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COUNCIL OF GOVERNORS 15 March 2017
5pm – 7pm Board Room, Aintree Lodge
AGENDA
d = document v = verbal p = presentation
No Item Reference
Preliminary Business – Chairman
1. Apologies for Absence
To note the apologies
CG16-17/033 (v)
2. Declarations of Interest
To receive declarations of interest in agenda items and/or any changes to the register of governors’ declarations of interest pursuant to Standing Orders
CG16-17/034 (v)
3. Minutes from the last meeting (8 December 2016)
To approve the minutes from the last meeting and discuss any matters arising:
Exit Interviews (Director of People & Corporate Affairs)
CG16-17/035 (d)
CG16-17/036 (d)
Overview
4. Strategic Update
Chairman/Chief Executive
To note
CG16-17/037 (p)
5. Lead Governor Report
To note
CG16-17/038 (d)
Quality & Performance Management
6. Emergency & Acute Care Programme
Deputy Chief Operating Officer
CG16-17/039 (p)
7. Assurance on Key Indicators:
Quality & Safety
Finance & Performance
Non-Executive Directors
CG16-17/040 (p)
Internal System of Control
8. Key Issues & Assurances
Audit
Non-Executive Director
CG16-17/041 (p)
Governance
9. Appointment of External Auditor
Non-Executive Director & Governor Representative
To approve
CG16-17/042 (d)
10. Governor Committees:
Committee Chairs
Membership Committee (1 February 2017) for noting
Quality of Care Committee (9 February 2017) for noting
Nominations Committee (15 March 2017) for approval
CG16-17/043 (d/v)
Cou
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Aintree University Hospital NHS Foundation Trust
Agenda: Council of Governors’ Meeting15 March 2017 2/2
Concluding Business
11. Any Other Business
Chairman
CG16-17/044 (v)
12. Date and Time of Next Meeting:
Thursday 15 June 2017 at 12:30pm – 2.30pm
Council of Governors – Objectives 2016/17
To further develop skills and knowledge base in order to collectively understand and constructively challenge and support the quality of care agenda provided by the Trust
To improve communication and engagement with members of the Trust in line with the membership strategy objectives
To monitor the performance of the Board of Directors through holding the Non-Executive Directors individually and collectively to account
To deliver its statutory duties in line with regulatory requirements
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Council of Governors
Wednesday 8 December 2016 12:30pm
Board Room Aintree Lodge
MINUTES
Present: Neil Goodwin - Chairman
Pamela Peel - Lead Governor
Sharon Bird - Public Governor
Mike Bowker - Public Governor
Tony Byrne - Public Governor
Gerry Hill - Public Governor
John Johnson - Public Governor
Tony Kneebone - Pubic Governor
Julie Naybour - Public Governor
Stephen Thornhill - Public Governor
Rose Milnes - Public Governor
Helen Frankland - Staff Governor (Nursing)
Lorraine Heaton - Staff Governor (AHPs)
Kerry McManus - Staff Governor (Other)
Paul Cummins - Appointed Governor (Sefton Council)
In Attendance:
Steve Evans - Medical Director
David Fillingham - Non-Executive Director
Michael Games - Corporate Governance Manager
Sue Green - Director of People & Corporate Affairs
Tim Johnston - Non-Executive Director
Ian Jones - Director of Finance & Business Services
Caroline Keating - Associate Director of Corporate Governance/Board
Secretary
Emily Kelso - Corporate Governance Officer
Kevan Ryan - Non-Executive Director
Angie Smithson - Deputy Chief Executive/Chief Operating Officer
Apologies: Tracey Barnes - Public Governor
Mike Booth - Public Governor
Brian Lawless - Public Governor
Rosemary Urion - Public Governor
Andrew Swift - Staff Governor (Medical)
Barbara Hunter-Douglas - Appointed Governor (Edge Hill University)
John Wilding - Appointed Governor (University of Liverpool)
Joanne Clague - Non-Executive Director
Paul Fitzpatrick - Director of Estates & Facilities
Juliet Herzog - Non-Executive Director
Andrea Thomas - Acting Director of Nursing & Quality
Steve Warburton - Chief Executive
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Minutes: Council of Governors’ Meeting 8 December 2016 2/6
Ref Minute
Preliminary Business
CG16-17/023 Apologies for Absence
The apologies were noted as above.
CG16-17/024 Declarations of Interest
There were no declarations of interest.
CG16-17/025 Minutes from the last meeting (18 October 2016)
The minutes from the previous meeting held on 18 October 2016 were approved as an
accurate record. There were no matters arising.
Overview
CG16-17/026 Strategic Update
Prior to the strategic update, the Chairman advised that the Council of Governors had
met earlier and approved the appointment of Mandy Wearne to the post of Non-
Executive with effect from 3 January 2017 to replace Juliet Herzog who was leaving the
Trust on 31 March 2017.
The Chairman and Deputy Chief Executive then advised the meeting of the following
matters:
Aintree/Royal Merger – it was confirmed that the target date for the proposed merger
was 1 April 2018. A Programme Board had been established to oversee the process
with the Chairs, Chief Executives and Medical Directors of both Trusts in attendance.
Further consultancy support was being sought for high level strategic and tactical advice.
Regular updates will be provided to Governors through the formal Council meetings and
Board feedback sessions hosted by the Chairman.
Sustainability & Transformation Plan (STP) – the proposed merger with the Royal
Liverpool formed a significant part of the Trust’s Local Delivery Plan in North Mersey for
the Cheshire & Merseyside STP. It was acknowledged that STP’s both locally and
nationally had received negative media coverage but the local delivery plan was
considered to be credible and the proposed merger had broad political support locally.
Liverpool Community Services – the contract for services in Liverpool had been
awarded to the consortium led by Bridgewater, which included Aintree, with the contract
for South Sefton being awarded to Mersey Care. Overall, there were 13 transactions to
be undertaken before 1 April 2017. Whilst there was expected to be challenges with
having two different providers, the Trust would continue to work closely with them going
forward.
Members of the Council then sought and received clarification in relation to the following
matters:
The Trust continued to work with NHS Improvement on the detail of the merger
process for a Foundation Trust and an NHS Trust. As RLBUHT only had a shadow
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Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 8 December 2016 3/6
Ref Minute
Council of Governors in place there was no necessity for a joint meeting for the time
being and the Trust’s Lead Governor would continue to meet with the Royal’s
shadow Lead Governor.
