public trust board meeting to be held at on thursday 31 march 2016 … papers... · 2017-09-08 ·...

TB Public Agenda 31.3.16 FINAL

PUBLIC TRUST BOARD MEETING TO BE HELD AT ON THURSDAY 31 MARCH 2016 AT 10.00 AM IN ROOM 10009/11, CLINICAL SCIENCES

BUILDING, UNIVERSITY HOSPITALS COVENTRY& WARWICKSHIRE, CV2 2DX

PUBLIC BOARD AGENDA

ITEM TITLE BOARD ACTION PAPER TIME

Standing Items

1. Apologies for Absence Chairman

2. Declarations of Interest Chairman

For Assurance Verbal

3. Minutes of Public Board Meeting held on the 25 February 2016 Chairman

For Approval Enclosure 1

4. Matters Arising Chairman

For Assurance Verbal

5. Trust Board Action Matrix Chairman

For Approval Enclosure 2

Business Items

6. Chairman’s Report Chairman

For Assurance Enclosure 3 5

7. Chief Executive’s Report Chief Executive Officer


Patient Experience

8. Patient Story - Hello My Name Is Campaign Chief Medical & Quality Officer

For Assurance Enclosure 5 Inc. presentational video

10

Performance

9. Integrated Quality, Performance and Finance Monthly Report Chief Workforce & Information Officer

For Approval Enclosure 6 10

Patient Quality and Safety

10. Medical Education Report Chief Medical & Quality Officer


11. Board Assurance Framework 2015/16 and 2016/17 Director of Corporate Affairs


Strategy

12. Developing Sustainability and Transformation Plans Chief Finance and Strategy Officer


Research and Innovation

No reports

Regulatory, Compliance and Corporate Governance

13. Information Governance Toolkit Annual Submission 2015/16


TB Public Agenda 31.3.16 FINAL

ITEM TITLE BOARD ACTION PAPER TIME

Director of Corporate Affairs

14. Register of Interests and Gifts / Hospitality 2015/16 Director of Corporate Affairs


15. Audit Committee Terms of Reference Director of Corporate Affairs


16. Establishing an Auditor Panel Director of Corporate Affairs


17. Matters delegated to Board Committees Chairman

For Assurance Verbal 5

Feedback from Key Meetings

18. Private Trust Board Meeting Session Report of 25th February 2016 Chairman


19. Audit Committee Meeting Report of 24th February 2016 Chair, Quality Governance Committee


20. Finance and Performance Committee Meeting Monthly Report of 17th February 2016 and 23rd March 2016 Chair, Finance & Performance Committee


21. Quality Governance Committee Monthly Report of 21st March 2016 Chair, Quality Governance Committee


22. Any Other Business

23. Questions from Members of the Public Relating to Agenda Items

24. Date of Next Meeting: The next meeting of the Trust Board will take place on Thursday 28th April 2016 at 10.00 am, University Hospitals Coventry and Warwickshire

Resolution of Items to be Heard in Private (Chairman) In accordance with the provisions of Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, and the Public Bodies (Admissions to Meetings) (NHS Trusts) Order 1997, it is resolved that the representatives of the press and other members of the public are excluded from the second part of the Trust Board meeting on the grounds that it is prejudicial to the public interest due to the confidential nature of the business about to be transacted. This section of the meeting will be held in private session.

Agenda Item 3 Enclosure 1

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MINUTES OF A PUBLIC MEETING OF THE TRUST BOARD OF UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

HELD ON THURSDAY 25 FEBRUARY 2016 AT 10.00 AM IN ROOM 10009/11 OF THE CLINICAL SCIENCES BUILDING, UNIVERSITY HOSPITAL, COVENTRY

AGENDA ITEM

DISCUSSION ACTION

HTB 16/028

PRESENT

Ms L Abolins, Director of Nursing (LA) Mrs B Beal, Non-Executive Director (BB) Mr I Buckley, Vice Chair (IB) Mr D Eltringham, Chief Operating Officer (DE) Mrs D Griffiths, Associate Director of Workforce (DG) Mr A Hardy, Chief Executive Officer (AH)

Mr E Macalister-Smith, Non-Executive Director (EMS) Mr A Meehan, Chairman (AM) Mr D Moon, Chief Finance & Strategy Officer (DM) Professor M Pandit, Chief Medical & Quality Officer/Deputy Chief Executive Officer (MP)

Mr D Poynton, Non-Executive Director (DP) Mrs B Sheils, Non-Executive Director (BS) IN ATTENDANCE Mrs S Brennan, Patient Experience Manager (SB) - item HTB/16/041

Mrs E Clarke, Associate Director of Nursing (EC) – item HTB/16/041 Mrs M Cox, Volunteer (MC) – item HTB/16/041 Ms K Horne, Head of Voluntary Services (KH) – item HTB/16/041 Ms I Karbo, Modern Matron (IK) – item HTB/16/041 Mrs R Southall, Director of Corporate Affairs (RS) Mrs P Young, Corporate Secretary (PY) – note taker

HTB 16/029

APOLOGIES FOR ABSENCE

Mrs K Martin, Chief Workforce and Information Officer (KM) Professor M Radford, Chief Nursing Officer (MR) Professor P Winstanley, Non-Executive Director (PW)

HTB 16/030

CONFIRMATION OF QUORACY

Apologies were noted and the Chairman declared the meeting to be quorate.

HTB 16/031

DECLARATIONS OF INTEREST

There were no conflicts of interest declared. HTB 16/032

MINUTES OF TRUST BOARD MEETING HELD ON 28 JANUARY 2016

DM noted that the first sentence of paragraph four on page two of the minutes should read ‘The Chairman observed that DTOC exists due to lack of beds in the community’. DE observed that he had left the Trust Board meeting to attend a gold command


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DISCUSSION ACTION

meeting following the events of the previous day, which resulted in a bed crisis situation. The minutes were APPROVED by the Trust Board as a true and accurate record of the meeting, subject to the above amendments.

HTB 16/033

TRUST BOARD ACTION MATRIX HTB/15/013: DP confirmed that assurance around compliance with the process for recruiting medical locums was received at the Audit Committee of the previous day. HTB/15/013: DP confirmed that he had met with the Director of Finance and Strategy to agree what information, in respect of non-pay, is to be presented at the Finance and Performance Committee going forward. The Trust Board NOTED the items in progress and APPROVED the removal of those actions marked as complete.

HTB 16/034

MATTERS ARISING

There were no matters arising that were not on the action matrix or the agenda.

HTB 16/035

CHAIRMAN’S REPORT

The Chairman presented the report summarising the commitments he had attended since the previous Trust Board meeting. There were no were no questions raised by other Trust Board members. The Trust Board RECEIVED ASSURANCE from the Chairman’s report.

