%
92.7%
90%
85%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=95.9%
Q3=94.5%
Q4=93.7%
Q1=94.4%
Q2=92.8%
2013/14
2014/15
Chart 32
Incomplete pathways by specialty: August 2014
General Surgery (2580)
91.0%
Urology (1523)
93.8%
Trauma & Orthopaedics (3318)
95.1%
ENT (1762)
86.0%
Ophthalmology (2073)
95.1%
Oral Surgery (972)
92.2%
Neurosurgery (24) ←62.5%
Cardiothoracic Surgery (24)
95.8%
General Medicine (2555)
90.7%
Dermatology (1459)
91.0%
Rheumatology (403)
97.8%
Geriatrics (180)
97.8%
Gynaecology (1329)
94.3%
Other (1516)
96.4%
Specialty (number
85%
90%
95%
100%
of pathways)
% within 18 weeks
Chart 33
number over
18 weeks
300
RTT: Incomplete Admitted pathways
(local target <=175 by July 2014)
The admitted backlog increased to 216 at the end
of August. Backlog reduction will improve in line
with the extra activity plan and managed failure
of target as described above.
216
200
100
0
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
2013/14
www.stockport.nhs.uk
2014/15
IPR
15
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Indicator Detail
Accident & Emergency total time in dept. M
Chart 34
Return to FRONT page
A&E time from arrival to admission/
transfer/ discharge (quarterly Monitor
target >=95%)
% within 4
hours
100%
ED performance significantly improved in August
and has continued to do so in September. As a
result the monitor trajectory is being achieved.
95.4%
95%
Chart 36 shows the current quarter-to-date and
September-to-date performance position of
Stockport in relation to the other hospital sites in
Greater Manchester
90%
monthy performance
85%
20
Monitor trajectory
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Q4=91.1%
Q1=91.2%
Q2=94.5%
2013/14
Q3
Q4
The attendances are still higher than last year,
currently running at 5.9% year to date increase
(April to August).
2014/15
Chart 35
average
attendances
per day
280
Trend of A&E attendances
2014/15 and previous year
The key factors that are influencing the
performance improvement as reported last
month are:
260
238

240
220
200

2014/15
2013/14
Apr May Jun
Q1
Jul
Aug Sep Oct Nov Dec Jan Feb Mar
Q2
Q3

Q4
Chart 36
A&E department
(Major, Type 1)
Greater Manchester A&E performance,
total time in dept. within 4 hours
Bolton
Bury
Central Manchester
95.4%
Oldham
93.3%
93.1%
93.6%
96.6%
South Manchester
96.8%
94.6%
Stockport
98.0%
95.3%
98.5%
92.9%
Wigan
85%
85.7%
94.9%
Salford
Tameside
86.4%
90.8%
North Manchester
These are to be complemented in October with
the new Assertive In Reach community team
pilot.
93.7%
93.1%
94.2%
95.4%
90% 95% 100%
Quarter-to-date
The GP in ED pilot which commenced in
August
The minors ENP service running until
midnight instead of 10pm from July
Additional
management
input
at
weekends and evenings managing the
processes
98.0%
85%
90% 95% 100%
Month-to-date
Source: Greater Manchester Commissioning
Support Unit. Data includes 16th September.
www.stockport.nhs.uk
IPR
16
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Indicator Detail
Cancelled Operations
Return to FRONT page
Chart 37
% of elective
admissions
1.2%
Last minute elective operations cancelled
for non clinical reasons
(shown against threshold <=0.85%)
Cancelled operations continue to be below
threshold target levels.
1.0%
0.8%
0.65%
0.6%
0.4%
0.2%
0.0%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=0.57%
Q3=0.68%
Q4=0.77%
Q1=0.53%
Q2=0.65%
2013/14
2014/15
Chart 38
number of
patients
6
Patients not treated within 28 days of last
minute elective cancellation
(monthly KPI target =0)
There were two breaches of this standard in
August:
5
4

Orthopaedics patient cancelled twice due
to no High Dependency Unit (HDU) bed
availability

Surgical patient cancelled due to no HDU
bed availability.
3
2
2
1
0
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=0
Q3=2
Q4=1
Q1=5
Q2=2
2013/14
2014/15
Discharge summary (48 hours)
Chart 39
% of
discharges
100%
Thanks to a program of education and support
plus significant advances in the IT systems (as
part of the Building a Sustainable Future –
Service Transformation work stream); in July and
August of 2014 the Trust had the highest rates of
achievement yet suffering little effect from the
usual annual leave and change of junior medical
workforce. The Trust now expect to see a further
rise in achievement to reach a consistent level of
>95% for all discharge summaries to reach the
GP within 48hrs by December 2014
Discharge summary published within 48
hours (to reach 95% by December 2014)
77.6%
75%
50%
Admitted patients only
25%
agreed trajectory
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Q4=63.2%
Q1=65.9%
2013/14
www.stockport.nhs.uk
Q2=78.3%
Q3
Return to FRONT page
Q4
2014/15
IPR
17
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Indicator Detail
Commissioning for Quality and Innovation (CQUIN) 15
Return to FRONT page
Individual indicators with concerns
See also CQUIN Position (page 33)
Red risk
Amber risk
Advancing Quality: Stroke
Measures were met in 13/14; from April 2014
the threshold was increased. An action plan has
now been developed and will be implemented by
the Business Manager.
Dementia FAIR:
All three elements were achieved in July 2014
however sustainability remains a concern. CCG
requesting assurance of resilience built into
process. One element was not achieved in April
therefore the CCG will pay 70% of this CQUIN
Indicator Q1 finance. They have stated that any
failure in future quarters will not receive any
payment.
Advancing Quality Heart Failure
Achieved in April & May then failed in June due to
staff absence. Performance is vulnerable due to
no contingency for sickness absence.
Safety
thermometer
Pressure
Ulcer
prevalence
Requirement of below 3.7 for six consecutive
months; June achieved 3.2. July 3.3.
August 4.06
Stockport Tissue Viability team is currently
supporting Tameside & Glossop which has
impacted
upon
Stockport’s
performance.
www.stockport.nhs.uk
Advancing Quality: Chronic Obstructive
Pulmonary Disease (COPD):
AQUA has advised Implementation from August
discharges. Target is now for Q4.
IPR
18
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Indicator Detail
Cancer waiting times M 16
Return to FRONT page
Chart 40
Urgent Cancer: referral to date first seen
(quarterly Monitor target >=93%)
% within
2 weeks
100%
Cancer performance is no longer a declared issue
to Monitor. The risk assessment has been
reviewed and is now 16.
95%
93.9%
90%
85%
The Trust continues to meet the urgent cancer
referral target. Capacity and demand reviews are
being undertaken across all specialties to ensure
performance against target is maintained.
80%
75%
70%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=96.2%
Q3=96.3%
Q4=96.0%
2013/14
Q1=94.7%
Q2=93.6%
2014/15
Chart 41
Breast patients: referral to date first seen
(quarterly Monitor target >=93%)
% within
2 weeks
100%
The year-to-date performance is 92.7% for April
to August.
96.2%
95%
Performance for symptomatic breast referrals
returned to required levels in July and August.
Work continues to ensure that performance
against target is maintained going forward.
90%
85%
80%
75%
70%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=94.3%
Q3=94.6%
Q4=94.7%
2013/14
Q1=91.3%
The reported position for August 2014 is the
projected performance for the month, final
position will be available in early October 2014.
Q2=94.5%
2014/15
Chart 42
% within
31 days
All cancers: diagnosis to first treatment
(quarterly Monitor target >=96%)
100%
100.0%
95%
90%
85%
80%
75%
70%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=98.9%
Q3=97.2%
2013/14
Q4=97.3%
Q1=97.7%
Q2=100.0%
2014/15
Cancer waiting times indicators continue on next
page
www.stockport.nhs.uk
IPR
19
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Indicator Detail
Chart 43
% within
31 days
Return to FRONT page
2nd or subsequent anti-cancer treatment:
Surgery (quarterly Monitor target >=94%)
100%
100.0%
95%
90%
85%
80%
75%
70%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=100.0%
Q3=100.0%
Q4=100.0%
2013/14
Q1=100.0%
Q2=100.0%
2014/15
Chart 44
% within
31 days
2nd or subsequent anti-cancer treatment:
Drug (quarterly Monitor target >=98%)
100%
100.0%
95%
90%
85%
80%
75%
70%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=100.0%
Q3=100.0%
Q4=100.0%
2013/14
Q1=100.0%
Q2=100.0%
2014/15
Chart 45
% within
62 days
100%
Urgent GP cancer referral to first
treatment - with breach reallocation
(quarterly Monitor target >=85%)
The reported position for August 2014 is the
projected performance for the month, final
position will be available in early October 2014.
95%
90%
85%
86.0%
80%
75%
70%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=89.4%
Q3=85.1%
2013/14
www.stockport.nhs.uk
Q4=86.1%
Q1=87.8%
Q2=86.6%
2014/15
IPR
20
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Indicator Detail
Staff Sickness Absence
Return to FRONT page
Chart 46
% staff
absent (FTE)
5%
Since the start of year 2014/2015 sickness
absence rates have started to increase gradually
and the gap to target is now 0.25%. This is the
highest it has been since October 2013.
Staff with Sickness Absence
(<=4% Full Time Equivalent basis)
4.05%
4%
3%
The August 2014 4.05% sickness percentage is
higher than the August 2013 figure of 3.73% but
lower than the August 2012 figure of 4.85%.
2%
1%
0%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=3.9%
Q3=4.2%
Q4=4.4%
Q1=4.2%
2013/14
As in July 2014 Community Healthcare has the
highest sickness absence rate closely followed by
Medicine, as seen in Chart 47. However both
Business Groups have seen a reduction in
sickness absence for August.
Q2=4.2%
2014/15
Chart 47
The Trust target for 2014/15 remains at 4% or
less, and this will be reviewed as part of the
Workforce Health and Wellbeing Project of the
People and Policies Programme and which is
being led by the Deputy Director of Workforce.
Detailed analysis of sickness absence will form
part of the workforce report that is presented to
Workforce and OD Committee at each meeting.
Return to FRONT page
Essentials Training
Chart 48
% staff
trained
100%
August 2014 has seen a slight decrease from
92.93% to 91.83%. As with the appraisals, it is
most likely that this is due to staff capacity. We
should see this start to rise again from September
onwards
Staff attending "Essentials" Mandatory
Training in last 3 years (snapshot at end
of month, target >=95%)
95%
90%
91.8%
85%
Changed from
needed in last
2 years
80%
75%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=n/a
Q3=83.8%
2013/14
www.stockport.nhs.uk
Q4=83.4%
Q1=86.8%
Q2=92.2%
2014/15
IPR
21
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Indicator Detail
Staff Appraisals
Return to FRONT page
Chart 49
% staff
appraised
100%
Staff having annual appraisal
(target >=95%)
The Trust appraisal figure for August is 79.43%;
this has slowly decreased since it peaked at
80.52% in June 2014. This is most likely due to
this being peak holiday season and the staffing
capacity to undertake appraisals has been lower
than normal. We should see the figure rise again
once staffing levels return to normal. An interim
report will be presented to the Workforce and OD
Committee in October 2014
90%
80%
79%
70%
60%
50%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Q2=76%
Q3=72%
2013/14
Q4=71%
Q1=77%
Q2=80%
2014/15
Chart 50
www.stockport.nhs.uk
IPR
22
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Finance Report
 The Trust is reporting a deficit of £1,916k as at the
end of August 2014.
Overall Summary
I & E Position:
£ 1,916k deficit
Variance Against Plan:
£ 305k favourable
Movement in Month:
£ 175k adverse
EBITDA Position:
£ 3,146k surplus
EBITDA Margin:
2.6%
Cash at Bank:
£46.4m
Liquidity Days:
29 days
COS Risk Rating:
3
· The reported deficit is £305k favourable against the
planned deficit of £2,221k and a deterioration
against plan of £175k in-month.
· Performance against the Trust savings target was
£0.2m below plan during August. Against the
year-to-date target of £5.5m savings totalling £5.0m
have been achieved; an adverse variance of £0.5m.
 The Continuity of Services Risk Rating remains
unchanged from the previous month as a 3 which
is on
plan. £2.1m £0.7m
£2.2 m
Cost Improvement Programme as at Month 5 (Target £18.2m)
£8.3m
(62%)
2014-15 In Year
(16%)
£5.3m
(29%)
2014-15 Recurrent
0
£3.0m
(16%)
2
4
6
(16%) (6%)
£5.4m
(30%)
8
10
£4.4m
(24%)
12
14
16
18
20
Savings (£m)
Identified and Actioned
Identified with budget and phasing
Identified without budget and phasing
Unidentified
 The year-to-date savings target to the end of August 2014 is £5.5m which now includes the additional
targets required to resource the PMO and turnaround. Against this savings totalling £5.0m have
been achieved which is an adverse variance of £0.5m. This is a deterioration of £0.2m from the
previous month when the cumulative shortfall against the target was £0.3m.
· The in-year value of the savings achieved to date is £8.3m and £5.3m recurrently. There are amber
rated plans to deliver further savings of £2.2m in-year and £3.0m recurrently with red rated, less
secure plans, totalling £2.1m in year and £5.4m recurrently. This leaves an unidentified shortfall of
£0.7m in-year and £4.4m recurrently. The in-year unidentified element has decreased by £0.3m
from the previous month when it totalled £1.0m.
 EBITDA as at the end of August is £3,146k which is a
2.6% margin on income, a deterioration in-month of
0.3%. The reported EBITDA position is £271k (9%)
favourable against the planned EBITDA of £2,875k.
EBITDA Plan vs Actual Month 5 Year to Date
3,900
47
3,700
(505)
876
3,500
3,300
3,146
3,100
2,875
2,900
(68)
· Stripping out CRP so we can see the underlying
movements, the position in relation to clinical
income deteriorated by £285k in-month due to
lower than anticipated levels of activity and, as a
result, is now £68k below plan cumulatively.
· Expenditure budgets are underspent by £923k
year-to-date comprised of an underspend on pay
budgets of £876k and an underspend on non-pay
budgets of £47k.
(77)
2,700
2,500
Planned EBITDA Clinical Income Other Income
www.stockport.nhs.uk
Pay Costs
Non Pay Costs
CRP
Actual EBITDA
IPR
 However,
cost
reduction
onGlossop
both
Stockport
| Highplans
Peak | impacting
Tameside and
23
income
and expenditure are £505k behind plan.
Integrated Performance Report
September 2014 Finance Report
In-Year Financial Performance
Return to FRONT page
st
1. Finance Tables—for the period ending 31 August 2014
Income and Expenditure Statement
Year-to-date
Trust
Annual
Plan
£k
Plan
£k
Actual
£k
Variance
£k
M04
Movement
FORECAST
FORECAST
Variance
M04 - M05
Out-turn
Actual
Variance
to Plan
£k
£k
£k
INCOME
Elective
Non Elective
Outpatient
A&E
Total Income at Full Tariff
Community Services
Non-tariff income
Clinical Income - NHS
41,731
64,071
31,467
9,293
146,562
17,067
26,383
12,834
4,026
60,311
17,115
26,308
12,666
4,198
60,288
48
(75)
(168)
171
(24)
157
(87)
11
185
266
(108)
11
(179)
(14)
(290)
41,903
63,951
30,998
9,321
146,172
172
(120)
(469)
28
(389)
59,871
54,809
24,951
22,774
24,962
22,590
12
(184)
9
(166)
2
(18)
60,447
54,070
575
(739)
261,242
108,036
107,840
(196)
109
(305)
260,689
(553)
Private Patients
Other
113
1,219
47
508
32
475
(15)
(33)
(14)
(35)
(1)
2
62
1,105
(51)
(113)
Non NHS Clinical Income
1,331
555
507
(48)
(49)
1
1,167
(164)
625
7,783
5,842
15,283
29,533
253
3,286
2,663
6,544
12,746
209
3,345
2,503
6,798
12,854
(44)
59
(160)
253
108
(43)
76
(50)
356
339
(1)
(17)
(110)
(102)
(231)
536
7,885
5,452
17,313
31,186
(89)
102
(390)
2,030
1,653
292,106
121,337
121,201
(136)
400
(535)
293,042
936
Pay Costs
Drugs
Clinical Supplies & services
Other Non Pay Costs
(210,568)
(14,843)
(21,426)
(37,739)
(87,343)
(6,369)
(8,953)
(15,796)
(87,332)
(6,427)
(8,907)
(15,388)
10
(58)
46
408
(147)
(176)
43
347
157
119
4
61
(211,544)
(14,969)
(21,561)
(37,027)
(977)
(126)
(136)
712
TOTAL COSTS
(284,575)
(118,462)
(118,054)
407
67
340
(285,102)
(527)
7,530
2,875
3,146
272
467
(195)
7,940
409
(7,645)
(3,208)
(3,257)
(49)
(41)
(8)
(7,847)
(202)
Research & Development
Education and Training
Stockport Pharmaceuticals/RQC
Other income
Other Income
TOTAL INCOME
EXPENDITURE
EBITDA
Depreciation
Interest Receivable
88
36
53
17
13
3
106
18
Interest Payable
(802)
(343)
(343)
(0)
(0)
(0)
(803)
(0)
Other Non-Operating Expenses
(637)
(154)
(88)
66
39
27
(571)
67
-
-
-
-
Unwinding of Discount
Profit/(Loss) on disposal of fixed assets
PDC Dividend
(46)
2
(3,432)
2
(1,430)
2
(1,430)
0
0
2
0
(2)
0
(46)
2
(3,432)
0
0
RETAINED SURPLUS / (DEFICIT) FOR
PERIOD
(4,943)
(2,221)
(1,916)
305
480
(175)
(4,651)
292
Fixed Asset Impairment
Statement of Financial Position as at 31st August 2014
31st March
2014
£000
Non Current assets
31st August
2014
£000
134,808
135,332
2,258
9,867
46,559
(28,232)
(2,682)
27,770
2,251
10,603
46,444
(31,809)
(2,160)
25,330
Total Assets Less Current Liabilities
162,578
160,662
Non Current Liabilities
Provisions for Liabilities and Charges
(17,832)
(2,072)
(17,832)
(2,072)
Total Assets Employed
142,674
140,758
82,901
45,711
14,062
82,901
45,711
12,146
142,674
140,758
Current Assets/(Liabilities)
Inventories
Trade receivables and prepayments
Cash and cash equivalents
Current Liabilities
Provisions under 1 year
Financed by:
Taxpayers' Equity
Public Dividend Capital
Revaluation Reserve
Income and Expenditure Reserve
Total Taxpayers Equity
www.stockport.nhs.uk
IPR
24
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September
2014 Finance Report
2. Income
Income Plan Vs Actual at Month 5
121,400
121,337
0
75
157
(£000)
121,300
171
12
5
10
33
44
59
160
121,201
68
10
121,200
121,100
Actual Income
CRP
Other income
Stockport
Pharmaceuticals/RQC
Education and Training
Research & Development
Other
Private Patients
Non-tariff income
Community Services
A&E
Outpatient
Non Elective
Elective
Planned Income
121,000
· Total income as at the end of August is £121,201k against a plan of £121,337k; a cumulative adverse
variance of £136k (0.1%) following an adverse variance in-month of £536k. Total income received during
August was £23,542k which was a decrease of £873k against the previous monthly average run-rate.
Although a reduction in income during August was anticipated and planned for at the start of the year,
the reduction in income was more than anticipated particularly with regards elective and outpatients.
· Elective income, excluding income generation plans, was £133k below plan during August, taking the
position to on-plan cumulatively. Actual income earned during August was £3,171k which was the lowest
of this financial year, and lower than any month during the previous financial year, with the run-rate
being £454k less than the previous 4 months average. As a result several specialties were below plan inmonth including Hands which was £61k adverse to plan due to annual leave and General Surgery which
was below plan by £53k with 127 spells in-month against an average of 189 for April to July.
· Non-elective income was £12k above plan in-month, the cumulative adverse variance now being £75k.
Obstetric income has stabilised in the second quarter of the year and was £11k favourable to plan during
August, however the cumulative position is still adverse and stands at £120k (4%) as at the end of month
5. Urology was below plan for the third consecutive month, the adverse variance in August being £15k
taking the year-to-date adverse variance to £28k (2%). All other specialties remain on-plan or above
plan.
· Outpatient income was below plan by £176k during August taking the year-to-date variance to £157k
below plan. 27 out of 36 specialties were below plan in-month with the combined over performance of
the remaining 11 specialties being £66k. A reduction in income was anticipated due to seasonal
expectations however the actual income reduction was greater than planned, the actual income in-month
being £2,261k, £382k below the average monthly run-rate. The specialties with the largest adverse
variances in-month were Paediatrics (£40k), Gastroenterology (£22k) and Trauma & Orthopaedics
(£20k). 23 out of 36 specialties remain above plan at the end of August the most significant being
Cardiology (£56k), ENT (£31k) and Orthodontics (£23k).
· Income earned for A&E attendances was £51k (6%) below plan during August which was partially offset by
an improvement in the position on financial penalties due to the A&E 95% threshold being achieved inmonth. Year-to-date, income remains favourable by £171k; £242k favourable in relation to attendances
partially offset by £71k adverse in relation to financial penalties.
· Non-tariff income was above plan by £20k in-month, the cumulative favourable variance now being £5k.
Despite this, Adult Critical Care income was below plan by £91k during August due to fewer than
anticipated number of bed days, the year-to-date adverse variance now being £225k (8%) which is partly
offset by expenditure underspends of £75k, particularly within variable cost categories such as drugs and
clinical supplies and services.
· The position in relation to Specialist Pharmacy Units income worsened significantly during August, the inmonth adverse variance being £110k; the cumulative adverse variance now being £160k. This is only
partly offset by an expenditure underspend of £45k giving a net adverse position of £115k. This issue was
discussed in detail at the D&CSS Performance Management meeting on 16th September 2014 and
subsequently the business group are putting in place a recovery plan to address this issue.
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Integrated Performance Report
September 2014 Finance Report
3. Expenditure
Expenditure Plan Vs Actual at Month 5
119,000
118,462
876
118,500
118,054
(£000)
515
118,000
82
26
103
117,500
117,000
Planned Expenditure
Pay Costs
Drugs
Clinical Supplies
Other Non Pay Costs
CRP
Actual Expenditure
· The following analysis strips CRP out so that the underlying position can be seen.
· Total expenditure as at the end of August 2014 is £118,054k against planned expenditure of £118,462k; a
favourable variance of £408k (0.3%). Business group budgets are underspent by £923k which is
comprised of an underspend against pay budgets of £876k and an underspend against non-pay budgets of
£47k. These underspends are partially offset by the shortfall against the expenditure reduction plan which,
as at the end of month 5, stands at £515k.
· Actual pay costs in August were £17,418k which was an improvement of £61k on the run-rate of the previous
4 months. The improvement in run-rate was seen mainly within Surgery and Medicine business groups
where the run-rate improvement was £91k and £84k respectively. This however was partially due to less
activity being undertaken and income earned. Within Surgery there was a £72k reduction in expenditure
incurred on medical locums and agency staffing whilst the reliance on waiting list initiatives also lessened
during August causing a £20k reduction in expenditure. The reduction in pay costs within Medicine was
largely due to a reduction in medical locum costs particularly within Gastroenterology (£26k) and Cardiology
(£25k). Similarly the closure of ward C2 resulted in a reduction in expenditure of £72k. Conversely, the rate
of expenditure within D&CSS increased by £42k during August due mainly to locum cover for annual leave
and a staff grade vacancy within Pathology which cost £56k in-month.
· Excluding CRP, drugs budgets were underspent by £115k in-month taking the year-to-date adverse variance
to £82k. The underspend in-month reflects the reduction in activity and specialist pharmacy units income
described in section 2. Specific significant in-month favourable variances include medicine
outpatients
(£26k), inpatient orthopaedics (£6k) and specialist pharmacy production expenses (£53k). Actual drugs
costs in-month were £1,049k which were the lowest of the financial year (and lower than any month during
2013/14) and is £296k less than the average for the previous 4 months.
· Clinical supplies and services budgets, excluding CRP were underspent by £22k in August taking the
cumulative favourable variance to £26k; the main underspends relating to the reduced levels of activity
particularly in relation to orthopaedic prosthetics and theatre consumables. Actual expenditure on these
items was £93k less in August compared to the average of the previous 4 months. This was partially offset
by an increase in blood sciences chemical and equipment expenditure of £60k due to the timing of several
significant purchases. Total clinical supplies and services expenditure during August was £1,769k which was
£16k less than the previous 4 month average.
· Other non-pay costs, excluding CRP, were overspent by £27k in-month; the cumulative favourable
variance
being £103k as at the end of month 5. Actual other non-pay costs in-month were £3,023k which was £68k
less than the month 1 to month 4 average monthly expenditure. The costs of outsourced
activity within
Surgery decreased in-month to £54k which was £32k less than the previous monthly average. Outsourced
endoscopy activity continues within D&CSS at the same rate as in previous months and additional costs inmonth in relation to the non-medical prescribing project are funded by additional income.
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Integrated Performance Report
September 2014 Finance Report
Cost Reduction Programme
Return to FRONT page
20
4. Business Group CRP and Building a Sustainable Future progress
· The table below shows the in-year CRP plan split by BaSF project, business group and financial
RAG rating as at the end of August 2014. The total column is equal to the red, amber, green