The proposed merger makes reference to three Trusts coming together, including
Liverpool Women’s Hospital (LWH). However, LWH was currently going through an
options appraisal process with the Commissioners which will require consultation on
the future location of services. Once this process was concluded a decision would be
made about the best way for LWH services to be merged into the one entity.
There would be a single budget for the merged organisation with effect from April
2018. The costs associated with the merger would be borne by both Trusts and had
been included in the Trust’s annual plan. The merger would seek to sustain services
going forward whilst also creating efficiencies and savings without compromising the
quality of care.
If strong political views emerged that meant that the STP would be difficult or
impossible to achieve it may have an impact on the timetable for merger. The Trust
had raised its concerns on the governance arrangements for the STP particularly in
relation to the financial commitments for a review of services and whether the Trust
could contribute given the costs associated with the merger.
CG16-17/027 Lead Governor Report
The Lead Governor made reference to the report issued at the meeting and highlighted
the following matters:
Board Feedback Sessions – Governors were encouraged to attend these sessions
hosted by the Chairman. The next session was Monday 12 December 2016
Governor Activity – there had been positive involvement by Governors at recent events
including the Fazakerley Health and Wellbeing Forum, monthly Aintree Volunteer
Inductions, the Proud of Aintree Excellence Awards, Quality Conversation hosted by the
Patient Experience Team, Catering Food Quality Group and the Aintree/Edge Hill return
to Practice Nurse Interviews.
Governor Issues Log – the key themes arising from Governor queries had been
included for information purposes.
Lead Governor Activity – the Lead Governor continues to meet informally with the
shadow Lead Governor at RLBUHT and would feed back further on the development of
the Lead Governors’ Network. The national Lead Governor network had been working to
get more recognition from NHSI, some progress had been made with this and a
conference call had been set up to discuss ways to work alongside each other. Further
progress would be reported on in due course.
The Council noted the update.
Quality & Performance Management
CG16-17/028 Assurance on Key Indicators
Quality & Safety
Kevan Ryan (Non-Executive Director), member of the Quality & Safety Committee, gave
a presentation on assurance on key indicators relevant to quality and safety which
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Minutes: Council of Governors’ Meeting 8 December 2016 4/6
Ref Minute
covered the key areas of focus, where on-going assurance was received and where
assurance was sought on areas of concern. He highlighted the main areas of Committee
focus including serious incidents together with the main themes and trends, the Quality
Strategy delivery plan, infection prevention & control, mortality and the risk register. He
also referred to the on-going assurance relating to workforce and patient experience as
well as the areas of concern in respect of the Trust’s response to the CQC report and
ophthalmology. An overview was also provided on the Trust’s performance against the
main quality indicators.
Finance & Performance
David Fillingham (Non-Executive Director), member of the Finance & Performance
Committee, then gave a similar presentation on assurance on key indicators relevant to
finance and performance which covered the key areas of focus including the operational
plan for 2017-19, the financial outturn for 2016-17, performance against cancer targets
and divisional deep dives. He also highlighted the areas of on-going assurance in
relation to emergency & acute care, transformation and the progress against the annual
business plan priorities. Reference was also made to the areas of concern in relation to
stroke services and agency staffing. An overview was also provide on performance
against the financial and activity indicators, including access to services and workforce
targets.
Members of the Council then sought and received clarification in relation to the following
matters:
The steady increase over the last three quarters in the mortality rates for the
Standard Hospital Mortality Indicator (SHMI) and the maintenance of a watching brief
over the coming months
The increase in the number of Serious Incidents reported and the value of the
lessons learned arising from these cases to improve systems and processes to
minimise further cases arising
The work being undertaken through increased staff training to reduce the level of
pressure ulcer cases whilst also reviewing the key trends
The continued efforts being exerted on recruitment of staff to make the Trust
attractive for potential employees as well as focussing on compliance with mandatory
training and further development of current staff to enhance retention.
The capacity and resourcing issues being dealt with within Ophthalmology to clear
the backlog and tackle the demand for the service
The Trust’s AED performance in comparison to others locally and nationally and the
support being provided to the Trust by Emergency Care Improvement Programme
(ECIP) hosted by NHS Improvement. Also, the improvements made to systems and
processes arising from the establishment of the Purple to Gold (Added Value)
Scheme
The improvements made by the Trust in conjunction with NWAS on reducing
ambulance handover times
The concerns with the stroke service not achieving its prescribed standards and the
continued work being undertaken to address staffing levels
The analysis of exit interviews to determine any themes in relation to turnover of staff.
A report was to be provided to the next Council meeting in regard to this matter.
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Minutes: Council of Governors’ Meeting 8 December 2016 5/6
Ref Minute
The Council noted the presentations.
Internal System of Control
CG16-17/029 Key Issues & Assurance (Audit)
Tim Johnston (Non-Executive Director), Chair of the Audit Committee, gave a
presentation which covered the key areas of assurance gleaned from the Committee’s
deliberations which included internal audit reports on A&E Data Quality and Equality &
Diversity together with the assurance sought on areas of concern relating to sickness
absence management and additional clinical activity sessions.
Members of the Council then sought and received clarification in relation to the following:
The Trust’s internal systems and controls in place to combat cyber-attacks and the
continued work with the Counter Fraud Team on raising awareness amongst staff.
Governance
CG16-17/030 Reports of Governor Committee Chairs
Membership Committee – 10 November 2016
The Council of Governors received the report of the Committee which was taken as read
and noted.
Quality of Care Committee – 16 November 2016
The Council of Governors received the report of the Committee which was taken as read
and noted.
Reference was made to the Purple to Gold (Value Added) scheme and Governors were
encouraged to get involved where appropriate with the initiative as well as attending the
MADE events to be arranged during the festive period.
Nominations Committee –8 December 2016
The Council of Governors received the verbal report of the Committee relating to the
approval of the appointment of Mandy Wearne to the post of Non-Executive.
CG16-17/031 Governors Elections
The Associate Director of Corporate Governance presented the report which provided
and update on forthcoming Governor elections which will take place January to March
2017. NHSI had been consulted on the necessity for elections to take place given the
merger discussions and confirmation had been received that the Health & Social Care
Act required the elections.
The Council noted that 1 staff post (AHP/Scientists) and 8 public posts were to be
advertised. Three Governors would not be eligible to stand for election as they had
completed two consecutive terms of office. Prospective governors would be invited to
attend a prospective Governors event and full details would be circulated in due course.