HTB 16/036

CHIEF EXECUTIVE OFFICER’S REPORT

AH presented the report detailing the key meetings and events that he had attended since the previous Trust Board meeting, and highlighted key policy issues and publications. AH proceeded to provide an update on progress with the development programme that the Trust has embarked on with the Virginia Mason Institute (VMI), and delighted in sharing details of the first Rapid Process Improvement Workshop (RPIW), in relation to the first of three workstreams regarding outpatient follow-up appointments in Ophthalmology. He explained that the RPIW surpassed all expectations and the ‘report out’ at the end of the week summarising lessons learnt proved to be a great success, in what was a very powerful week for all staff involved. As a result of the RPIW a decision has been taken to remove partial booking from within Ophthalmology, with the expectation for this to be rolled out amongst other specialties. Further ‘report outs’ at days 30, 60 and 90 will continue in order to monitor success of this initiative, taken to eliminate waste and improve productivity. AH confirmed that the second monthly VMI Trust Guiding Team meeting was held


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DISCUSSION ACTION

of the previous week, which was very positive and examined the success of the first ‘report out’ of the ophthalmology workstream and next steps. AH noted that he had attended the VMI Trust Guiding Board in London and observed that a significant event is to be held on 11th March 2016, when the Trust Guiding Teams for each of the acute trusts that have recently embarked on the VMI development programme will have opportunity to meet with Gary Kaplan, Chair and Chief Executive Officer of VMI at an event in London. Furthermore, the Trust Guiding Teams for each of the five acute trusts will meet in June, as an opportunity to share progress and learning. The Chairman observed that the Chairs of each of the five acute trusts have ben invited to meet with Sir Peter Carr, Chair of the Trust Development Authority (TDA) in March. Regrettably, due to existing commitments he is not able to attend but confirmed that the Vice Chair will be attending to represent the Trust. AH attended the NHS Improvement (NHSI) Provider Conference in London earlier in the month to mark the launch of NHSI, responsible for overseeing foundation trusts, NHS trusts and independent providers. Announcement of the Executive Team appointments were made and AH was pleased to note that Chief Officers had existing relationships with several of the members of the newly appointed Executive Team. AH added that the event was an opportunity for NHSI to set out its vision for providers and the support it will offer the health service. He added that the key messages related to finance in 2015/16 and the credibility of the NHS. There is a window of opportunity between now and May to make significant changes, through Sustainability and Transformation Plans, across the health economy. In response to a query from BS; AH confirmed that there is alignment between the VMI development programme and the Trust’s leadership programme, with VMI training dovetailing into the dedicated masterclasses that play an integral part of the leadership programme. DG assured that demonstration of the synergy between the two programmes and learning outcomes are presented to the Chief Officers Forum. DG added that from April onwards, the second tier of staff including Team and Service Leaders will commence the programme. DP observed that the focus of key messages from NHSI is around finance and observed that the Trust is presently in a good position and queried whether that would result in further pressure being applied to the Trust. AH acknowledged that the Trust had been asked, and had identified, further capital opportunities and was confident that the Trust would not be required to offer up further capital. He assured the Board that the Trust was in a positive position in terms of being above plan, unlike many organisations that were under daily scrutiny. DM added that the Trust is required to submit monthly returns in relation to a number of accounting methodologies and assured the Board that, following submission of the two returns completed thus far, there has been no unsatisfactory feedback. AH added that a £1.8b sustainability and transformation fund has been identified to help challenged hospitals to achieve financial balance by reducing their deficits and to transform services to deliver high quality patient care seven days a week. In response to a query from IB regarding the conditions that will be applied to the


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DISCUSSION ACTION

allocation of money from the centre; AH emphasised that trusts are expected to take a tight grip of finances and that the transformation fund is predicated upon meeting a series of strict and non-negotiable conditions. EMS observed that trusts are entangled in the maelstrom of pressures and suggested that the Foundation Trust (FT) regime no longer appears to distinguish good organisations; AH concurred with this and added that the clear message is that focus must be what is best for the Local Health Economy (LHE) and achieving FT status is no longer seen as a priority. The Trust Board RECEIVED ASSURANCE from the Chief Executive’s report.

HTB 16/037

INTEGRATED QUALITY, PERFORMANCE AND FINANCE REPORT (IQPFR)

DM presented the report highlighting that the Trust’s overall performance has improved this month; however underperformance continues against standards related to aspects of the emergency pathway (A&E waiting times and delayed transfers of care) and the elective pathway including referral to treatment (RTT) incomplete pathways. Furthermore, performance continues to fall below the required standard for cancer 62 day urgent referral to treatment, which continues to be related to the planned treatment of Urology long waiters. Monthly performance reviews continue between Chief Officers and each of the clinical groups to focus on the aforementioned key areas behind plan, as well as the Trust’s financial plan. DM proceeded to provide a finance update, confirming the Trust has a changed plan of £10.023m deficit, representing the inclusion of capital to revenue transfer and offset by case 915. The improvement in control total deficit is as a result of a capital to revenue transfer enacted by the centre. He was pleased to add that the Trust is forecasting just under £9.5m deficit, which is over £500k above the revised plan. The Trust is forecasting delivery of £34.7m against £35.5m of potentially identified savings: this gives a potential over-delivery of £700k against the Trust target of £34m for 2015/16. Furthermore, for 2016/17 Groups have documented £7.4m of potentially identified savings; representing some 50% of the identified CIP target of £14.8m for 2016/17. DM confirmed that year end settlements had been agreed with Commissioners and Specialised Commissioning. In response to a query from the Chairman; DM acceded that the Trust remains under close scrutiny regarding agency spend and confirmed that whilst the Trust delivered the agency cap spend for quarter three, it was breached in the month of December. He added that challenges around recruitment have contributed to this, but he assured that there were plans in place to manage the use of excess capacity going forward. DG added that the Trust is in negotiations with agencies to bring their rates in line with the agency cap; and emphasised the considerable time taken focusing on this. In response to a query from BB regarding the number of registered nurses recruited in January and the conversion rate of agency to bank nurses; DG


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AGENDA ITEM

DISCUSSION ACTION

acknowledged that despite best efforts, recruitment to nursing was static and the Trust is looking at different approaches to meet this challenge, including exploring options internationally. She assured the Board that considerable work has been undertaken to convert agency nurses to bank and the enhanced rates has proved successful. She added that all new substantive nurses’ recruited are encouraged to enrol on the Trust nurse bank. In response to a query from BB regarding the equal application of bank rates; DG assured that bank rates are applied in line with substantive rates across the board with enhanced rates for band 5 nurses, as these are considered the most challenging group to recruit to. BS conveyed concern that the Trust was still not demonstrating good performance against RTT, despite a revised trajectory and suggested that the service improvement plans in place to deliver this together with actions to improve theatre efficiency, be presented to the next Finance and Performance Committee for closer scrutiny. EMS concurred with this adding that the percentage of theatre sessions commenced within 15 minutes requires further examination, observing that only 13% and 29% of theatre lists were commenced within 15 minutes of the planned start time for neurosciences and surgery respectively. DE assured that Chief Officers are conducting weekly risk assessments in relation to RTT performance and the Operations Team are working closely with the Programme and Performance Management Office to receive real time reporting that provides best, worst and likely case scenarios. He assured that there was still a possibility for the Trust to achieve 92.10% but that this was not without risk. He added that the TDA and Commissioners are supportive of the Trust’s approach. In terms of theatre utilisation; DE assured that close scrutiny of this forms the basis of discussions and challenges to the Groups during the monthly Performance Review meetings. He added that the Group Manager for theatres attends the weekly access meetings so there is no room for ambiguity in terms of what action needs to be taken to achieve the desired performance position. In response to a query from the Chairman regarding 62 day cancer standard; DE confirmed that the Trust is on track to meet the trajectory. He added that operating lists are closely monitored and all endeavours to prevent cancelling surgery for cancer patients has paid dividends. IB reflected upon the discussions at the Audit Committee of the previous day and queried whether the Trust was fully aware of concerns identified in relation to the practice of some agencies, and sought assurance around the controls in place around the engagement of agency staff. DG confirmed that robust controls were in place and agencies are required to meet rigorous criteria. She assured that any issues identified with respect to medical locums would be reported back through the framework, through which the agency is engaged or for non-framework locums to the agency direct. She added that the Trust has eliminated the use of non-framework agency usage for nursing. EMS applauded the robust action taken to eradicate non-framework nurse agency usage. EMS highlighted the potential never event detailed on page 6 of the report, relating to wrong site surgery discovered in January 2016 following surgery performed in 2013, and the Trust’s responsibility under the duty of candour to be