graph shown on page 1. £10,482k of the in-year savings are planned to be delivered by
Business as Usual projects and this accounts for 83% of the total plan for the year which now
totals £12,572k. The total plan has increased by £340k during August.
· There are plans to deliver in-year savings of £1,201k through the Service Transformation
project however these plans are currently rated as red and need further work before savings
are achieved. The People and Policies project has achieved full year savings of £156k as at
the end of August and has plans in place to deliver further savings totalling £433k, £152k of
which are rated as amber.
-
-
-
-
Red
13
-
Amber
-
Total
Green
151
375
-
Red
-
Amber
-
Green
-
Red
13
10
7
18
Amber
2
3
41
37
59
BSF - Estates & Facilities
Green
-
Red
105
-
BSF - Technology
Amber
-
Green
Red
152
179
43
107
1
-
Red
Amber
885
365
80
429
()
86
39
Amber
Green
1,370
1,003
743
874
1,874
283
269
404
BSF - Service
Transformation
BSF - People & Policies
Green
Red
BSF - Income Generation
Amber
Businesss Group
Medicine
Surgery
Child & Family
D&CSS
Community
Estates
Facilities
Corporate
Cross Business
Group
Grand Total
Business As Usual
Green
£000
1,372
1,006
784
911
1,933
283
269
416
885
375
204
429
()
86
56
303
554
43
107
1
-
1,298
-
-
2
35
96
-
118
281
-
-
675
-
-
50
-
-
-
1,300
153
1,102
8,117
1,883
482
2
140
96
156
152
281
-
-
1,201
-
13
50
-
-
-
8,274
2,188
2,111
Grand Total
12,572
2014/15 CRP
Target
13,313
Shortfall /
(Surplus)
741
· The table below shows in-month and year to date performance in relation to each of the
business groups. Child & Family, Community Healthcare and Estates met their in-month
target for August and continue to be above target cumulatively.
· Five of the remaining business groups continue to fall short of their monthly target and
consequently are below target cumulatively. Of these, Medicine, Surgery and D&CSS
continue to be significantly below plan their target and, as at the end of month 5 these three
business groups are £1,735k below target.
£000
Business Group
Medicine
Surgery
Child & Family
D&CSS
Community
Estates
Facilities
Corporate
Cross Business Group
Total
www.stockport.nhs.uk
Target
(£000)
248
258
105
224
216
15
37
61
1,164
Month 5
Actual
Variance
Savings
% Variance
(£000)
(£000)
182
(66)
-27%
126
(133)
-51%
109
5
4%
91
(133)
-59%
251
35
16%
25
11
72%
32
(5)
-14%
51
(10)
-16%
75
75
0%
943
(221)
-19%
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Target
(£000)
1,164
1,212
492
1,053
1,014
69
175
287
5,466
Year-to-date
Actual
Variance
Savings
% Variance
(£000)
(£000)
570
(594)
-51%
500
(713)
-59%
528
37
7%
625
(428)
-41%
1,241
227
22%
111
42
61%
141
(35)
-20%
222
(65)
-23%
1,024
1,024
0%
4,961
(505)
-9%
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Finance Report
Continuity of Services Risk Rating M
Return to FRONT page
5. Continuity of Service Risk Rating
Financial Metric
Debt Service Cover (times)
Liquidity (days)
Actual
Rating
Excellent
4
3
1.38
29
2
4
2.50
0
1.75
-7
Continuity of Services Risk Rating
2
Poor
1
Weight
weighted
score
1.25
-14
< 1.25
< -14
50%
50%
1
2
3
· There was a deterioration in relation to the debt service cover metric during August due to the
increase in the Trust deficit. The metric decreased from 1.54 as at the end of July to 1.38 as at the
end of August. Despite this deterioration, however, the score for this metric remains unchanged
from the previous month as a 2. As described in previous months, this metric is particularly
sensitive to changes in the overall surplus or deficit and had the overall deficit been c.£0.3m worse
as at the end of August, this metric would have scored a 1 overall.
· There was also a deterioration in the Trusts liquidity ratio during August. Despite the fact that the
Trust cash balance increased by £0.3m in-month, the value of net current assets decreased by c.£1m
in month due to higher current liabilities including PDC dividend and deferred income. As a result,
liquidity days decreased from 31 days as at the end of July to 29 days as at the end of August. The
score for this metric remains unchanged at a 4. The Trusts cash balance would need to decrease
by c.£25.6m for this metric to be rated as a 3 overall.
· The overall Continuity of Services Risk Rating remains unchanged from the previous month as a 3
which is on plan.
6. Year-end forecast
· The forecast year-end outturn position as at the end of August is a deficit of £4,651k. This is a
favourable variance to the Monitor APR plan of £292k and an adverse movement to the forecast
presented at the end of July of £52k.
· The forecast takes account of current income and expenditure trends and updated assumptions
regarding CRP, financial penalties and activity projections. There are however still uncertainties
around issues such as CQUIN and the impact of winter which could significantly improve or worsen
the year-end position depending on their outcome. A graph showing the planned cumulative deficit
and forecast cumulative deficit is shown below.
· A more detailed analysis of the year-end forecast and the assumptions currently being used within it
will be presented to the Finance Strategy and Investment Committee on 1st October 2014.
Forecast
Deficit Vs Plan as at M5 14-15
M1
M2
M3
M4
M5
M6
M7
M8
M9 M10 M11 M12
(1,000)
Cumulative actual
£000
(2,000)
Cumulative plan
(3,000)
(4,000)
(5,000)
(6,000)
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Integrated Performance Report
September 2014 Finance Report
Capital Programme
Return to FRONT page
7. Capital Programme
Capital Programme 2014/15 - Month 5 August 2014
Capital Scheme
Monitor Tracking - Month 5
2014/15 Budget
Planned
Spend
Actual
Spend
Variance
to Planned
Spend
£'000
£'000
£'000
£'000
Site Security Upgrades
D-Block Extension
Catering Strategy (Building)
Minor Projects
Backlog Maintenance / Site Infrastructure
Statutory Compliance
Environmental / CMIP
Corporate / Facilities
Invest to Save
150
150
78
5,112
2,474
270
140
245
150
145
750
1,590
80
40
65
50
70
399
1,273
95
29
22
102
29
351
317
(15)
11
43
(52)
41
11
(11)
100
Estates & Facilities Total
8,786
Medical Equipment Schemes
1,217
Patientrack
Aspen House server room expansion/refurb
IM&T Rolling Programme
500
220
1,160
IM&T Projects Total
1,880
Revenue to Capital Transfers
125
2014/15 Capital Total
12,008
Funding Sources
2014/15 Depreciation
Cash Surpluses
Loan Repayment
2014/15 Base Capital Budget Allocation
2,795
345
246
45
634
925
72
2,037
758
820
(475)
199
0
247
446
47
45
386
479
125
125
-
4,189
3,428
761
7,645
5,309
(1,071)
11,883
Revenue to Capital Transfers
Revised 2014/15 Capital Budget
125
12,008
· The Trust’s capital budget for 2014/15 is £12,008k. Actual expenditure to month 5 is £3,428k
against a budget of £4,189k, an underspend of £761k (18.2%). This is further underspend of
£603k in-month.
· Capital plans are reported to Monitor on a quarterly basis and there is a tolerance of +/- 15%
at which if triggered then a full capital reforecast is required. As the underspend this
month is 18.2% then a reforecast is already underway as at this stage it is expected to be
under by at least 15% in month 6.
· The catering scheme is still expected to be on time, opening before Christmas; however there
has been about 2 to 3 weeks slippage in the building timetable and the specialist catering
equipment has been
delayed. This has caused an underspend in month of £366k.
· D block remains behind the profiled plan as reported previously, as the business case was
approved later than planned and there is further slippage of £175k in-month.
· Within IM&T as reported previously there is slippage on a number of schemes and a reforecast
plan will also be prepared for this are giving a revised year end out-turn.
· Medical equipment continues ahead of plan by £475k to date and is due to procurement of
items on the plan earlier than expected.
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IPR
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Net Cash Inflow/(Outflow)
Balance c/fwd
14.
15.
45,748
46,095
347
(522)
(25,543)
(350)
(456)
(2,435)
(75,157)
(783)
(11,483)
(6,084)
(7,454)
12,449
25,890
33,927
74,374
(33,328)
(18,452)
(20,136)
13,441
40,447
45,748
£000
£000
46,531
Actual
Actual
46,445
350
(54)
(80)
(493)
(23,732)
(11,030)
(6,159)
(5,916)
10,094
24,082
13,988
46,095
£000
August
July
Quarter
1
Actual
44,625
(1,820)
(1,423)
(27,012)
(11,326)
(5,908)
(6,652)
(1,703)
11,379
25,192
13,813
46,445
£000
Forecast
2014/15
Sept
41,596
(3,030)
(341)
(456)
(3,073)
(76,919)
(34,291)
(18,607)
(20,151)
33,418
73,889
40,471
44,625
£000
Quarter
3
Forecast
37,018
(4,578)
(34,358)
(18,585)
(19,660)
(1,703)
(54)
(80)
(3,027)
(77,467)
32,418
72,889
40,471
41,596
£000
Quarter
4
Forecast
37,018
(9,513)
(135,816)
(73,795)
(79,969)
(3,406)
(799)
(1,071)
(10,973)
(305,829)
133,685
296,316
162,631
46,531
£000
Total 2014/15
13,785
(23,233)
(135,148)
(74,340)
(76,563)
(3,726)
(750)
(1,072)
(16,852)
(308,451)
130,678
285,218
154,540
37,018
£000
Total
2015/16
· Cash is expected to decrease during September as the Trust’s interim PDC dividend payment of £1.7m will be paid during the
period. The Trust cashflow forecast reflects its forecast outturn income and expenditure for 2014/15 which is £292k better
than plan for the year and this impacts correspondingly into the 2015/16 cashflow forecast presented above. The forecast cash
balance as at 31st March 2016 has increased by £0.8m from last months forecast to £13,785k and this forecast will be reviewed
in more detail at the November meeting of the Finance Strategy and Investment Committee.
 The cash balance as at 31st August 2014 is £46.4m and has increased by £0.3m from the previous month which is partly due to
settlement of outstanding invoices paid by Stockport CCG.
Expenditure:
Salaries & Wages
Tax/NI/Superann
Payments to Suppliers & Contractors
PDC Dividends/DOH Repayments
Interest Payable
Loan Principal
Capital Payments
Total Payments
Income:
Stockport CCG
Public Dividend Capital/DOH Allocations
Other Income
Total Receipts
2.
3.
4.
5.
6a.
7b.
8.
9.
10.
11
12
13.
Balance b/fwd
1.
8. Cash flow forecast as at 31st August 2014
Integrated Performance Report
September 2014 Finance Report
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
September 2014 Finance Report
9. Service Line Reporting Summaries—Hospital based clinical business groups
 The bubble graph above details contribution by the core acute specialties as at month 5 2014/15
based on full cost absorption for all points of delivery. The position on the graph indicates level of
contribution with bubble colour highlighting whether these contributions translate to an overall
surplus or deficit after fair allocation of overheads.
· The work undertaken by Value Dynamics suggests that a contribution margin of 35% is appropriate
for all
specialties; only the pain management service, rheumatology and oral surgery and
orthodontics are currently achieving this required level.
· The contribution percentages for the specialties profiled above remain similar to the 2013/14
positions. In order to ensure the financial stability of the Trust it is essential that the larger
specialties move towards a stronger
contribution position, facilitating improvement in overall
surplus/(deficit).
· Please note that in service line reporting, clinical income is based on CIS estimates, allocating full
non-elective rates to service lines, not taking into account the block impact. These figures give an
early representation of the quarter 1 position, but a full quarter 1 refresh based on patient level
results will be calculated when data is available (due late September).
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Integrated Performance Report
September 2014 Finance Report
10.
Conclusion
The Board of Directors is asked to note the above report.
Bill Gregory
Director of Finance
18th September 2014
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Integrated Performance Report
CQUIN Position
Return to FRONT page
Q1 CQUIN Position - As of 15th September 2014
National CQUIN Performance
Increase
Response Rate:
Inpatients
Staff Implementation
Safety
Thermometer: SK
Reducing Pressure
Ulcers
Safety
Thermometer: T&G:
PU / Catheter Care
Phased
Expansion
(Community)
Early
Implementation
Dementia:
Supporting
Carers
Year End Risk CQUIN's
Dementia FAIR
Safety Thermometer
Dementia FAIR
70% of payment agreed by CCH for Q1
Safety
Thermometer
& Dementia
Friends &
Family
NOTES:
Dementia:
FAIR
Dementia:
Clinical Leadership
Response Rates
(A&E & Inpts)
Greater Manchester CQUIN Performance
Learning Disability
(Acute)
EWS:
Deteriorating
Patient
Clinical
Effectiveness:
Deteriorating Patient
Lessons
Learned
Once: Falls
Stockport
Acute
Tameside &
Glossop
Community
Stockport
Community
Lessons
Learned
Once: Falls
Ambulatory
Care: COPD
Learning
Disability (SK)
Ambulatory
Care: COPD
Clinical
Effectiveness:
Lessons
Learned
Once: Falls
Ambulatory
Care: LVSD
Learning
Disability
(TGCH)
Ambulatory Care:
Diabetes
Local CQUIN Performance
Patient/Carer
Empowerment
Improve
Communications
Patient/Carer
Empowerment
Improve
Communications
Tameside &
Glossop
Local
Stockport
Community
Stockport
Acute
Patient
Experience
Improve
Clinical
Leadership
Patient
Experience
Improve
Clinical
Leadership
Heart Failure
Breast milk in
Pre-term Infants
Antibiotics
Awareness
Frail Elderly
LTC: Diabetes
LTC: Diabetes
Clinical
Leadership: Adults
Clinical
Leadership:
Children &
Transition
Medical Safety
Improving Diabetes
COPD
NOTES:
Acute & Community
Further evidence is to be reviewed 16th September. This
may turn ambers to green.
Advancing
Quality
Stroke
Pneumonia
AQ Audits
Improving
Diabetes
Care:
Emotional /
Psychological
Conditions
Specialised
Services &
Public Health
Adult Critical Care
Dashboard
Secondary
Dental:
Coding
AQ
Q1 results confirmed status as reported in August.
Q2
Will be forecast next month as evidence is gathered.
New reporting form to be shared with CQUIN leads.
CQUIN leads to be invited to 6 monthly update with Director
of Nursing & Midwifery; Turnaround Director; CQUIN
Finance contract lead & Outcome and Assurance Manager.
Health Inequalities
Stocktake
REPORT
KEY:
COLOUR KEY:
Achieved
Not Fully Achieved
Not Achieved
Not Applicable
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In Month Performance
Quarter to Date Performance
Year to Date Performance
Stockport | High Peak | Tameside and Glossop
Integrated Performance Report
Nursing Dashboard
Nursing Dashboard 2014/15
topcat
Trust Charts (Trends)
Ward Charts (Trends)
August 2014 Data
Clinical
Care
Indicators
Trust Total
Internal CQC
Inspections
99%
Patient Experience
Nursing
Medication
Related
Incidents
Falls *
9
2
5
2
0
7
Workforce
Overall
FFT
Response
Rate
Complaints
Appraisals
Attendance
Total
Performance
Perf
on
last
Mth
1
41.6%
6
75.0%
95.2%
8.7
0.7
0
1
0
0
0
0
1
0
34.3%
37.8%
49.9%
2
3
1
0
85.7%
62.2%
91.2%
87.5%
96.6%
94.2%
96.6%
91.7%
5.6
10.9
6.3
9.0
1.1
0.7
0.6
0.6
34.3%
Pressure
Ulcers *
Confirmed
Avoidable
Stage 3-4
C. Dificile
1
8
1
0
0
0
1
0
7
1
0
FFT
Score
NB: FFT Response Rate and Score is an input Total & not calculated.
Business Groups Performance:
C&F
Medicine
S & CC
Community
99.4%
98.9%
97.9%
99.0%
0
6
1
NA
NB: Trust & Business Group RAG rating proportionate to that of the Wards
Wards by Business Group:
Child & Family
1
Jasmine
100.0%
NA
0
0
0
0
0
1
87.0%
96.8%
9
1.8
1
M2
100.0%
NA
2
0
0
0
0
1
86.2%
95.0%
11
1.6
1
M3
99.5%
NA
0
0
0
0
0
0
93.8%
98.4%
2
0.5
1
NNU
100.0%
NA
0
0
0
71.4%
98.6%
2
0.4
1
Tree House
97.3%
NA
0
0
0
0
0
0
90.0%
94.2%
4
1.0
0
0
0
0
0
70
21.2%
2
89.6%
96.4%
12
1.0
2
0
0
0
0
67
40.9%
0
67.6%
96.1%
10
0.8
5
80
0
Medicine
1 A1 AMU
99.8%
1 A3 AMU
98.2%
0
Good
1 A10
95.3%
2
Inadequate
0
0
0
0
0
33
46.2%
0
16.1%
92.5%
10
0.5
1 A11
100.0%
1
Req. Improv't
0
0
2
0
0
69
17.3%
0
53.9%
94.3%
17
0.7
1 A12
100.0%
0
0
1
0
0
0
0.0%
0
92.6%
93.4%
14
0.7
1 A14
98.6%
0
0
0
0
0
100
6.2%
0
45.5%
95.9%
12
0.6
1 A15
98.3%
NA
1
0
0
0
0
71
18.1%
0
14.3%
95.3%
17
0.8
1 CDU
95.0%
NA
0
0
0
0
0
80
40.7%
0
31.6%
95.4%
7
0.4
1 B2
97.8%
NA
0
0
0
0
0
84
56.3%
0
92.6%
94.3%
4
2.0
1 B4
99.1%
NA
0
0
0
0
0
79
53.3%
0
57.1%
96.2%
5
0.3
1 Bluebell
100.0%
NA
0
0
0
0
0
0
32.4%
93.1%
7
0.5
1 C4
100.0%
NA
0
0
0
0
0
75
11.8%
0
57.7%
93.1%
12
0.6
1 CCU
100.0%
NA
1
0
0
0
0
92
54.5%
0
57.1%
95.6%
12
1.0
1 D'shire
100.0%
NA
0
0
0
0
0
50
66.7%
0
94.3%
86.7%
7
0.8
1 E1
100.0%
NA
0
0
0
0
0
56
58.6%
0
59.6%
89.5%
10
0.8
1 E2
99.8%
0
Good
0
0
2
0
0
82
47.9%
1
92.9%
93.5%
11
1.1
1 E3
99.1%
1
Req. Improv't
0
0
1
0
0
46
53.0%
0
58.8%
92.7%
15
1.1
1
0
1
1
0
51
24.6%
0
67.7%
96.3%
25
1.3
0
0
0
0
0
56
63.2%
0
100.0%
99.8%
0
0.0
NA
NA
1
Req. Improv't
NA
ED
99.5%
1 SSOP
18
1
Req. Improv't
Surgical & Critical Care
1 B3
91.6%
NA
0
0
1
0
0
35
62.2%
0
76.9%
97.8%
9
1.0
1 B6
97.9%
NA
0
0
0
0
0
52
26.4%
0
100.0%
98.1%
5
0.5
1 C3
99.6%
NA
0
0
0
0
0
68
83.1%
0
81.8%
96.8%
2
0.4
1 C6
99.6%
NA
1
0
0
0
1
39
14.3%
1
87.5%
99.7%
16
0.9
1 D1
99.0%
NA
0
0
0
0
0
64
37.1%
0
93.1%
93.2%
9
0.6
1 D2
98.9%
NA
0
0
0
0
0
91
61.3%
0
96.0%
98.6%
0
0.0
1 D4
94.8%
NA
0
0
0
0
0
74
58.9%
0
94.7%
100.0%
4
0.3
NA
0
0
0
0
0
0
90.5%
95.3%
4
2.0
0
0
0
0
0
0
93.9%
93.6%
4
0.6
1 D5
1 ICU/HDU
100.0%
1
Req. Improv't
1 M4 #NOF
98.4%
NA
0
0
0
0
0
45
39.3%
0
89.2%
93.7%
9
0.4
1 Sh Stay Surg
11
99.3%
NA
1
0
0
0
0
74
66.8%
0
100.0%
95.5%
7
1.8
NA
0
1
0
0
0
0
87.5%
91.7%
9
0.0
Community Services
1 Shire Hill
99.0%
35 RAG Ratings (Per Ward):
n
0-89%
Inadequate
1
2
1
1
3
>40%
4
0-69%
0-92%
>=15
>10% Worse
n
90-94%
Req. Improv't
NA
1
NA
NA
2
NA
1
70-94%
93-95%
10-14
0-10%Worse
n
95%+
Good
0
0
0
0
0
>=40%
0
95%+
96%+
<10
Better
= Not Applicable
* Falls - Consist of Major, severe & Catastrophic
* Pressure Ulcers - Grade 2's from Safety Cross
NB: Total Performance is rated on a point scoring system for each of the indicators Red = 5, Amber = 2, Green = 0.
Trust & Business Group Totals show ward average
NB: Friends and Family Test results will not match the figures shown by ward in the Dashboard due to Escalation wards being included in the Trusts total and not in the Nursing Dashboard
www.stockport.nhs.uk
IPR
34
Stockport | High Peak | Tameside and Glossop
Board of Directors
Date
25th September 2014
Title of Report
High Profile Report
Judith Morris
Director of Nursing and
Midwifery
Presented by:
Name & Title
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Item
No.
Part
Public/Private
Public
Prepared by:
Name & Title
Cathie Marsland
Head of Risk and Customer
Services
This report provides information on:
 Outcomes of high profile inquests held in the preceding month, with details
of those planned for the next months.
 Outcomes from any SUI/SAE, Complaints and Claims.
 External investigations/recommendations from the PHSO and any Reports
to prevent future deaths from H.M Coroner.
Patients’ health and well-being is supported by high quality, safe and timely
care
Patients and their families feel cared for and empowered
Is this on the
No
√
Yes
If Yes,
Trust’s risk
Score
register?
Confirm that Datix and the BAF reflect this risk
and assurance information. Or state the date
when they will be updated.
Board action
Approve
Ratify so
Endorse
sought (X)
as fit for
comes
management
purpose
into force
action
Points to note re the
Patient safety standards within CQC regulations
Trust’s CQC registration
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for Nil
Consideration:
Note
√
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
RMC 19-9-14
QGC 19-9-14
1
High Profile Inquests Held in August 2014
ID
Date
of death
1434
6-4-14
Risk
High
Moderate
Moderate
1449
5-5-14
Moderate
1446
26-4-14
Moderate
Inquest
Date
21-08-14
26-08-14
28-08-14
Synopsis
Business
Group
Verdict
Patient attended ED and SSOP then ward E2; she
had fallen and fracture was initially missed. Family
have concerns re missed fracture and nursing
care. Multiple statements sent from nursing staff.
Inquest set for whole day.
Patient diagnosed hepatocellular carcinoma. Fall
in hospital. Initial management did not include CT
scan. Following deterioration, CT performed and
acute subdural haematoma identified.
Fall at home, patient sustained head injury/bleed.
Treated at Salford Royal Hospital then repatriated
to Stepping Hill. Falls on ward, deteriorated and
died.
Medicine
Criticism of Dr for poor documentation
Concerns regarding pressures on Emergency Department
Writing PFD report to Secretary of State for Health
Accidental Death
Surgery & Critical
care
Criticism for nursing staff who did not complete hourly neuro
observations but accepted this did not impact on death.
Accidental Death
Medicine
Inquest adjourned to November 6th
Possible High Profile Inquests –September/October 2014
Date
death
of Risk
High
Moderate
Inquest
Date
1468
26-5-14
Moderate
11-09-14
1462
20-5-14
Moderate
21-09-14
1450
2-5-14
Moderate
23-09-14
1489
7-7-14
Moderate
1-10-14
1391
29-11-13
High
1240
5-1-13
Moderate
13-10-14
1491
5-7-14
High
30-10-14
9-10-14
Synopsis
Business
Group
Called
Admitted for surgery to fractured neck of femur. Deteriorated post-surgery. SAE
investigation ongoing due to poor and inaccurate recording of EWS leading to delay in
escalation.
Fall at home, GP called. Member of community team attended to take bloods but did not
escalate or call ambulance as patient unresponsive, waited for GP
Patient had cerebral bleed and died.
Fall at home – fractured neck of femur. Developed DVT but was over anti-coagulated on
warfarin. Re-admitted for evacuation of possibly infected haematoma. Additional
information requested by coroner following concerns raised by family
Patient fell at home and attended ED; was discharged. Attended as a surgical patient the
following day and was found to have a sub-dural bleed and died. SAE investigation
underway.
Fall at home – fractured neck of femur, cardiac arrest day 1. SAE held and failures noted
regarding lack of escalation (nursing), poor ownership (medical), system issues –
pharmacy.
Gentleman attended ED after self-harm (laceration to throat); was transferred to University
Hospital South Manchester where he later allegedly jumped from the ward window and
sustained fatal injuries. Legal representation obtained
Complications causing bleed post laparoscopic cholecystectomy. Failure found at SAE in
escalation and management of deterioration. Legal representation being obtained.
Surgery/Medicine
Only Orthopaedic
consultant called to
inquest
Not confirmed
Stockport
Community
S&CC
Not confirmed
Medicine
Not confirmed
S&CC
Not confirmed
Medicine
Anaesthetic
consultant
S&CC
Not confirmed
2
Serious Untoward Incidents confirmed August 2014
ID 116385
Brief Incident description
Expectant mother admitted to maternity triage on the 7.7.14 at 36+5 weeks gestation with a history of episodic pain ? labour. CTG was commenced
and 30 minutes of reassuring fetal heart tracing recorded. CTG was discontinued. Mother was transferred to delivery suite for further management to
include further CTG, IV access and blood investigations. Seen by Registrar and Consultant – working diagnosis - urinary tract infection or constipation.
Analgesia administered for abdominal pain.
After further examination, decision for category 2 caesarean section. Transferred to theatre, routine auscultation prior to commencement of procedure
was unsuccessful – fetal heart not heard; baby girl delivered in poor condition. Following intensive resuscitation baby was transferred to neonatal unit,
intubated and ventilated. Subsequently transferred to Royal Oldham Hospital for head cooling and on-going care; baby died on 12.7.14.
Incident date: 7.7.14
Incident type: Patient safety
Specialty: Obstetrics
Effect on patient: Neonatal death
Severity level:
Major
Level of investigation conducted Level 2
Involvement and support of the patient and/or relatives
 Parents debriefed at 20:10 on 7.7.14 by Registrar re findings at caesarean section – informed of signs of infection found.
 Mother informed of baby’s poorly condition by transport team prior to baby’s transfer to the Royal Oldham Hospital
 Since baby’s death several attempts made to contact parents, messages left on voicemail by Head of Midwifery. Postnatal care provided by team
midwife.
 Head of Midwifery wrote to parents on 15.8.14 requesting opportunity to feedback investigation findings.
Detection of Incident - Datix reported incident no 116385
2
Care and Service Delivery Problems
Normal Procedure
Incident
Spontaneous Preterm Rupture of
Membranes Guideline March 2013 state:
Delivery should be considered at 34 weeks
gestation.
Delivery should be advised by 36 weeks
gestation
Consultant review of all high risk women on
delivery suite.
Failure to monitor fetal wellbeing in a high
risk pregnancy
Consultant review on 3.7.14 at 36+1 weeks.
Scan showed breech presentation. Booked for
Elective Section 17.7.14 at 38+1 weeks.
Co-ordinator aware of all women on delivery
suite
Caesarean Section categorisation
multifactorial
Women’s and partners’ views considered.
Co-ordinator aware but did not physically
review.
No auscultation of fetal heart to contribute to
classification of CS
Reported tightening/contractions not
considered to be signs of labour.
Numerous occasions when documentation not
completed fully including CTG traces.
Documentation completed as per trust policy
No documentation of consultant review
In the presence of acute pain and distress,
fetal wellbeing should be confirmed.
Was there a
change?
Did the
change
contribute to
the incident?
Care Delivery
Problem
Service
Delivery
Problem
Yes
Yes
CDP1
Yes
No
CDP2
Yes
Yes
CDP3
Yes
Yes
CDP4
Yes
Yes
CDP5
Yes
Yes
CDP6
Yes
No
CDP7
Contributory Factors