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Minutes: Council of Governors’ Meeting 8 December 2016 6/6
Ref Minute
Concluding Business
CG15-16/032 Any Other Business
No further business was raised
Date and Time of Next Meeting:
Wednesday 15th March 2017 in the Board Room Aintree Lodge at 5.00pm
The meeting closed at 2.15pm Chair’s Signature: Date:
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Agenda Item (Ref) CG16-17/036 Date of Meeting: 15 March 2017
Report to Council of Governors
Report Title Exit Interviews
Executive Lead Sue Green, Director of People and Corporate Affairs
Lead Officer Steven Richardson, HR Business Partner
Action Required To review & agree any actions arising
Substantial assurance
High level of confidence
in delivery of existing
mechanisms / objectives
Acceptable
assurance
General confidence
in delivery of existing
mechanisms/
objectives
Partial assurance
Some confidence in
delivery of existing
mechanisms /
objectives
No
assurance
No
confidence
in delivery
Key Messages of this Report (2/3 headlines only)
A Trust-wide approach to exit interviews is being developed to enable trends and themes to be
more easily identified and remedial action to be initiated in a more timely way.
By using the data provided and through close working between HR and the Divisions the Trust
can identify if there are particular actions required to improve retention in key areas.
Impact (is there an impact arising from the report on the following?)
Quality
Finance
Workforce
Equality
Risk
Compliance
Legal
Equality Impact Assessment (if there is an impact on E&D, an Equality Impact Assessment must
accompany the report)
Strategy Policy Service Change
Strategic Objective(s)
Deliver outstanding care
Achieve best patient outcomes
Promote research and education
Deliver sustainable healthcare to meet people’s needs
Provide strong system leadership
Be a well-governed and clinically-led organisation
Governance (is the report a……?)
Statutory requirement
Annual Business Plan Priority
Key Risk
Service Change
Other
rationale for Board submission required:
Next Steps (actions following agreement by Board/Committee of recommendation/s)
Review the outputs from the current Nursing Retention Review underway;
Engage key stakeholders in reviewing the Policy/toolkit
Submit proposed Policy and plan to Workforce Executive Led Group April 2017
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Exit Interviews: Council of Governors – 15 March 2017 2/6
REPORT HISTORY
Committee / Group Name
Agenda Ref
Report Title Date of submission
Brief summary of key issues raised and actions
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Exit Interviews: Council of Governors – 15 March 2017 3/6
Exit Interviews
Executive Summary
1. The purpose of this report is to update the Council of Governors on progress made on exit
interviews and how the Trust uses these and will use these to gain an understanding of the
main themes of reasons for staff leaving the Trust.
Key Issues / Proposals
2. The Trust does not currently have a centrally managed Trust wide approach to exit
feedback/interviews. This is not unusual in NHS Trusts given the size and nature of services
and professional groups. Local managers are always encouraged to meet with staff
members submitting their resignation and to reflect on the feedback received when
considering replacement. In addition, staff members can contact another appropriate
manager or request an exit discussion if they do not feel comfortable discussing their reason
with their own manager.
3. Recruitment; retention and turnover information is reviewed by the HR teams in liaison with
Divisions. Any particular trends or themes are then highlighted and a bespoke piece of work
undertaken to understand if there are any underlying reasons within the organisations gift or
to spot any issues with the “competitor” organisations (i.e. other Trusts paying higher
banding for similar roles or offering different working patterns).
4. One example of work undertaken to inform recruitment activity and methodology was a piece
of work undertaken within the Medicine Division in 2015/16, and specifically with Acute and
Emergency Medicine and the Accident and Emergency Department to understand why staff
were leaving the Trust. This informed recruitment campaigns and as a result both nursing
establishments were fully recruited to.
5. As part of our planning for 2017/18 resource planning, a high level analysis has recently
been completed to identify the most common reasons for staff leaving the Trust during the
period 1 April 2016 to 28 February 2017. This analysis has primarily focused on the reasons
for leaving, as contained within Leaver Forms submitted by the Clinical Business Units, in
which they notify Human Resources that an employee is leaving the Trust.
6. Table One shows the top five reasons for leaving the Trust and the percentage this
represents of total leavers. During this period there were a total of 559 leavers; the top five
account for just over 92% of all leavers.
Table One: High Level Reasons for Leaving
Reason for Leaving Number of
Leavers % of Total
Leavers
Voluntary Resignation 340 60.82%
End of Fixed Term Contract 98 17.53%
Retirement 38 6.80%
Dismissal 27 4.83%
Retirement - Ill Health 12 2.15%
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Exit Interviews: Council of Governors – 15 March 2017 4/6
7. The data shows that almost two thirds of staff left the Trust due to voluntary resignation.
Further analysis has been undertaken to identify the key reasons for voluntary resignation,
again as submitted on the Leaver Form.
8. Table Two shows a breakdown of the reasons given for resignation:
Reason for Resignation Number of
Leavers % of Total
Resignations
Other/Not Known 81 23.82%
Relocation 64 18.82%
Work Life Balance 63 18.53%
Promotion 58 17.06%
To undertake further education or training 22 6.47%
Better Reward Package 15 4.41%
Caring Responsibilities (Family) 14 4.12%
Health 10 2.94%
Lack of Opportunities 10 2.94%
Incompatible Working Relationships 3 0.88% Table Two: Reasons for Resignation
9. Almost a quarter of resignations are for reasons unknown. Of the other reasons given,
relocation and work-life balance make up around a fifth of all resignations with promotion
opportunities another factor worth noting.
10. This information is useful as it clearly demonstrates that more work is required to engage
with our staff in order to better understand the reasons for leaving and to ascertain whether
other interventions may have been possible to affect the outcome.
11. Building on the high level data, work is underway to produce more detailed data to help
inform:
How many staff have left the Trust, broken down by Division, job role, and grade
What the reasons for leaving have been and whether or not the reason for leaving
was voluntary or as a result of action taken by the Trust
Where possible to identify the destination of the leaver, and to understand how
many of our leavers left the organisation to work elsewhere within the NHS; and
how this level compares to the number leaving to further their education and/ or
training and the number of leavers exiting the NHS altogether.
Review in detail the groups – Work Life Balance (anecdotally there is a suggestion
that this may be linked to the long shifts for nurses and Nursing Assistants); Better
Reward Package and the Other/Not Known
12. At the same time, work on an exit interview template and process is being undertaken by HR
to ensure that a consistent approach can be taken across the Trust.