DE


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AGENDA ITEM

DISCUSSION ACTION

open and transparent, including informing people about when things go wrong. MP acknowledged that whilst there appears to be a delay in reporting, this is not the case as it was only recognised during planned revision of the original surgery. MP assured that a root cause analysis is being undertaken, which will determine whether this is indeed a never event. DP observed the termination of 83 bank staff and queried whether exit interviews had been conducted and lessons learnt. DG advised that the Trust policy is to remove any bank staff that have not undertaken bank shifts for six months and confirmed that prior to removal from the bank, all individuals are invited to indicate whether they wish to remain. DP explored this further and suggested that it would be prudent to provide staff with a questionnaire that includes a question seeking to understand why they have not accepted any bank shifts offered within the previous six months. BB concurred with this and added that there is soft intelligence suggesting that other trusts are offering more competitive banks rates to attract staff. DG acknowledged that bank staff will work across a wide geographical area and assured that rates offered by the Trust have been benchmarked and are relative to the LHE. DP observed that the level of sickness absence is almost reaching 5% equating to several million pound, despite efforts to help and encourage staff return to work. He accepted that Operational Managers have little time to prioritise this whilst juggling the day to day operational pressures but suggested the need to invest in this, in order to save money. DG acknowledged this and whilst there has been a slight reduction in sickness absence, she agreed the need to increase pace. She confirmed that the Trust is in the process of reviewing the attendance policy whilst simultaneously looking at initiatives to keep staff well with opportunities to access physiotherapy or psychological support. The Trust Board RECEIVED ASSURANCE from the IQPFR for January 2016 and NOTED actions being taken.

HTB 16/038

ANALYSIS FOLLOWING BLACK ALERT ESCALATION

DE introduced the report, summarising the black alert escalation following a period of increasing and sustained pressure over the period Friday 22nd to Sunday 24th January 2016, and an inability to stabilise the position over Monday 25th January, resulting in a bed crisis situation. He proceeded to provide a diagnosis of the reasons why the crisis situation occurred, a summary of the findings of the debrief including lessons learnt and key actions taken to address these going forward. The debrief highlighted the responsiveness and energy that was felt in the organisation, in part driven by visible Chief Officer involvement and leadership. The call to the Board Room for the Clinical Directors (CD) changed the routine nature of the problem and escalated the importance. There was felt to be a heightened threshold on discharges to achieve the number that occurred in one day, through good senior clinical engagement and team working. DE emphasised that work must continue on delivery of the FREED metrics as a matter of routine to embed “getting the basics right”. Processes need challenge


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AGENDA ITEM

DISCUSSION ACTION

and review, particularly across the escalation levels and the operational delivery on a day to day basis allowing staff to concentrate on and maximise the day job effectively. He added that the key message, which must be understood is that the best care is not achieved by keeping people in hospital. DE observed that the Trust was in the middle of a third Perfect Week initiative and conveyed disappointment that in spite of this, the current week’s performance is worse than the preceding week. DE acknowledged; however, that the impact becomes ever more diluted as the Perfect Week initiatives become normalised. He countered this with recently published figures showing the Trust to be in the top half of the Emergency Department (ED) performance league tables; however, which suggests that the position nationally is challenging and tight. In response to a question from the Chairman regarding focus on getting the basics right and whether work with VMI and Together Towards World Class (TTWC) were distractions to this; AH gave assurance that the Trust strives to achieve a culture of continuous improvement through increased productivity and elimination of waste and this will be realised through adoption of VMI lean methodologies, which underpin the Trust’s vision for world class status. He added that Care Quality Commission (CQC) post-inspection regimes titled ‘getting the basics right’ which have been undertaken internally, following the CQC report demonstrating that 66% of clinical areas are scoring better. DP reflected upon the lessons learnt from previous Perfect Week initiatives including increasing portering and phlebotomy staff and queried whether the Trust was exhausting all options to fulfil this. DE assured that additional portering staff had been deployed within ED and Acute Medicine and phlebotomists were focused on ward areas, in order that tests can be performed and decisions made earlier to determine the need for further examinations or discharge. DE went on to say that during the Perfect Week, there is an increase in the use of facilities and the focus to improve capacity and flow is relentless. IB observed the need for balance between transactional and transformational management in order to drive the necessary organisational change; DE concurred with this and assured that conversations have commenced around providing discharge to assess beds but acknowledged that this was at an embryonic stage. EMS acknowledged that the analysis was helpful in demonstrating the significant challenge the escalation situation presented to the Trust and sought clarity as to who did what differently in a black alert. DE acknowledged that due to the continuous heightened state of pressure on the Trust, as a result of the unremitting challenge to manage patient flow on a daily basis, there were only very marginal process changes that occurred, including external conference calls with regulators and partners to seek support with system-wide issues. He acknowledged; however, that due to the frequency of black alerts as a result of sustained operational pressures, these provoke an insipid response. Recognising this, Chief Officers called CD’s to the Boardroom to strengthen the message of what needed to be done to help progress patient discharge and restore patient flow. In response to a query from IB; DE advised that there is no external escalation policy that maps against the Trust’s internal escalation process.


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DISCUSSION ACTION

BB praised the work of staff, led by the Executive Team to safeguard patients and ensure that they receive the best possible care under very difficult circumstances. She added that whilst performance was important, patient safety must be paramount and praised Chief Officers for taking the approach they did. The Chairman concluded that the Executive Team’s actions were exemplary and their drive to accomplish what the Trust sets out to achieve in terms of finance and performance raises the credibility of the Trust. He expressed gratitude to Chief Officers on behalf of the Board. The Trust Board NOTED the positive response the hospital achieved in the later period of the Black alert and the reduction of clinical risk and ACKNOWLEDGED the need to sustain Trust delivery of good patient care and flow, through completion of the actions described, and avoid future repeat of this situation.

HTB 16/039

TRUST DEVELOPMENT AGENCY OVERSIGHT MONTHLY SELF-CERTIFICATION REQUIREMENTS

DM presented the report to inform the Trust Board that the TDA Self Certification process is not included on the Accountability Framework and is no longer in line with Monitor reporting requirements. The TDA has therefore, decided to cease this requirement with immediate effect until further notice and will inform the Trust when new reporting requirements evolve. The Trust Board NOTED the cessation of the requirement to produce the monthly self-certification return to the NHS Trust Development Authority.