Staff statements and documentation in the case notes indicate that the taco-graph is used for auscultation of the fetal heart – this is not best
practice. A sonic aid or Pinards stethoscope should be used for intermittent auscultation.

Sub-clinical infection identified at caesarean section likely to have been from the amniocentesis, may have contributed to the extreme abdominal
pain that was experienced in the period leading up to establishment of labour.
Root Causes
Risk assessment made on clinical factors but decision was not that which a ‘reasonable body of other obstetricians’ would make.
Failure to make contemporaneous notes
Failure to confirm fetal wellbeing in a high risk pregnancy
Failure to follow Trust guideline for fetal monitoring following vaginal examinations in labour.
Delivery suite Junior Co-ordinator unaware of the significance in her reviewing high risk women in person.
3
Failure to follow guideline for auscultation of fetal heart – poor practice
Not listening to woman and her husband re labour.
Misdiagnosis
Incomplete documentation - Poor practice
Lessons Learned
 Current guidance recommends that in cases of premature pre-labour rupture of membranes delivery should be achieved by between 34 – 36
weeks.
 Importance of confirming fetal wellbeing in a high risk pregnancy
 High risk of subclinical infection in preterm pre-labour rupture of membranes therefore should have been considered as a differential diagnosis.
Recommendations
 Attempts to be continued to engage with the family to share findings of investigation - ongoing
 Support and guidance offered by CD to consultant involved - ongoing
 Medical Director to discuss appropriate management of consultant issues - completed
 Head of Midwifery to manage performance issues for midwives involved including relevant referrals to regulatory body – ongoing
 Case to be presented at joint perinatal mortality meeting
 Executive review meeting to be undertaken – 22-9-14
Arrangements for Sharing Learning
Presentation at a Joint Perinatal meeting
Case discussion with midwives involved.
Discuss at Supervisors of Midwives meeting.
4
Serious Adverse Events confirmed August 2014
Datix
11306
114121
115597
117633
SAE Date
1 August
2014
11 August
2014
14 August
2014
15 August
2014
Location
Description
Care and Service Delivery problems
Root Causes
Key Actions
Communication book now used by district nursing
staff. Completed.
Staff have completed pressure Ulcer training and
reviewed knowledge around categorisation of
wounds. Completed.
Triggers to be used on the electronic patient record
to identify when patients are due review.
District
Nursing
Stockport
Pressure Ulcer
Failure to undertake a holistic
assessment and pressure ulcer risk
assessment when patient transferred
into home.
Change in patient’s condition – review
of care should have been undertaken –
delay of 7 days before undertaken.
Seen regularly by Assistant Practitioner
and not reviewed regularly by senior
member of nursing team.
None could be identified as the area is
proximity access only and it has not
been possible to identify anyone who
did not have legitimate access. The
police were notified but have closed
their investigation.
Proximity access has been reviewed - Completed
Review of referral process - Completed.
Paediatrics
A tray of paediatric referrals
for scanning to Evolve
system was removed from
the department. (All of the
referrals had been actioned
previously)
Paediatrics
40 BCG Vaccination
referrals were sent to
Public Health England
based in Manchester and
should have gone to Child
Health in Stockport.
ICO reportable for
information only.
Incomplete hand over of tasks between
secretarial team following reorganisation. Human Error.
Incident not reported on Datix once it
was made known an error had
occurred.
Admin and clerical functions to be reviewed to
ensure thorough handover Completed.
Staff reflection of incident with line manager
Completed
Elderly patient admitted for
surgery to fractured neck of
femur. Deteriorated postsurgery. Poor and
inaccurate recording of
EWS leading to delay in
escalation.
Incorrect recording of urine output and
subsequently EWS.
No escalation when BP could not be
recorded.
High scoring on EWS not re-escalated
appropriately
Calculating of EWS to be re-enforced with staff
Completed
Lack of escalation regarding BP to be discussed
with nurse in question via NHSP Completed
Reflective practice regarding lack of re-escalation
when EWS remained high Completed
S&CC
Medicine
2
Datix
SAE Date
117699
20 August
2014
F29498
20 August
2014
115455
27 August
2014
Location
Medicine
Description
Pressure Ulcer
Sexual Health
Community
Healthcare
Confidentiality
S&CC
Untimely review of clexane
Patient developed DVT
Care and Service Delivery problems
Root Causes
Pressure Ulcer Care Bundle was not
followed, and ‘red rules’ not adhered
to.
Poor nursing documentation.
No evidence of daily skin inspections.
Long gaps between pressure relief.
Advice from dietician not followed.
MUST Score plans not completed.
No individualised core care plan
evident.
Breakdown in the process for giving
out letters to patients.
th
115492
29 August
2014
Surgical &
Critical Care
Pressure Ulcer
Request for review made on 7 July
not actioned.
Removal of medical device was not
documented in patient notes.
Pressure ulcer not reported on Datix or
a referral made to Tissue Viability.
Pressure ulcer noted on wound chart,
but not on Pressure Ulcer Prevention
Care and Management Plan.
No consistent handover to enable
management of wound on each shift.
Key Actions
All nurses working on ward to complete a reflective
piece of work. Ongoing
Business group to ensure that safety huddles take
place after the patient handover.
Pressure ulcer summit to be arranged by the Tissue
Viability Team to be attended by all ward managers.
Spot audit to be undertaken following the pressure
ulcer summit.
Staff to complete the ‘read and sign’ pressure ulcer
document at this meeting.
Review of escalation ward SOP to be undertaken.
Designated Band 7 to be recruited for escalation
wards including staff recruitment.
All staff on escalation wards to be aware of pressure
ulcer care bundle.
Written flow chart now developed for giving out
letters to patients. Completed.
Cascade process to staff during team meetings
across the business group.
Letters to be printed out whilst patient is still in
treatment room.
Awareness raising with all designations of staff on
reviewing notes and using communications book.
Completed
Awareness to be raised with all staff on ward around
accurate record keeping and associated standards.
Incident to be discussed with individual nursing staff
for learning and reflective practice,
Case to be presented to the S&CC Sisters Meeting.
Review of the equipment availability and associated
guidance around use.
Ensure staff are aware of the need to check for
pressure damage around the Thomas Splint Ring
during use and for 48 hours after its removal.
Training to be provided around management of
medical devices and pressure areas.
All above completed
Tissue Viability to undertake a review of NICE
Guidance around pressure management to ensure
Compliance.
3
High Profile Complaints received August 2014
Datix
15546
Date
Received
20-2-13
Location
Medicine
Description
Stage
Family concerns raised regarding discharge planning:
Failure to involve family in discharge planning decisions
Poor documentation regarding plans
Loss of essential documentation
To include importance of family involvement in discharge
planning
Ongoing investigation
High Profile “Being Open Cases August 2014
Datix
BOP00115
Date
Contact
made
27 May
2014
Incident
Date
Location
27 May
2014
Description
Stage
Intra partum stillbirth; confirmed SUI
Meeting held with family
Further questions asked by family
Delivery Suite
High Profile Claims August 2013
Name
and Datix
Date
Received
Incident
Date
Location/Sp
eciality
Description
Stage
Risk Management Report
MNC1401
4
28/08/14
28/11/14
Maternity
It is alleged the Trust failed to identify
a complex cardiac abnormality
(Complex Pulmonary Atresia with
VSD, ASD and MPCCA with extra
cardiac features of facial dysmorphia).
It is alleged that the Trust should have
identified this condition at 12, 20 and
37 week scans.
Particulars of Claim have
been received and the
NHSLA informed.
MNC14014
4
Reports to prevent future deaths received/responded to from H.M Coroner in August 2014 (previous Rule 43)
Datix
1437
Date
Received
5-7-14
Inquest date
10-4-14
Location/
Speciality
Trauma and
Orthopaedics
Areas of concern
Response due
Changes to Practice
Trust practice of proactive management of
patient having knee replacement in that they
are automatically prescribed laxatives due to
use of opiate medication
27-8-14
No changes to practice, coroner advised
that the practice of proactive management
of these patients who receive strong
analgesia is appropriate.
Cases accepted by the Health Service Ombudsman for Investigation in August 2014
Name and
Datix
OMB46713
Date
Original
complaint
November
2012
Date accepted
by
Ombudsman
August 2014
Location/Speciality
Various surgical
wards
Description
Trust position
Family have complaints regarding care post operatively; this
has been answered and the only areas upheld were around
poor communication.
Both relatives have made similar and separate complaints
and have been offered a meeting, however they have
chosen to go to PHSO
Local resolution undertaken
Family have been offered
meeting
Cases where investigation completed by Health Service Ombudsman in August 2014
Name and
Datix
Date
Original
complaint
OMB17314
July 2013
OMB17214
27
June
2012
(FC17213)
Date accepted
by
Ombudsman
August 2014
20 June 2014
Location/Speci
ality
Dermatology
Medicine
Description
Decision
Patient unhappy with provision
of wig and quality of product.
Despite numerous attempts to
improve
product,
patient
remained
unhappy
and
meeting to try to resolve.
Patient’s
son
submitted
complex
complaint
which
raised
concerns
about
unnecessary administration of
Warfarin, poor communication
and poor nursing care
Not upheld
Changes to Practice
Not upheld
5
a
OMB08314
22-05-2012
22-5-14
Medicine
Patient sent to ED with
neutropenic sepsis, diagnosis
and treatment delayed
Partially Upheld
Delay
in
diagnosis
and
treatment not fully actioned to
reduce reoccurrence
Poor complaint handling
Unscheduled care programme
continues
Introduction of Advantis ED
6
Board of Directors
25th September 2014
Part
Public/Private
Unscheduled Care Programme Report
Date
Title of Report
James Sumner, Chief
Operating Officer &
James Catania, Medical
Director
Presented by:
Name & Title
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Prepared by:
Name & Title
Public
Item
No.
Sarah Shingler, Associate
Director of Medicine
The paper outlines progress with the Trust Unscheduled Care Programme,
the milestones and Key Performance Indicators and Risks associated. It
also asks the Board to consider and approve an approach to revise the
governance/reporting arrangements of the programme from next meeting.


Achievement of the Emergency Department 95% standard
Service Transformation of Unscheduled Care
Is this on the
No
Yes
x
If Yes,
20
Trust’s risk
Score
register?
Confirm that Datix and the BAF reflect this risk This is reflected in the Risk Register
and assurance information. Or state the date
when they will be updated.
Board action
Approve
Ratify so
Endorse
X
Note
sought (X)
as fit for
comes
management
purpose
into force
action
Points to note re the
The achievement of the ED standard is a Monitor Licence compliance
Trust’s CQC registration
issue
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for
Consideration:
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
Unscheduled Care Transformation Programme Update September 2014
Key actions completed this month







ED Front of House (FoH) GP project commenced in August, small team of GPs
recruited, good working arrangements established with Mastercall
Clinical Decision Unit (CDU) opened middle of August, operational Monday-Friday,
the ambition is for the Unit to be a 7 day model – this will be regularly reviewed in
line with ED Consultant recruitment
The CDU and GP FoH model has contributed to reduced breaches during 8pm-12MN
from 198 in July to 102 in August and ‘department full’ breaches from 222 in July to
82 in August.
Additional triage cubicle in operation, triage plus model achieved partial
implementation throughout August/September, as staffing levels allow.
Recruitment continues through agreed fast track processes
Recruitment for the Community Assertive In-reach team continues, with anticipated
full implementation by end of October 2014.
Process for the way that GP Medical referrals are received into the Trust reviewed
and new phone line launched, it is anticipated that this will reduce the number of GP
referrals who are currently going through ED by streamlining the pathway
The Acute Medicine assessment/pathway has been re-established and is being led by
the Medical Director. Additional resources from winter funding are included in
workforce planning to identify the best possible service model for winter and beyond
Action Tracker- Unscheduled Care Programme



A number of risks to programme delivery have been identified and these are
included within the risk register which can be found in Appendix 2
White Board roll out is proceeding, but with some planned slowing down of roll-out
plan to increase sustainability. Clinical engagement continues to be a challenge,
Clinical Champion and Associate Medical Director for Medicine meeting with
clinicians. KPIs for this stream of work are not showing the required pace of
improvement
The main risk to the programme continues to be the successful recruitment of ED
Consultants, we are currently back out to advert with an enhanced recruitment and
retention package offered
Page | 1
Key Performance Indicators

Performance against Unscheduled Care KPIs for August are shown in the table
below. The Board will see that we have seen marked improvement in a number of
KPIs.
UNSCHEDULED CARE INDICATORS
Baseline Apr-Aug Monthly
2013/14 YTD 14/15 Aug-14
13 month
Target
Ambulance HAS compliance
80%
88%
91%
85%
Ambulance handover > 30 minutes*
7.3%
5.0%
3.4%
10%
GP referred ED attendances (number per day)*
17
21
19
10
ED time to triage 95th percentile (via ambulance)
0:21
0:22
0:17
0:15
ED time to triage 95th percentile (walk-in)*
0:42
0:41
0:35
0:35
ED seen for treatment (median time)
0:57
0:59
0:42
1:00
ACU number of patients from ED*
36%
46%
50%
40%
ACU number of patients >= 8hrs*
10.7%
7.7%
8.9%
10%
Medicine patients discharged LoS < 3 days*
47%
46%
46%
55%
Medicine patients discharged via Transfer Unit*
14%
19%
24%
40%
Patients discharged from AMU prior to 12:30*
25%
24%
21%
30%
Trend
Actions to support red and amber KPIs




This month we have seen improvement in the ED time to triage via ambulance
performance. Patient level data is being reviewed to understand the triage outliers
who are skewing the 95th percentile figures.
Of note is the significant improvement in the time to triage for the 95%ile of walk in
patients which has achieved the target of 35 mins for the first time.
Work is continuing with the Acute Physicians, however agreeing and implementing a
change in the current model of care remains challenging due to a lack of consensus,
work is ongoing to improve performance in discharging more patients before 12.30
in AMU
Use of the Transfer Unit has improved but still has a significant step change to make
Programme Governance


The Executive Team have reviewed the programme management and leadership
arrangements, changes made and now in place. Executive Sponsorship has
transferred to Dr James Catania and the Programme Lead role has transferred to the
Unscheduled Care Programme Director, Gloria Cooke. A programme governance
structure has been established which ensures that the operational teams are still
embedded within the programme but it is already clear that having additional
resource to focus on the programme on its own has reduced the risk of delays.
It is proposed to the Board that the Medical Director and Chief Operating Officer
review the Board reporting process for the Unscheduled Care Programme as it is
now a programme within the reporting structure of the Building a Sustainable Future
Page | 2
(BaSF) Committee. If this is managed appropriately it is envisaged that the
performance reporting element of the Unscheduled Care Programme (i.e. ED
performance and KPI metrics) could be reported to Board through the Integrated
Performance Report and the programme progress and risks through BaSF.
Summary




CDU, GP FoH model have been implemented, early outcomes favourable with a
reduction in out of hours breaches
New phone line launched for receiving of GP referrals into Medicine
Improvement in performance against Unscheduled Care KPIs in August
Programme Governance arrangement reviewed
Recommendations
The Board is asked to:


Note the contents of the report;
Approve the proposal for future reporting of the Unscheduled Care Programme
through the BaSF programme board report and Trust Board IPR.
Sarah Shingler
Associate Director Medicine
September 2014
Appendices

Appendix 1 – Action Tracker

Appendix 2 – Risk Register
Page | 3
Date: 27.08.14
Appendix 1 - PHASE II UNSCHEDULED CARE TRANSFORMATION PROGRAMME PLAN
Version: 2.11
Executive Sponsor:
Dr James Catania
Element
Aim
Programme Lead:
Person(s) responsible
Clinical Champion
Project Manager
Colin Wasson /
Karen Hatchell
Dr Krishnamoorthy
/ Sarah Shingler
Dr Reddy
Jane Drummond
Gloria Cooke
External Review
Source
10-Mar 17-Mar 24-Mar 31-Mar 07-Apr 14-Apr 21-Apr 28-Apr 05-May 12-May ##### ##### 02-Jun 09-Jun 16-Jun 23-Jun 30-Jun 07-Jul 14-Jul 21-Jul 28-Jul 04-Aug 11-Aug 18-Aug 25-Aug 01-Sep 08-Sep 15-Sep 22-Sep 29-Sep 06-Oct 13-Oct 20-Oct 27-Oct 03-Nov 10-Nov 17-Nov 24-Nov 01-Dec
July - risk to August - risk
delivery to
to delivery
timescale
to timescale
1) Theme: ED Flow
1.1
To review the process by which referrals are
accepted into the Trust and patients assessed,
holding specialties to account for response times.
All referrals (GP and ED) should move to a
dedicated area for assessment and further
management within 2 hours of arrival.
1.2
To develop additional systems to manage surges in
demand within ED, so that workloads can be
managed.
To improve ED response times by improving early
triage / assessment, diagnostics and streaming of
patients, across all specialties.
Jane Drummond
Dr Reddy
Paula Bennett
UM/Oldham Review
1.3
To review current minor injuries model and consider
implementing 'see & treat' - without triage.
To shift patients in 'majors' stream to 'minors',
consequently reducing overall ED response times across all specialties - to maintain flow from ED,
24/7, and thus avoid any backlog.
Jane Drummond
Dr Reddy
Paula Bennett
Oldham Review
COMPLETE
COMPLETE
1.4
To review ED Consultant package and re-advertise.
To attract high calibre applicants to the Trust.
Sarah Shingler /
Dr Reddy
Jane Drummond
UM/Oldham
Review/Internal SHH
plan
COMPLETE
COMPLETE
1.5
To improve ED time to triage for ambulance arrival
compliance.
To revise / refresh SOP and improve compliance to
15 minutes CQI.
Jane Drummond
Jackie Capener
Internal SHH Plan
1.6
To enhance Trust Wide Pressures Reporting/Bed
Reporting.
To improve the regular capacity & demand
planning report. Utilise predictive data to improve
our ability to respond.
Sarah Shingler /
Michael Woods
Michael Woods
/ Clare Downey
UM Review
COMPLETE
COMPLETE
1.7
To evaluate success of pilot (ED/Acute Physician
Clinical Model) and agree clinical strategy moving
forward.
To stream patients to medicine for assessment by
acute physicians, having a named physician as
'point of contact'.
Dr Kong /
Dr Krishnamoorthy
Dr Hodgson
Jane Drummond
Internal SHH Plan
1.8
To implement 2-day working reporting for all plain
film x-rays from ED.
To improve decision-making and better the patient
experience.
Mary Burney
Dr Whittaker
Karen Snelson
UM Review
1.9
Review and revise current breach review process
To provide clarity of reasons for breaches, trends
and a forum to challenge practice.
Michael Woods
/ Jane Drummond
Michael Woods
UM Review/Internal SHH Plan
COMPLETE
COMPLETE
1.10
To implement a CDU model
To provide a 12-24hr stay for patients who meet
the criteria for CDU pathways.
Sarah Shingler
Dr Reddy
Jane Drummond
COMPLETE
1.11
To implement Primary Care Front of House (FOH)
model
To stream minor illness/primary care patients to
GPs to reduce pressure on majors.
Jane Drummond
/ Dr Reddy
Dr Reddy
Paula Bennett
COMPLETE
1.12
To extend minor injuries stream to 12 midnight, 7
days a week
To reduce pressure on majors' stream after 10pm.
Jane Drummond
Dr Reddy
Paula Bennett
Dr Ngai Kong /
Jane Drummond
Dr Hodgson
Jane Drummond
Dr Reddy
COMPLETE
COMPLETE
COMPLETE
COMPLETE
2) Theme: Early Discharge
2.1
To review ward round discharge process on AMU, to
ensure that all clinical discharge letters are
completed at the point that patient is deemed suitable
for discharge.
To ensure that patients have TTOs and that
discharge letters are completed at the time of
decision to discharge. To ensure that patients are
discharged earlier in the working day.
2.2
The implementation of:- robust white board rounds,
clarity and standardisation of white board rounds,
setting of EDDs and detailing a comprehensive
management plan.
To clarify expectations of all senior decision
makers and incorporate in job plans (where
necessary) to minimise internal delays & reduce
LoS.
Dr Catania /
Dr Krishnamoorthy
Dr Das
Chris Gidley and
Stuart Rogers
2.3
To communicate a defined process for early
identification of in-patients who can have their
diagnostic investigations as urgent outpatients (< 2
weeks).
To ensure access to diagnostics is needs-based
rather than place-based, thus reducing diagnostic
delays.
Dr Krishnamoorthy /
Mary Burney
Dr Das /
Dr Whittaker
Karen Snelson
UM Review
2.4
To pilot the process for selected radiology
investigations to be completed as an outpatient within
To reduce LOS and improve flow.
2 weeks: USS, CT, MR scan, endoscopy, carotid
doppler.
Dr Krishnamoorthy /
Mary Burney
Dr Das /
Dr Whittaker
Karen Snelson
UM Review
2.5
The setting and implementation of minimum
standards for junior doctor cover on the wards.
To support the Trust's ability to discharge patients
by 1pm.
Dr Kayan / Sarah Shingler
Dr Das
Stuart Rogers
UM Review
2.6
To evaluate success of 3 month SSOPU pilot.
To evaluate performance against agreed KPIs for
SSOPU and success of model.
Monica Duncan
/ Dr Kayan
Dr Vassallo
David Taylor
SHH Internal Plan
2.7
To introduce 7-day therapy working.
To introduce 7-day therapy cover across wards increase weekend discharges.
Mary Burney
Karen Snelson
UM Review
2.8
To review Transfer Lounge operational policy and
criteria.
To improve access and use of Transfer Lounge.
Judith Morris /
Michael Woods
Jane Carpenter
David Taylor
UM/Oldham
Review/Internal SHH
plan
COMPLETE
COMPLETE
COMPLETE
UM/Oldham
Review/SHH Internal
Plan
COMPLETE
COMPLETE
Oldham Review
COMPLETE
COMPLETE
3) Professional Standards
3.1
To agree internal professional standards across
Medicine Business Group, stating target times for
junior & senior doctor review, across AMU and
specialty wards.
To improve the response times for review of
patients.
Dr Krishnamoorthy /
Sarah Shingler
Dr Hodgson / Dr
Das
Element
Aim
Person(s) responsible
Clinical Champion
Project Manager
External Review
Source
Current
risk to
delivery to
timescale
10-Mar 17-Mar 24-Mar 31-Mar 07-Apr 14-Apr 21-Apr 28-Apr 05-May 12-May ##### ##### 02-Jun 09-Jun 16-Jun 23-Jun 30-Jun 07-Jul 14-Jul 21-Jul 28-Jul 04-Aug 11-Aug 18-Aug 25-Aug 01-Sep 08-Sep 15-Sep 22-Sep 29-Sep 06-Oct 13-Oct 20-Oct 27-Oct 03-Nov 10-Nov 17-Nov 24-Nov 01-Dec
4) In Reach
4.1
To develop specialty in-reach model for cardiology.
To improve the response times for specialist inreach.
Sarah Shingler /
Dr Krishnamoorthy
Dr Das
Charlotte Walton
Oldham Review/Internal
SHH Plan
4.2
To develop specialty in-reach model for
gastroenterology.
To improve the response times for specialist inreach.
Sarah Shingler /
Dr Krishnamoorthy
Dr Das
Stuart Rogers
Oldham Review/Internal
SHH Plan
4.3
To develop specialty in-reach model for respiratory.
To improve the response times for specialist inreach.
Sarah Shingler /
Dr Krishnamoorthy
Dr Das
Charlotte Walton
Oldham Review/Internal
SHH Plan
4.4
To develop specialty in-reach model for diabetes.
To improve the response times for specialist inreach.
Sarah Shingler /
Dr Krishnamoorthy
Dr Das
Stuart Rogers
Oldham Review/Internal
SHH Plan
4.5
To develop a process to facilitate clinical ownership
of patient flow at ward level through implementing
ward manager led flow meetings
To introduce a daily meeting with all ward
managers. Expect them to identify patients and
'pull' clinically appropriate patients into their wards
from the AMU in a responsive manner.
Jane Carpenter
4.6
To clarify expectations, undertake a gap analysis
To review current consultant job plans to implement 7and incorporate into job plans to enable in-patients
day working model in Cardiology.
to be reviewed by a senior doctor every day.
Dr Krishnamoorthy /
Sarah Shingler
Dr Kayan / Dr
Kong
4.7
To clarify expectations, undertake a gap analysis
To review current consultant job plans to implement 7and incorporate into job plans to enable in-patients
day working model in Stroke.
to be reviewed by a senior doctor every day.
Dr Krishnamoorthy /
Sarah Shingler
Dr Kayan / Dr
Kong
Michael Woods /
Jane Carpenter
COMPLETE
COMPLETE
Oldham Review
COMPLETE
COMPLETE
Charlotte Walton
UM/Oldham
Review/SHH Internal
Plan
COMPLETE
COMPLETE
David Taylor
UM/Oldham
Review/SHH Internal
Plan
COMPLETE
COMPLETE
Deborah Clough
/Jane Drummond
UM Review/SHH
Internal Plan
5) Community Support
5.1
To implement Community In-reach to the
ED/ACU/AMU/SSOPU.
To define a process to identify patients earlier in
their stay to be discharged to a lower dependency
setting outside of the Acute Hospital. To clarify and
communicate community based options.
Michelle Lee /
Sarah Shingler
Green
Amber
Red
completed
delay of <2
weeks
delay of >2
weeks
J:\Operations\Board reports\ED Reports\Meetings 2014\September 2014\Copy of appendix 2.xlsx
BUILDING A SUSTAINABLE FUTURE
ISSUE LOG FOR UNSCHEUDLED CARE PROGRAMME - AUGUST 2014
Status Key:
To Planned Schedule
LAST UPDATED
PRINTED ON
On schedule
19/09/2014
Behind schedule
ISSUE - A relevant event that has happened, was not planned, requires management action and has had a negative impact on the Programme, Project or workstream.
Issue No
Date
Raised
Raised By
dd/mm/yy
Programme
Project
Work stream
Issue Description
Action
DATE FOR
NEXT ACTION
dd/mm/yy
Owner
Status
To aid ED flow and support the running of the second triage
cubicle, funding for a Band 2 HCA and a Band 5 nurse has
been approved. The Band 2 and Band 5 posts are currently
being recruited to. However, staff will not be in place in these
roles until late October.
ED staff are being asked to pick up extra shifts to cover
until new staff members are in place.
09/14 update
Paula Bennett
Open
Request approval for payment for any additional hours
worked on top of contracted hours.
Allow staff who have worked extra hours to undertake
training to take time back.
09/14 update
Paula Bennett
Open
1
25/07/14
PEB
Unscheduled Care
ED Flow
1.2: Triage Plus
2
25/07/14
PEB
Unscheduled Care
ED Flow
1.2: Triage Plus
3
25/07/14
PEB
Unscheduled Care
ED Flow
1.3: Minors stream
Workload review has identified that 'minors' stream is
under-established by 2.2 WTE based on
current streaming patterns.
Success is Business Case dependent.
Business Case to be submitted; awaiting approval.
09/14 update
Paula Bennett
Open
4
14/07/14
JCap
Unscheduled Care
ED Flow
1.5: Time to triage for ambulance
arrival compliance
Need to get a better understanding of the triage outliers who
are skewing the 95th percentile figures.
Data review underway
09/14 update
Jackie Capener
Open
5
29/08/14
JCap
Unscheduled Care
ED Flow
1.5: Time to triage for ambulance
arrival compliance
Errors with poor data inputting, resulting in
'incorrect' data being produced.
An Away Day for reception staff to be held in September.
09/14 update
Jackie Capener
Open
2.2: Robust white board rounds
Insuficient engagegement with this essential process has
been gained. Outcome measures poor.
Additional action needed.
09/14 update
Gloria Cooke
Chris Gidley
Stuart Rogers
Open
6
09/09/14
GAC
Unscheduled Care
Early Discharge
Staff are required to be released from clinical duties to
undertake training on new processes and pathways.
To be discussed with Executive Sponsor.
7
J:\Operations\Board reports\ED Reports\Meetings 2014\September 2014\Copy of appendix 2.xlsx
Escalate to Programme Board
J:\Operations\Board reports\ED Reports\Meetings 2014\September 2014\Copy of appendix 2.xlsx
Status Key:
To Planned Schedule
LAST UPDATED
PRINTED ON
On schedule
19/09/2014
Behind schedule
ISSUE - A relevant event that has happened, was not planned, requires management action and has had a negative impact on the Programme, Project or workstream.
Issue No
Date
Raised
Raised By
dd/mm/yy
Programme
Project
Work stream
Issue Description
Action
J:\Operations\Board reports\ED Reports\Meetings 2014\September 2014\Copy of appendix 2.xlsx
DATE FOR
NEXT ACTION
dd/mm/yy
Owner
Status
Escalate to Programme Board
Board of Directors
Date
25th September 2014
Title of Report
Strategic Risk Register
Judith Morris
Director of Nursing &
Midwifery
Presented by:
Name & Title
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Item
No.
Part
Public/Private
Public
Prepared by:
Name & Title
Risk and Safety Team
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
All strategic outcomes 2014/15
Is this on the
No
N/A
Yes
Trust’s risk
register?
Confirm that Datix and the BAF reflect this risk
and assurance information. Or state the date
when they will be updated.
Board action
Approve
Ratify so
sought (X)
as fit for
comes
purpose
into force
Points to note re the
All CQC regulations
Trust’s CQC registration
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for
Consideration:
If Yes,
Score
Endorse
management
action
Note
√
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
Trust wide Risk and Severity Distribution
1.1.
There are currently 485 live risks recorded on the Trust Risk Register system. Trust wide
distribution of risk is shown below.
Low
2
3
25 51
26 48
1
3
3
Aug
Sep
Significant
5
6
8
5 70 63
5 69 64
4
94
92
High
9 10 12
43 10 94
38 10 91
Very High
15
16
5
27
7
25
Severe
20
8
7
Unacceptable
25
0
0
Severity Distribution
8%
35%
Low
Significant/High
V High/Severe/Unacceptable
57%
Distribution by Business Group
Diagnostics and Clinical Support – 263 Live Risks
Low
Significant
High
Very High
1
3
2
25
3
42
4
65
5
2
6
34
8
36
9
16
Medicine – 21 Live Risks
Low
Significant
1
0
2
0
3
1
4
4
5
0
6
3
8
0
2
0
3
0
4
0
5
0
6
2
8
0
12
30
High
9
1
Child and Family – 14 Live Risks
Low
Significant
1
0
10
2
10
0
10
0
12
5
15
3
12
5
15
1
16
2
Very High
Page 2 of 11
Board of Directors September 2014
16
6
Very High
High
9
4
15
0
16
2
Severe
Unacceptable
20
2
25
0
Severe
Unacceptable
20
2
25
0
Severe
Unacceptable
20
0
25
0
Community Healthcare – 18 Live Risks
Low
Significant
High
1
0
2
0
3
0
4
1
5
0
6
3
8
0
9
3
10
0
Very High
12
10
15
0
12
8
15
0
Surgery and Critical Care – 29 Live Risks
Low
Significant
High
1
0
2
0
3
4
4
3
5
0
6
3
8
4
9
0
10
1
Severe
Unacceptable
20
0
25
0
Severe
Unacceptable
20
0
25
0
16
1
Very High
16
6
Corporate Risk (incl. Nursing, Finance and Human Resources – 63 Live Risks)
Low
Significant
High
Very High
Severe
Unacceptable
1
0
2
0
3
1
4
6
5
0
6
12
8
8
9
4
10
2
12
19
15
1
16
7
20
3
25
0
Severity Distribution in Business Groups
160
140
120
100
80
60
40
20
0
Low Risk
Significant-High
Very High -Severe
Top Five Sources of Risk across the Trust
18
17
60
Equipment
142
Compliance (with
standards/mandatory or legislative)
Staffing
IT Systems
Environment
97
Page 3 of 11
Board of Directors September 2014
Distribution of Strategic Risk across Business Groups
2
1
5
Diagnostics and Clinical
Support
Finance
Medicine
1
Information and IT (IM&T)
1
Corporate Nursing
1
Surgical & Critical Care
Trust Executive Team
14
Page 4 of 11
Board of Directors September 2014
Corporate Strategic Risk Register
Busines
s Group
Finance
Corporate
Nursing
ID
2528
1878
Source
Financial
Compliance
with
standards
Compliance
with
standards
Medicine
Trust
D&CS
1881
2317
(Initial
2373)
2274
Compliance
with
standards
Documentati
on/
Risk
Trust is
unable to
deliver
£22.5m
CRP
savings
required in
2014/15.
Staff failure
to adhere to
Trust
polices and
guidelines
Failure to
deliver ED
Waiting
Times
Performanc
e Standards
Potential of
Healthier
Together
decisions
to radically
alter the
model of
service
provision in
Stockport
Inability to
provide a
Trust is
unable to
deliver
CRP of
£15m
savings in
2014/15
Non
adherence
to
processes
which
enhance
patient
safety
ED waiting
time target
of 4 hours
continues
to be a
challengin
g target
and
Monitor
are in
close
contact
with the
Trust re
this
Consequence
Rating
(initial)
(CxL)
Rating
(residual
risk after all
mitigating
actions)
Outstanding
Actions
Trust will be in
significant
breach of its
licence
25
(5x5)
20
Collation of outputs from
Clinical Engagement
event 6/11/2013
BSF transformation and
CRP programme 14-17
whith full programme
management office
structure and rescourse
including Turnaround
Director. Increased
central financial and
recruitment controls in
place
Serious patient
harm
20
(4x5)
12
None
Financial
penalties due to
licence breach
and National
Reputational
issues
20
(4x5)
12
Possible
loss of
areas of
service
provision
contract
Possibility of
SNHSFT
suffering a
significant loss
of income, and
service
destabilisation.
15
(5x3)
10
Backlog of
plain film
Misdiagnosis by
clinicians
16
(4x4)
4
This risk will be
managed through the
combination of actions
and a health economy
wide continuity plan,
supported by daily
escalation processes.
Align priorities for
building services
following HT proposition
Reconfigure service
model if required
Ensure stakeholder and
governor engagement
5 yr. strategic plan to
feed into Healthier
Together
Monitoring of
effectiveness of
Rating (current
or residual –
after controls but
before mitigating
actions)
(CxL)
Open
Actions
Date for
action
completion
Progres
s
Exec
Owner
20
(5x4)
1/3
31/3/2015
BG
16
(4x4)
2/19
30-09-14
JM
20
(4x5)
8/26
26-10-14
JS
10
(5x2)
2/6
31-03-15
JS
12
1/5
06-01-15
JS
Busines
s Group
ID
Source
Communicat
ion
Corporate
Nursing
D&CS
2424
1555
Risk
timely
radiological
report for
plain film
imaging
X-rays
requiring
reporting
Consequence
Rating
(initial)
(CxL)
Rating
Outstanding
Actions
(residual
risk after all
mitigating
actions)
resulting in
inappropriate
treatment
Potential delay
in treatment-
implemented actions
Clinical
Procedures
Failure to
review
blood
results and
radiology
results in a
timely
manner
Increase
in number
of serious
incidents
where a
failure to
review
results
was
considere
d a root
cause
Possible fatality
if delayed blood
results
16
(4x4)
8
Compliance
with
standards
After a
period of
achieving
the Cancer
62 target,
the
predicted
position Q4
2013/14 is
Breaches
and
reduced
number of
treatments
Failure to meet
targets
12
(4x3)
8
Test results working
group met and was
updated as follows:
1.Review of radiology
results:
Radiology have visited
Whiston Hospital and
identified that the email
alert system
implemented there
would be ideal.
Discussions with the
supplier have resulted in
an order for the new
system.
2.Review of blood
results:
Prior to providing an
email alert system for
review of blood results, it
is required to achieve a
high level of compliance
with sign off of results.
This will ensure that
email alerts are reduced
to a minimum. A
software upgrade of the
current IT system
underway.
Individual service issues
are being addressed to
ensure sufficient
capacity and capability
to meet the standards.
Intensive Suppor Team
visited and action plan in
progress.
COO meeting at GM
Page 6 of 11
Board of Directors September 2014
Rating (current
or residual –
after controls but
before mitigating
actions)
(CxL)
Open
Actions
Date for
action
completion
Progres
s
Exec
Owner
16
(4x4)
5/14
30-09-14
JC
16
(4x4)
2/48
28/11/14
JS
(4X3)
Busines
s Group
D&CS
ID
1520
Source
Other
Risk
failure to
meet the
local target.
2014/15
target
remains at
risk for
quarter 1 –
complex
cancer
pathways at
significant
risk
Impact of
the
redesign of
pathology
services in
Greater
Manchester
Insufficient
capacity in
Endoscopy
to meet the
current
demand
resulting in
a breach in
targets
D&CS
2130
Clinical
Procedures
Consequence
Rating
(initial)
(CxL)
Rating
Outstanding
Actions
(residual
risk after all
mitigating
actions)
Open
Actions
Date for
action
completion
Progres
s
Exec
Owner
level working to improve
multisite cancer
pathways.
Extended
loss of
essential
service in
more than
one critical
area
A cancer
diagnosis
could be
delayed
for a
patient
and/or the
Trust
could incur
financial
penalties
for failing
any of the
national
targets.
Loss of
service
delivery
for bowel
screening
would
result in
Almost certain to
change the way
in which
Pathology
services are
delivered within
Greater
20
(4x5)
8
None
12
(4x3)
4/28
31-01-2015
JS
None
16
(4x4)
0/14
Completed
JS
Manchester.
Currently only 1
in 4 patients
coming through
on the bowel
screening
programme can
be
accommodated
in the
Endoscopy unit.
20
(4x5)
12
Page 7 of 11
Board of Directors September 2014
Rating (current
or residual –
after controls but
before mitigating
actions)
(CxL)
Busines
s Group
ID
Source
Risk
Vacant
hours in
Health
Records
staffing
D&CS
2579
Compliance
with
standards
Rising
trends and
outbreaks
in
Carbapene
mase
producing
Enterobact
eriaceae
(CPE)
Corporate
Nursing
2589
Infection
Prevention
an
estimated
loss of
income
circa
£100k.
Inability to
locate,
retrieve
and
provide
records in
time for
patient
care.
Inability to
provide
adequate
outpatient
reception
service
Failure to
meet
national
guidelines,
patient
complaints
if found to
be
colonised
with CPE,
potential
patient
fatality and
onward
litigation,
coroner’s
inquest/inv
estigation,
potential
national
media
coverage.
Consequence
Rating
(initial)
(CxL)
Rating
Outstanding
Actions
(residual
risk after all
mitigating
actions)
Open
Actions
Date for
action
completion
Progres
s
Exec
Owner
Risk to patient
care
Less than 10
patients have
been identified
as carriers of
CPE while inpatients in
Stockport NHS
FT in the last 6
years
20
(4x5)
12
20
(5x4)
10
None
20
(4x5)
3/8
31/12/14
JC
To screen, isolate and
manage patients quickly
and efficiently, reducing
the risk of cross infection
20
(5x4)
7/12
04/10/14
JC
Page 8 of 11
Board of Directors September 2014
Rating (current
or residual –
after controls but
before mitigating
actions)
(CxL)
Busines
s Group
Corporate
Nursing
ID
2601
Source
Compliance
with
standards
Risk
Safety
Thermomet
er –
Reducing
the
Prevalence
of Pressure
Ulcers
CQUIN
Programme
Corporate
Nursing
Corporate
Nursing
Corporate
Nursing
2594
2597
2606
High
numbers
of
pressure
ulcers
results in
poor
patient
experienc
e and
financial
shortfall
within the
Trust
Financial
risk
Compliance
with
standards
Compliance
with
standards
Staffing
Dementia
FAIR &
Supporting
Carers
CQUIN Data
Collection
Reduction
in tissue
viability/co
mplex
wound
service due
to staff
sickness
Despite
the
introductio
n of a
nursing
resource
not all
elements
have been
achieved
Patients
not being
seen in a
timely
manner
which
could lead
to delayed
healing
time
Deteriorati
Consequence
Rating
(initial)
(CxL)
The Trust failed
to meet its
2013/14 target
to reduce overall
safety
thermometer
pressure ulcers
16
(4x4)
Unless actions
are taken to
meet the
indicators then
we will fail some
of the
programme
The collation of
FAIR is reliant
on one person
and will not be
sustainable
15
(3x5)
Length of stay
on caseload
may increase
Referrals not
being seen
within agreed
criteria
20
(4x5)
16
(4x4)
Rating
Outstanding
Actions
(residual
risk after all
mitigating
actions)
Open
Actions
Date for
action
completion
Progres
s
Exec
Owner
12
Develop an integrated
pathway to reduce
pressure ulcer incidence
and prevalence, and
effectively heal pressure
ulcers across Stockport
health economy.
16
(4x4)
29/29
30/09/14
JM
Risk assess each
indicator and produce
project plans on the
action required to deliver
the indicator.
15
(3x5)
10/10
24/09/14
JM
To achieve CQUIN for
Dementia FAIR and
Supporting Carers –
Data Collection
16
(4x4)
2/3
30/09/14
JM
20
(4x5)
5/18
29/09/14
JM
9
8
12
Page 9 of 11
Board of Directors September 2014
Rating (current
or residual –
after controls but
before mitigating
actions)
(CxL)
None
Busines
s Group
ID
Source
Risk
Loss of
Aspen
House
Server
Room
IM&T
2567
IT Systems
on of
pressure
ulcers/
complex
wounds
In the
event of
losing
Beech
House,
Aspen
House will
not be
able to
host
adequate
computer
services in
the future
Consequence
This will
severely impact
on our ability to
deliver
acceptable
patient care.
Rating
(initial)
(CxL)
Rating
(residual
risk after all
mitigating
actions)
Outstanding
Actions
Rating (current
or residual –
after controls but
before mitigating
actions)
(CxL)
Open
Actions
Date for
action
completion
2/6
07/12/14
Progres
s
Exec
Owner
16
(4x4)
12
16
(4x4)
None
JS
Risks no longer considered significant and removed from strategic risk register in last month
Business
Group
ID
Source
Corporate
Nursing
1933
Staffing
Risk
Reduced Number of Nursing
Staff
Rating
(initial)
20
(4x5)
Reason for downgrade
Action plan completed and risk closed. To be revisited
if required after a planned staffing stock take.
Page 10 of 11
Board of Directors September 2014
Rating (current or
residual – after
controls but before
mitigating actions)
12
(4x3)
Open Actions
None
Progress
Exec
Owner
JM
6. RISK ASSESSMENT SCORING/RATING MATRIX
LIKELIHOOD OF HAZARD
LEVEL
5
4
3
2
1
DESCRIPTER
Almost certain
Likely
Possible
Unlikely
Rare
DESCRIPTION
Likely to occur on many occasions, a persistent issue - 1 in 10
Will probably occur but is not a persistent issue - 1 in 100
May occur/recur occasionally - 1 in 1000
Do not expect it to happen but it is possible - 1 in 10,000
Can’t believe that this will ever happen - 1 in 100,000
QUALITATIVE MEASURES OF CONSEQUENCE OF RISK
Level
Descriptor
Injury/Harm
Service Continuity
Quality
1
Low
Minor cuts/ bruises
Minor loss of noncritical service
2
Minor
3
Moderate
Service loss in a
number of non-critical
areas <2hours or 1
area or <6 hours
Loss of services in any
critical area
4
Major
First aid treatment
<3 days absence
<2 days extended
hospital stay
Medical treatment
required
>3 days absence
>2 days extended
hospital stay
Fatality
Permanent disability
Multiple injuries
5
Catastrophic
Extended loss of
essential service in
more than one critical
area
Loss of multiple
essential services in
critical areas
Multiple fatalities
Costs
Litigation
Reputation/Publicity
Minor out-of-court
settlement
Within unit
Local press <1 day
coverage
Within unit
Local press <1 day
coverage
Minor noncompliance of
standards
Single failure to meet
internal standards of
follow protocol
<£2K
£2K-£20K
Civil action Improvement notice
Repeated failures to
meet internal
standards or follow
protocols
£20K-£1M
Class action
Criminal prosecution
Prohibition notice
served
Regulatory concern
Local media <7 day
of coverage
Failure to meet
national standards
£1M-£5M
Failure to meet
professional
standards
>£5M
Criminal prosecution
- no defence
Executive officer
fined
Imprisonment of
Trust Executive
National media <3day
coverage
Department executive
action
National media >3
day of coverage
MP concern
Questions in the
House
Full public enquiry
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.
1
2
CONSEQUENCE
3
Low
Minor
Moderate
Major
Catastrophic
5 - Almost
Certain
AMBER
(significant)
AMBER
(high)
RED
(very high)
RED
(severe)
RED
(unacceptable)
4 - Likely
GREEN (low)
AMBER
(significant)
AMBER
(high)
RED
(very high)
RED (severe)
3 - Possible
GREEN (low)
AMBER
(significant)
AMBER
(high)
AMBER
(high)
RED
(very high)
2 - Unlikely
GREEN (low) GREEN (low)
AMBER
(significant)
AMBER
(significant)
AMBER
(high)
1 - Rare
GREEN (low) GREEN (low) GREEN (low)
GREEN
(low)
AMBER
(significant)
LIKELIHOOD
Page 11 of 11
Board of Directors September 2014
4
5
Board of Directors
25th September 2014
Part
Public/Private
Maintaining Safe Staffing Levels
Date
Title of Report
Judith Morris
Director of Nursing &
Midwifery
Presented by:
Name & Title
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Prepared by:
Name & Title
Public
Item
No.
Tyrone Roberts
Deputy Director of Nursing &
Midwifery
The report provides an overview, by exception, of actual versus planned
staffing levels, for the month of August 2014. Staffing levels are split between
day and night duties and between registered staff and care assistants.
All strategic objectives 2014/15
Is this on the
No
√
Yes
Trust’s risk
register?
Confirm that Datix and the BAF reflect this risk
and assurance information. Or state the date
when they will be updated.
Board action
Approve
Ratify so
sought (X)
as fit for
comes
purpose
into force
Points to note re the
Outcomes 13 and 14
Trust’s CQC registration
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for
Consideration:
If Yes,
Score
Endorse
management
action
Note
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
1
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
1.
Executive Summary
As part of the ongoing monitoring of staffing levels, this paper presents to the Board a
staffing report of actual staff in place compared to staffing that was planned for the month of
July 2014.
Despite an observed improved performance in rostering, August’s data illustrates minor
overall reductions in fill rates. Movement of Registered Nursing staff during night duty
remains a recurrent feature, and whilst ‘safe staffing’ has been maintained, continued
reduction of staffing against ‘night’ establishments needs to improve. The overall issue
affecting this concern is ongoing recruitment to vacancies.
The Board is asked to note the contents of this report.
2.
August 2014 Staffing
NHS England is not currently RAG (Red, Amber, Green) rating fill rates. A review of local
organisations shows that fill rates of between 85-90% and over are adopted with exception
reports provided for those areas falling under this level. Exception reports for this
organization will highlight all areas that fall below 90%.
August 2014
RN/RM Average Fill Rate
Care Staff Average Fill Rate
DAY
91.1% (*76.1%-102.6%)%)↓
101.6% (75.8% - 121.7%)↑
NIGHT
90.9% (63.7%-103.5%)↓
110.9% (54.8% - 133.3%)↑
3. Exception Report
Registered Nurse/Midwife
Wards A1 and A12 still show reduced fill-rate that is caused by the establishment template
holding incorrect data. The Head of Nursing for Medicine has provided assurance that this
will be amended in time for September’s report and therefore fill rate recorded should then
reflect established levels.
Coronary Care Unit records reduced RN day levels. It should be noted that Coronary Care
Unit has 6 patients and always at least 2 Registered Nurses. Ward E1 has reduced overnight cover due to movement of staff to support deficiencies elsewhere. Whilst movement is
always a last resort, the organisation is committed to reducing any occurrences of 1
Registered Nurse on duty in an area.
Surgical Business Group reveals safe staffing maintained and reductions in Child and Family
due to expected seasonal changes in demand.
Care Staff
Intensive Care Unit reported reduced care staff overnight. Registered Nursing levels were
maintained.
2
4. Staffing Comparisons YTD since May 2014
August 2014
RN/RM Average Fill Rate
Care Staff Average Fill Rate
DAY
91.1% (*76.1%-102.6%)%)↓
101.6% (75.8% - 121.7%)↑
NIGHT
90.9% (63.7%-103.5%)↓
110.9% (54.8% - 133.3%)↑
JULY 2014
RN/RM Average Fill Rate
Care Staff Average Fill Rate
DAY
91.4% (70.9-112.9%)
101.2% (59.7-142.2%)
NIGHT
92.1% (59.7 – 107.4%)
105.5% (67.7 – 123.7%)
June 2014
RN/RM Average Fill Rate
Care Staff Average Fill Rate
DAY
93% (58.2 – 107%)
100.8% (64.7 – 138.9%)
NIGHT
89.9% (47.3 – 101.7%)
107.4% (76.7 – 150%)
May 2014
RN/RM Average Fill Rate
Care Staff Average Fill Rate
DAY
91.8% (76.3 – 105.7%)
102.6 % (83.2 – 119%)
NIGHT
87.7 (54.8 – 103.2%)
109.5 % (77.4 – 137.9%)
5. Nursing & Midwifery Staffing Review / Recruitment