13. Additionally, the Business HR Team working with the respective Divisions are analysing the
data to identify ‘hot spot’ areas where staff turnover is constant or where clear trends and
“peaks” can be identified. The Divisional HR Business Partner can then help individual
departments and Clinical Business Unit’s put strategies in place to begin to manage
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Exit Interviews: Council of Governors – 15 March 2017 5/6
retention. Such initiatives may involve targeting recruitment for certain skills or specialties, or
over-recruitment into areas where high turnover is present.
14. Divisions will be encouraged to carry out exit interviews on every leaver, with the results fed
back to the HR in order for themes and trends to be identified. Such information can be
relayed and the themes presented through Divisional Workforce Group meetings on a
monthly basis and work with the Senior Leadership Teams of each Division to ensure that
feedback from exit interviews is acted upon and any changes or improvements identified can
be considered and, where practicable and possible, acted upon.
15. Any themes that are identified by exit interviews that cannot easily and practicably be
adopted by the Division / Clinical Business Unit will be escalated from the Divisional
Workforce Group to the Workforce Exec Led Group (WELG) in order for the organisation to
take a view and where appropriate, consider further action.
16. WELG receives notes of Divisional Workforce Group meetings on a monthly basis and will be
sighted on actions taken following analysis of exit interviews.
Implications / Impact
Quality
17. Retention of trained, qualification and professional staff will improve the quality of care our
patients receive.
Finance
18. It is widely acknowledged that the cost of retaining staff is much lower than the cost of
recruiting new staff, so improvements in retention rates will support effective use of
resources.
Workforce
19. Maintaining a stable, committed workforce is a key objective within the 2017 / 2018 strategic
plan. A reduction in staff turnover will likely have a positive impact on staff morale and
therefore staff survey results, and will likely have a positive impact of sickness absence rates
and ultimately will help the Trust develop a workforce capable of meeting the challenges
faced by the organisation over the coming years.
Equality & Diversity
20. The revised process and Policy will be subject to an Equality Impact Assessment. In
addition, Exit Interviews will include an assessment of any opportunities to promote Equality
and Diversity as well as ensuring no detrimental impact on people within the protected
characteristic groups.
Legal
21. The provisions of the Data Protection Act will apply in relation to data produced and stored
as a result of exit interviews.
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Exit Interviews: Council of Governors – 15 March 2017 6/6
Conclusion
22. A more effective Trust wide approach and process is necessary in order to gain a better
understanding of why staff choose to leave the Trust; this will help to provide legitimate
intelligence around issues or interventions that can be deployed to change outcomes and
improve retention.
Recommendation
23. To note the contents of this report.
Author: Steven Richardson, HR Business Partner
Date: 9 March 2017
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Lead Governor Report
Report to Council of Governors
Date 15 March 2017
Committee Name Council of Governors
Chair’s Name & Title Pamela Peel, Lead Governor
Core Governor Activity
Attendance at Board meetings and Board Feedback sessions with the Chairman
Director Walkabouts – Governors participated in two walkabouts in January (Sharon Bird, Tony
Kneebone), one in February (Pam Peel)
Nominations Committee
Quality of Care Committee
Membership Committee
Quarterly Informal Council of Governors – the meeting on 7 March was chaired by John Johnson and
was preceded by a formal presentation of the Quality Account and Business Planning Process
Appointment of the external auditor – Tony Byrne and Gerry Hill served as Council of Governor
representatives on the tender process for the current appointment process.
Wider Trust Activity
Aintree Volunteer Induction each month – this is an opportunity for Governors to recruit members
from amongst people who are already committed to the Trust, and also to engage with them, hear
their ‘stories’ and recognise the contribution they make to the smooth running of the hospital.
MADE – John Johnson, Tony Byrne, Sharon Bird, Gerry Hill and Pam Peel attended the sessions on
various dates
Workstream – Tony Kneebone continues to be involved in the Catering Food Quality Group
Well Led Governance Review (WLGR): Governor Focus Group, 8 December – Tony Byrne, Sharon Bird, Steve
Thornhill, Kerry McManus, Gerry Hill, Julie Naybour and Pam Peel participated
ACE Panel, 13 December – Pam Peel participated. Wards are accredited ACE (Aintree Champions
Excellence) status when they have had 3 consecutive green AAA assessments and are successful in
their application to obtain ACE standard. On that day the Panel awarded ACE status to Ward 4. The
Panel is currently looking at new ways of managing the accreditation process and it was interesting
to play a small part in that trialling.
WLGR Final Briefing at the Board of Directors’ Session, 21 December – Lorraine Heaton and Pam
Peel were invited to attend, this was an opportunity to get up to speed on the progress made by RSM
Consulting Services working with the Corporate Governance Team on the very detailed responses to
‘How is the Board assured (evidence)’ against a series of very specific questions, and how the Board
is addressing known gaps in the evidence.
Kidney Focus Event, 18 January – Sharon Bird attended
Prospective Governor Information Session, 31 January – Sharon Bird, Tony Byrne, Mike Booth,
Lorraine Heaton and Pam Peel met with potential governors and responded to questions
Staff Induction: Staff Governor Presentation, 6th February - Lorraine Heaton presented on staff
membership
Helipad Turf Cutting, 2 March – Tony Byrne participated in the traditional ceremony
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Lead Governors’ Report: Council of Governors 15 March 2017 2/2
World Kidney Day, 9th March – a number of Governors attended the free screening, advice and
information events as a way of supporting Aintree’s excellent Nephrology Team and also as an
opportunity to engage with patients and members of the public
Nutrition and Hydration Week, 13th – 18th March - A number of Governors attended the drop-in events
External Activity
Fazakerley Health & Wellbeing Forum, AGM, 12 January - Pam Peel was invited as guest speaker,
and was accompanied by Kerry Higham, Lead Nurse, Quality and Safety – Patient Experience, who
did a great job getting to know people present and answering their questions. The Forum is a small
but useful local arena for Governors to meet with, listen to and engage with members of the public.
Governor Issues Log
Issues added to the Log during the last trimester and currently in the process of receiving responses,
and where appropriate additional updates, concern the following:
The Trust’s reputation and obligations as a responsible landlord
Potential areas of development identified by the Reward and Recognition Survey
The status of Bank staff viz-a-viz job opportunities
How the Trust works with the CCGs regarding ‘revolving door’ patient data to seek alternative
solutions to hospital admission
Use of the Sefton Suite at times of increased pressure on the hospital, and how the current approach
might impact on the Trust’s reputation to offer good quality private care
Recommendation
The Council of Governors is asked to note the report.