HTB 16/040

MEDICAL REVALIDATION AND APPRAISAL SIX MONTHLY UPDATE

MP appraised the Board of Medical Appraisal and Revalidation within the Trust, confirming the actions taken to date and developments since the report to Board of July 2015. Medical revalidation was confirmed as a statutory requirement, by the Secretary of State for Health, on the 3rd December 2012; and was introduced nationwide and in the Trust from April 2013. Its purpose is to demonstrate that licensed doctors are up-to-date and fit to practice. The Trust is regarded as a Designated Body (DB), and all DB’s have a statutory duty to support their Responsible Officers (RO) in discharging their duties under the RO Regulations. Data reported for the appraisal year 1st April 2015 - 31st March 2016 reflects those who have successfully completed an appraisal or where the RO accepts that postponement was reasonable: • Quarter 1 – 86% • Quarter 2 – 75% • Quarter 3 – 81% For quarter 4, NHS England were informed that of the 188 appraisals due, 88 doctors did not hold an appraisal meeting in this period. Eleven have a valid reason for postponement e.g. sickness absence and maternity leave, 41 were still


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DISCUSSION ACTION

within the 15 month window and five have since left the Trust. MP assured that a robust process is in place for non-compliance and doctors with outstanding appraisals (between 12-15months) are written to at the end of each quarter to remind them of their contractual and professional obligation to participate in annual appraisal and instructed to complete an appraisal before the end of the following quarter. Where doctors fail to comply, the General Medical Council (GMC) is notified and they receive an early concerns letter from the GMC at the request of the Trust. There are currently 97 trained appraisers in the Trust and the Medical Revalidation Appraiser training programme runs biannually to ensure the appraiser to appraisee ratio is maintained, and to give colleagues the opportunity to become a medical appraiser. Revalidation-ready medical appraisal training must be updated on a triennial basis. The Trust has 573 prescribed connections, for which the RO is responsible and to date 502 recommendations have been submitted to the GMC for these connections. By 31st July 2016 the GMC require all named Educational and Clinical Supervisors to be formally approved. This will depend upon completion of appropriate training and an adequate educational appraisal as part of the appraisal process. The Revalidation Management system (RMS), the Trust’s online appraisal system, has been developed to facilitate educational appraisals and now includes the seven required domains which must be evidenced and discussed as part of an adequate educational appraisal. Due to issues with collating a report on educational appraisal completion, the RMS providers, Equiniti 360 Clinical, were asked at a meeting on 28th January to provide this reporting function, with a plan for the required improvements to be implemented by end of March 2016. In response to a query from BS regarding the feasibility of meeting the July deadline; MP assured that the Associate Director for Medical Education is working with the Revalidation Team to ensure that all Educational and Clinical supervisors will have received an appropriate educational appraisal by July 2016 and that GMC and Health Education West Midlands requirements are met. The Trust Board NOTED the contents of the report along with progress made against the action plan to date.

HTB 16/041

PATIENT STORY

The Chairman welcomed MC to the meeting to share with the Board her positive hospital experience as an inpatient following thyroid surgery. MC explained that she had been a hospital volunteer for five years and wanted to express her sincere gratitude and thanks for the exemplary care received. She particularly, praised the work of the consultant and nursing staff throughout her hospital stay. She observed that there were two areas that required further improvement; the quality of food and noise levels at night. EC assured the Board that there was a


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DISCUSSION ACTION

rolling programme of night visits to ward areas undertaken by Modern Matrons, which has identified actions required to enhance the quality of patient care, such as improved lighting to prevent patient falls, and the Trust is working with its Hard Services Supplier to progress this. IK added that ward staff have welcomed the unannounced night visits and the support that this offers them in providing the best quality patient care and experience. The visits are undertaken on a quarterly basis and the focus of the next visits will be noise levels at night and actions that can be taken to address this. LA concurred with this and praised MC for sharing her valuable feedback to inform positive change. The Trust Board NOTED the contents of the report and ENDORSED the actions being taken as a result of feedback.

HTB 16/042

SIGNIFICANT INCIDENT GROUP REPORT, INCLUDING ACTION PLANS AND NEVER EVENTS

MP presented the report and provided a summary of serious incidents (SI’s), including never events that met the criteria for reporting to the Clinical Commissioning Group (CCG) under the Serious Incident Framework (NHS England, March 2015) for the six months from August 2015 to January 2016. Three hundred and sixty three new SI actions were assigned during the aforementioned period. Thirty-one action plans due for completion prior to 31/01/16 are overdue. MP assured that all SI’s (including never events) are reviewed at the weekly Serious Incident Group (SIG), to ensure that investigations are undertaken and appropriate actions put in place to reduce identified risks. Furthermore, SIG is applying increased scrutiny of “due dates” for actions to ensure that they are realistic and not over-ambitious. Learning from SIG cases is shared via the Chief Medical Officer and Chief Nursing Officer weekly safety messages that are sent out to all staff and MP assured that feedback from staff around these messages, in particular from junior doctors and nurses is good. Details of investigations, including root causes and lessons learned, are also presented monthly to the Patient Safety Committee. MP confirmed that in addition to the two never events relating to wrong site surgery as detailed in the report, a third never event as subsequently been declared in relation to a k-wire, which was introduced into the wrong finger. She assured that there was no harm caused to the patient and the Trust awaits the outcome of the root cause analysis. Furthermore, she has written to Surgical and Theatre Clinical Directors (CD’s) to seek assurance that checklists are adhered to and supervision of trainees continues to be closely monitored. She emphasised that discussions are ongoing at a national level regarding the limited national guidance relating to quantifying wrong site spinal surgery as never events, given that there is no set way of counting vertebrae. MP advised that in response to serious incidents, never events and clinical negligence claims, the Trust included “Human Factors” (HF) education and training in its Sign up to Safety implementation plan. The aim of this is to improve safety by implementation of HF interventions and to embed HF principles in a


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DISCUSSION ACTION

sustainable way. Funding of £250k was awarded by the NHS Litigation Authority (NHSLA) to support the implementation of HF. She added that the Trust has invited expressions of interest for one consultant (at one PA per week) and one nurse/allied healthcare professional (for 12.5 hours per week) to help embed the HF principles, and hoped to make appointments in due course. MP observed that the second VMI value workstream will focus on SI’s and will be led by DE as executive sponsor. DE added that the work will review clinical incident reporting from report to the dissemination of learning. Kaizen Promotion Office Leads will help facilitate the workstream supported by colleagues from VMI. This will be followed by RPIW’s and a ‘report out’ of the findings of the RPIW will be presented in the lecture theatre, with progress reports at days 30, 60 and 90. In response to a query from BS regarding safety in theatres; MP confirmed that an external West Midlands Quality Review Service (WMQRS) quality review of theatres was undertaken and separately Internal Audit were commissioned to undertake a piece of work in theatres, the outputs of both action plans have been monitored through the Quality Governance Committee. The Trust Board RECEIVED ASSURANCE from the report.