The Nursing and Midwifery staffing review has been completed and will be presented
at Trust Board in September 2014.

Recruitment remains a key area of focus with the following actions recently
completed;
 Ongoing ‘open advert’ revised with 3 applicants recruited in August
 Additional recruitment day planned for Sunday 14th September and included
request for 3rd year student nurses to apply – 40 applicants shortlisted
 Overseas recruitment planned for October 2014
 Winter advert with additional option of rotation between Medicine and Surgery
6. Recommendations
The Board is asked to note the contents of this report.
3
Appendix A
4
Fill rate indicator return
Staffing: Nursing, midwifery and care staff
Org:
RWJ - Stockport NHS Foundation Trust
Period:
August_2014-15
Please provide the URL to the page on your trust website where your staffing information is available
http://www.stockport.nhs.uk/look
Day
Hospital Site Details
Main 2 Specialties on each ward
Ward name
Site code
Hospital Site name
Specialty 1
Specialty 2
Night
Registered
midwives/nurses
Day
Registered
midwives/nurses
Care Staff
Care Staff
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
Night
Average fill
rate registered
nurses/mid
wives (%)
Average fill
rate - care
staff (%)
Average fill
rate registered
nurses/mid
wives (%)
Average fill
rate - care Head of Nursing Comment
staff (%)
RWJ09
STEPPING HILL HOSPITAL RWJ09
NNU - Neonatal Unit
420 - PAEDIATRICS
2325
2123
0
0
1627
1387
0
0
91.3%
n/a
85.2%
n/a
Unit staffing safe for activity. Vacancies all recruited to with
new starters in October 2014
RWJ09
STEPPING HILL HOSPITAL RWJ09
TH - Tree House
420 - PAEDIATRICS
2790
2475
465
556
1860
1500
0
80
88.7%
119.6%
80.6%
n/a
Summer staffing plans in place - vacancies recruited to in
anticipation of winter pressures. Safe staffing levels.
JW - Jasmine Ward
502 - GYNAECOLOGY
930
927
465
442
620
600
0
0
99.7%
95.1%
96.8%
n/a
BC - Birth Centre
501 - OBSTETRICS
1395
1380
465
455
930
930
310
320
98.9%
97.8%
100.0%
103.2%
M1 - Delivery Suite
501 - OBSTETRICS
2790
2811
465
352
1860
1853
310
360
100.8%
75.7%
99.6%
116.1%
M2 - Maternity 2
501 - OBSTETRICS
1628
1670
930
918
620
630
310
316
102.6%
98.7%
101.6%
101.9%
ICU & HDU
192 - CRITICAL CARE MEDICINE
4650
4267
775
598
3410
3340
310
170
91.8%
77.2%
97.9%
54.8%
SSSU - Short Stay Surgical Unit
101 - UROLOGY
1801
1747
535
535
580
530
300
300
97.0%
100.0%
91.4%
100.0%
B3
100 - GENERAL SURGERY
1395
1065
930
1026
620
610
620
640
76.3%
110.3%
98.4%
103.2%
Recruiting under-way, safe staff maintained by moving staff
from other wards to maintain establshment .
B6
100 - GENERAL SURGERY
101 - UROLOGY
1395
1074
1163
1646
620
610
620
770
77.0%
141.5%
98.4%
124.2%
Increase in care staff while recruiting to ensure safe staffing
C3
100 - GENERAL SURGERY
101 - UROLOGY
1628
1501
1116
1032
806
746
620
610
92.2%
92.5%
92.6%
98.4%
C6
101 - UROLOGY
100 - GENERAL SURGERY
1395
1299
1395
1359
620
540
620
670
93.1%
97.4%
87.1%
108.1%
1627
1327
1395
1365
620
620
620
620
81.6%
97.8%
100.0%
100.0%
1217
1078
930
893
620
610
620
600
88.6%
96.0%
98.4%
96.8%
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ09
RWJ88
RWJ09
RWJ09
RWJ09
RWJ03
RWJ09
RWJ09
RWJ09
RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
THE MEADOWS - RWJ88
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
CHERRY TREE HOSPITAL RWJ03
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
STEPPING HILL HOSPITAL RWJ09
D1
D2
D4
M4
100 - GENERAL SURGERY
100 - GENERAL SURGERY
110 - TRAUMA &
ORTHOPAEDICS
110 - TRAUMA &
ORTHOPAEDICS
110 - TRAUMA &
ORTHOPAEDICS
110 - TRAUMA &
ORTHOPAEDICS
Recruitment ongoing safe staffing maintained
930
847
930
924
620
563
620
650
91.1%
99.4%
90.8%
104.8%
2093
1967
2093
2030
930
774
930
1055
94.0%
97.0%
83.2%
113.4%
81.7%
113.1%
Ward template recording band 4 assistant practitioners
incorrectly as registered nurses hence incorrect showing of
underfil of RN and overfill of unqualified
A1
300 - GENERAL MEDICINE
2945
2240
2139
2304
1860
1520
1550
1753
76.1%
107.7%
A3
300 - GENERAL MEDICINE
2294
2102
1798
2032
1550
1440
1240
1440
91.6%
113.0%
92.9%
116.1%
Vacancies being recruited to
A10
430 - GERIATRIC MEDICINE
1674
1400
1674
1773
620
642
620
690
83.6%
105.9%
103.5%
111.3%
Staff supoort provided from closure of winter escalation
whilst recruitment in progress
A11
300 - GENERAL MEDICINE
1054
1046
1395
1395
620
630
930
1030
99.2%
100.0%
101.6%
110.8%
Vacancies being recruited to, safely staffed
A12
300 - GENERAL MEDICINE
1736
1689
1457
1321
620
310
620
940
97.3%
90.7%
50.0%
151.6%
Night reduction in night registered nurses due to a change
in staffing establishment. This means that planned levels
are now lower than current template dictates. Safety
maintained.
A14
300 - GENERAL MEDICINE
1116
1103
1798
1773
620
600
620
640
98.8%
98.6%
96.8%
103.2%
Vacancies being recruited to.
A15
300 - GENERAL MEDICINE
1643
1439
1395
1608
620
620
620
751
87.6%
115.3%
100.0%
121.1%
Vacancies being recruited to.
B2
430 - GERIATRIC MEDICINE
1426
1270
1302
1332
620
620
620
560
89.1%
102.3%
100.0%
90.3%
Smaller ward, safety has been maintained
B4
300 - GENERAL MEDICINE
1240
1173
961
939
620
620
620
620
94.6%
97.7%
100.0%
100.0%
Night RN moved occasionally to support other areas, safety
maintained
BW - Bluebell Ward
430 - GERIATRIC MEDICINE
1116
1116
2077
2068
620
620
620
620
100.0%
99.6%
100.0%
100.0%
C4
300 - GENERAL MEDICINE
1240
1195
961
1014
620
595
620
593
96.4%
105.5%
96.0%
95.6%
Safety on ward maintained
CCU
300 - GENERAL MEDICINE
496
195
496
604
620
610
310
310
39.3%
121.8%
98.4%
100.0%
6 bed unit safety maintained always 2 RN per shift
CLDU
430 - GERIATRIC MEDICINE
496
489
496
496
310
310
310
310
98.6%
100.0%
100.0%
100.0%
DCNR - Devonshire Centre
314 - REHABILITATION
1271
1193
2263
2259
620
620
620
620
93.9%
99.8%
100.0%
100.0%
E1
430 - GERIATRIC MEDICINE
2604
2162
2821
2754
1240
790
1240
1590
83.0%
97.6%
63.7%
128.2%
E2
430 - GERIATRIC MEDICINE
2666
2599
1674
1659
930
830
930
1240
97.5%
99.1%
89.2%
133.3%
E3
430 - GERIATRIC MEDICINE
2666
2666
1674
1652
930
760
930
1150
100.0%
98.7%
81.7%
123.7%
SSOP - Short Stay Older People
430 - GERIATRIC MEDICINE
837
687
434
419
620
410
310
310
82.1%
96.5%
66.1%
100.0%
58509
53322
40867
41533
31223
28390
20140
22328
91.1%
101.6%
90.9%
110.9%
Total
300 - GENERAL MEDICINE
Safety maintained
RN from day and night moved to suppport reductions
elsewhere - safety maintained
RN from day and night moved to suppport reductions
elsewhere - safety maintained
RN from nights moved to support reductions in other areas,
safety maintained
8 bedded unit, safety maintained
Board of Directors
25th September 2014
Title of Report
Part
Public/Private
Nursing and Midwifery Staffing Review
Presented by:
Name & Title
Judith Morris – Director
of Nursing and Midwifery
Date
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Public
Item
No.
Tyrone Roberts – Deputy
Director of Nursing and
Midwifery
The nursing and midwifery staffing review has identified three actions:
 Ensure registered nurse to patient ratios compliant during day shifts
with NICE Safe Staffing guidelines
 Achieve supervisory status for ward Sisters/Charge Nurses in line with
National Quality Board Expectations
 Allocate additional nursing staff to those ward establishments identified
as non-compliant according to evidence based acuity audit results
Prepared by:
Name & Title
This will cost £1,450,897 and it is proposed that this will be funded through the
review of ward establishments, amendments to shift patterns and the use of
existing funding.
All Strategic Objectives 2014/15
Is this on the
No
X
Yes
If Yes,
Trust’s risk
Score
register?
Confirm that Datix and the BAF reflect this risk
and assurance information. Or state the date
when they will be updated.
Board action
Approve
Ratify so
Endorse
Note
sought (X)
as fit for
X
comes
management
purpose
into force
action
Points to note re the
Staffing – Outcome 13, but impact on all care outcomes
Trust’s CQC registration
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for
Consideration:
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
1
1. Executive Summary
National Quality Board guidance1: How to ensure the right people, with the right skills, are in the right place
at the right time (2013) was published on the 19th November 2013. Recommendations from the guidance
seek to support organisations in making the right decisions regarding safe staffing levels and state that
there is no single ratio or formula that can calculate defined staffing ratios and is not something that can be
mandated or secured nationally. The guidance supports the use of evidence based acuity tools, examples
of good practice and the exercise of professional judgment. This was followed more recently by the
publication of NICE guidance into the setting of safe staffing levels within in-patient, acute care settings.
All Trusts are expected to agree staffing levels, which will be evaluated by the commissioners and
regulators. Trusts are now expected to publish monthly staffing levels on the NHS Choices website from
April 2014 and all Boards should receive a full update on nurse staffing twice a year.
The organisation undertook a comprehensive review of nursing staffing levels in July 2014, employing an
evidence based tool (Safer Nursing Care Tool) and utilising NICE guidance to ensure Registered Nurse to
Patient ratios were compliant, whilst also taking account skill mix, overall staff to bed ratio, ward layout and
professional judgment.
The nursing and midwifery staffing review has identified three actions:
 Ensure registered nurse to patient ratios compliant during day shifts with NICE safe Staffing
guidelines
 Achieve supervisory status for ward Sisters/Charge Nurses in line with National Quality Board
Expectations
 Allocate additional nursing staff to those ward establishments identified as non-compliant according
to evidence based acuity audit results
This will cost £1,450,897 and it is proposed (option 4, page 17) that this will be funded as follows:
Released from review of ward establishments
Amendments to shift patterns
 Introduction of 100% long days for all staff on wards
with ‘over’ establishment (D1, D2, D4)
 Introduction of long days for 25% of staff on all other wards
£245,956
Keogh funding included in the contract
£503,000
Total:
£143,027
£563,153
£1,455,136
The Board is asked to approve the recommendations in section 7 and to agree the changes and investment
required.
2. Background
The National Quality Board recommendations are detailed in Table 1 with recent additional actions
highlighted in bold.
1
: How to ensure the right people, with the right skills, are in the right place at the right time, National Quality Board (2013), NHS
England.
2
Expected
Trust Response
The Board takes full responsibility
for patients and, as a key
determinant of quality, take full and
collective responsibility for nursing,
midwifery and core staffing
capacity and capability
The Director of Nursing and Midwifery has clear procedures in
place for setting staffing levels.
A Minimum Staffing Escalation Policy is in draft.
Service reconfigurations involving changes to staffing levels are
agreed by the Director of Nursing and Midwifery.
Staffing levels are monitored on a shift by shift basis and levels
adjusted by the senior nurse covering the wards to support acuity
and dependency – this is to be expanded with the planned roll
out of enhanced software December 2014.
A Nursing and Midwifery workforce dashboard has been
implemented from September 2014 highlighting vacancies as % of
budget.
An established preceptorship programme in place for new nursing
graduates.
Processes are in place to enable
staffing establishments to be met
on a shift by shift basis.
Evidence based tools are used to
inform nursing and midwifery
staffing capacity
There are different systems in place to monitor shift by shift
staffing:
 E-Rostering
 Daily staffing huddles to commence October 2014
 Minimum Staffing Escalation policy in draft
 Daily monitoring at bed meetings
 Twice daily monitoring
Inpatient establishment reviews are undertaken every six months
currently using the Safer Nursing Care tool.
Timeframe for Accident and Emergency, Child and Family and
Community areas to be agreed
Birthrate Plus is used to determine midwifery staffing levels.
HCAs have clinical induction and formal training in preparation for a
Certificate of Fundamental Care recommended in the Cavendish
Report (2013)
A range of clinical nursing ward indicators are reviewed monthly
and monitored in regular reviews between matron and ward sister
and at business group quality governance committees from July
2014.
Clinical and managerial leaders
foster a culture of professionalism
and responsiveness, where staff
feel able to raise concerns
The Trust has in place:
Revised Strategic Heads of Nursing Forum to discuss professional
issues and meet with the Director of Nursing and Midwifery.
Monthly Director of Nursing meetings with Sisters and Charge
Nurses from September 2014.
Clinical leadership supported by new Coaching Academy.
Escalation processes in place to raise concerns and
Whistleblowing policy.
3
Regular forum to meet staff side representatives
Staffing and E-Rostering policy in place and revised
Staffing raised at bed meetings
Staff survey including Family and Friends tests by staff in place to
capture staff feedback.
A multi-professional approach is
taken when setting nursing,
midwifery and care establishments
Evidence based tool employed, in discussion with Heads of
Nursing, Matrons and Ward Managers.
Professional judgment used for final decision
Nurses, midwives and care staff
responsibilities that are additional
to the direct care duties and
establishments afford ward or
service sisters/charge nurses/team
leaders to assume supervisory
status
All in-patient ward band 7 senior sisters/charge nurses to have 0.60
WTE supervisory status from October 2014.
Boards receive monthly updates
on workforce information. Staffing
capacity and capability is
discussed at a public board
meeting every six months on the
basis of a full nursing and
midwifery establishment review.
Establishment review using Safer Nursing Care Tool already in
place.
NHS providers clearly display
information about the nurses,
midwives and care staff present on
each ward, clinical setting,
department or service on each
shift.
In place already – all wards display daily notices detailing staff on
duty:
Who is in charge
Number of staff planned to be on shift
Number of staff actually on shift
Wards display staff uniform and each member of staff’s title.
Providers of NHS services take an
active role in securing staff in line
with their workforce requirements.
Recruitment monitored by Strategic Nurse Staffing Committee
Commissioners actively seek
assurance that the right people,
with the right skills are in the right
place at the right time with the
providers with who they contract
Board papers are public and inform commissioners of
establishment reviews.
Supervisory status already in place in Critical Care and Neonatal
Unit.
There are monthly updates on staffing capacity and any shortfalls
will be identified along with actions taken. This is reported to the
Trust Board in the monthly staffing report entitled ‘Maintaining safe
staffing levels’
Nurse staffing is on the agenda of the CCG Quality and
Performance Contract Monitoring Group.
This paper details the results of the evidence based review of nursing levels undertaken in July 2014.
There are established and evidenced links between patient outcomes and whether organisations have the
right people, with the right skills, in the right place at the right time. Compassion in practice2, emphasised
the importance of getting this right, and the publication of the report of the Mid-Staffordshire NHS
Foundation Trust Public Inquiry3, and the more recent reviews by Professor Sir Bruce Keogh into 14 Trusts
2
3
Compassion in Practice, NHS England, December 2012
Report of the Mid- Staffordshire NHS Foundation Trust Public Inquiry, The Mid-Staffordshire NHS Foundation Trust Public Inquiry,
February 2013.
4
with elevated mortality rates4, Don Berwick’s review into patient safety5 and the Cavendish review into the
role of healthcare assistants and support workers6, also highlighted the risks to patients of not addressing
this.
Sub-optimal nurse staffing levels impact on patient experience and delivery of sustained, high quality care.
Recent reports from the Patients’ Association7, Care Quality Commission8 and Health Service
Ombudsman9 have outlined that differences are emerging between wards that provide high quality care
and those that under-perform10. Whilst it is accepted that staffing is not the sole factor in determining good
quality care, ‘ideal’ staffing levels must be in place to enable: effective leadership, high quality outcomes to
be both attained and maintained and appropriate performance management of Ward Sisters who are
responsible for ward-based nursing care.
Nursing indicators reveal that nationally, wards providing low quality care employ half as many staff as
those providing high quality care. High performing wards, as matched by outcome, employed 2.56 staff per
bed compared to 1.29 for low performing wards (total number of budgeted nursing staff divided by total
number of funded beds).
Since the publication of the 11Francis 2 Report highlighting concerns about nurse staffing levels in Mid
Staffordshire Foundation Trust, a review of nurse staffing levels has become of increased importance in
terms of the quality of nursing care and the impact on patient experience. The content of some complaints,
concerns and patient feedback indicate real concerns with delivery of safe, consistent nursing care in the
Trust. We are not consistently meeting the fundamentals of nursing such as pressure ulcer prevention,
nutrition and hydration and early warning scoring, and complaints about nursing attitude and
communication are unacceptable. Whilst staffing levels are not the sole factor, it is important to ensure staff
are provided with the right resources (staffing levels) to undertake their duties.
Most recently, NICE published guidance on safe staffing for nursing in adult inpatient wards 12 which
detailed the approach to take when determining safe staffing levels. Whilst a comprehensive report, it
specifically advocates the use of an evidence based tool (decision support toolkit) in the assessment of
staffing levels. Such tools are already used by the Trust (Safer Nursing Care Tool), and, over time, such
tools will be subject to accreditation by NICE.
3. Process for determining staffing levels
In line with the NICE recommendations, the following factors were taken into consideration to determine
safe staffing levels:
a) Registered Nurse to Patient Ratio
The registered nurse (RN) to patient ratio is based on the number of RNs on duty to care for a maximum of
6 – 8 patients each during the day shift with 1 RN to care for 10 patients at night. In addition, the Ward
Sister / Charge Nurse should be supernumerary / supervisory and this has been proposed within the Trust
as 0.60 WTE. This is based on NICE evidence highlighting that there is increased risk of harm to patients
when RNs care for more than 8 patients at any one time.
4
Review into the quality of care provided by 14 hospital trusts in England: overview report, Prof. Sir Bruce Keogh, NHS England,
July 2013
5
A promise to learn, a commitment to act: improving the safety of patients in England, Don Berwick, Department of Health, August
2013
6
The Cavendish Review: an independent review into healthcare assistants and support workers, Camilla Cavendish, Department
of Health, July 2013.
7
Patients’ association 2010 – report into the care of the elderly
Care Quality Commission 2011 – Unannounced dignity and nutrition inspections
9
Ann Abraham, Health Service Ombudsman 2011
10
Nursing Standard, Vol 206, No 10, 2011
8
12
NICE Safe Staffing for nursing in adult inpatient wards in acute hospitals, July 2014
5
b) Headroom / Uplift
Headroom relates to the percentage of non-effective working days that are included in each establishment
(for training, sickness, annual leave etc.) whilst uplift is the required increased staffing to cover the noneffective days to ensure the shifts are covered.
A national assessment has been made of the amount of time that ward staff are likely to spend away from
the ward, and an uplift of 22% has been recommended. This is in place in the Trust.
c) Skill Mix
This is the ratio of registered nurses to unregistered staff such as Healthcare assistants and Assistant
Practitioners.
Traditionally, the nationally recommended benchmark has been 60% registered nurses to 40%
unregistered staff, whilst the Royal College of Nursing (RCN) has advocated a benchmark for general
hospital wards as 65% registered to 35% unregistered staff. This metric has been included in the
calculations as a reference. The recent NICE guidance has focused more specifically on the RN to Patient
ratio, as skill mix can be skewed by higher numbers of unregistered staff whilst the ratio of RN to Patient
can actually also be compliant.
d) Nurse to bed ratio
This benchmarks the total numbers of staff per ward against the numbers of patients. The absolute
minimum should be 1:2 – 1:4 i.e. a ward of 24 beds that has an occupancy rate of over 85% should have
an establishment of 24 WTE nurses; this figure is recommended by both the RCN and the Safer Staffing
Alliance. National benchmarks show that the average across all hospitals in England is 1.29 rising to 2.56,
with wards where ratios are higher having demonstrably improved quality of care. Occupancy rates can
also be misleading as some wards, for example day wards, may have 3 patients through one bed in a day.
e) Professional Judgment
The judgment of senior experienced nurses should also be factored in when determining staffing levels.
Each Head of Nursing was requested to liaise with each Ward Sister/Charge Nurse when reviewing the
staffing levels on her/his ward with the Matron, with support from the Deputy Director of Nursing and
Midwifery and Finance colleagues. This judgment will take into account issues such as:






cohort nursing requirement
ward leadership
ward layout and environment (presence of side rooms, visibility of bays, non-linear layouts)
additional specific training requirements
support of carers or parents
specific factors relating to the type of care provided
f) Safety Indicators
NICE have also, within the safe staffing guideline, determined the considered Safe Nursing Indicators of
care required when reviewing establishments. In acute adult inpatient wards these are:
i) Patient reported outcome measures;



Adequacy of meeting patients’ nursing care needs
Adequacy of provided pain management
Adequacy of communication with nursing team
These are available via the national inpatient survey and work is underway to ensure these can be provided
for subsequent staffing reviews
ii) Safety outcomes measures;


Falls
Pressure Ulcers
6

Medication administration errors by nursing staff
These are included within the revised Nursing Dashboard from August 2014 and will therefore be available
for the next staffing review
iii) Staff reported measures;


Missed breaks
Nursing overtime (both paid and unpaid)
These will be subject to a review and discussion with other organisations to agree consistent measurement.
iv) Ward nursing staff establishment measures



Monthly Safe Staffing report – in place
Reliance on temporary staffing – revised Nursing Workforce dashboard in place from September 2014
Compliance with mandatory training – this will be included going forward
g) Acuity and Dependency Analysis
Patient acuity and dependency is to be assessed every six months using the Safer Nursing Care Tool for
general wards which is a nationally validated tool (now requires accreditation from NICE). Each ward is
assessed for the acuity of their patients using the tool at the same time each day for 20 days (including
weekends). The data collection includes an assessment of the funded establishment of registered and
unregistered staff compared to the actual registered and unregistered staff available on duty, including
bank staff that have been requested to cover any gaps in the rota. To maximize validity of data collection, a
small team of senior nurses undertook this review, auditing areas outside of their business group, for the
duration of the audit.
The data is analysed to calculate the recommended number of staff required to care for the patients
according to their acuity level identified and is compared with the funded staffing establishments and the
actual staffing at the time of the audit.
The following section shows the results for the Trust for July 2014.
7
4. Evidence Based Acuity Audit Results
Background
This tool monitors the acuity and staffing levels over a 20 day period. The acuity is divided into 5 levels of care.
Establishment
Funded
Average actual
staff at the time
of audit
Ward
Establishment
Actual in post
July
Table 1 illustrates the staffing requirements as evidenced by analysis of acuity compared against funded establishments and actual establishments during the
audit, averaged over 20 days
Actual establishment figures still awaited
No data at this level
Acuity
Acuity Tool
Result
(Multiplier Levels
set for Stockport
NHS FT Trust)
% Level 0
% Level 1a
% Level 1b
Medicine A10
32.78
32.44
33.66
42.17
25.5%
0.1%
72.1%
28.72
28.33
31.46
35.82
31%
16%
36%
31.59
28.51
30.32
56.5%
7.1%
25.1%
31.54
30.9
10.02+22.02
unfunded
33.60
32.20
53.8%
9.4%
32.8%
30.53
30.19
28.11
32.20
54.4%
12.1%
30.3%
24.74
28.12
27.25
17.42
63.5%
1.1%
26.1%
28.41
24.36
21.09
18.78
69.6%
11.8%
13.1%
24.73
24.59
24.43
17.34
71.2%
21.2%
4.3%
18.69
18.52
15.29
7.20
36.6%
4.1%
26.6%
56.33
56.03
56.55
46.69
45.5%
0
53.2%
44.42
44.39
41.34
56.17
7.3%
3.2%
92.6%
44.37
44.22
41.19
48.21
47.5%
0.5%
55.7%
8.41
56.5%
3%
0.3%
Medicine A11
% Level 2
0
0
0
0
Medicine A12
Medicine A14
Medicine A15
Medicine B2
Medicine B4
Medicine C4
% Level 3
0.3%
0
0
0
0
0
0
0
0
0
0
0
13.3%
0
0.8%
Medicine CCU
Medicine E1
Medicine E2
Medicine E3
Child & family Jasmine ward
15.9
0.1%
0
0
0
0
0
0
8
Surgical & Critical Care B3
0
0
0
0
0
0
0
0
25.09
25.09
25.09
25.46
66.8
12.2%
18.8%
25.09
25.09
25.09
24.13
56.8%
8.4%
17.7%
30.20
30.20
30.20
25.32
66.8%
4.4%
16.4%
25.39
25.39
25.39
17.79
52.3%
4.2%
15.2%
21.79
21.78
21.78
15.23
65.3%
5.9%
9.3%
0.3%
40.15
39.60
18.5%
25.7%
51.4%
1.6%
Surgical & Critical Care B6
Surgical & Critical Care D1
Surgical & Critical Care D2
Surgical & Critical Care D4
Surgical & Critical Care M4
40.15
40.15
0
0
A brief explanation of levels is as follows:
Level 0 (Multiplier = 1.00* Patient requires hospitalisation. Needs met by provision of normal ward care.
Level 1a (Multiplier =1.39*) Acutely ill patients requiring intervention or those who are UNSTABLE with a GREATER POTENTIAL to deteriorate
Level 1b (Multiplier = 1.73*) Patients who are in a STABLE condition but are dependent on nursing care to meet most or all of their activities of daily living
Level 2 (Multiplier = 1.98*) Patients requiring non-invasive ventilation / respiratory support; CPAP / BiPAP in acute respiratory failure, greater than 50%
oxygen continuously, continuous cardiac monitoring and invasive pressure monitoring – may require transfer to a level 2 (HDU) facility
Level 3 (Multiplier = 6.01*) Patients needing advanced respiratory support and / or therapeutic support of multiple organ failure, invasive monitoring –
typically requiring Critical Care facilities
9
Table 1 highlights the following results;
Surgery & Critical Care Business group
Wards B3, M4 and B6 require no change with results largely matching funded establishment. C6 has been subject to recent investment and so will be
reviewed following the next audit in January 2015. Wards D1, D2 and D4 all have establishments higher than that reported as needed by the acuity audit.
These areas were then reviewed using the factors discussed in section 3 and this confirmed that reducing overall headcount to match acuity audit results
would lead to unsafe RN to Patient ratios. However, in order to provide assurance of maximum efficiency of resources, these areas are recommended to
adopt long-day working, thereby retaining RN to Patient ratios.
Medicine Business group
Wards A10 and A11 are highlighted as key priority areas. The Safer Nursing Care tool is less sensitive to rehabilitation areas and hence was applied with
caution to ward A10, with the other factors discussed in section 3 reviewed alongside, but with awareness that rehabilitation wards will have increased levels
of AHP support. Cardiology wards revealed areas of over establishment along with the Coronary Care Unit. Similarly, Stroke wards also highlighted potential
over establishments. Both areas are currently subject to business group reviews and these results have been used to inform these developments. E2 and E3
were re audited due to the significant difference in results for two very similar wards, however, the results, by a different auditor, remained exactly the same.
A15 requires some investment due to the presence of a ward based clinic. A15, at the time of audit, was not accepting patients on new ‘non-invasive
ventilation’ (NIV), which, in first 24 hours of treatment, requires 1 RN to 2 patients. Should this change in the future, then the staffing model will need revisiting.
Child and Family
The Gynaecology ward showed an over-establishment. However, staff on this ward also support the Gynaecology assessment unit.
10
Table 2 illustrates the variance between Funded Establishment and Acuity Tool Recommendation positioned in order of largest positive variance
Ward
Funded
Establishment
Acuity Tool
Recommendations
Variance
CCU
18.52
7.20
11.32↑
B2
28.12
18.78
10.7↑
E1
56.03
46.69
9.36↑
Jasmine
8.41
7.49↑
C4
Combined
with
Assessment Unit
24.59
17.34
7.25↑
D2
25.39
17.79
7.6↑
D4
21.78
15.23
6.55↑
B4
24.36
17.42
5.58↑
D1
30.20
25.32
4.88↑
B6
25.09
25.63
0.96↑
A12
30.9
30.32
0.58↑
M4
40.15
39.60
0.55↑
B3
25.09
25.46
0.37↑
E2
44.39
56.17
11.78↓
A11
28.33
35.82
10.49↓
A10
32.44
42.17
9.73↓
E3
44.22
48.21
4.0↓
A15
30.19
32.30
2.01↓
A14
32.04
32.30
0.66↓
11
Table 2 supports the recommendation to fund additional staff for A10 and A11 as a priority and to consider
changes to some shift patterns to maximise efficiency.
5. Nursing and Midwifery review for Child and Family, Community and Specialist areas
Staffing reviews typically consider in-patient wards, mainly because evidence based acuity tools
predominantly support these areas. Nonetheless, there is guidance for other areas of Nursing and
Midwifery and a description of compliance for these areas is included below for completeness.
Paediatrics
Neonatal Nurse staffing establishment - Compliant
The DOH Neonatal Toolkit (2012) and BAPM (2011) staffing levels guidance suggests nursing
requirements at the following ratios:NICU – 1:1
HDU – 2:1
SCBU – 4:1
Using our current average activity this would suggest a workforce between 30-34 WTE qualified nursing
staff (this includes 25% uplift and a shift leader on every shift). Current nurse staffing levels are showing a
total of 28.94 WTE nursing workforce (includes unit manager at band 7 but excludes supernumerary shift
leader).
Skill mix reviews are currently underway. Each shift needs to have at least 2 nurses qualified in speciality
on every shift; this is usually at least one Band 6 or 7 and a Band 5 nurse who has completed a specialist
training course. The Band 4 workforce is Assistant Practitioners who can only work in the SCBU area under
the supervision of a qualified nurse.
Our current workforce is very flexible and adapts well to fluctuations in activity; there is some flexing of
workforce between Paediatrics and Neonates, but the unpredictability of neonatal activity makes this
difficult to plan for. Neither NHSP nor any of our agencies can provide any additional suitably qualified staff
for either Neonates or Paediatrics.
Paediatric Ward staffing establishment - Compliant
Guidance around staffing a paediatric ward is less clear; the Treehouse Children’s unit consists of the
following areas:





8 Observation and Assessment beds (Open 10.00 – 22.00)
4 Day case surgical beds (Open daily around surgical activity)
10 Surgical in-patient beds (including 2 side rooms)
12 Medical in-patient beds
10 Medical in-patient side rooms
2 bedded High Dependency Unit
The ward staff also cover 2 pre op clinics per week, a dental list in Maple Suite and day case medical
activity on the ward and in the Dolphin outpatient unit on the ground floor.
The most comprehensive and relevant guidance in relation to staffing paediatric wards is produced by the
RCN and was updated in 2013 “Defining staffing levels for children and young people’s services”. The
headlines from this document were:



Supernumerary shift supervisor on top of supervisory ward manager role
At least one RN on every shift be APLS trained
Minimum staffing ratio of 70:30 Registered : Unregistered
Minimum of 2 qualified RN (Child) in every setting where children are in patients or day cases.
12


Nurses working with children should be trained children’s nurses.
Support workers should have additional training in working with Children and Young People.
The document lists dependency/acuity levels as follows (all based on RN: Child ratio 24 hours per day):HDU – 0.5:1
Children <2 years of age – 1:3
Children >2 years of age – 1:4
Additionally there should be at least 1 play specialist, but ideally one per day shift 7 days per week.
Skill mix should include 1 Band 7 supervisory ward manager and then Band 6 sister roles throughout the 24
hour period. There is also the expectation within a DGH of a senior Children’s nurse in a minimum of an
8(a) position to advise the organisation and the nursing team in relation to nursing sick children.
The Trust’s paediatric establishment covers all the areas listed above with flexibility built in around HDU
activity, assessment beds and the day case surgical workload. This makes it difficult to measure our
staffing levels against dependency as the age factor also complicates the equation.
Looking at average bed occupancy against staffing levels our ratios are generally 1:5 on most shifts – this
is affected by HDU occupancy as we are often nursing one HDU child in the dedicated space with 1 nurse.
Maintaining a high registered nursing ratio ensures we meet the standards for HDU care, APLS and the
ability to flex the workforce across all of our areas.
Maternity
Midwifery staffing levels within the Women’s Unit are determined by the national Birth Rate Plus Tool, a tool
used to determine the recommended ratio of Clinical Midwives to births to ensure safe staffing levels.
The current recommended ratio is as follows:
 For hospital births: 1: 29.5
 For home births: 1: 35
As of July 2014, our ratio based upon activity data was 1:29.49. This calculation includes the Assistant
Practitioners within the Community Teams and Antenatal Clinic.
Within Delivery Suite the Birth Rate Plus Acuity Tool is completed at four hourly intervals, to demonstrate
acuity, staffing levels and activity. Bi-annual reviews are conducted by the Head of Midwifery and Financial
Accountant for the Business Group, in March / September each year, to monitor the ‘Birth-rate Plus’ ratio of
midwives to births to ensure safe staffing standards are maintained. Any deficits in staffing levels are risk
assessed using an RA1 and then presented at the business group’s Governance and Risk meeting with a
formulated action plan.
In addition, the Head of Midwifery reports to the business group Quality Board on a monthly basis to
provide analysis of staffing related incidents which occurred in the previous month. The Trust’s Risk
Management Committee also oversees the monitoring and is provided with a quarterly report.
Regular skill mix reviews have been undertaken in all areas and there has been more than one review of
the Specialist roles within the service. Staffing has been closely monitored over a long period and the
business group have when required made disinvestment decisions to reduce staffing in line with reducing
activity in order to match staffing to activity.
Community Staffing
Greater Manchester Local Area Team recently commissioned a review into community nursing (district
nursing) staffing and this has now been concluded. Once the results are received, a group will be
established to review the findings and agree next steps.
13
Specialist areas
Within Nursing and Midwifery, there are several areas that do not fall within the scope of in-patient
wards/areas. These include; ITU, Theatres and Out-patients. Staffing levels for these areas have also been
reviewed and do not yield cause for concern.
The Emergency department is due to be reviewed using the BEST model during autumn 2014.
6. Option Appraisal
The key considerations are;