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th o
f S
tay (
LO
S)
•A
MU
Bays /
Enha
nced C
are
beds
(Max 4
8hr
LO
S)
with 3
ward
/board
revie
ws
•A
mbula
tory
Care
(M
ax 1
2 h
r LO
S)
Up
date
fro
m O
cto
ber
•M
ain
tain
ed d
ischarg
e h
om
e r
ate
acro
ss
both
AM
U a
nd A
EC
fro
m 3
6%
to 5
1%
(targ
et
50%
)
•S
cru
ms im
pro
vin
g c
om
munic
ation &
team
work
with A
ED
involv
em
ent
•P
rote
cte
d a
ssessm
ent capacity b
ein
g
main
tain
ed for
most
of
the t
ime f
rom
mid
Feb
•O
pen d
ays f
or
sta
ff a
nd G
Ps f
or
AE
C –
positiv
e feedback
•F
ocus o
n im
pro
vin
g n
um
ber
of
patients
thro
ugh A
EC
•P
art
of
national S
urg
ery
AE
C P
rogra
mm
e –
sta
rtin
g t
his
month
•P
ositiv
e feedback r
eceiv
ed fro
m E
CIP
revie
w
•W
inners
of
Pro
ud o
f A
intr
ee A
ward
Page 18 of 41
•R
evis
ed A
mbula
nce h
andover
pro
cesses
•S
tream
ing N
urs
e r
epla
cin
g T
riage
•P
it-s
top in M
ajo
rs
•E
NP
-led M
inors
Serv
ice
•C
o-o
rdin
ation
•C
lear
clin
ical path
wa
ys b
etw
een A
ED
& S
pecia
ltie
s
Up
date
fro
m O
cto
ber:
•Im
pro
vin
g 4
hour
perf
orm
ance b
ut
still
work
to d
o t
o e
nsure
consis
tency
•Im
pro
ved a
mbula
nce h
andover
tim
es –
Team
work
ing w
ith E
merg
ency C
are
Imp
rovem
ent
Pro
gra
mm
e (
EC
IP)/
NW
Am
bula
nce S
erv
ice f
ollo
win
g r
evie
w
•S
tream
ing –
as p
er
national “d
irective”
AE
D P
roc
es
se
s
6. C
G16
-17/
039
- E
mer
genc
y &
Acu
te C
are
Pro
gram
me
Page 19 of 41
•F
railt
y A
sse
ssm
ent U
nit R
ap
id A
sse
ssm
en
t M
od
el
•C
om
pre
he
nsiv
e G
eri
atr
ic A
sse
ssm
en
t
•F
railt
y In
-Re
ach
Te
am
Up
da
te f
rom
Oc
tob
er
•Im
pro
ve
me
nt in
dis
ch
arg
e h
om
e r
ate
pe
rfo
rma
nce
•P
ositiv
e fe
ed
ba
ck fro
m r
ece
nt E
CIP
re
vie
w
•Jo
int w
ork
with
RL
BU
HT
an
d w
ith
EC
IP
Fra
ilty
Mo
de
l
Page 20 of 41
Wa
rd P
roce
ss
es
(S
AF
ER
)
•C
onsultant pre
sence a
t w
ard
and b
oard
rounds;
daily
rounds in the m
orn
ing
•D
aily
in
-reach p
rovid
ed b
y s
pecia
lty b
y 1
2 n
oon
to ‘pull’
patients
fro
m a
ssessm
ent a
reas
and incre
ase n
um
bers
of
patients
adm
itte
d t
o t
he r
ight
bed,
firs
t tim
e
•Im
pro
ved d
ischarg
e p
lannin
g o
n the w
ard
s,
to f
acili
tate
im
pro
ved d
ischarg
e r
ate
s
•Im
pro
ved d
ischarg
e r
ate
s,
part
icula
rly b
efo
re 1
2 n
oon a
nd a
t th
e w
eekend,
to h
elp
flo
w
thro
ughout
the h
ospital
•P
urp
le to G
old
Up
date
fro
m O
cto
ber
•Im
pro
vem
ent
in n
um
be
rs a
nd tim
elin
ess o
f dis
charg
es b
efo
re m
idday a
nd n
um
bers
at
weekends
•Im
pro
ved u
se o
f dis
charg
e lounge
•V
isit fro
m S
alford
follo
win
g E
CIP
feedback
6. C
G16
-17/
039
- E
mer
genc
y &
Acu
te C
are
Pro
gram
me
Page 21 of 41
•U
pd
ate
d t
he
pa
tie
nt
ch
oic
e p
olic
y a
nd
im
ple
me
nte
d a
ne
w
‘Ad
mis
sio
n to
Dis
ch
arg
e’ p
atie
nt
info
rma
tio
n le
afle
t
co
nsis
ten
tly a
cro
ss A
UH
an
d R
LB
UH
T
•D
eve
lop
ed
a w
ard
an
d b
oa
rd r
ou
nd
SO
P a
nd
ch
eck lis
t to
be
imp
lem
en
ted
co
nsis
ten
tly a
cro
ss A
UH
an
d R
LB
UH
T
•H
om
e F
irst
mo
de
l im
ple
me
nte
d in
Liv
erp
oo
l a
nd
Se
fto
n –
wo
rk t
o p
rog
ress t
o e
nsu
re c
ap
acity m
ee
ts d
em
an
d
•R
evie
w o
f N
ort
h M
ers
ey b
ed
ba
se
Rap
id I
mp
rovem
en
t –
Dela
y T
ran
sfe
r o
f C
are
Page 22 of 41
A
ny Q
ue
stio
ns?