HTB 16/043

CODE OF CONDUCT AND STATEMENT OF RESPONSIBILITIES – BOARD OF DIRECTORS

RS presented the report reminding the Board that the Code of Conduct and Statement of Responsibilities was prepared following consultation with members of the Board and was initially presented for approval at the February 2015 Trust Board meeting. To ensure that the Code remains live and to demonstrate on-going commitment to abiding by its provisions, it was agreed that the Trust Board would re-confirm commitment on an annual basis. The Code of Conduct and Statement of Responsibilities for the Board of Directors aims to set out what is required of the Board of Directors and individual members thereof, from a regulatory and statutory perspective and from the Trust itself and to describe the internal systems and processes that are in place to ensure that individual and collective responsibilities are discharged. Values are as important in terms of effective corporate governance as the systems and processes that are in place, as the Trust Board is responsible for setting the tone and culture of the organisation and must therefore, lead by example in terms of both conduct and decision making. Accordingly, the Code of Conduct links expectations, responsibilities and accountabilities with the Trust’s values and the values expected of those in public office (Nolan Principles); these elements, combined with the systems and processes that are in place describe the Trust’s approach to corporate governance. EMS observed that Non-Executive Directors are not involved in operational matters; however, in view of the heightened state of pressure placed upon the Trust due to daily operational pressures and the consequences that this brings to bear in the form of black alert escalation, it is inevitable that discussion at Board and the Board Committees become somewhat operational. He queried whether the balance of discussion at Board and its Committees was right or whether focus should be placed on more strategic discussion.


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DISCUSSION ACTION

The Chairman acknowledged this and accepted the need for some operational detail in order for Non-Executive Directors to support the actions of Chief Officers and that to achieve the right balance of discussion; Non-Executive Directors should not be involved in the solution but seeking assurance from Chief Officers that the actions taken are appropriate. MP concurred with this and observed that the balance is mostly right, adding that Non-Executive Directors requiring operational detail reflects absence of assurance provided by Chief Officers. DM accepted that it is a fine line between delivering too much and not enough detail and emphasised that this must be balanced by open and honest debate. AH observed that there is too much focus on assurance and not enough on strategic discussion, which is partly driven by the performance position. EMS suggested that in order to achieve a balance, more items with a strategic focus be scheduled on the agenda. The Chairman concluded that this is often fulfilled within the private session of the Board agenda. BB observed that implementation of the recommendations from the external governance review will help through refining the annual work programme for the Trust Board and the committees, adding that this will encourage board level discussion at the committees. AH added that the a programme of board development commissioned by the Trust will also support this. The Trust Board COMMITTED to complying with the provisions of the Code of Conduct and Statement of Responsibilities in the execution of Trust business, both on an individual and collective basis.

HTB 16/044

MATTERS DELEGATED TO BOARD COMMITTEES

RS confirmed that the service improvement plans in place to deliver the 18 week wait RTT incomplete pathway target and improvement in theatre efficiency, outlining the current position and what action is being taken to achieve the desired position will be presented to the next Finance and Performance Committee for closer scrutiny.

HTB 16/045

PRIVATE TRUST BOARD MEETING SESSION OF 28 JANUARY 2016

The Chairman presented the report of 28th January 2016. There were no questions raised by other Trust Board members. The Trust Board RECEIVED ASSURANCE from the report.

HTB 16/046

QUALITY GOVERNANCE COMMITTEE MEETING REPORT:18 JANUARY 2016

EMS presented the report of 18th January 2016 and observed the Committee received a well written and positive report demonstrating the increasing volume of work that was being undertaken by the Safeguarding Children and Vulnerable Adults Team. The Trust Board RECEIVED ASSURANCE from the report.


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DISCUSSION ACTION

HTB 16/047

ANY OTHER BUSINESS

In response to a query from IB regarding the impending Junior Doctors Industrial Action; DG confirmed that industrial action is planned for three episodes of 48 hours between Wednesday 9 March and Friday 11 March, Wednesday 6 April and Friday 8 April and Tuesday 26 April and Thursday 28 April. She added that Junior Doctors will provide emergency care only during these periods. She further added that a Task and Finish Group Chaired by the Director of Operations has been set up and contingency plans are in place to ensure continuity of care. The Trust does not expect the future planned industrial action to present any more of a challenge than previous events. In response to a query from DP regarding the sentiment amongst Junior Doctors; MP acknowledged that the morale of staff, not limited to Junior Doctors, was low within the NHS. She assured that the Trust shared good relations locally with Junior Doctors and that she and AH meet with Junior Doctors quarterly and the feedback is that they have a sense of belonging. Junior Doctors recognise that this is a national issue and are content to participate in their duties. AH echoed this and added that a very small proportion of Junior Doctors were involved in the most recent strike.

HTB 16/048

QUESTIONS FROM MEMBERS OF THE PUBLIC A member of the public observed the actions taken in response to the recent black alert escalation and hoped that the strategy deployed would help to prevent further similar events. In response to a question from the member of the public; DE confirmed that a minimal number of inpatient and outpatient appointments were cancelled during the most recent Junior Doctors industrial action. A member of the public observed the value of national media to raise awareness of the early signs and symptoms of stroke and suggested that this would be a valuable vehicle to promote awareness for pancreatic cancer. In response to a question from a member of the public regarding what revenue the Trust receives from treating visiting European Union (EU) nationals and non-EU nationals. DM confirmed that he would be happy to provide this information within his presentation at the Annual General Meeting in July. In response to a question from a member of the public; AH confirmed that the Trust is in the process of recruiting staff to support the reopening of a six bedded unit within the Hospital of St Cross.

DM


Page 14 of 14

AGENDA ITEM

DISCUSSION ACTION

HTB 16/049

DATE OF THE NEXT MEETING The next Public Trust Board will be held on Thursday 31st March 2016 at 10.00 am at University Hospitals Coventry & Warwickshire. The minutes are approved

SIGNED

…………………………………………........................

CHAIRMAN

DATE

…………………………………………........................

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST ACTION MATRIX PUBLIC TRUST BOARD MEETINGS

31 MARCH 2016 AGENDA ITEM 5 ENCLOSURE 2

1

The Trust Board is asked to NOTE the progress with regards to the actions below and to APPROVE the removal of those that are marked completed.

AGENDA ITEM ACTION RESPONSIBLE OFFICER

COMPLETION DATE

UPDATE REMOVAL

ACTIONS FROM JUNE 2015 MEETING

HTB/15/843

FREEDOM TO SPEAK UP

The Trust Board requested a progress report in six months detailing statistics and analysis of concerns raised.

RS April 2016 The outcome of the consultation has still not been forthcoming. The Trust Policy will need to be revisited when the final version of the national Policy is released as adherence will be a requirement. It is suggested that this item be scheduled for May 2016.

No

ACTIONS FROM NOVEMBER 2015 MEETING

HTB 15/941 NURSING AND MIDWIFERY REVALIDATION UPDATE

The Trust Board agreed to receive an update on progress in relation to first registrants in July 2016.

MR July 2016 Not yet due No

ACTIONS FROM FEBRUARY 2016 MEETING

HTB 16/037 INTEGRATED QUALITY, PERFORMANCE AND FINANCE REPORT (IQPFR)

The service improvement plans in place to deliver the 18 week wait RTT incomplete pathway target and actions to improve theatre efficiency, be presented to the next Finance and Performance Committee for closer scrutiny.

DE March 2016 Presented and discussed at the March Finance & Performance meeting.

Yes

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST ACTION MATRIX PUBLIC TRUST BOARD MEETINGS

31 MARCH 2016 AGENDA ITEM 5 ENCLOSURE 2

2

AGENDA ITEM ACTION RESPONSIBLE OFFICER

COMPLETION DATE

UPDATE REMOVAL

HTB/16/048 QUESTIONS FROM MEMBERS OF THE PUBLIC

In response to a question from a member of the public regarding what revenue the Trust receives from treating visiting European Union (EU) nationals and non-EU nationals. DM confirmed that he would be happy to provide this information within his presentation at the Annual General Meeting in July.