Closer alignment of staffing to acuity audit results
The nationally recommended ratio of 1:6-8 RN to patients to prevent patient harm
The recommended supervisory status of Ward Sisters and Charge Nurses, proposed within the
Trust as 0.60 wte, with a change in uniform, in response to patient complaints regarding lack of
clarity of ‘who is in charge’ and to represent a shift in expectations
The incorporation of ‘long days’ into shift patterns in specific areas to improve efficiency whilst
retaining minimum, overall, WTE numbers required
Option Appraisal:
Option 1: Status Quo (Do Nothing) – retain current status of in-patient staffing
Advantages
 No investment required
Disadvantages
 Non-compliance with NICE safe staffing
guidance and guidance for Supervisory ward
Sr/CN status
 Inconsistency across inpatient areas thereby
reducing ability to drive quality improvement
 Wards with establishments not aligned to
current acuity, and with ratios greater than 1:68 pose an increased risk of patient harm
 Potential criticism from NHS England, Care
Quality Commission and other regulators
 No action in response to ongoing concerns
raised by patients citing difficulties in
determining who is ‘in charge’
Cost: NIL
14
Option 2:
 Movement of funding from areas with identified over-establishment
 Achieve supervisory status
 Adopt uniform revision
 Nil change to current shift patterns
Advantages
Disadvantages
 Partial improvement of alignment of
 Financial investment required
ward staffing to acuity tool results
 Changes to practice / working not
 Supervisory status of ward Sr/CN
adopted consistently resulting in
inequity across areas with staffing
 Ward Leadership clearly defined
levels
 Wards with establishments not
aligned to current acuity, and with
ratios greater than 1:6-8 pose an
increased risk of patient harm
 Potential criticism from NHS England,
Care Quality Commission and other
regulators
Cost:
Overall cost:
Funded by:
Investment:
£1,450,897
(£245,956) from release from review of ward establishment
£1,204,941 plus £5k uniform
Option 3:
 Movement of funding from areas with identified over-establishment
 Achieve supervisory status
 Adopt uniform revision
 Implementation of 100% ‘long-days’ to wards D1, D2 and D4 (due to acuity results
highlighting over-establisment)
Advantages
Disadvantages
 Partial improvement of alignment
 Financial investment required
ward staffing to acuity tool results
 Changes to practice / working not
 Supervisory status of ward Sr/CN
adopted consistently resulting in
inequity across areas with staffing
 Improved efficiency of wards
levels
 Ward leadership clearly defined
 Wards with establishments not
aligned to current acuity, and with
ratios greater than 1:6-8 pose an
increased risk of patient harm
 Potential criticism from NHS England,
Care Quality Commission and other
regulators
 100% ‘long days’ can present
difficulties with temporary staff fill due
to sickness and other absences
Cost:
Overall cost:
Funded by:
Investment:
£1,450,897
(£245,956) from release from review of ward establishment
(£143,027) from introduction of 100% long days on D1, D2 and D4
£1,061,914 plus £5k uniform
15
Option 4:
 Movement of funding from areas with identified over-establishment
 Achieve supervisory status
 Adopt uniform revision
 Implementation of 100% ‘long-days’ to wards D1,D2 and D4
 25% ‘long’ days to all remaining wards
Advantages
Disadvantages
 Improvement of alignment of ward
 Additional
Financial
investment
staffing to acuity tool results
required
 Supervisory status of ward Sr/CN
 100% ‘long days’ can present
difficulties with temporary staff fill due
 Improved efficiency of wards with
to sickness and other absences
reduced potential negative impact of
reduced
overall
WTE
from
introduction of a higher ratio of ‘long
days’
 Ward leadership clearly defined
Cost:
Overall cost:
Funded by:
Investment:
£1,450,897
(£245,956) from release from review of ward establishment
(£143,027) from introduction of 100% long days on D1, D2 and D4
(£563,153) from introduction of long days for 25% of staff on other wards
£498,761 plus £5k uniform
Option 5;
 Movement of funding from areas with identified over-establishment
 Achieve supervisory status
 Adopt uniform revision
 Implementation of 100% ‘long-days’ to wards D1,D2 and D4
 50% ‘long’ days to all remaining wards
Advantages
Disadvantages
 Partial improvement of alignment
 Financial investment required
ward staffing to acuity tool results
 Changes to practice / working not
 Supervisory status of ward Sr/CN
adopted consistently resulting in
inequity across areas with staffing
 Improved efficiency of wards
levels
 Ward Leadership clearly defined
 Wards with establishments not
aligned to current acuity, and with
ratios greater than 1:6-8 pose an
increased risk of patient harm
 Potential criticism from NHS England,
Care Quality Commission and other
regulators
 100% ‘long days’ can present
difficulties with temporary staff fill due
to sickness and other absences
 50% long days may further reduce
overall WTE to levels below acuity
audit recommendations requiring
further investment in the future
16
Cost:
Overall cost:
Funded by:
Investment:
£1,450,897
(£245,956) from release from review of ward establishment
(£143,027) from introduction of 100% long days on D1, D2 and D4
(£563,153) from introduction of long days for 25% of staff on other wards
(£179,699) from introduction of long days for 50% of staff on other wards
£319,062 plus £5k uniform
7. Recommendations
Safe nurse staffing levels are receiving significant national attention and particularly during the recent
Keogh mortality reviews and CQC inspections. In some areas of Stockport NHS Foundation Trust,
registered nurse staffing levels do not meet the national guidance in specific aspects such as skill mix,
nurse to bed ratios or registered nurse to patient ratio. This position is not sustainable for patient safety,
quality, patient experience or patient flow.
The Board is asked to approve the following recommendations:
1. To implement option 4 at a total cost of £498,761 (+ 5K uniforms)
2. Priority for investment allocated as follows;
 Additional staffing to wards A10 and A11 (see tables 1 and 2)
 Supervisory Status for ward sisters/charge nurses
 Investment to all remaining areas as discussed
3. To approve realignment of some areas where acuity results confirm over-establishment (see Table
2)
17
Board of Directors
Part
Public/Private
Date
25 September 2014
Title of Report
GOVERNANCE REVIEW – HIGHLIGHT REPORT
Presented by:
Name & Title
Ann Barnes
(Chief Executive)
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Prepared by:
Name & Title
Public
Item
No.
6.6.1
John Pierse
(Trust Secretary)
The attached report provides an overview to the Board on progress against the
action plan produced to deliver the recommendations from the Deloitte’s review
into the Trust’s governance arrangements. As actions to implement the
recommendations are completed, they are removed from the Highlight Report.
The report highlights those milestones / deliverables achieved during the reporting
period (August 2014) and identifies those due to be delivered during the next
reporting period.
Attached to the report is an appendix which provides a summary of the
recommendations.
For ease of reference, I am also attaching a progress report prepared in August
2014 as there was no Board meeting that month.
Strategic /
Corporate
Objective(s)
supported by this
paper
Good Governance
Quality and Performance
Is this on the
No
Yes
If Yes,
Trust’s risk
X
15
Score
register?
Confirm that Datix and the BAF reflect this risk Trust Board Assurance Framework 2014/15 –
and assurance information. Or state the date
Risk 2
when they will be updated.
Board action
Approve
Ratify so
Endorse
Note
X
sought (X)
as fit for
comes
management
purpose
into force
action
Points to note re the
Completion of the recommendations of the Deloitte’s review forms part of the
Trust’s CQC registration
Monitor enforcement / regulatory undertakings.
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for
Consideration:
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Weekly
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
PROJECT HIGHLIGHT REPORT
Executive Sponsor :
Project Lead:
Ann Barnes
John Pierse
Reporting Period:
Aug-14
More than 2 weeks behind planned schedule
R
Up to 2 weeks behind planned schedule
To planned schedule
A
G
Project: Strenthgen Trustwide Governance & Assurance Arrangements
This Month
Green
Status Update
Milestones/ Deliverables Rec: 3 Theme: 1A Completed
Achieved
Rec: 5/6 Theme: 1B Completed
Rec: 14 Theme: 3A Completed
Rec: 16 Theme: 3A Completed
Rec: 21 Theme: 3C Report complete and approved by Executive Team for submission to Sept Board (due
to no Board meeting in Aug)
Rec: 22 Theme: 3C Completed
Rec: 23 Theme: 4A Completed
Rec: 25 Theme: 4B Completed
Rec: 27 Theme: 4C Completed
Red
Workstream
Last Month
RAG
Milestones/ Deliverables Rec: 4 Theme: 1A Quality Strategy to be submitted to the Sept Board
Rec: 24 Theme: 4B Information Strategy to be submitted to Finance, Strategy & Investment Committee in
Slipped
October 2014 and to Board formally in November 2014
Green
Deloittes Review Action Plan
Page 1
Expected
Completion
Date
Aug-14
25/09/2014
27/11/2014
PROJECT HIGHLIGHT REPORT
Deloittes Review Action Plan
Executive Sponsor :
Project Lead:
Ann Barnes
John Pierse
Green
Last Month
Reporting Period:
Aug-14
More than 2 weeks behind planned schedule
R
Up to 2 weeks behind planned schedule
To planned schedule
A
G
Project: Strenthgen Trustwide Governance & Assurance Arrangements
Workstream
Green
Deloittes Review Action Plan
This Month
RAG
Status Update
Milestones/ Deliverables Rec: 4 Theme: 1A Quality Strategy to be submitted to the Sept Board
planned for next
Rec: 7 Theme: 1B Protocol being developed
reporting period
Rec: 10 Theme: 2B Ongoing
None at this time
Green
New/ Emerging Risks
Page 2
Expected
Completion
Date
30/09/2014
PROJECT HIGHLIGHT REPORT
Executive Sponsor :
Project Lead:
More than 2 weeks behind planned schedule
R
Up to 2 weeks behind planned schedule
To planned schedule
A
G
Ann Barnes
John Pierse
Reporting Period:
Aug-14
Project: Strenthgen Trustwide Governance & Assurance Arrangements
This Month
Workstream
Last Month
RAG
Deloittes
Review Stakeholder
Action Plan
Engagement
- Benefits
Realisation
Status Update
Expected
Completion
Date
Milestones/ Deliverables Questionaires returned and collated
Report of findings produced
Achieved
Green
Red
Green
Milestones/ Deliverables Report of findings to be considered at Executive Team
Slipped
Milestones/ Deliverables Consideration of report and benefits identified to be added to the Project Initiation Document
planned for next
reporting period
New/ Emerging Risks
None at this time
Page 3
Oct-14
PROJECT HIGHLIGHT REPORT
Executive Sponsor :
Project Lead:
Ann Barnes
John Pierse
Reporting Period:
Aug-14
More than 2 weeks behind planned schedule
R
Up to 2 weeks behind planned schedule
To planned schedule
A
G
Project: Strenthgen Trustwide Governance & Assurance Arrangements
This Month
Expected
Completion
Date
Milestones/ Deliverables PID for overall project finalised
Phase 2 project plan started with stakeholder questionnaire
Achieved
Red
Green
Green
Green
Deloittes
Review Project Structure
Action Plan
Status Update
Milestones/ Deliverables Phase 2 project plan to be finalised and signed off
Slipped
Green
Workstream
Last Month
RAG
Milestones/ Deliverables PID for overall project signed off
planned for next
Phase 2 project plan to be finalised and signed off
reporting period
New/ Emerging Risks
None at this time
Page 4
Oct-14
Board of Directors
Date: 18th August 2014
Agenda Item
Governance Review Highlight Report
Title of Report
To provide an overview to the Board of progress against the action
plan produced to deliver the recommendations that came out of the
Deloitte Governance review. To highlight key milestones achieved and
Purpose of the report future milestone targets.
and the key issues
for consideration /
Included with the Highlight Report for reference is Appendix 1 –
decision
summary of recommendations included in the Deloittes Report.
For the Board to be assured as to the status of delivery of the plan
against agreed targets within the action plan.
Ann Barnes – Chief Executive
Presented by:
Name & Title
Nick Graham – Portfolio Director
Prepared by:
Name & Title
Action Required
(please X)
Approve
Adopt
Receive for
information
X
Strategic / Corporate Governance
Objective(s)
supported by this
Quality & Performance
paper
Is this on the Trust’s
risk register?
Which Standards
apply to this report?
Have all implications
related to this report
been considered?
No
Yes
X
CQC
NHSLA
BAF Objectives 14/15
If Yes,
Score
N/A
N/A
Risk 2
Finance Revenue & Capital
National Policy / Legislation
N/A
N/A
NHS Contract
N/A
Human Resources
Consultation / Communication
Other:
N/A
YES
N/A
Equality & Diversity
Patient Experience
Governance & Risk
Management
Terms of Authorisation
Human Rights
Carbon Reduction
N/A
N/A
YES
YES
N/A
N/A
Previous Meetings
Please insert the date the paper was presented to the relevant Committee:
Audit
Committee
Quality &
Safety
Committee
Provider
Efficiency
Board
ET
Remuneration
Committee
Assurance &
Risk
Committee
Other
PROJECT HIGHLIGHT REPORT
Executive Sponsor :
Project Lead:
Ann Barnes
Nick Graham
Reporting Period:
Aug-14
More than 2 weeks behind planned schedule
R
Up to 2 weeks behind planned schedule
To planned schedule
A
G
Project: Strenthgen Trustwide Governance & Assurance Arrangements
This Month
Workstream
Last Month
RAG
Green
Green
Deloittes Review Action Plan
Status Update
Rec: 1 Theme: 1A Delivered in full
Rec: 7 Theme: 1B Revised trust governance meeting structure reviewed and revised as appropriate
Rec: 8 Theme: 2A Delivered in full
Rec: 10 Theme: 2B Fully adressed across all BGs
Rec: 11 Theme: 2B Implemented a cultural dashboard for the organisation
Rec: 12 Theme: 3A Delivered in full
Rec: 13 Theme: 3A Delivered in full
Rec: 14 Theme: 3A First meeting has taken place
Rec: 15 Theme: 3A Delivered in full
Rec: 17 Theme: 3A Delivered in full
Rec: 18 Theme: 3A Delivered in full
Rec: 26 Theme: 4B Delivered in full
Milestones/ Deliverables Rec: 27 Theme: 4C Delivered in full
Rec: 28 Theme: 4C Delivered in full
Achieved
Evidence base created
Milestones/ Deliverables None at this time
Slipped
Expected
Completion
Date
Deloittes Review Action Plan
PROJECT HIGHLIGHT REPORT
Executive Sponsor :
Project Lead:
Ann Barnes
Nick Graham
Reporting Period:
Aug-14
More than 2 weeks behind planned schedule
R
Up to 2 weeks behind planned schedule
To planned schedule
A
G
Project: Strenthgen Trustwide Governance & Assurance Arrangements
Green
This Month
Workstream
Green
Last Month
RAG
Deloittes Review Action Plan
Status Update
Expected
Completion
Date
Milestones/ Deliverables Rec: 3 Theme: 1A To have been delivered in full
planned for next
Rec: 4 Theme: 1A To have been delivered in full
reporting period
Rec: 5/6 Theme: 1B On track to be delivered in full by end of September
Rec: 9 Theme: 2A On track to deliver all actions identifed to be delivered in September
Rec: 14 Theme: 3A To have been delivered in full
Rec: 16 Theme: 3A To have been delivered in full
Rec: 21 Theme: 3C To have been delivered in full
Rec: 22 Theme: 3C To have been delivered in full
Rec: 24 Theme: 4B To have been delivered in full
Rec: 25 Theme: 4B To have been delivered in full
Evidence
base
populated
New/ Emerging Risks
None at this
time
Green
Green
Aug-14
PROJECT HIGHLIGHT REPORT
Executive Sponsor :
Project Lead:
Ann Barnes
Nick Graham
Reporting Period:
Aug-14
More than 2 weeks behind planned schedule
R
Up to 2 weeks behind planned schedule
To planned schedule
A
G
Project: Strenthgen Trustwide Governance & Assurance Arrangements
This Month
Workstream
Last Month
RAG
Status Update
Expected
Completion
Date
Milestones/ Deliverables Questionaires returned and collated
Achieved
Report of findings produced
Green
Green
Deloittes
Review Stakeholder
Action Plan
Engagement
- Benefits
Realisation
Milestones/ Deliverables None at this time
Slipped
Milestones/ Deliverables Benefits identifed added to the Project Iniation Document (PID)
planned for next
reporting period
New/ Emerging Risks
None at this time
Green
Green
Aug-14
PROJECT HIGHLIGHT REPORT
Executive Sponsor :
Project Lead:
Ann Barnes
Nick Graham
Reporting Period:
Aug-14
More than 2 weeks behind planned schedule
R
Up to 2 weeks behind planned schedule
To planned schedule
A
G
Project: Strenthgen Trustwide Governance & Assurance Arrangements
This Month
Workstream
Last Month
RAG
Status Update
Expected
Completion
Date
Milestones/ Deliverables PID for overall project finalised
Achieved
Phase 2 project plan started
Green
Green
Deloittes
Review Project Structure
Action Plan
Milestones/ Deliverables None at this time
Slipped
Milestones/ Deliverables PID for overall project signed off
planned for next
Phase 2 project plan finalised and signed off
reporting period
Green
Green
New/ Emerging Risks
None at this time
Aug-14
(Public) Agenda Item No. 6.6.2.1
Board of Directors’ Key Issues Report
Building a Sustainable Future
Report Date:
18/08/14
Committee:
Building A Sustainable Future
Date of last meeting:
13/08/14
Membership Numbers:
Quorate
1.
Key Issues Highlighted:
 The need for the continued rapid development of 15/16 CRP plans to
ensure we meet the challenging timeframe required to prepare the Trust
for future years (and to satisfy Monitor’s expectations).
 In order to overcome practical problems with financial reporting, the
Committee will realign the meeting schedule with the Finance monthly
cycle.
 The alignment of Trust corporate strategies with change programmes,
particularly the IT strategy as it is a key enabler of transformational
change.
 The need for the PMO to lead on a series of interdependency workshops
to avoid duplication and ensure integrated working across the
programmes.
2.
Risks Identified
 The consistency of risk evaluation was highlighted as a particular risk as
there is significant variation across the Programme. The PMO will lead
on the application of a standard risk measure.
3.
Actions to be considered
at the Trust Board
 The contents to be noted.
4.
Report Compiled by
John Schultz (Chair)
5.
Minutes available from
Agenda Item
Board of Directors’ Key Issues Report
Report Date: 17/9/14
Committee: Finance, Strategy & Investment
Date of last meeting:
Membership Numbers:
9/9/14
Quorate (11)
Apologies from Les Wilcock
1.
Key Issues Highlighted:
 Amended Terms of Reference agreed – IM&T section to be added, and
will be presented to the next meeting.
 Future Calendar of work agreed.
 At the end of Month 4 the Trust had a deficit of £1.2m, an improvement
of £22k against plan in-month. COSRR remains a 3.
 Clinical Income is cumulatively £375k ahead of plan, however this is a
deterioration of £44k from Month 3. Operating costs are cumulatively
£67k favourable to plan, although this is a deterioration of £288k in
month. In-month, we have failed to meet either the income or
expenditure plan.
 Shortfall against CRP delivery remains the Trust’s biggest financial
issue.
 The £12m CRP target has been increased by £1.3m due to the costs of
Turnaround and PMO staffing, to £13.3m.
 Concern was noted about the level of expenditure on medical locums /
waiting list initiative payments and a detailed analysis / forecast was
requested for the next meeting.
 A detailed year-end forecast is being prepared for inclusion in the Month
5 Board paper and will be considered at the next Committee Meeting.
 The reduction in the forecast 2015/16 cash position from Month 4 was
noted, and the Committee asked for a detailed forward cash flow
forecast to enable problems to be anticipated and solutions planned. To
be considered in detail at future meeting.
 There is slippage on the capital programme in the kitchen scheme and
D-Block. This is likely to trigger a re-forecast requirement from Monitor.
 Forecast CQUIN performance and the level of financial penalties against
KPIs is a concern.
 Progress against developing 2015/16 CRP plans was noted.
 The Monitor feedback from the August PRM letter was noted and
discussed, a response will be presented to Board and next Committee.
 The recent RTT & Resilience bids were discussed, and the CCG concern
that the cash will not be forthcoming was noted. The non-recurrent
nature of the resilience funding was also noted.
 Noted the Education & Training Reference Cost submission.
 Noted the pause in the Urology Cancer tender process.
 Concern was noted regarding the current Southern Sector Pathology
status.
1
 D-block progress report was received.
 Gas contract paper was considered and recommended for approval and
email to be sent to Board members.
 IM&T update considered, and Patient-track nurse training issue
considered.
 Pharmacy Shop progress report received.
2.
Risks Identified










3.
Actions to be considered
at the (insert appropriate
place for actions to be
considered)
Board
 Note the key issues and consider the risks.
 Consider the year-end forecast.
 Consider the email regarding the gas contract, and approve the attached
paper.
Risk of reduced future cash flow due to some factors below.
Shortfall against CRP targets.
Increased CRP target resulting in more difficult task.
Poor CQUIN and KPI performance.
High level of Medical Locum and WLI expenditure.
Capital Programme delivery shortfall.
2015/16 CRP plan development critical.
RTT & Resilience bids – cash flow, and non-recurrent nature.
Pause in the Urology Cancer tender due to specification clarification.
Southern Sector Pathology financial shares previous agreement now
disputed by other DoFs. No new agreement yet in place.
Gas Procurement
Exercise - September Board Paper 2014.pdf
 Note the Committee’s forward work plan.
Forward Calendar
2014-15 and 2015-16 pdf for key issues paper.pdf
BaSF
 Pursue the 2014/15 CRP delivery
 Consider the 2015/16 CRP plan delivery
4.
Report Compiled by
Malcolm Sugden, Chair
5.
Minutes available from
Nicola Greenfield, Deputy Director of Finance
2
Board of Directors
Title of Report
Part
Public Item
No.
Public/Private
Completing the Procurement of the Trust Gas Provision
Presented by:
Name & Title
Bill Gregory - Director of
Finance
Date
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Prepared by:
Name & Title
Paul Holt – Director of
Estates and Facilities
To complete the procurement exercise transferring our gas supply from the
current provider to the government procurement body – Crown Commercial
Services.
Update presented to and accepted by the September Finance, Strategy and
Investment Committee. Approval received by Board members to sign the CCS
Customer Access Agreement prior to the Board in order to maximise the benefits
associated with the CCS procurement programme
Quality – Safe and Effective Care
Is this on the
No
x
Yes
If Yes,
Trust’s risk
Score
register?
Confirm that Datix and the BAF reflect this risk
and assurance information. Or state the date
when they will be updated.
Board action
Approve
Ratify so
Endorse
sought (X)
as fit for
comes
management
purpose
into force
action
Points to note re the
Compliance with Trust financial instructions
Trust’s CQC registration
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for
Consideration:
Note
X
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
X
1|Page
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
X
Other
Procurement Exercise for the Provision of Gas Supply
1. Executive Summary
We advised the May Board of the preferred option to appoint Crown Commercial
Services (CCS) as our partner in the procurement of gas, commencing April 1st 2015.
In developing the proposal we demonstrated compliance with the Trust Standing
Financial Instructions, whilst also addressing the concerns raised by the October 13
audit report. The Audit Committee signed off the approach at their July 14 meeting.
In concluding our discussion with CCS, our recommendation to sign contracts was
accepted by the September Finance, Strategy and Investment Committee – subject to
approval of the September Board. However due to the time critical nature of the
procurement exercise Board members were asked approve contract signing prior to
the Board. Approval was received and the CCS Customer Access Agreement signed
and returned.
The risk of not signing the contract until after the Board on the 25th September might
have resulted in the Trust being excluded from the September CCS procurement
exercise. This would have prevented the Trust benefiting from the negotiated contract
for a period of 6 months from April 1st 2015. The consequence would be that the Trust
would then be exposed to the purchase of its energy on the open market
This paper sets out the activity leading to acceptance of the Finance, Investment and
Strategy Committee and subsequent contract approval.
2. Background
In accepting the recommendation to transfer the gas contract to CCS the Board asked
the Director of Estates and Facilities and Head of Procurement to:





Complete formal discussions with CCS. This was to include the development of a
procurement strategy for the purchase of gas for potentially the next 3 years – the
value estimated at circa £ 3.76m
Review the two available options of a 1 year rolling contract (with 6 month notice to
exit clause) or a 3 year contract (with 30 month notice to exit clause) and advise on
the most appropriate course of action
Receive a final recommendation based on the previous details
Receive and sign formal contracts appointing the new broker and gas supplier
Consider the appointment of CCS as a broker and the subsequent future purchaser
of electricity commencing in April 2016 using the same procurement
methodology/framework used for gas – subject to the satisfactory performance of
CCS in the intervening period
The Board of Directors asked to receive a final recommendation based upon the
issues detailed in the paper at their meeting in September 2014. However, the
decision to accept had to be accelerated in order to meet the strict procurement
deadlines set out by CCS.
2|Page
3. Current Situation
3.1. Contract provision
Discussions have concluded with CCS examining their two contracts. In each
case they are standard CCS contracts prepared by their government legal team.
The principles of the contracts are as follows:
1. CCS – Customer Access Agreement – This grants the Trust access to
the CCS frameworks.
We are advised by CCS that by signing the contract we are committed to
moving forward into the procurement exercise. On submission CCS will
start the process of registering the Trust buildings, including the associated
gas volume into the purchase baskets for our traders to cover. The model
contract from the supplier is then presented to the Trust, to ensure
everything is correct and there is no missing data.
Corona Energy Contract – This is the framework agreement for natural
gas supply provided by Corona energy. This underpins the operational
requirements and obligations of both parties.
In each case we have identified our obligations and will manage in the previously
proposed quarterly governance board.
3.2. Timing in Signing the Contract and associated risks
The Customer Access Agreement (clause 3.4.3) states that the Trust needs to give
CCS 6 months' notice to join a Procurement Round, i.e. 6 months prior to the start of
the Procurement Year ("the Procurement Round Commitment Point"). The
Procurement Year can start on 1 October or 1 April of each year.
This creates a tight deadline to complete our overall assessment and report to the
September Board. In the event we miss this deadline, we will be frozen out of the
latest round of purchasing and not benefit from the competitive rates until 1 October
2015.
Given that we have written to FEML serving notice to exit our current arrangement,
this will leave the Trust exposed to accepting an interim position through CCS, which
in turn exposes the Trust to the vagaries of the gas market as we purchase on a short
term basis.
3.3. Length of Contract
There are several options available to the Trust in purchasing gas via CCS. The
table below indicates the options and the reasons for the proposed
recommendations.
3|Page
Framework
Agreement
Options
Trust Choice
Procurement
round/year
The next basket is April 14 for all
new customers
Trust to commit by September
th
19 to ensure it is included in
the ‘procurement basket’
Commencement
of procurement
and contract
length
30 months prior (3 yr contract)
6 months prior (1 year contract)
3 year Contract as we benefit
from a longer term risk strategy
with reduced exposure to the
market vagaries
Trust can also better plan
procurement over a 3 year
period rather than have to
revisit the exercise on an
annual basis
Locked / variable
Product
Locked is where the energy is
bought prior to commencement and
the price is fixed throughout basket.
Variable is where only a percentage
of the energy is bought before
basket commencement and the rest
is bought throughout the basket, the
price here is only a reference price.
Variable as we can be
protected from significant
fluctuations, whilst benefitting
from trading when markets are
favourable
3.4. Development of the North West CCS Procurement Process
We are advised several North West Trusts have already committed to the new
contract/procurement round, based on the supporting evidence led by SFT. These
include our partners in developing the original business case – Salford Royal Hospital
and the North West ambulance Services.
4. Summary
The paper represents the completion of the negotiations for the procurement of gas for
the next 3 years commencing April 1st 2014.
The work and subsequent recommendation remains in line with the methodology set
out and agreed at the May Board 2014.
In order to benefit from the proposals, we are duty bound to complete and return the
Customer Access Agreement by the 23rd September 2014. This allows CCS to
complete their initial assessments of our data and include within their procurement
process before the end of September
4|Page
5. Recommendation
We asked the Finance, Strategy and Investment Committee to approve the following
actions:






Agree to the signing of the CCS Customer Access Agreement committing the Trust
to the procurement of energy via the CCS framework
Permit the signing of the subsequent supplier (Corona) Contract agreement
Accept the proposal to commit the Trust to a 3 year contract
Submit a full report to the September Board of Directors confirming the actions
Consider the appointment of a broker and the subsequent future purchase of
electricity commencing in April 2016 using the same procurement
methodology/framework used for gas – subject to the satisfactory performance of
Crown Commercial Services in the intervening period – to be reviewed over the
next 12 months within the FSI Committee
Monitor the governance of the contract via the Audit Committee – report to be
presented by the Director of Estates and Facilities on a quarterly basis
6. Conclusion
The Finance, Strategy and investment Committee approved the signing of the
contract. However, they recognised that they had not got the authority to confirm the
signing of contracts valued at circa £ 3.6m over 3 years.
They therefore asked the Director of Finance to seek approval of Board members to
sign the CCS Customer Access Agreement contract prior to the Board meeting on 25th
September 2014.
This action would commit the Trust to a contract that had been agreed to in principle at
the May Board
It will also lead to the presentation of the supply contract with Corona Gas, finalising
the supply agreement. Signing this contract is a follow up to the commitment made by
signing the CCS agreement
Board members approved the signing of the CCS Customer Access Agreement, which
has since been returned.
Paul Holt - Director of Estates and Facilities
September 2014
5|Page
Finance, Strategy & Investment Committee Forward Workplan
2014/15 and 2015/16
3rd September 2014
Finance
Statutory Returns
submitted
(exception reports
on issues)
Month 4 Monitoring
Return
1st October 2014
Month 5 Monitoring
Return
5th November 2014
Month 6 Monitoring
Return
Quarter 2 Monitoring
Return
Contracting
Costing
3rd December 2014
Month 7 Monitoring
Return
January 2015
Month 8 Monitoring
Return
DH 5 Year Capital
Submission
February 2015
Month 9 Monitoring
Return
Quarter 3 Monitoring
Return
March 2015
Month 10 Monitoring
Return
Quarterly Contracts
Financial Performance
Report
Education Return
Treasury
Management
Community SLR;
Urology SLR
Trauma and
Orthopaedics SLR;
Monitor PLICS
Submission
Treasury Management
Policy / Review of
Overdraft facilities
available
Financial Planning
KPMG Benchmarking
Report
April 2015
2014/15 Annual
Accounts
Month 11 Monitoring
Return
May 2015
Month 12 Monitoring
Return
Quarter 4 Monitoring
Return
June 2015
Month 1 Monitoring
Return
Quarterly Contracts
Financial Performance
Report
Report on overall Trust Obstetrics SLR
results from Q2 Patient
Level Costing
2015/16 Financial
Strategy
Ophthalmology SLR
July 2015
Month 2 Monitoring
Return
August 2015
Month 3 Monitoring
Return
Quarter 1 Monitoring
Return
September 2015
Month 4 Monitoring
Return
Quarterly Contracts
Financial Performance
Report
Report on overall Trust General medicine SLR
results from Q3 Patient
Level Costing
2014-15 Reference
Costs (subject to
external timetable)
October 2015
Month 5 Monitoring
Return
November 2015
Month 6 Monitoring
Return
Quarter 2 Monitoring
Return
Quarterly Contracts
Financial Performance
Report
December 2015
January 2016
Month 7 Monitoring
Return
Month 8 Monitoring
Return
February 2016
Month 10 Monitoring
Return
Monthly SLR focus on
single specialty
Report on overall Trust
results from Q3 Patient
Level Costing
Quarterly Contracts
Financial Performance
Report
2014-15 Education
2014-15 Monitor PLICS Report on overall Trust Monthly SLR focus on
Return (if still separate Submission (subject to results from Q1 Patient single specialty
from main Ref Cost
external timetable)
Level Costing
Submission)
Draft 2015/16 Financial 2015/16 Financial Plan 2015/16 to 2019/20
Plan
Financial Plan
Report on overall Trust Monthly SLR focus on
results from Q2 Patient single specialty
Level Costing
2016/17 Financial
Strategy
Draft 2016/17 Financial 2016/17 Financial Plan
Plan
Draft 5-year Financial
Plan
Planning
Planning & Strategy
Paper (July Board) &
Update
Post Investment
Appraisal
Programme TBC
IM&T
TBC
Procurement
Capital
CPDG
Monthly Update
including D Block
report
Monthly Update
including D Block
report
Monthly Update
including D Block
report
Site Development
Strategy - half
yearly review
QCNW / SPU
2016/17 Initial Planning
assumptions
Review of Planning
Cycle Process
Review of Planning
Cycle Process
2015/16 Procurement
Plan
Capital Programme
The Pharmacy Shop
Draft 5-year Financial
Plan
2015/16 Initial Planning
assumptions
2014/15 Procurement
Plan
March 2016
Month 9 Monitoring
Return
Quarter 3 Monitoring
Return
Monthly
Monthly
Financial position
implementation update implementation update update
Monthly Update
Monthly Update
including D Block
including D Block
report
report
1st Review of the
2015/16 capital
programme
Review and revision of
Current Strategy
Financial position
update
Monthly Update
including D Block
report
Final draft and
preparation for April
Board
Monthly Update
Monthly Update
including D Block
including D Block
report
report
Sign off and agreed
submission to the April
Board
Monthly Update
including D Block
report
Monthly Update
including D Block
report
Monthly Update
including D Block
report
Monthly Update
including D Block
report
Monthly Update
including D Block
report
Monthly Update
including D Block
report
Review and revision of
Current Strategy
Financial position
update
Financial position
update
Financial position
update
Monthly Update
including D Block
report
Monthly Update
Monthly Update
including D Block
including D Block
report
report
1st Review of the
2015/16 capital
programme
Review and revision of
Current Strategy
Monthly Update
including D Block
report
Final draft and
preparation for April
Board
Monthly Update
including D Block
report
Sign off and agreed
submission to the April
Board
Financial position
update
QCNW Strategy
I:\Finance\Finance Strategy and Investment Committee\2014-15\Forward Calendar 2014-15 and 2015-16.xlsx
18/09/2014
Agenda Item:
Board of Directors’ Key Issues Report
Report Date:
th
19 September 2014
Date of last meeting:
21st August 2014
1.
Committee:
Quality Assurance Committee
Membership Numbers:
10
Key Issues Highlighted:
•
Quality Governance Committee – further assurance from hotspot
areas needed.
•
Quality strategy – final draft to be sent to committee members with
end date to Board of Directors in September.
•
CQUIN 14/15 – the committee noted a red reading for ‘stroke’ and
requires a report and action plan as soon as possible.
•
High profile report – extensive discussion took place, especially with
respect to cross referencing this report with similar reports recorded
elsewhere, and an understanding of the way in which findings link to
quality improvement.
o
It was noted in the high profile report that problems in the
administration of insulin and general issues with
documentation.
consequently:
2.
Risks Identified
o
an urgent report has been requested from the quality
governance committee about the prescribing and
administration of insulin
o
a less urgent report is requested from the quality governance
committee to review and address documentation in the
clinical record which should include issues of timeliness
detail, accuracy and clinical engagement
•
.
Corporate risk register – improve link between hotspots and risk
register.
•
Advancing Quality Stroke achievements
•
Prescribing and administration of insulin
•
Documentation
1
3.
Actions to be considered
at the Quality Governance
Committee
•
Assurance on hot spots
•
Action plan for AQ Stroke
•
Update report from the Task & Finish Diabetes Group
•
Plan for taking forward documentation problems.
4.
Report Compiled by
Dr M Cheshire
Non-executive Director
5.
Minutes available from
Mrs S Raistrick
P.A. to Director of Nursing & Midwifery
2
Board of Directors’ Key Issues Report
Workforce & Organisational Development Committee
Report Date:
Committee:
25th September 2014
Workforce & Organisational Development
Committee
Date of last meeting:
Membership Numbers:
31st July 2014
Quorate
1.
Key Issues Highlighted:

Detailed workforce metrics to be
developed for review by the committee

Draft OD Strategy presented for initial
comment and feedback

Annual Quality Assurance Report –
Medical revalidations was signed off on
behalf of the Board of Directors.
2.
Risks Identified:
3.
Actions to be considered at the
Board of Directors
The contents to be noted.
4.
Report Compiled by:
Carol Prowse
5.
Minutes available from:
Claire Dearman
Board of Directors
25th September 2014
Item
No.
Title of Report
Part
Public
Public/Private
Draft Quality Improvement Strategy 2014-19
Presented by:
Name & Title
Judith Morris
James Catania
Fifty-word
abstract – allows key
The Trust’s strategy for quality improvement has been reviewed and updated; it is
designed as a blueprint for the achievement of strategic quality objectives over the
next five years.
Date
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Prepared by:
Name & Title
Judith Morris
James Catania
It is presented to the Board as a final draft for discussion and amendment, having
been developed by the Quality Assurance Committee and many clinical leaders.
Patients’ health and well-being is supported by high quality, safe and timely
care.
Patients and their families feel cared for and empowered.
Is this on the
No
√
Yes
If Yes,
Trust’s risk
Score
register?
Confirm that Datix and the BAF reflect this risk
and assurance information. Or state the date
when they will be updated.
Board action
Approve
Ratify so
Endorse
sought (X)
as fit for
comes
management
purpose
into force
action
Points to note re the
All patient safety and patient experience regulations
Trust’s CQC registration
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for
Consideration:
Note
√
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
21/08/14
24/09/14
Draft 4 (18/09/14)
Page 1
Quality Improvement Strategy
2014-2019
Executive Summary
Stockport NHS Foundation Trust’s first priority is its commitment to putting patients, carers and
families first. This means that in both the hospital and the community we strive every day to
provide the best, safest and most effective care and a positive experience for our patients and their
families. Each of our services aims to:



Deliver safe, high quality care in clean and safe environments.
Provide effective, efficient and timely care – right care, right place right time.
Communicate in a clear, open and transparent way and treat people with dignity and
respect.
The Trust’s Quality Improvement Strategy 2014-19 sets out how this will be achieved by reducing
harm and mortality, providing reliable care and improving the patient experience. It outlines the
Trust’s objectives for the next five years together with the approach all our staff will take to
improve quality during this time.
Introduction
This strategy builds on the Trust’s first Quality Improvement Strategy 2008-2012 which was based
on the definition of quality articulated in Lord Darzi’s report, “High Quality Care for All” (DH, 2008),
as comprising patient safety, clinical effectiveness and the patient experience. It was updated twice
during that period; during that time there was a separate Patient and Family Experience strategy.
The quality strategy of 2008-2012 identified two main objectives: reduction of the Hospital
Standardised Mortality Ratio (HSMR) from 100 to 80 and reduction of inpatient adverse events by
50% from baseline. A number of quality improvement projects were established to deliver these
objectives and the impact of these is outlined in the table below (some indicators were not
available in 2008).
Draft 4 (18/09/14)
Page 2
Quality indicator
Mortality: HSMR (overall)
 HSMR (weekend)
 HSMR (fractured neck of femur)
Improve venous thromboembolism
(VTE) prophylaxis (percentage of
patients risk assessed)
Falls (causing injury or death)
Pressure Ulcers (prevalence)
Reliable Care (percentage of patients
receiving recognised bundle of
care): Acute Myocardial Infarction
 Heart Failure
 Hip & Knee replacement
 Community Acquired Pneumonia
Reducing Infection: MRSA bacteraemia
 Clostridium difficile infection
2008
2010
2013
112.1
Not available
110
105
115
41.6%
98.7
103.4
60
>95%
11%
23
9%
Not available
43
69.25%
3.83%
75.50%
45.84%
59.47%
56.48%
91.74%
61.69%
13
80
0
33
Progress has been made in most of the selected areas of focus. Over the same period the Trust has
also been associated with very low mortality rates in colorectal surgery as well as excellent
outcomes in hip and knee replacement surgery.
Background
We are proud of our achievements to date but there is still much to do, as the pursuit of improved
safety and experience for our patients must be relentless. Our strategy for the next five years takes
into account the progress we have made and the strides made in the measurement and monitoring
of quality. It is also underpinned by the relevant national drivers of quality, in particular the Francis
report and Berwick review and the NHS financial climate.
The Trust embraced the Francis Report on the public enquiry into Mid-Staffordshire Foundation
Trust, published in 2013, which provided a critical driver in the pursuit of high quality care. The
report stressed the importance of an organisation exhibiting common values and culture, strong
leadership, compassion and candour, but it also summed up the essential element of quality care:
putting the patient first.
Putting the patient first is necessarily determined by staff behaviour; in the Francis Report it is
described as staff putting patients before themselves, empathising with patients and doing
everything in their power to protect patients from avoidable harm. The organisation fully commits
to this principle.
The Berwick Review (2013) advocated that the NHS should continually reduce patient harm by
“embracing wholeheartedly an ethic of learning” among staff and that organisations should seek
Draft 4 (18/09/14)
Page 3
out the ‘patient and carer voice’ as an essential part of monitoring the safety and quality of care.
This is taken on board within the Trust.
These national drivers have also to be viewed against the current financial situation within the NHS
and the need for all organisations to use all their resources effectively and efficiently.
The Trust aims to become one of the safest organisations in the NHS, and therefore must deliver
significant improvements in a range of areas of care. This must be underpinned by a culture of
strong leadership and clinical engagement, of enhancing capacity and capability for quality
improvement amongst our staff, of robust measurement and monitoring and of putting the patient
first. This strategy should therefore be read alongside the other Trust strategies which will help to
enable its objectives: Workforce and OD, Culture and Engagement and Information Technology.
Our Vision of Quality 2014-2019
As an organisation we aim to become one of the safest organisations in the NHS and to provide
safe, high quality care, underpinned by evidence-based practice, whilst also providing an excellent
patient experience. To achieve this we will focus on two main strategic outcomes:
1.
2.
Patients’ health and well-being is supported by high quality, safe and timely care
Patients and their families feel cared for and empowered
In our Trust Annual Plan we have already agreed improvement objectives for 2014/15; those that
are focused on clinical quality are shown in the table below:
Strategic
Outcome
Patients’
health
and
well-being is
supported by
high quality,
safe
and
timely care
Improvement objective
Meet national service standards:
 Hospital acquired infections
(MRSA, C diff)
Reduce hospital related mortality:
 Implement Patientrack, a vital
signs monitoring system, to
enhance use of early warning
signs indicators
 Reduce incidence of ventilator
acquired pneumonia
 Increase presence of senior
clinicians 24/7
Provide harm free care:
 Reduction in the number and
Draft 4 (18/09/14)
Completion
date
Key performance
indicators
March 2015
38 or less C. difficile
infections due to ‘lapses in
care’ (avoidable)
March 2015
Patientrack implemented
as per roll out plan by
March 2015
Target of 5 or less per 1000
ventilator days
Senior
cover
rotas
embedded
/
Daily
whiteboard round on every
ward
March 2015
Stockport acute and
community pressure ulcer
Page 4
severity of pressures ulcers
acquired in hospital and
community settings
grade 2-4 prevalence less
than 3.7% for 5
consecutive months

Reduce incidence of falls which
cause harm
At least 95% acute patients
having falls risk assessment
and 10% reduction on
2013/14 total of 23 (target
21)

Reduce incidence of devicerelated bacteraemias
associated with urinary
catheters
Reduce by 50%
2013/14 level
More than 95% patients
receiving
VTE
risk
assessment

Reduce incidence of venous
thromboembolism (VTE)
Patients and Friends and Family Test (FFT):
their families  Roll out FFT to day-cases,
feel cared for
outpatients and 20% of
and
community services
empowered
 Roll out FFT to all remaining
services
 Increase response rate to 40%
in inpatient areas and 25% in
A&E (response rate not
specified for all other areas)
Dementia:
 Improve dementia care
focussing on dignity and
respect, but also ensure 90% of
appropriate patients are
assessed for dementia on
admission
Communication:
 Focus on improving
communication by Trust staff
with patients and their carers,
by ensuring patients and their
GPs receive timely electronic
discharge letters
Draft 4 (18/09/14)
from
Commencing Friends and Family Test in
October
place in these areas, with
2014
required response rates
March 2015
March 2015
Dementia Strategy 2014-18
in progress with agreed
milestones
Monthly
throughout
2014/15
December
2014
Dementia ‘Finding’
question asked of at least
90% of emergency
patients aged 75 years or
over within 72 hours of
admission
Discharge
summary
published to GPs within 48
hours
of
patients’
discharge to reach 95% by
December 2014
Page 5
Our improvement objectives for 2014/15 incorporate the key areas for improvement for the next
five years, but these will be built on and taken further in the years to come. Using the same
framework, our objectives for the next five years are set out below, with the understanding that
these may develop as both healthcare and the Trust change during this period.
Strategic outcomes
1. Patients’ health and well-being is supported by high quality, safe and timely care
The Trust continues to hold patient safety as its first priority. We know that we have improved
patient safety through changes to clinical practice and patient care, through adoption of evidence
based guidance and compliance with care bundles.
We also know that we have a good safety culture, as demonstrated by our staff reporting high
numbers of incidents (National Reporting and Learning System (NRLS) data) and by our current
position in band 6 of the Care Quality Commission Intelligent Monitoring Report (CQC, July 2014),
denoting the lowest risk on 150 indicators.
However all this would be worthless if we had not also improved the ways in which we measure and
monitor patient safety; we now have data available to compare indicators across time and between
teams and organisations. An underpinning objective for all the following patient safety goals is that
the Trust continues to invest in the effective use of patient safety data and outcomes.
1.1 Reduce hospital related mortality:
The aim over the next five years is to reduce mortality risk-adjusted rates to the best 10% of NHS
hospitals. There are three specific areas that require focus:
1.1.1 The management of sepsis
1.1.2 Reduction in the incidence of urinary tract infections
1.1.3 Overall weekend mortality
1.2 Provide harm free care:
1.2.1 Pressure ulcers
Reduce the prevalence and incidence of pressures ulcers (grades 3 and 4) avoidable and
unavoidable, acquired in hospital and community settings year on year towards an
aspirational target of zero avoidable pressure ulcers by 2019.
We will work with our staff and in collaboration with other health and social care staff across
the health economy to reduce the burden of pressure ulcers, by improving knowledge and
awareness of the prevention and management of pressure ulcers, ensuring compliance with
the pressure ulcer prevention bundle and sharing best practice.
1.2.2 Falls
Reduce incidence of falls associated with injury and death (in 2013/14, total of 23 graded as
major, severe or catastrophic) by 10% year on year by 2019; reduce all avoidable falls
(number to be determined) associated with injury and death to 0 by 2019.
Draft 4 (18/09/14)
Page 6
1.2.3 Venous thromboembolism (VTE)
Reduce by 50% hospital acquired venous thromboembolism (VTE) by 2019, by:
a) Increasing to 95% compliance for root cause analysis (RCA) completion for incidents of
patients diagnosed with VTE within 30 days of discharge
b) Achieving 95% compliance for RCA completion for incidents of patients diagnosed with
VTE whilst in hospital
1.2.4 Medication errors
Reduce medication incidents which cause harm by 50% by 2019 from a 2013/14 baseline of
44 graded as major, severe or catastrophic.
1.2.5 Reduce healthcare associated infections
The aim over the next five years is to reduce healthcare acquired infections as follows:
a) MRSA bacteraemias – 0 cases attributed to the Trust year on year
b) Clostridium difficile – 0 cases due to lapses in care by 2019
c) Ventilator associated pneumonia (VAP) – lowest rate in the north of England
d) Central line infections – 0 cases by 2019
e) Catheter associated urinary tract infections – 50% reduction by 2019
1.3 Provide reliable care:
1.3.1 Acute myocardial infarction
1.3.2 Heart failure
1.3.3 Community acquired pneumonia
1.4 Reduce hospital readmission rates to the best 10% of NHS hospitals
2. Patients and their families feel cared for and empowered
The Trust will build upon systems and processes already in place to strengthen the cycle of
continual listening, learning and service improvement; working together with our patients, their
families and our partners in care, to ensure their feedback is routinely captured and used to
enhance patient experience and service improvement.
2.1 Capturing and learning from patient feedback
2.1.1 We will make it easy for patients, their families and carers to have the opportunity to tell us
about their experience of our services by a variety of methods, and that we will act on their
feedback to improve our services.
2.1.2 In addition to using the data captured from national and local surveys, patient stories and
the Friends and Family Test, we will endeavour to include and involve patients in all
appropriate Trust strategic or operational meetings where their input can make a difference
to our services.
2.1.3 We will extend and embed the Friends and Family Test in accordance with national guidance
and use the results to learn and to improve our care and the experiences of patients and
their families.
Draft 4 (18/09/14)
Page 7
2.2 Delivering dignity and care standards
2.2.1 We will ensure that the Trust’s Dignity and Respect standards are monitored for
effectiveness through the appropriate patient feedback methodology, enabling learning and
improvement.
2.2.2 We will ensure the annual Patient-Led Assessments of the Care Environment (PLACE)
robustly assess the dignity aspects of patient care and act on the results.
2.2.3 For nursing and midwifery staff in particular, we will incorporate specific objectives on the
themes of dignity and respect embodied within the Trust’s Nursing and Midwifery strategy
which is built around the national strategic driver of ‘Compassion in Practice – the 6Cs’.
2.2.4 We will continue to make improvements to the ways in which we care for patients with
dementia so that these patients and their families and carers have a positive experience of
care.
2.3 Complaints management
2.3.1 We will continue to improve the complaints process based on patient and family feedback
and also any changing national guidance for example, the Clwyd/Hart review (2013); this will
help to make it easier for complainants and enable the Trust to learn more effectively from
complaints.
2.3.2 We will improve the Trust’s complaints response rate, achieving our annual target of 85%
responses within the required timeframe, by introducing the following classification of
complaints:
Complaint level
Complex
Timeframes allowed
45 working days
Routine
35 working days
Simple
Less than 25 working days
Examples
Multiple issues relating to one or
more areas and/or one or more
professions
Mixed issues relating to one
area/profession
Appointment delay
This will incorporate a revision of existing complaints training for staff to encourage and
empower staff to resolve complaints as near to the ‘source’ of the complaint wherever
possible as this improves resolution and learning.
2.3.3 We will continue to embed and strengthen our duty of candour towards all patients involved
in a complaint or serious incident by:
a) Ensuring that all patients involved in a serious incident receive details on how it will be
investigated and the results of that investigation, face to face whenever possible
b) Demonstrating our duty of candour with all serious incidents by including a mandatory
section on all incident investigations
Draft 4 (18/09/14)
Page 8
c) Awareness raising for staff on the use of the NHS Litigation Authority leaflet ‘Saying
sorry’
Conclusion:
Our vision of quality for 2014-19 is that we will continue to put patients at the heart of everything
we do, and specifically prioritise patient safety and patient experience through the objectives
described above.
We cannot do this without our staff and an addendum to this strategy will be a plan to further
develop the quality improvement capability that already exists amongst staff in a more structured
way in the future.
Draft 4 (18/09/14)
Page 9
Board of Directors
Date
Date: 25th September 2014
Title of Report
CQC Consultation Briefing
Presented by:
Name & Title
Fifty-word
abstract – allows key
Part
Public/Private
Public
Item
No.
Judith Morris
Prepared by:
Risk and Safety Assurance
Manager
Director of Nursing and
Name & Title
Matron for Quality Improvement.
Midwifery
The purpose of this paper is to provide the Board of Directors with an overview
of the current CQC consultations on:
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.


The guidance for providers on meeting the fundamental standards and
on CQC’s enforcement powers
The guidance for NHS bodies on the fit and proper person requirement
for directors and the duty of candour
Strategic /
All strategic outcomes 2014/15
Corporate
Objective(s)
supported by this
paper
Is this on the

No
Yes
Trust’s risk
register?
Confirm that Datix and the BAF reflect this risk
and assurance information. Or state the date
when they will be updated.
Approve
Ratify so
Board action
as fit for
comes
sought (X)
purpose
into force
Points to note re the
Trust’s CQC registration
All standards
or the Trust’s compliance
with the Monitor licence.
If Yes,
Score
Endorse
management
action
Note
Other Material Issues for
Consideration:
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Page 1 of 3
Board of Directors September 2014
Finance
Strategy &
Investment
Committee
Other

1.
Introduction
In 2013, the CQC proposed radical changes to the way they regulate health and social care
services to make sure that organisations provide people with safe, effective, compassionate and
high-quality care. Earlier this year, the Department of Health also consulted on new regulations
that set out the ‘fundamental standards’ of quality and safety that all providers of healthcare must
meet.
2.
Proposed Changes
The CQC has proposed a number of significant changes to the regulation. The summary of the
changes are set out below:
a) There will be 11 new regulations that set out the fundamental standards of quality and safety
which will replace the current 16 regulations. A comparison of the previous and the new
regulations is shown in table below.
Current quality and safety regulations vs new fundamental standards
Current Regulations
New Regulations
















Care and welfare of service users
Assessing and monitoring the quality of service
provision
Safeguarding service users from abuse
Cleanliness and infection control
Management of medicines
Meeting nutritional needs
Safety and suitability of premises
Safety and suitability of equipment
Respecting and involving service users
Consent to care and treatment
Complaints
Records
Requirements relating to workers
Staffing
Supporting workers
Cooperating with other providers











Person-centred care
Dignity and respect
Need for consent
Safe care and treatment
Safeguarding service users from abuse
Meeting nutritional needs
Cleanliness, safety and suitability of premise
and equipment
Receiving and acting on complaints
Good governance
Staffing
Fit and proper persons employed


Fit and proper person requirement for directors
Duty of candour
b) The new regulations are more focused than the previous ones. They will enable the CQC to
pinpoint more clearly the standards ‘below which care must not fall’, and take appropriate
enforcement action. These regulations come into force in April 2015.
c) The introduction of 2 new regulations which will take effect from November 2014:

The duty of candour – this states what services must do to make sure they are open and
honest with people when something goes wrong with their care and treatment. When a service
is meeting the duty of candour the following should be evident:
o A culture within the service that is open and honest at all levels.
o Patients told in a timely manner when certain safety incidents have happened.
o Patients to receive a written and truthful account of the incident and an explanation
about any enquiries and investigations that the service will make.
Page 2 of 3
Board of Directors September 2014
o
o
Patients to receive an apology in writing.
Reasonable support for those directly affected by the incident.
If the service fails to do any of these things, the CQC can take immediate legal action
against the provider.

The fit and proper person requirement for directors – this clarifies that directors and
people in ‘equivalent’ positions of authority are personally responsible for the overall quality
and safety of care. When a service is meeting the fit and proper person requirement the public
should expect a named individual who will be held accountable if standards of care do not
meet legal requirements. That named individual should:
o be of good character
o have the necessary qualifications, skills and experience
o be able to perform the work that they are employed for
o supply information, such as certain checks and a full employment history
o have never been responsible for, or involved in, any serious misconduct or
mismanagement relating to any office or employment with a service provider.
d) There will be a new approach to enforcement power that allows CQC to take swifter action. CQC
will now be the main prosecution authority for health and social care at a national level.
Importantly, they will be able to prosecute providers for certain breaches of regulations without
first issuing them with a ‘warning’ notice. Their power includes:




Requirements - Where a provider is not meeting the fundamental standards (the
regulations), but people are not at immediate risk of harm, CQC will require the provider to
send a report. This must show what they will do to meet the standards. If they do not
improve, CQC will take further action.
Warning notices - Warning notices tell a provider that they are not meeting one of the
fundamental standards and can be published immediately. If an NHS trust or foundation
trust needs to make significant improvements CQC will issue a special warning notice
before they are placed into ‘special measures’.
Use of conditions - CQC can impose conditions on a provider’s registration with CQC.
This will affect the way they provide care for people. CQC can do this in a variety of ways
to keep people safe and ensure that legal requirements are met.
Prosecution - CQC can prosecute any provider that breaches certain requirements. CQC
will now be able to prosecute providers for serious, multiple or persistent breaches of the
fundamental standards without issuing a warning notice first.
e) The CQC is currently consulting on the guidance for providers on meeting the fundamental
standards and on CQC’s enforcement powers.
f)
In preparation for the introduction of the new regulations, all business groups are undertaking a
gap analysis on their compliance with the new fundamental standards so that any remedial action
can be taken prior to a CQC inspection.
The Board is asked to note the content of this paper.
Page 3 of 3
Board of Directors September 2014
Board of Directors
Part
Public/Private
Date
25 September 2014
Title of Report
REPORT OF THE CHIEF EXECUTIVE
Presented by:
Name & Title
Ann Barnes
(Chief Executive)
Fifty-word
abstract – allows key
facts and implications to
be identified in order to
allow for assessment as
to whether this paper
should come to the board
or go to one of the subcommittees. It will also
help to decide whether it
is sits in the public or
private part of the board.
Strategic /
Corporate
Objective(s)
supported by this
paper
Is this on the
Trust’s risk
register?
Prepared by:
Name & Title
Item
No.
Public
7.1
John Pierse
(Trust Secretary)
To update the Board of Directors on national and local strategic and
operational developments.




Quality
Partnership
Integration
Efficiency
No
Yes


Confirm that Datix and the BAF reflect this risk Confirmed.
and assurance information. Or state the date
when they will be updated.
Board action
Approve
Ratify so
sought (X)
as fit for
comes
purpose
into force
Points to note re the
Trust’s CQC registration
or the Trust’s compliance
with the Monitor licence.
Other Material Issues for
Consideration:
X
Pathology
Monitor
If Yes,
Score
Endorse
management
action


20
15
Note
X
Previous Meetings
Please insert the date the topic was escalated by the relevant Committee:
Audit
Committee
Quality
Assurance
Committee
Workforce &
OD
Committee
Exec
Team
Building a
Sustainable
Future
Committee
Finance
Strategy &
Investment
Committee
Other
16/09/14
1
Board of Directors’ meeting 25 September 2014
CHIEF EXECUTIVE’S REPORT
1. Monitor Issues
The most recent Progress Review Meeting with Monitor took place on Tuesday 5 August
2014.
Following each Progress Review Meeting, the Trust receives a letter from the Regional
Director at Monitor which provides a summary of the discussion and any key concerns
identified during the meeting by Monitor.
I thought it would be helpful if I provided a summary of the key concerns included in
Monitor’s letter for the Board together with a Trust response. Once seen by the Board of
Directors, it will be my intention to send a copy of the Board document to Monitor.
I am also attaching a letter from Monitor dated 17 September 2014 with regard to our
quarter 1 Monitor submissions.
2. South Sector Pathology
The Chief Operating Officer will update the Board at the meeting.
3. The 2015 Challenge Manifesto
Could I bring to the attention of the Board “the 2015 Challenge Manifesto”, a jointly owned
manifesto signed by a coalition of 21 major organisations across the health sector. This
was published on 11 September 2014.
The manifesto sets out a range of challenges facing the health service which must be
addressed in the period after the general election next year and proposes a route map to a
new health and care system. This includes a call for faster progress on payment systems
that support integrated, personalised care and reward good outcomes and also additional
transition funding of £4 billion over two years to help enable investment in service change.
4. Publications
a) Monitor Publications

NHS Healthcare Providers – working with choice and competition
This guidance is designed to help healthcare providers make the best decisions for
patients and explains how Monitor applies competition rules.

NHS Payment System: documents and guidance
This provides guidance and information on the NHS payment system, a set of prices
and rules regulating how hospitals and other providers are paid for care.

Choice and Competition – hypothetical scenarios for NHS providers
This provides examples of the types of conduct that can breach the competition
condition of the NHS provider licence and competition law.
2

Monitor survey of NHS Foundation Trust Governors
All Trust Governors have been provided with a link to the 2014 survey of NHS
Foundation Trust Governors. This examines Governors’ experiences as
representatives of patients, staff and other members and asks whether they feel
well equipped to do their role.

Monitor press release – Tameside and Glossop
Monitor has issued a press statement indicating that a team of experts is being sent
to help turn Tameside Hospital NHS Foundation Trust into a new more integrated
healthcare organisation providing public health, social care and wellbeing services.
b) NHS News
The NHS News Bulletins previously issued by NHS England have now been ceased
and replaced by a weekly ‘Informed’ publication.
Could I draw the attention of the Board of Directors to the following items from issues 67
to 70 of the NHS News and issues 1 to 3 of Informed.

Friends and Family Test Guidance published
Following an in depth review of existing practice, NHS England has published new
implementation guidance to support the expansion of the Friends and Family test
across the NHS. The test will be rolled out to GP Practices in December with mental
health, community services, NHS dental practices, ambulance and patient transport
services, acute hospitals’ outpatients and day cases following in later months.

NHS England publishes Annual Report
NHS England has published its first Annual Report and Accounts setting out its
achievements in the last year and its aspirations for 2014/15. The report features
key milestones since its inception in April 2013, the annual accounts and a
Directors’ report. In his introduction Chief Executive Simon Stevens recognises the
major transition that has seen two thirds of health service funding entrusted to local
groups of family doctors and other clinicians.

NHS England works in partnership for good governance
NHS England has commissioned the Good Governance Institute to carry out a
major piece of work to support CCGs with developing good governance
arrangements. The work will develop a range of tools to help CCGs formulate
governance arrangements that fit their organisation’s structure and aims and help
achieve the desired outcomes for patients and the public.

NHS takes action to tackle race inequality across the workforce
The NHS Equality and Diversity Council, chaired by Simon Stevens have
announced action to ensure employees from black and ethnic minority (BME)
backgrounds have equal access to career opportunities and fair treatment in the
workplace.
Read the press release here

NHS England works in partnership to provide £2million of support for
vulnerable patients this winter
NHS England has announced that up to eight voluntary sector organisations will
share £2 million to provide extra help over the busy winter months. Groups like Age
3
UK will run local projects that target those most at risk of admission to hospital and
who need extra support when they are discharged.

Survey reveals more needs to be done on choice for patients
Results of a survey for NHS England and Monitor, have shown that less than two
fifths of patients were offered a choice of hospital when being referred for an
outpatient appointment. Patients have a legal right to choose as set out in the NHS
Constitution.

NHS England engages on the NHS Standard Contract 2015/16
NHS England are welcoming comments on the NHS Standard Contract used by
NHS commissioners to contract for all healthcare services other than primary care.
Feedback will be used to inform an update for 2015/16. A discussion paper and
response document are available setting out key issues.

Urgent and Emergency Care Review Update
NHS England has published an update on the Urgent and Emergency Care Review.
The publication reports on work with local commissioners to development their
strategic and operational plans and provides an update on planning to develop
demonstrator sites to trial new models, including the new NHS 111 service
specification.

NHS England praises the NHS for referring more cancer patients early
NHS England has praised NHS staff for referring and treating patients earlier for
cancer. NHS England also announced the creation of a taskforce to help maintain
waiting time standards under the pressure of these increased referral and treatment
rates.
Mrs ADL Barnes
Chief Executive
JJP/SC/Notes/BoD/2014/25.09.14/Public/Chief Exec Report 25.09.14
19 September 2014
4
BOARD ASSURANCE
MONITOR LETTER FOLLOWING PRM ON 5 AUGUST 2014
1. The letter to the Trust following the Progress Review Meeting on 5 August 2014 details at
paragraph 6 a number of next steps.
One of these (6.1) says that:
“The Trust Board is expected to provide assurance as to the sufficiency and
sustainability of actions taken to address Monitor’s concerns set out above”.
The next steps (paragraphs 6.2, 6.3) also require submission of monthly and weekly
information. This is taking place.
Paragraph 6.4 refers consideration of a potential buddy organisation to provide additional
expertise to support the Trust in A&E. I will update the Board of Directors at the
September meeting.
With regard to paragraph 6.5, the next Progress Review Meeting is scheduled to take
place on 30 September 2014 at Monitor’s offices in London.
2. Key concerns
In summary, the key concerns identified by Monitor are:
a) Board Governance

We discussed the need for the Trust to be able to provide sufficient evidence to
Deloitte that the recommendations have been implemented and embedded at the
time of the follow-up review. The Board undertook to discuss further with Deloitte
the proposed timing of the follow-up review.
Trust Response
We have a robust process for delivering on the recommendations, including
collection of evidence to substantiate this.
Further discussions have now taken place with Deloitte and the follow-up review
will now take place in mid-November 2014 with the report available in midDecember 2014.

At our next meeting we will want to understand the Trust’s progress in
implementing the recommendations of the Deloitte review; the Board’s assurance
that all recommendations have been appropriately implemented and embedded;
and the agreed timetable for the Deloitte follow-up review.
1
Trust Response
The Trust will continue to update on progress until completion. Progress is
reviewed weekly by a Task and Finish Group and separately by the Executive
Team. A monthly update is provided to the public Board meeting and to Monitor.
Assurance is provided through the monthly progress update to the Board and will
be validated as part of the Deloitte’s follow up review in November 2014.
b) A&E

We note that the Board considers that the increase in management capacity,
during evenings and weekends, has contributed to the improvement in the Trust’s
performance. However, we also note that the Board considers that this increased
capacity cannot be sustained beyond August 2014.
Trust Response
This support has been secured throughout September and a survey taken of all
the managers to see how they feel the Trust could take forward such an
increased level of support in a more sustainable way. This has been discussed in
a senior management forum and the future model is being agreed at the end of
September at the monthly senior management team meeting.

We discussed the further actions being taken by the Trust to sustain the recent
improvements in the Trust’s performance when the additional management
capacity is removed. In particular we note that the Trust is considering including a
requirement to increase management capacity, in the same way as has proven
effective over recent months, in its A&E escalation process, triggered when
performance issues arise within the emergency department.
Trust Response
This is the same management actions outlined above and one of the options put
forward by and being considered by the senior managers is one of using
escalation triggers to determine additional management presence.