6. C
G16
-17/
039
- E
mer
genc
y &
Acu
te C
are
Pro
gram
me
Page 23 of 41
Co
un
cil o
f G
ov
ern
ors
15 M
arc
h 2
01
7
7 &
8. C
G16
-17/
040
and
041
- A
ssur
ance
on
Key
Indi
cato
rs:Q
ualit
y &
Saf
ety
and
Fin
ance
& P
erfo
rman
ce -
Key
Issu
es a
ndA
ssur
ance
s: A
udit
Com
mitt
ee
Page 24 of 41
Str
ate
gic
Up
da
te
•A
intr
ee
/Roya
l Liv
erp
ool m
erg
er –
late
st positio
n
an
d p
roce
ss
•C
om
mun
ity H
ealth S
erv
ices –
late
st positio
n
•S
usta
ina
bili
ty &
Tra
nsfo
rmation
/N M
ers
ey L
DS
•C
ontr
act
Upd
ate
/ O
pe
ratio
na
l P
lan
Page 25 of 41
Qu
ality
& P
erf
orm
an
ce
Ma
na
ge
me
nt
As
su
ran
ce o
n K
ey I
nd
ica
tors
Kevan
Ryan
, N
on
Execu
tive D
irecto
r
Jo
an
ne C
lag
ue, N
on
Execu
tive D
irecto
r
7 &
8. C
G16
-17/
040
and
041
- A
ssur
ance
on
Key
Indi
cato
rs:Q
ualit
y &
Saf
ety
and
Fin
ance
& P
erfo
rman
ce -
Key
Issu
es a
ndA
ssur
ance
s: A
udit
Com
mitt
ee
Page 26 of 41
Key A
reas
of
Ass
ura
nce
Qu
ality
& S
afe
ty
Key
Are
as
of
Fo
cu
sO
n-g
oin
gA
ssu
ran
ce
As
su
ran
ce
so
ug
ht
on
are
as
of
co
nc
ern
Seri
ous I
ncid
ents
inclu
din
g
Incid
ent R
eport
ing
Work
forc
eA
dvancin
g Q
ualit
y P
rogra
mm
e
(inc
CQ
UIN
s)
Mort
alit
yP
ractice,
Impro
vem
ent
&
Lessons L
earn
ed
Ophth
alm
olo
gy
Infe
ction P
revention &
Contr
ol (I
PC
)
Patient experience
Patient &
Fam
ily S
hadow
ing
and E
ngagem
ent
Impro
vem
ents
in E
merg
ency
Laparo
tom
y
Qualit
y S
trate
gy D
eliv
ery
Pla
n
Pre
ssure
Ulc
er
Pre
ven
tion
Ris
k R
egis
ter
Ain
tree A
ssessm
ent &
Accre
ditation F
ram
ew
ork
Page 27 of 41
Leg
en
d
Ind
icato
rT
ren
d
On T
arg
et
On t
arg
et and im
pro
vin
g
On
ta
rget,
no c
hange
On t
arg
et, b
ut
dete
riora
ting
Off
targ
et
Off targ
et,
but
impro
vin
g
Off targ
et,
no c
hange
Off ta
rget
and
dete
riora
ting
7 &
8. C
G16
-17/
040
and
041
- A
ssur
ance
on
Key
Indi
cato
rs:Q
ualit
y &
Saf
ety
and
Fin
ance
& P
erfo
rman
ce -
Key
Issu
es a
ndA
ssur
ance
s: A
udit
Com
mitt
ee
Page 28 of 41
Cli
nic
al In
dic
ato
rs
TA
RG
ET
Q1
16-1
7Q
2 1
6-1
7Q
316-1
7Jan
uary
(Mth
10)
TR
EN
D
C-D
IFF
(Tru
st att
ribute
d)
76
11
4
MR
SA
00
01
PR
ES
SU
RE
ULC
ER
S
-G
rade 2
15
14
15
6
-G
rade 3
+4
01
0
PA
TIE
NT
SA
FE
TY
TH
ER
MO
ME
TE
R98.4
%98.5
%98.3
%98.1
%
SE
RIO
US
INC
IDE
NT
S10
94
1
MO
RTA
LIT
Y
-S
HM
I100.2
106.4
107.6
107.6
-H
SM
R94.1
94.2
93.7
93.3
Page 29 of 41
Key A
reas
of
Ass
ura
nce
Fin
an
ce
& P
erf
orm
an
ce
Ke
yA
rea
so
fF
oc
us
On
-go
ing
As
su
ran
ce
As
su
ran
ce
so
ug
ht
on
are
as
of
co
nc
ern
Refe
rral to
Tre
atm
ent
Recovery
Pla
nE
merg
ency &
Acute
Care
A&
E D
ata
Qualit
y
Div
isio
nal D
eep D
ives:
-M
edic
ine
-S
urg
ery
Opera
tio
nal&
Fin
ancia
l
Perf
orm
ance
Agen
cy S
taffin
g
Theatr
es:
-P
roductivity &
Effic
iency
-P
lans
for
Clo
sure
s
Tra
nsfo
rmation
Appre
nticeship
sA
nnual B
usin
ess P
lan P
riorities
Work
forc
e
7 &
8. C
G16
-17/
040
and
041
- A
ssur
ance
on
Key
Indi
cato
rs:Q
ualit
y &
Saf
ety
and
Fin
ance
& P
erfo
rman
ce -
Key
Issu
es a
ndA
ssur
ance
s: A
udit
Com
mitt
ee
Page 30 of 41
Fin
an
ce
s &
Acti
vit
y
TA
RG
ET
Q1
16
-17
cu
mu
lati
ve
Q2 1
6-1
7
cu
mu
lati
ve
Q3 1
6-1
7
cu
mu
lati
ve
Jan
uary
(Mth
10)
Tre
nd
UN
DE
RLY
ING
DE
FIC
IT(v
s P
LA
N)
£0
.05
8m
£0
.18
2m
£0
.84
m£
0.8
5m
ST
F (
vs P
LA
N)
£0
.00
0m
-£0
.59
4m
-£0
.79
2m
-£0
.83
2m
RE
PO
RT
ED
DE
FIC
IT
(vs P
LA
N)
-£1.5
70m
-£0.4
12m
-£0.7
08m
-£0.7
47m
RE
PO
RT
ED
DE
FIC
IT
(actu
al)
-£1
.57
0m
-£1
.98
9m
-£1
.29
2m
-£0
.31
5m
RIS
KR
AT
ING
33
33
CA
PIT
AL
On P
lan
On P
lan
Behin
d P
lan
Behin
d P
lan
CA
SH
On
Pla
nO
n P
lan
On P
lan
On P
lan
Page 31 of 41
Acce
ss
(1
)TA
RG
ET
Q1
16
-17
Q2 1
6-1
7Q
3 1
6-1
7J
an
ua
ry
(Mth
10
)
TR
EN
D
AE
D
RT
T
CA
NC
ER
-2
We
ek
-3
1 D
ays
-3
1 D
ays s
urg
ery
-3
1D
ays d
rug
s
-6
2 D
ay c
lassic
-6
2 d
ay s
cre
en
ing
-B
rea
stsym
pto
ma
tic
-C
on
su
lta
nt u
pg
rad
es
DIA
GN
OS
TIC
S
7 &
8. C
G16
-17/
040
and
041
- A
ssur
ance
on
Key
Indi
cato
rs:Q
ualit
y &
Saf
ety
and
Fin
ance
& P
erfo
rman
ce -
Key
Issu
es a
ndA
ssur
ance
s: A
udit
Com
mitt
ee
Page 32 of 41
Acc
ess
(2
)
TA
RG
ET
Q1
16
-17
Q2 1
6-1
7Q
3 1
6-1
7Jan
uary
(Mth
10)
TR
EN
D
OP
ER
AT
ION
S
CA
NC
ELLE
D
OU
TP
AT
IEN
TS
CA
NC
ELLE
D
ST
RO
KE
UN
IT
Page 33 of 41
Wo
rkfo
rce
TA
RG
ET
Q1
16
-17
Q2 1
6-1
7Q
31
6-1
7Jan
uary
(Mth
10)
TR
EN
D
WO
RK
FO
RC
E
-V
AC
AN
CIE
S3
73
37
53
78
38
4
-A
PP
RA
ISA
LS
71
.8%
69
.3%
73
.6%
80
.5%
-M
AN
DA
TO
RY
TR
AIN
ING
57
.0%
63
.0%
66
.7%
65
.6%
-A
TT
EN
DA
NC
ER
AT
E9
5.7
%9
5.7
%9
5.7
%9
5.6
%
7 &
8. C
G16
-17/
040
and
041
- A
ssur
ance
on
Key
Indi
cato
rs:Q
ualit
y &
Saf
ety
and
Fin
ance
& P
erfo
rman
ce -
Key
Issu
es a
ndA
ssur
ance
s: A
udit
Com
mitt
ee
Page 34 of 41
Key A
rea
s o
f A
ssu
ran
ce
Inte
rnal
Syste
m o
f C
on
tro