DM July 2016 Not due until AGM No

AGENDA ITEM 6 ENCLOSURE 3

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

REPORT TO THE TRUST BOARD: PUBLIC

31 MARCH 2016

Subject: Chairman’s Report

Report By: Andy Meehan, Chairman

Author: Andy Meehan, Chairman

Accountable Executive Director:

Andy Meehan, Chairman

PURPOSE OF THE REPORT:

To update the Trust Board of the key details of meetings and events attended by the Chairman.

SUMMARY OF KEY ISSUES:

Since the last Board meeting, the major meetings and areas of interest were as follows:

Recruitment of new Trustees for UHCW Independent Charity

Dinner following the Coventry and Warwickshire Health Summit

New Charity Fund Managers meetings

Board Seminar

Together Towards World Class Board meeting (including 2nd birthday celebrations)

Health and Well-being Strategy and Performance Workshop

STRATEGIC PRIORITIES THIS PAPER RELATES TO (Please check one):

To Deliver Excellent Patient Care and Experience

To Deliver Value for Money

To be an Employer of Choice

To be a Research Based Healthcare Organisation

To be a Leading Training and Education Centre

RECOMMENDATION / DECISION REQUIRED:

The Trust Board are asked to RECEIVE ASSURANCE from the report.

IMPLICATIONS:

Financial: None Highlighted

HR/Equality & Diversity:

None Highlighted

Governance: None Highlighted

Legal: None

NHS Constitution: None Highlighted

Risk: None Highlighted

COMMITTEES/MEETINGS WHERE THIS ITEM HAS BEEN CONSIDERED: None –the report is for the Trust Board.


PUBLIC TRUST BOARD PAPER

Title Hello My Name Is Campaign

Author Clare Ingram, Consultant Anaesthetist Chris Turner, Consultant in Emergency Care Sarah Brennan, Patient Experience Manager

Responsible Chief Officer

Meghana Pandit, Chief Medical and Quality Officer

Date 31st March 2016

1. Purpose To update the Trust Board on the Trust’s ‘Hello My Name Is Campaign’ and present the promotional video that supports this campaign. 2. Background and Links to Previous Papers This story forms part of the Patient Story Programme that was agreed by the Board in

January 2015.

3. Narrative In keeping with ‘Together Towards World Class’ and the Trust’s vision of becoming a national and international leader in healthcare, the Patient Experience and nursing and midwifery teams believe that patient stories are important to further inform the Board, and add additional patient experience information to compliment the Integrated Quality, Finance and Performance Report. Patient Stories also align with the organisations values of Compassion, Care, Openness, Partnership, Learning and Improvement.

The international #hellomynameis campaign, created by Dr Kate Granger MBE, is a campaign to improve communication between NHS staff and patients, and their relatives starting with one simple step – just introducing themselves. Kate founded the campaign following her own experience as an inpatient. The Trust launched this campaign as part of the Patient Experience Week (25th February- 2nd March) and in this week, over 700 staff signed up to the campaign. Today the Trust Board will have the opportunity to listen to the presentation that was delivered at Grand Round during this week.

4. Areas of Risk This campaign should be shared with all staff so that they have the opportunity to further improve future patient care and experience.

5. Governance NHS Constitution Principle 3- The NHS aspires to the highest standards of excellence and professionalism.

of 2

Principle 4 – The NHS aspires to put patients at the heart of everything it does….NHS services must reflect and should be coordinated around and tailored to, the needs and preferences of patients, their families and their carers. 6. Responsibility Chief Nursing Officer, Mark Radford Chief Medical Officer and Quality Officer, Meghana Pandit 7. Recommendations The Board is invited to NOTE the ‘Hello My Name Is Campaign’ as part of the Patient Experience Programme and to RAISE any questions. Name and Title of Author: Consultants Clare Ingram and Chris Turner and Sarah Brennan, Patient Experience Manager Date: 31st March 2016

Agenda item 9 Enclosure 6


Title Integrated Quality, Performance & Finance Report – Month 11 – 2015/16

Author Mrs. Laura Crowne, Director of Performance and Programme Management


Mrs. Karen Martin, Chief Workforce and Information Officer


1. Purpose To inform the Board of the performance against the key performance indicators for the month of February 2016. 2. Narrative

The most key contents of the report are:

Areas of underperformance – Headlines. This section allows three KPIs to be reported on. These have been selected on the basis of their profile, acuity and trends of deterioration.

The flash report section flags those significant matters occurring outside of the ‘reported’ month.

In this report, 17 KPIs achieved the target; 4 of which are classified as national standards and 13 are corporate objectives.

3. Areas of Risk As detailed in Areas of underperformance – Headlines. 4. Recommendations The Board is asked to confirm their understanding of the contents of the February 2016 Integrated Quality, Performance and Finance Report and note the associated actions. Name and Title of Author: Mrs. Laura Crowne, Performance and Programme Management Date: 31st March 2016

Integrated Quality, Performance and Finance Reporting Framework Reporting period: Month 11 – February 2016

Section Page

Trust Scorecard 3

Scorecard matrix 5

Trust Heatmap 6

Areas of underperformance 8

Flash report 10

Key achievements 10

Finance overview – position summary 11

Finance overview – statement of comprehensive income 12

Finance overview – statement of financial position 13

Finance overview – cost improvement programme 14

Workforce overview 15

Appendix 1 – Ward Staffing Levels 17

Appendix 2 – Cancer Information 18

Appendix 3 – New Trust and Supplementary Scorecards and Heatmap 19

Integrated Quality, Performance and Finance Reporting Framework

Contents


Trust Scorecard Reporting Month February 2016

3

Trust Scorecard Reporting Month February 2016

4

Behind plan On plan Ahead of plan

Improving

18 week RTT Incomplete 62 days urgent referral to treatment cancer target A&E 4 hour wait target Vacancy rate compared to funded establishment Number of medical outliers – average per day Delayed transfers as a percentage of admissions Emergency admissions (local definition) Last minute non-clinical cancelled ops (elective) No of pts recruited into NIHR portfolio – cumulative Hand hygiene – clinical – annual MRSA - decolonisation score MRSA - elective screening

HSMR (basked of 56 diagnostic groups) Peer reviewed publications (calendar year cumulative) Cannula – full compliance Forecast recurrent and non recurrent efficiency compared to plan

Not Changing

Enrolled on leading together programme 12 hour trolley waits in A&E Succession plan SHMI MRSA bacteraemia (Trust acquired) – cumulative

Diagnostic waiters, 6 weeks and over Staff survey – recommending as a place of treatment Staff survey – recommending as a place of work NCE POD categorised E Deaths – cumulative Forecast I&E compared to plan (£,000)

Deteriorating

18 week RTT admitted 18 week RTT non-admitted Bed occupancy rate (basket of wards) Length of stay – average YTD income and expenditure compared to plan

Harm Free Care

Two week cancer wait (GP referral to OP appointment) 31 day diagnosis to treatment cancer target Hand hygiene – Non clinical - initial Clostridium difficile (Trust acquired) – cumulative

Scorecard matrix

5 Integrated Quality, Performance and Finance Reporting Framework


Trust Heatmap

6


Trust Heatmap

7


Areas of underperformance | Headlines

Indicators achieved

Indicators in exception

Indicators in watching

status

Total indicators

National Standards 4 5 0 9

Corporate Objectives:

Chief Workforce and Information Officer 3 2 0 5

Chief Operating Officer 0 6 0 6

Chief Medical Officer 4 1 0 5

Chief Nursing Officer 4 3 1 8

Chief Finance and Strategy Officer 2 1 0 3

8

Scorecard Summary | 17 KPIs achieved the target; 4 of which are classified as national standards and 13 are corporate objectives.