The Trust reported that there is a risk that its delivery of the A&E performance
trajectory for August may be delayed by up to two months, due to delays in the
implementation of the triage and community inreach schemes. The Trust reported
that it is already taking further action to mitigate this risk, in particular by
escalating the establishment of points within the hospital which can receive GP
referrals outside of the emergency department. We expect the Trust to continue to
take the necessary action to minimise the impact of the identified delays, so that
the Trust continues to meet the A&E performance trajectory, as required by the
Trust’s discretionary requirements.
Trust Response
Other actions have been taken to mitigate this risk including creating additional
areas to receive GP referrals outside of ED and additional middle grade medical
staffing at weekends whilst the more permanent solutions are delivered. These
are likely to have contributed to the improved performance to date.
2

At the next meeting we will want to understand the Trust’s progress in
implementing the Urgent Care Plan, and the further actions being taken to
mitigate identified risks to delivery; the Trust’s plans to sustain the recent
improvements in performance, in particular when the additional management
capacity is removed; and how the Trust will manage the transition of the executive
leadership of the programme.
Trust Response
The progress against plan will be presented in the Trust Board Unscheduled Care
Paper in September. A governance structure has been designed which outlines
how the transition of the executive leadership works and ensures that both the
Programme leadership and the Operations departments are clearly working
together on the developments in Urgent Care.

The Trust Board has reported that the development of the local health economy
(LHE) urgent care plan has not progressed since our progress review meeting in
July 2014. We note the Board’s concern that the continued delay may impact the
timely implementation of a LHE plan and consequently the ability of the Trust and
the LHE to respond effectively to winter pressures. The Trust is expected to
continue to engage with its partners in the LHE to ensure there is a robust
strategy in place prior to the emergence of winter pressures and to escalate the
issue around delays and lack of engagement by other stakeholders where
necessary and appropriate.
Trust Response
This has been discussed with the CCG in local meetings and also with NHS
England at an Urgent Care Performance meeting in September. The local
economy now has its new Urgent Care Programme structure in place and the
Trust are part of the senior leadership team who are taking the strategy forward.
c) Finance

We note the further work being undertaking by the Trust to increase the £12m CIP
target currently forecast for 2015/16. However we note that the Trust does not
currently anticipate that this further work will significantly change the financial
forecast for 2015/16.
Trust Response
The Trust has invested significantly in Turnaround and PMO resource, and
therefore would expect a significant return from this investment. The initial list of
areas for targeting in 2015/16 prepared by the Turnaround Director totalled
c.£22m. The Turnaround Director has initiated a structured process which
workstreams are undertaking throughout September, and by the end of October
there should be far greater clarity on the achievable value for 2015/16.
However, at the time of the PRM letter, and this update we have no further firm
information with which to update the 2015/16 forecast.
3

We appreciate there are a number of potential scenarios in respect of the Trust’s
longer term strategy due to uncertainties around the final outputs of Healthier
Together and the Challenged Health Economy work. However, at the next
meeting we would like to understand how the Board has assured itself that the
Trust is doing all that it can to secure the sustainability of the Trust, in advance of
the reconfiguration processes.
Trust Response
Whilst being supportive of the Healthier Together and Challenged Health
Economy work, the Board is also clear that it cannot rely on these to secure the
Trust’s future financial viability.
The Trust’s work with Value Dynamics identifying the service line strategy is being
developed and built on.
The Trust has therefore invested £1.3m in experienced Turnaround and PMO
resource to secure the CIP position, and is ensuring that managerial priority is
given by Operational managers to develop CIP and ensuring the 2015/16 position
is as large as possible.
The Trust has taken decision to move forward with the £17.25m D-block. This
decision was made to secure additional theatre capacity to enable the Trust to
continue to grow to meet demand, and to ensure we are best placed to benefit
from Healthier Together and Southern Sector outcomes.
The Trust will keep future financial plans firmly under regular and robust review,
and will also need to ensure that extra care over the 2015/16 contract
negotiations, to ensure that the settlement agreed covers the costs of delivering
our activity. Consideration needs to be given to the Trust’s course of action,
should the Contracts Team not be able to reach agreement on an acceptable
contract value for 2015/16. The Trust also needs to be firm in ensuring that an
acceptable margin is generated from any new investments.
JJP/SC/Monitor/PRMs/05.08.14/Board assurance – Monitor PRM letter 05.08.14
19 September 2014
4
17 September 2014
Ms Ann Barnes
Chief Executive
Stockport NHS Foundation Trust
Oak House
Poplar Grove
Stockport
Cheshire
SK2 7JE
Wellington House
133-155 Waterloo Road
London SE1 8UG
T: 020 3747 0000
E: [email protected]
W: www.monitor.gov.uk
Dear Ann
Q1 2014/15 monitoring of NHS foundation trusts
Our analysis of your Q1 submissions is now complete. Based on this work, the Trust’s
current ratings are:


Continuity of services risk rating
Governance risk rating
-
3
Red
These ratings will be published on Monitor’s website later in September.
The Trust is subject to formal enforcement action in the form of discretionary requirements
and an additional licence condition. In accordance with Monitor’s Enforcement Guidance,
such actions have also been published on our website.
In addition to the issues contained within the discretionary requirements and additional
licence condition referred to above, the Trust has also failed to meet the Cancer two week
wait (breast) targets at Q1.
Monitor uses the above target (amongst others) as an indicator to assess the quality of
governance at foundation trusts. A failure by a foundation trust to achieve the targets
applicable to it could indicate that the Trust is providing health care services in breach of its
licence.
We expect the Trust to address the issues leading to the target failures and achieve
sustainable compliance with the targets promptly. Monitor does not intend to take any
further action at this stage, however should these issues not be addressed promptly and
effectively, or should any other relevant circumstances arise, it will consider what if any
further regulatory action may be appropriate.
We also note the following risks from our review of the Trust’s Q1 submission:

The Trust has achieved its CIP target of £3m for Q1 2014/15, by mitigating the
£1.8m shortfall in recurrent CIPs with non-recurrent schemes.
Failure to deliver the planned level of recurrent CIPs will increase the financial
challenge in 2015/16.

As noted in our PRM letter of 14 August 2014, the Trust has developed plans for
£9.3m of CIPs i.e. 78% of its target for 2014/15.
We expect the Trust Board to assure itself that robust plans are developed to deliver
the CIP target for 2014/15 in full.
A report on the FT sector aggregate performance from Q1 2014/15 will shortly be available
on our website (in the News, events and publications section) which I hope you will find of
interest.
For your information, we will shortly be issuing a press release setting out a summary of the
key findings across the FT sector from the Q1 monitoring cycle.
If you have any queries relating to the above, please contact me by telephone on
2037470099 or by email ([email protected]).
Yours sincerely
Claudia Griffith
Senior Regional Manager
cc:
Ms Gillian Easson, Chairman
Mr William Gregory, Director of Finance & Deputy Chief Executive
The 2015 Challenge Manifesto
a time for action
Contents
The 2015 Challenge Manifesto: a time for action
2
A health and care system fit for the future
3
Support people to stay as well as possible for as long as possible
4
Reshape care around the needs, aspirations and capabilities of people today
5
Develop and support our workforce to meet future needs
7
Strive to continually improve quality and outcomes
8
Have adequate funding
9
Our commitments as health and care leaders
10
The time for action on health and care is now
11
Appendix: The 2015 Challenge Summary Declaration
12
References13
Further information
The 2015 Challenge Manifesto: a time for action
13
01
The 2015 Challenge Manifesto: a time for action
The 2015 General Election comes at a critical time for
health and care services. The pressures on the whole
system have never been greater.
The 2015 Challenge Declaration laid out the seven
challenges that politicians, policymakers and the
public need to address after the election: needs,
culture, design, finance, leadership, workforce and
technology. This powerful and comprehensive case
for change was produced by a partnership of national
organisations representing health and care charities,
local government, communities, staff and leaders
speaking with one voice. Since its publication, our
partnership has grown further. We have worked
together to set out in this manifesto both our vision
for health and care and how this can be achieved.
We recognise that during the pre-election period,
change in a politically sensitive area like health and
care is difficult to achieve. After the General Election
in May 2015, we hope, regardless of which party or
parties form a government, to have a period in which
the prevailing conditions accelerate the changes the
health and care system needs to make.
The years beyond the 2015 election must be a
historical turning point in the way we keep people
well and how we care for people who need care.
But if the way we support healthy lives and provide
care now is inadequate, what does the high-quality,
compassionate health and care service we wish
for ourselves and our loved ones in the future look
like, and how are the many willing people trying to
shape a better future going to know what they are
working towards?
02
This manifesto is a contribution from us all to making
that happen.
It sets out what we believe are the essential
components of a new health and care system and
how they might look and be experienced by people
using and working in health and care, and the
wider public.
It also sets out some shared ‘asks’ of politicians and
policymakers that are essential to achieve this vision.
We are sure these will be echoed across the system.
These will not be the only asks our organisations
make. The health and care system is complex
and diverse and there are legitimately different
perspectives on the best ways to achieve the vision.
This is what makes the asks in this manifesto so
powerful – if a partnership as representative of the
system has been able to agree on them, we hope and
believe that politicians and policymakers will take
them seriously.
“The years beyond the 2015
election must be a historical
turning point in the way
we keep people well and
how we care for people who
need care.”
A health and care system fit for the future
Our future health and care system must have the
following essential characteristics.
Its first priority would be to keep people as well
as possible for as long as possible. Services would
be reshaped around communities’ current and
future needs and resources, which are very different
now from in past decades, and be delivered by
appropriately skilled staff. Power would be shared,
with individuals able to shape their care around
their needs, aspirations and capabilities. The public
would have a real say about their services. Care
would be high-quality, compassionate and joinedup. Every organisation would strive continually to
improve quality and efficiency, making full use of
data and feedback, engaging staff and deploying
new technologies to this end. Real and continued
progress on eliminating discrimination and reducing
inequalities in outcomes would be seen.
Jointly held principles and values would bind health
and care together, working ever more closely as one
system. These would also be shared by service users,
citizens and staff. Principles and values include:
•aspiring to the highest standards of excellence
and professionalism
•supporting people to manage their health and
wellbeing as successfully as possible, with
maximum independence and control
•working across organisational boundaries and in
partnership with other organisations in the interest
of patients, citizens, local communities and the
wider population
•providing best value for taxpayers’ money and the
most effective, fair and sustainable use of finite
resources
They are already reflected in the NHS Constitution
and have informed the development of the Care Act
2014.
At an individual level, this future health and care
system would mean:
•a person using services would be empowered to
personalise care to their needs, aspirations and
capacities – and services would work together
to join up this care around them. They would be
supported to stay as well as possible for as long as
possible, and be pleased with their experience and
outcomes
•a citizen would be supported to maintain their
health, and confident they can access high-quality,
compassionate, joined-up care when needed. Local
leaders would engage with them to help ensure
services reflect people’s needs, aspirations and
capacities
•all staff at every level would be developed,
valued and supported to deliver high-quality,
compassionate, joined-up care and work in
partnership with service users. Their experience and
insight would influence how care is provided and
prevent failures, and they would be supported to
maintain their own wellbeing.
We all – service users, families, carers, communities,
staff, politicians and system leaders – would feel
deeply proud of our health and care services.
Our route map to the future health
and care system
We explain our vision of a new health and care system
in more detail below, alongside the main things we
collectively ask of politicians and policymakers in
England to enable us to achieve this vision.
•accountability to the public, communities and
individuals we serve.
The 2015 Challenge Manifesto: a time for action
03
We need to...
support people to stay as well as possible
for as long as possible
Much ill health is caused by factors like smoking,
obesity and inactivity that are preventable. Too
often, people who have or develop health conditions
don’t get the support they need to build their
resilience and stay well, resulting in distressing and
expensive crises.
Our starting point must be a strong, whole-system
focus on supporting people to stay in good mental
and physical health. Not only is this critical in its
own right to improve lives, it is also crucial to the
long-term sustainability of our health and care
services. Making the fastest progress in improving the
wellbeing of people with the greatest risk or burden of
ill health must be a priority.
Health and wellbeing boards have a crucial role to
play in ensuring all decisions about local services
(including those beyond health and care) reflect
local priorities for improving people’s health and
reducing preventable illness. The potential of national
government to affect people’s health, including in
relation to alcohol, tobacco and unhealthy foods, is
also important.
We ask all political parties to set out in their
manifestos how they would support local efforts
to reduce preventable illness and improve wellbeing.
Prevention, health promotion, maintaining people’s
wellbeing and addressing the wider determinants
of ill-health must be shared, fundamental priorities
across not only the whole health and care system,
but also the whole public sector and local and
national government, working with the voluntary and
community sector and business. Joined-up solutions
must be adopted in every local area.
“Our starting point must be a strong, whole-system
focus on supporting people to stay in good mental
and physical health.”
04
We need to...
reshape care around the needs, aspirations
and capabilities of people today
The way we provide care no longer meets the needs
of the people we are caring for – particularly the
growing number of people with multiple illnesses,
whose care is too often fragmented and focused on
single illnesses.
Instead, care needs to be joined up around people’s
needs as a whole, and maximise the capacities of
individuals, families and communities. Everyone with
a continuing condition must be able to plan their
care with people who work together to understand
them and their carer(s), give them control, and bring
together services to achieve the outcomes important
to them.
Many services will need to be redesigned, to deliver
radically different models of care which better
meet the needs of all citizens, reflect advances in
care and overcome historic boundaries between
organisations and care pathways which get in the way
of fully joined-up care. Local leaders must work in
partnership with people to reshape services, focusing
on delivering the outcomes that matter to people
as well as greater sustainability. They must also
use the experience and insight of community and
voluntary sector groups that support people’s health
and wellbeing.
The major changes required in many places will
be tough and cannot be delivered overnight.
Stability of the system’s structures is important to
enable change.
We ask all political parties to commit publicly
that they will not impose another top-down
structural reorganisation on the NHS, and will instead
focus on enabling locally-led improvement of care.
The 2015 Challenge Manifesto: a time for action
Each local area should adopt their own solution that
works for local people’s needs and uses local assets,
but common characteristics would include:
•a coordinated, preventative approach to health
and wellbeing as a priority
•proactive, readily accessible community-based
services (including community health, primary
care and social care) that work closely together to
provide a high proportion of care closer to, and
in, people’s homes, as well as working closely
with hospitals and supporting people to remain
independent
•sustainable, high-quality hospitals that offer
excellent acute care in specialised settings when
required and work collaboratively with other
providers – hospitals that are more than a building,
with teams that work closely with communitybased colleagues and are accessible, where
appropriate, outside hospital
•urgent and emergency care delivered in a range
of settings to best meet service users’ needs
•sustainable, high-quality mental health services
that have parity with, and work closely alongside,
other services, address people’s mental and
physical needs in a joined-up way, and focus
on recovery
•multi-professional teams that work together and
communicate effectively across traditional service
boundaries in order to provide continuity of care,
and work in partnership with patients, service users
and carers
•individuals, communities and the voluntary and
community sector engaged and supported to
contribute to holistic, supportive care.
05
Debates about change must focus on the implications
for people’s outcomes, experience and wellbeing,
rather than on buildings and organisation charts.
National and local politicians should play a leadership
role in bringing this about.
Politicians must recognise that change in the way
we organise care is necessary, and that this change
will be driven locally and must be right for the
local population.
We ask the next Government to avoid mandatory,
‘one size fits all’ models for reform.
We ask all politicians, national and local, to
recognise that change in the way we organise care
is necessary, and to play a leadership role in ensuring
debates about change focus constructively on the
implications for people’s outcomes, experiences
and wellbeing.
Every organisation needs to be able to plan for a
sustainable future. Some NHS trusts have little
realistic prospect of meeting the sustainability tests
for foundation trust status, often because of longstanding sustainability challenges across their wider
local health and care system that they cannot address
on their own.
Service users, their families, friends and wider
communities provide vital support alongside more
‘formal’ care, without which our health and care
services could not operate. This support will be
essential to the long-term sustainability of health
and care.
We must value support for self-managed care just
as much as we value care managed by health and
care professionals. This means ensuring people with
long-term conditions feel confident, equipped and
supported to play a far greater role in managing their
own condition(s), empowered by new technologies
and professionals who work in partnership with
them. Health and care organisations and staff need
to feel able to trust the capacities that service users
can bring. Changing skills, cultures and behaviours
to enable and support self-managed care will require
support.
We ask all parties to commit to supporting a
national sector-led programme to support health
and social care organisations to adopt participation,
personalised care and support planning, shared
decision making and supported self-management
approaches for all who would benefit.
We ask the next Government and national bodies
to make available a range of organisational
models for providers, including small providers from
the voluntary and community sector, to enable them to
deliver clinically and financially sustainable services
and reflect the needs and aspirations of local service
users and communities. We also ask the Government
to clarify as soon as possible its strategic intent for the
‘pipeline’ of NHS trusts still seeking foundation status.
“We must value support for self-managed care just
as much as we value care managed by health and
care professionals.”
06
We need to...
develop and support our workforce
to meet future needs
New models of service will need different skills and
roles across health and care. As many staff are asked
to take on more flexible roles, including working more
often in community settings and addressing multiple
conditions simultaneously, we will need to support
them to make the transition.
The future health and care system needs staff to feel
valued, and equipped and supported to:
•work in partnership with the public, people who use
services and their families and carers
•deliver more personalised care
•support self-management and promote
independence
The Government should recognise the need to
value, develop and support our staff. We ask that
the next Government:
•initiates and resources a development programme
that equips and supports today’s workforce for
the challenges of working in new ways, including
working across and with different sectors and
professions, engaging service users and supporting
personalised care and support planning, shared
decision-making and self-management
•helps build consensus around the expectations on
the health and care workforce in providing sevenday services more widely, and provides support for
making the changes required to achieve this.
•work collaboratively across professional and
organisational boundaries (including across
health, social care and public health) and in
multi-professional teams
•harness new technologies.
We also need to address shortages in the skilled
people we need across the health and care system.
Leaders of health and care organisations must engage
with staff to build trust and confidence, which in turn
demonstrates staff are valued, encourages retention
of skills and enhances the reputation of the NHS and
social care as a great place to work.
The 2015 Challenge Manifesto: a time for action
07
We need to...
strive to continually improve quality
and outcomes
Health and care services must consistently be good
enough for us and our loved ones.
Common standards and targets have a role to play
in improving outcomes and reducing variation.
Addressing the stark differences in people’s ability
to access mental and physical healthcare is one
area where this approach is particularly crucial.
Mental and physical health are equally important,
and essentially inseparable: the physical health of
someone with enduring mental ill health is just as
important as the mental health of someone which a
long-term physical condition.
We call on all parties to set out concrete plans to
make mental health services as accessible to
people as physical health services, over the course of
the next Parliament. This must include committing to:
•extending rights – all mental health service users
should be able to access services from a provider of
their choice on the same basis as service users with
physical health problems
•continuing to tackle stigma, including by funding
the Time to Change programme over the lifetime of
the next Parliament.
However, we cannot rely on national standards and
targets alone to secure consistently high-quality,
compassionate care. To continually improve care and
prevent failures, we also need to value and engage
staff fully, establish cultures where people feel safe to
report and learn from mistakes, and look to clinicians
and managers to manage priorities and use data
and feedback well. Transparency and accountability
matter at local and national levels.
We look to politicians and national bodies to support
a shift to a new way of working which focuses on
improving people’s outcomes over the long term
and delivering compassionate care in partnership
with service users, rather than being dominated by
meeting short-term, process-driven targets. The
outcomes that are measured and rewarded must be
developed with service users to reflect what matters
to them – including outcomes which can only be
08
delivered if services work in partnership. Nationally
determined outcomes will need to allow room for
local commissioners to also focus on delivering
personalised outcomes developed and agreed
with individuals, and to respond to communitylevel priorities.
Organisations need to know what they are
accountable for, and this needs to be simple,
consistent across the system, and measured once.
We call on the Government and NHS England
to develop a simplified outcomes framework,
with indicators that clearly align across health and
social care.
Staff at all levels must be valued and engaged,
their concerns listened to, and their knowledge and
experience used to continually improve care. Staff
wellbeing must also be supported. This is essential for
high-quality, compassionate care and will also reduce
sickness absence.
The right conditions will be needed to enable
technology, data and research to be used to
underpin new models of care and improve quality,
coordination, efficiency and people’s experience.
We need a culture of innovation and a good basis for
investment in further research and new technologies.
Digital technology has transformed many areas of our
lives and now needs to be used across health and care
to support our ongoing relationships with citizens and
people who use our services; support teams to work
together for individuals and communities; provide
people with better information about their choices
about their care; help them manage their health
efficiently and effectively; and support independence.
People should be enabled to be masters of new
technologies, not slaves to unresponsive systems.
We call on the next Government to ensure the
right conditions are in place to enable the locally
led deployment of new technologies, coordinated
information systems and research at pace and scale to
underpin better models of care and improve quality,
efficiency and people’s experience.
We need to...
have adequate funding
Health and care leaders are committed to ensuring
our services are efficient and deliver the best possible
outcomes from the finite resources allocated.
But the health and care system cannot achieve
financial sustainability without changing models
of care to become fundamentally more efficient.
More proactive services in community settings
will be central to improved care. To deliver this, we
will need to shift resources into community-based
care, and tackle recognised pressures in social care,
general practice and community health, at the
same time as addressing risks to other services from
shifting resources.
Many of the service changes we need to make will
require investment, and we cannot do this without
support from government.
We call on the next Government to generate
the stability that would enable longer-term
approaches to investing to achieve savings. All parties
should set clear expectations on the level of health and
care spend for at least the next Parliament. National
bodies should be tasked with facilitating health and
care organisations to take a longer-term approach to
investing in service change, particularly those that
require spending upfront in order to deliver
savings later.
The way commissioners currently pay for services is a
barrier to new, integrated models of care, and focuses
too little on measuring and rewarding people’s
outcomes. Urgent action is needed to remedy this.
We call on government and national bodies to
commit to making faster progress towards new
payment mechanisms that support integrated,
personalised care and reward good outcomes.
The 2015 Challenge Manifesto: a time for action
Up-front investment will be vital to support the safe
transfer to new models of care. If we do not make
changes now, the cost of doing nothing will be even
greater in the long term.
We call on the next Government to put in place as
soon as possible a transition fund of at least £2bn
per year of new money, for two years, to help enable
investment in service change.
With demand for care rising inexorably, it is clear
that the solutions identified so far cannot come close
to filling the whole NHS funding gap.1 While there
is some room to improve efficiency, our health and
care system is already one of the most efficient in the
world.2
Social care is also under immense pressure from
significant increases in demand and reductions in
funding.3 Health and social care funding are two sides
of the same coin: the solution is not to rob one to pay
the other.
We all have a duty to be frank with the public that the
health and care system cannot continue to absorb the
pressures on it and deliver everything it currently does
in future years without more funding.
Everyone across health and care must focus on
securing the best possible outcomes for people from
the resources allocated. But, ultimately, the level of
resources for health and care, and the consequences
of this, is a political choice.
We demand that the political parties recognise
their accountability for the decisions they make
on funding health and care adequately.
09
Our commitments as health and care leaders
High-quality local leadership will be vital if we are
to achieve this vision for health and care. Local
leaders must ready themselves to drive the changes
required, and should not wait for permission to
transform services.
Service users, carers and citizens must be supported
to get involved with and shape health and care
decisions, and develop as leaders.
Leadership operates at all levels and the climate
created by leaders at national level, including
politicians, influences leaders at local level. A punitive
environment would work against the courage and
resilience local leaders will need to drive the major
changes required. Politicians and national bodies
must set a tone which is supportive of local leaders
as they face these unprecedentedly severe challenges
head on.
•prioritise meaningful engagement as equals
We are looking to politicians and policymakers to
create the conditions for locally-led change. We also
set out some commitments from health and care
leaders in return.
Equally, the views of staff must be sought, listened
to and acted on. In future, more health and social
care professionals should be supported and enabled
to take on leadership roles, including developing
proposals for service improvement, and our health
and care leadership should look more like the citizens
we serve: more women and BME people should be in
leadership roles.
Partnership working between local leaders at all levels
from a wide range of health, care, public health and
related organisations, focused on achieving the best
possible outcomes for populations, will be essential.
Health and care leaders will commit to reach
beyond the boundaries of their own
organisations, and to work in partnership as
‘place-based’ leaders with shared values and a clear
and shared set of priorities for population health and
wellbeing outcomes.
10
Health and care leaders will commit to:
with service users and the public
•develop leadership roles and capabilities for local
‘lay’ or ‘patient’ leaders to help shape system
transformation and service redesign
•work with service users, the public and community
organisations in developing proposals for change,
explain pros and cons clearly, and be bold.
Health and care leaders will commit to ensure
care benefits fully from the huge value that staff
commitment brings. This means:
•ensuring staff are developed and supported,
feel respected and can influence their job
•seeking and responding to staff feedback.
The time for action on health and care is now
Words alone will not make a reality of this vision for a
modern, high-quality, compassionate, personalised
health and care system. We have set out our shared
asks that are essential to achieve the vision. What we
need now is action.
Strong leadership will be required at all levels, from
national government to the staff and service users at
the front line of day-to-day care.
Our organisations commit to continue working with
each other to highlight the changes required, and
with those we represent to enable local leaders to
sustain and reinvigorate health and care.
Leaders at all levels of health and care need to drive
changes to services locally, working in partnership
with each other, staff, service users and communities
to reflect local needs, aspirations and assets.
The 2015 Challenge Manifesto: a time for action
Government and national bodies must also do the
things that only they can do to create the conditions
to enable successful, locally led change.
As the 2015 General Election approaches, the
national political parties must not be silent on the
challenges which face the health and care sector. Our
organisations demand that the parties commit ahead
of the election to delivering on these shared asks,
which are essential to secure the services we wish for
ourselves and our loved ones in the future.
To join the conversation,
email [email protected]
or on Twitter use #2015Challenge
11
Appendix: The 2015 Challenge Summary Declaration
The 2015 Challenge Declaration set out seven challenges facing the health, care and wellbeing system.
1
2
3
4
5
6
7
12
The need challenge
Meeting the rising demand for care, particularly from people with complex needs
or long-term conditions, while maintaining people’s wellbeing and preventing ill
health for as long as possible.
The culture challenge
Building confidence in the health service by achieving a fundamental shift in
culture from the bottom up. Creating a more open and transparent NHS, which
enables patients, citizens and communities to be partners in decisions, and staff
to improve care.
The design challenge
Redesigning the health and care system to reflect the needs of people now – and
so that it remains sustainable in the future. Shifting more care closer to people’s
homes, while maintaining great hospital care. A focus on joining up all parts of
the health and care system so care revolves around the needs and capacities of
individuals, families and communities.
The finance challenge
Recognising the financial pressures on all parts of the system and squeezing value
from every penny of public money spent on health and care. Debating honestly
and openly the future levels and sources of funding of health and social care.
The leadership challenge
Creating value-based, system leaders across the NHS and empowering them to
improve health and wellbeing for local people. Supporting these local leaders to
work in partnership with a wide range of health, care and related organisations to
address the 2015 Challenge, involve patients and citizens as leaders, and have the
resilience to make the biggest changes in the recent history of health and care.
The workforce challenge
Planning for a workforce to better match changing demand. Developing staff roles
and skills to provide complex, multidisciplinary, coordinated care, in partnership
with individuals and communities and more often in community settings.
The technology challenge
Using technology to help transform care and enabling people to access
information and treatment in a way that meets their needs. Spreading innovation
to improve the quality of care while responding to the financial challenge facing
the NHS and care system.
References
Further information
1. Nuffield Trust (2012) A decade of austerity? p11:
“Taken together, however, releasing savings and
managing demand related to chronic conditions
will still not be sufficient to close the funding gap
if funding is frozen in real terms after 2014/15.”
The Academy of Medical Royal Colleges
www.aomrc.org.uk
See also Monitor (2013) Closing the funding gap,
which identifies that the potential savings from
changes to services could save from £10.6bn to
£18bn of the £30bn funding gap.
2. A recent Commonwealth Fund survey of 11
nations’ health systems found the UK system
to be the most efficient. See Commonwealth
Fund (2014) Mirror, mirror on the wall, 2014
update: how the US health care system compares
internationally.
3. National Audit Office (2014) Adult social care
in England: overview, highlights rising care
needs, a fall in spending on adult social care of
8 per cent in real terms between 2010/11 and
2012/13 and projections this will continue, and
found that: “Departments do not know if we
are approaching the limits of the capacity of the
system to continue to absorb these pressures.”
The Association of Directors of Adult Social Services
www.adass.org.uk/home
Age UK
www.ageuk.org.uk
The Association of Directors of Public Health
www.adph.org.uk
Asthma UK
www.asthma.org.uk
British Heart Foundation
www.bhf.org.uk
The Chartered Society of Physiotherapy
www.csp.org.uk
The College of Emergency Medicine
www.collemergencymed.ac.uk
Faculty of Medical Leadership and Management
www.fmlm.ac.uk
The Foundation Trust Network
www.foundationtrustnetwork.org
Healthcare Financial Management Association
www.hfma.org.uk
The Institute of Healthcare Management
www.ihm.org.uk
The Local Government Association
www.local.gov.uk
Macmillan Cancer Support
www.macmillan.org.uk
National Voices
www.nationalvoices.org.uk
The NHS Confederation
www.nhsconfed.org
The Royal College of General Practitioners
www.rcgp.org.uk
The Royal College of Nursing
www.rcn.org.uk
The Royal College of Physicians
www.rcplondon.ac.uk
The Royal Society for Public Health
www.rsph.org.uk
Scope
www.scope.org.uk
The 2015 Challenge Manifesto: a time for action
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