l (A
ud
it)
Tim
Jo
hn
sto
n, N
on
Execu
tive D
irecto
r
Key
Are
as
of
Fo
cu
sO
n-g
oin
gA
ssu
ran
ce
As
su
ran
ce
so
ug
ht
on
are
as
of
co
nce
rn
Inte
rnal A
udit R
eport
s:
-C
ar
Park
ing
-In
cid
ent R
eport
ing
Anti-F
raud a
nd B
ribery
Polic
y
A&
E D
ata
Qualit
y
Counte
r F
raud
Losses &
Com
pensations
Bank, A
gency &
Locum
sta
ff
Exte
rnal A
udit c
ontr
act
Tru
st P
olic
y C
om
plia
nce
Page 35 of 41
1/3
Agenda Item (Ref) CG16-17/042 Date of Meeting: 15 March 2017
Report to Council of Governors
Report Title External Audit Service – Tender for Service from 2017/18
Executive Lead Ian Jones, Director of Finance and Business Services
Lead Officer Dawn Gerrard, Head of Corporate Finance
Action Required Approve
Strategic Objective(s)
Deliver outstanding care
Achieve best patient outcomes
Promote research and education
Deliver sustainable healthcare to meet people’s needs
Provide strong system leadership
Be a well-governed and clinically-led organisation
Governance
Statutory requirement
Annual Business Plan Priority
Key Risk
Service Change
Other
rationale for submission required:
Key Messages of this Report (2/3 headlines only)
The current contract for External Audit services ends on 31 March 2017 and a tender exercise
has been undertaken for a new service.
As it is the role of the Governors to appoint the Trust’s external auditor, with support from the
Audit Committee, an assessment panel consisting of governors and audit committee members
have undertaken the assessment of tenders and made a recommendation to the Council of
Governors.
The recommendation is to award a contract to PWC for 3 years, with an option to extend for a
further 2 years (subject to no penalty termination should the service no longer be required).
Impact (is there an impact arising from the report on the following?)
Quality
Finance
Workforce
Equality
Risk
Compliance
Legal
Equality Impact Assessment (if there is an impact on E&D, an Equality Impact Assessment must
accompany the report)
Strategy Policy Service Change
Next Steps (actions following agreement by Board/Committee/Group of recommendation/s)
To award a contract for external audit services to PWC for a period of 3 years with the option to
extend for a further 2 years. Due to the possibility of organisational restructure during that
timeframe, the contract will be capable of termination without penalty.
9. C
G16
-17/
042
- A
ppoi
ntm
ent o
f Ext
erna
l Aud
itor
Page 36 of 41
Aintree University Hospital NHS Foundation Trust
2/3
External Audit Service – Tender for Service from 2017/18
Executive Summary
1. The current contract for External Audit services with PwC covered 3 financial years (2012/13, 2013/14 and 2014/15) with the option to extend for a further 2 years (2015/16 and 2016/17). This extension option has been utilised in full, therefore, a new contract will need to be in place prior to the start of the financial year 2017/18, i.e. April 2017.
Background
2. The FT Governors are responsible for the appointing of auditors to the foundation trust. This includes ensuring that, as part of the process, their appointed auditors meet the criteria included by Monitor in The Audit Code for NHS Foundation Trusts updated in December 2014.
3. The Audit Committee Terms of Reference state that it is the role of the committee to assess
the auditor’s work and fees and to ensure that the work is of a sufficiently high standard and that the fees are reasonable. The Audit Committee shall then make a recommendation to the Council of Governors with respect to the re-appointment of the auditor. Monitor recommends that the foundation trust should undertake a market-testing exercise for the appointment of an auditor at least once every five years.
Procurement Process
4. The first stage of the procurement process included drafting a specification for the service and reviewing the Office of Government Commerce (OGC) framework agreement for external audit services. An OGC framework is a tender that has already been undertaken at a national level and which we can then draw from. As a procurement route, it ensures competition whilst reducing the burden of a full tender.
5. As a framework agreement exists for this service, the Audit Committee (including Gerry Hill
representing the Governors) decided to utilise this and invite those providers on the agreement to tender their prices. This exercise was undertaken during the autumn 2016 and in January 2017 an Assessment Panel (consisting of a mix of Audit Committee members and attendees plus Tony Byrne representing the Governors) was created in order to review both the qualitative and costing aspects of the tenders.