Never Event | A wrong site surgery never event was declared in February.

The Trust’s overall performance has remained similar to last month. The Trust has faced a number of challenges including a spiked increase in attendances to A&E following half term alongside further junior doctor strike action. Progress is being made in line with the RTT incomplete pathway recovery trajectory and indications are that this should be met at year end. Despite improvement, 62 day urgent referral to treatment performance continues to fall below the national standard. This is explored in more detail later in this report. There has been a notable improvement in the MRSA decolonisation score due to enhanced observation and increased educational support. There has been a reduction in the average number of medical outliers per day. The Harm Free Care indicator has been placed in a watching status due to underachieving the target by 0.01%.

Unfortunately the Trust is reporting a further never event this month which relates to wrong site surgery. This is the third declared never event this financial year and is detailed later in this report.

A third never event has been declared for February 2016. This relates to wrong site surgery involving K-wiring of the finger. The event was noticed and therefore corrected during the procedure. The patient and family have received an explanation and apology from the Trust. The WHO surgical checklist had been completed. The incident is to be investigated by the Deputy Chief Medical Officer and a root cause analysis investigation was scheduled for 12 February 2016. The investigation report will be reviewed at Serious Incident Group (SIG) in due course.


Areas of underperformance | Headlines

Elective access indicators| The Trust continues to face challenges in the delivery of its elective access indicators including 18 week RTT and Cancer pathways.

In month performance shows slight improvement with a continued focus by the clinical groups on increased capacity and comprehensive action plans to continue with this progress. The size of the challenge to deliver by year end cannot be underestimated although month 11 currently shows continued improvement. Performance and delivery is being monitored through the weekly Access meeting with plans around Easter capacity already being discussed to prevent an adverse impact. The specialties with the largest challenge and highest risk to ensure delivery by the year end are Surgery and Trauma & Orthopaedics.

9

Cancer 62 day urgent Referral to Treatment performance shows the planned recovery to 82.12% against the 85% standard.

Non achievement of the standard continues to be related to the planned treatment of Urology long waiters.

Particular focus remains on the Head and Neck, Gynaecology and Colorectal teams to ensure improved and maintainable performance for Q4.

Further detail on tumour site specific performance is included on page 18 of this report.


Flash Report | February 2016

10

Key Achievements | February 2016 National Staff Survey indicates UHCW is one of the top places to work The Trust has seen improvements in almost all areas of the NHS Staff Survey, which is sent each year to employees of every NHS Trust in England. 93% of the staff surveyed said that they felt their work made a difference to patients. Staff also said they would recommend the Trust as a place to work or be treated, and praised the training and support they received. A score of more than 4 out of 5 was received for both staff satisfaction with the quality of work and patient care that they were able to provide, and staff feeling motivated in their jobs. UHCW received a score of 3.91 out of 5 for “engagement” – how informed staff feel about their organisation, and how involved they are in decisions.

The Perfect Week, 22-26 February The third UHCW Perfect Week, took place on Monday 22 to Friday 26 February. During the week, the Trust introduced a “multidisciplinary accelerated discharge event”, or MADE with the help of our community partners.

This is an increase from 3.78 in the previous year’s survey, and puts UHCW in the top 20% of acute (hospital) Trusts. In all, the Trust was named as in the top 20% of acute Trusts for 18 out of the 32 indicators in the survey, and above the national average for 28 out of 32.

Acute and community partners joined together each day in a ward setting to break down any barriers to discharge, and to gently challenge each other about why patients cannot be at home to receive any care they require. The community teams have looked at the areas they feel might give the greatest benefit, and also the areas that we might learn the most from conducting this exercise, which fed into a therapy challenge event held after the Perfect week. We were asked, as part of the ECIP programme, to run a series of Perfect Weeks to see if a cumulative effect on performance could be generated. The first week was very successful and had a positive performance impact. The second two weeks made no material impact on performance. This suggests no cumulative effect and as a result we will stop sunning Perfect Weeks as regularly as we currently are. The group responsible for planning these events will come back with a recommended work programme for the future.

Specialist Nurse shortlisted for international award Wendy Trodden, Tissue Viability Assistant Practitioner, has been shortlisted for the Patient Wellbeing Award in the Journal of Wound Care (JWC) Awards 2016, in recognition of her excellent wound dressings for patients undergoing radiotherapy treatments. The JWC Awards recognise individuals and teams who have excelled in wound care. Wendy was nominated for the award as a result of making a significant difference to the experience of patients who attend radiotherapy treatments at the Arden Cancer Centre

Junior Doctors' Industrial Action Industrial action in the form of strike action took place from 8am, Wednesday 10 March to 8am, Friday 11 March. The Trust put plans in place to minimise disruption and ensure services remained safe. The contingency plans included consultant staff providing urgent and emergency care as required.


Finance overview | position summary

• Income is forecast to underperform, primarily due to shortfalls in elective delivery; however, the Trust has closed down both Arden commissioner and specialised forecasts to mitigate risk.

• Non Pay is shown in escalation; however, this is primarily driven by timing differences in research and development funding, coupled with high agency fees and RTT pressures.

• Debtors over 90 days accounting for more than 5% of total debtors remain in escalation at month 11. The Trust performance in month 11 is 14.8% compared with month 10 at 5.6% after adjusting for impaired debts. The key issue is the proportion of unpaid invoices which are over 90 days old. The Trust is in negotiations to resolve any outstanding queries.

• Creditors over 90 days accounting for more than 5% of total creditors remains in escalation as at month 11. This is in part driven by longstanding queries on intra-NHS service level agreements and are actively being resolved.

The current financial indicators are still being reviewed by the Trust.

11

Indicator Measure Standard YTD YTD EscalationPlan Actual Status

Monitor COSSR score 3 1 1 No Escalation Required - on plan

Liquidity Days days >-7 days -25.2 -23.5 No esclation required - within tolerance

Capital Servicing Capacity score >1.25 0.7 1.09Escalation Required -

covered through debtors and creditor

PMR escalations

EBITDA Margin % >=11% 6.6% 6.8% No esclation required - within tolerance

EBITDA Achieved % >=85% of plan 100.0% 96.3% No esclation required - within tolerance

Net Return after Financing % >=2% -2.7% -4.0% Escalation Required - below plan

I&E Surplus Margin % >=1% -1.9% -1.3% Escalation Required - below plan

Liquidity Ratio* days >=15 days 9.9 8.8 No esclation required - within tolerance

Debtors % % > 90days 14.8% Escalation Required - below plan

Creditors % % > 90days 22.7% Escalation Required - below plan

Total Income % actual v plan w ithin 0.5% of plan -0.9% Escalation Required -

below plan

Pay Expenditure % actual v plan w ithin 0.5% above plan 0.4% No esclation required -

within tolerance

Non Pay Expenditure** % actual v plan w ithin 1.0% above plan 2.1% Escalation Required -

above plan

Non Operating Items % actual v plan w ithin 1.0% above plan 29.1% Escalation Required -

below plan

CIP % actual v plan w ithin 5% below plan 2.5% No Escalation

Required - on plan

Escalation triggered when YTD is red or amber and showing a deterioration from plan* Liquidity ratio - assumes 30 days working capital facility equivalent for Monitor metric** Non Pay Expenditure excludes Non Operating Items

Eight finance performance indicators are in reportable escalation this month.