6. Despite using a framework agreement with 7 eligible companies who could provide this
service, only the incumbent supplier submitted a tender. This tender has be assessed using the criteria set for the exercise in assessing both cost and quality as follows:
7. The tendered prices compare to the current cost as follows:
FT Basic
Audit
£
Charitable
Fund
£
Quality
Account
£
Total
Cost
£
Days
Current Cost (2016/17) 57,784 3,296 (included) 61,080
PwC Tender (2017/18) 46,700 4,250 8,000 58,950 112
Page 37 of 41
Aintree University Hospital NHS Foundation Trust
External Audit Tender 2017/18: Council of Governors15 March 2017 3/3
8. The qualitative assessment resulted in the following combined weighted scores:
Assessment Criteria
Weight Combined
Weighted
Score
Experience 30 22
Methodology 30 21
Resources 20 14
Communication 20 14
Total 100 71
Conclusion & Recommendation
9. The Assessment Panel jointly agreed to recommend the re-appointment of PWC and to award a contract for 3 years with an option to extend for a further 2 years. Due to the possibility of organisational restructure during the contract term, this contract will include a provision to terminate without penalty.
10. The Council of Governors is asked to formally ratify this decision and accept the tender from PwC for External Audit Service for 3 years with the option to extend for a further 2 years, i.e. 2017/18, 2018/19 and 2019/20 with the option to extend for 2020/21 and 2021/22.
Author: Dawn Gerrard, Head of Corporate Finance
Date: 27 January 2017
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1/1
Membership Committee Report
Report to Council of Governors
Date 15 March 2017
Committee Name Membership Committee
Date of Committee Meeting 1 February 2017
Chair’s Name & Title Pamela Peel – Lead Governor
Summary of Meeting
A progress update was provided on the ‘Get Involved with Aintree’ concept. Three members of the
group had either submitted a Nomination Form for the Governor elections or were giving it serious
consideration. There was some concern that the remaining group members were not being nurtured
or regularly communicated with and the Committee had agreed to invite those members to attend the
Council of Governors’ meeting in March 2017. Furthermore, arrangements were to be made for an
event/coffee morning to meet with members who are interested in being involved with Aintree.
The promotion of membership to Staff at Corporate Induction had been reviewed with the new format
being rolled out with effect from 6 February 2017 which included information on the Board and the
Council of Governors. It was the intention for the Chairman and/or a Director to be present at all
future staff inductions to welcome staff. Furthermore, a Governor, preferably a staff Governor, would
be invited to attend the session to present slides on Trust Membership and the role of Staff
Governors. Lorraine Heaton was to attend the Induction session Monday 6 February.
A media awareness session was to be arranged with the Communications Team to develop
Governor understanding on Media and Social Media – A date would be arranged and circulated to all
Governors.
Targeting young people to become members of the Trust remains high on the membership priority
list. Governors will be invited to attend Edge Hill University Nursing Career Fairs to promote
membership to newly qualified nurses. Also, contact has been made within the Youth Parliament
through Paul Cummins to promote membership of the Trust to this group.
An overview of the discussions held at the meeting with the Patient Experience Manager and
Volunteers Manager was provided. It was agreed that the Corporate Governance Team, Volunteers
and Patient Experience would work together utilising the various contacts within the Trust to pull
together a calendar of all Trust events. Ultimately this calendar would be uploaded onto the Trust’s
website to allow the public, members and Trust staff the opportunity to access the information as well
as encourage attendance and engagement.
Recommendation
The Council of Governors is asked to note the report.
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Quality of Care Committee Report
Report to Council of Governors
Date 15 March 2017
Committee Name Quality of Care Committee
Date of Committee Meeting 9 February 2017
Chair’s Name& Title Mike Booth
Summary of Meeting
A presentation was provided on Infection Prevention and Control which included an overview of
the Trust’s Healthcare Associated Infections (HCAIs) Aspirations for 2016/17. The main points taken
from the presentation were:
The levels of CDifficile infection cases for 2016/17 compared to the last two years together
with the key actions taken following the post infection reviews
Comparisons of MSSA and MRSA cases for the last three years together with the key actions
taken following the identification of the main sources of infection
Details of central line associated infections (CLABSI) within the Trust together with
comparisons for the last two years and the key actions taken to improve surveillance and
better use of technology
An overview of the measurement of Ventilator Associated Pneumonia together with details of
the Trust’s case review against the network definition for lapses of care
The increase in carbapenemase-producing enterobacteriacese (CPE) cases together with
details of the toolkit for the early detection of CPE and the Trust’s processes in place in this
regard.
A report was received on the progress being made on the delivery of the Year 3 Quality Strategy
which highlighted that despite the operational pressures on the hospital a high number of the quality
goals were still being achieved which was a credit to the staff. The main areas discussed were:
a reduction in grade 2 pressure ulcers was currently being achieved
an increase in grade 3 pressure ulcers was being investigated and lessons learned were
being developed into action plans to help reduce levels going forward
the Trust was working with the Cheshire & Merseyside collaborative on reducing pressure
ulcers
an overall reduction in the levels of falls with harm with a deep dive to be undertaken on
moderate falls
significant progress had been made on compliance with the Modified Early Warning system
(MEWS) scoring for deteriorating patients
A review of the Trust Mortality report highlighted the following:
the Trust’s Summary Hospital Mortality Indicator (SHMI) had risen slightly but remained as
expected
the Hospital Standardised Mortality Ratio (HSMR) continued to be below that expected
the Trust was mid-table compared to its peers in the North West for SHMI and was third
lowest for HSMR
for crude mortality, the number of discharges had shown a downward trend but the number of
deaths remained fairly stable which reflected in the SHMI level increasing
a deep dive into Acute Kidney Injury revealed that good progress was being made as part of
the AQuA programme.
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Aintree University Hospital NHS Foundation Trust
Quality of Care Committee Report – 9 February 2017: Council of Governors 15 March 2017 2/2
A report was presented on the Aintree Assessment & Accreditation Framework Q2 2016/17
highlighted that every ward had now received at least two assessments under the AAA framework
and that it had also been rolled out to Theatres. At the end of Q3 there were 10 wards that had
achieved an Aintree Champions Excellence (ACE) rating meaning that they had sustained a Green
rating for over 12 months. A further eight wards had received a Green rating and one ward that had
been Red rated had been reassessed and recently achieved an Amber rating.
A complimentary letter had been received from a patient in respect of treatment and care they
received from the nursing staff whilst in Aintree hospital. The letter particularly mentioned one of the
nursing staff who stood out as being an exceptional individual.
Recommendation
The Council of Governors is asked to note the report.
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