Finance overview | statement of comprehensive income

The improvement in control total deficit is as a result of a capital to revenue transfer enacted by the TDA. Contract income is forecast at £8m adverse to plan driven by under performance against activity targets, risks and penalties. Group expenditure forecasts include cost pressures of £7.5m mainly due to: • (£4.1m) Education & Research income and

expenditure timing differences • (£3.2m) premium cover for medical staff vacancies • (£1.5m) premium cost of covering ward nursing

vacancies • (£0.9m) RTT and capacity issues • (£0.9m) for specialing of patients • (£0.5m) Pathology network • £0.4m activity related variances and other cost

pressures • £0.8m over achievement of CIP • £1.8m staffing, primarily vacancies • £3.0m PFI variations and utility costs The Trust is reporting a £14.9m net deficit year to date and break-even position following technical adjustments. The net deficit is primarily due to underperformance against activity targets noted above.

12

Statement of Comprehensive IncomeOriginal

plan April 2015

Stretch Target Aug 15

Revised Target Dec

2015Budget Forecast

Outturn Variance Budget Actual Variance Budget Actual Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Income

Contract income from activities 479,062 479,062 479,062 495,093 487,122 (7,971) 453,792 446,583 (7,209) 40,784 41,648 864Other income from activities 20,317 20,317 32,717 18,783 19,799 1,016 17,932 18,964 1,032 1,933 2,047 114Other Operating Income 71,528 71,528 71,528 73,915 75,887 1,972 67,868 69,457 1,589 6,032 6,264 232

Total Income 570,907 570,907 583,307 587,791 582,808 (4,983) 539,592 535,004 (4,588) 48,749 49,959 1,210

Operating Expenses

Pay (336,170) (336,170) (336,170) (342,205) (344,645) (2,440) (313,680) (314,978) (1,298) (28,541) (29,128) (587)Non Pay (189,035) (189,035) (192,035) (197,748) (202,779) (5,031) (179,722) (183,440) (3,718) (17,281) (18,134) (853)

Additional savings required 0 0 0

Reserves (18,987) (15,987) (15,987) (8,722) (165) 8,557 (8,129) 57 8,186 (540) 0 540

Total Operating Expenses (544,192) (541,192) (544,192) (548,675) (547,589) 1,086 (501,531) (498,361) 3,170 (46,362) (47,262) (900)

EBITDA 26,715 29,715 39,115 39,116 35,219 (3,897) 38,061 36,643 (1,418) 2,387 2,697 310EBITDA Margin % 4.7% 5.2% 6.7% 6.7% 6.0% 7.1% 6.8% 4.9% 5.4%

Non Operating Items

Profit / loss on asset disposals 0 6 6 0 6 6 0 0 0Investment property gain 0 3,223 3,223 0 0 0 0 0 0Depreciation (21,043) (21,043) (21,043) (21,043) (19,398) 1,645 (19,289) (17,782) 1,507 (1,754) (1,617) 137Interest Receivable 100 100 100 100 123 23 92 116 24 8 5 (3)Interest Charges (789) (789) (789) (789) (346) 443 (757) (281) 476 (34) (26) 8Financing Costs (25,303) (25,303) (25,303) (25,303) (25,303) 0 (23,194) (23,143) 51 (2,109) (2,004) 105Unwinding Discount (36) (36) (36) (36) (35) 1 (36) (35) 1 0 0 0PDC Dividend (3,626) (3,626) (3,626) (3,626) (2,589) 1,037 (3,324) (2,373) 951 (302) (215) 87Impairments 0 0 0 0 (16,543) (16,543) 0 (16,543) (16,543) 0 0 0

Total Non Operating Items (50,697) (50,697) (50,697) (50,697) (60,862) (10,165) (46,508) (60,035) (13,527) (4,191) (3,857) 334

Net Surplus/(Deficit) (23,982) (20,982) (11,582) (11,581) (25,643) 14,062 (8,447) (23,392) (14,945) (1,804) (1,160) 644Net Surplus Margin % -4.2% -3.7% -2.0% -2.0% -4.4% -1.6% -4.4% -3.7% -2.3%

Technical adjustments

Donated/Government grant assets adjustment (74) (74) (74) (74) (399) (325) 240 135 (105) 22 (59) (81)Impairments 0 0 0 0 16,543 16,543 0 16,543 16,543 0 0 0IFRIC 12 1,633 1,633 1,633 1,633 0 (1,633) 1,493 0 (1,493) 136 0 (136)

Break-even in-year position (22,423) (19,423) (10,023) (10,022) (9,499) 523 (6,714) (6,714) 0 (1,646) (1,219) 427

2015/16 Year To Date Month

The Trust has a changed break-even plan of £10.023m deficit representing the inclusion of capital to revenue transfer offset by case 915.


Finance overview | statement of financial position The statement of financial position shows the assets, liabilities and equity held by the Trust and is used to assess the financial soundness of an entity in terms of liquidity risk, financial risk, credit risk and business risk.

13

Statement of Financial Position Resubmitted Plan

Forecast Outturn Variance Plan Actual Variance Planned

ChangeActual

Change Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

Non-current assetsProperty, plant and equipment 414,511 362,184 (52,327) 392,719 354,700 (38,019) 3,195 884 (2,311)Intangible assets 3,886 3,886 0 3,886 3,886 0 0 0 0Investment Property 5,007 8,230 3,223 5,007 5,007 0 0 0 0Trade and other receivables 18,245 25,191 6,946 23,226 30,072 6,846 (1,434) (1,031) 403Total non-current assets 441,649 399,491 (42,158) 424,838 393,665 (31,173) 1,761 (147) (1,908)Current assetsInventories 11,558 11,558 0 11,558 12,035 477 0 258 258Trade and other receivables 27,464 21,668 (5,796) 30,100 27,557 (2,543) (8,038) (23,150) (15,112)Cash and cash equivalents 2,742 2,742 0 2,763 5,665 2,902 5 (2,248) (2,253)

41,764 35,968 (5,796) 44,421 45,257 836 (8,033) (25,140) (17,107)Non-current assets held for sale 0 0 0 0 0 0 0 0 0Total current assets 41,764 35,968 (5,796) 44,421 45,257 836 (8,033) (25,140) (17,107)Total assets 483,413 435,459 (47,954) 469,259 438,922 (30,337) (6,272) (25,287) (19,015)Current liabilitiesTrade and other payables (50,008) (48,501) 1,507 (65,511) (65,240) 271 6,198 25,100 18,902Borrowings (186) (186) 0 (186) (144) 42 0 0 0DH Interim Revenue Support loan 0 0 0 0 0 0 0 0 0DH Capital loan (3,774) (2,489) 1,285 (3,774) (2,489) 1,285 0 (99) (99)Provisions (194) (194) 0 (1,309) (700) 609 0 (18) (18)Net current assets/(liabilities) (12,398) (15,402) (3,004) (26,359) (23,316) 3,043 (1,835) (157) 1,678Total assets less current liabilities 429,251 384,089 (45,162) 398,479 370,349 (28,130) (74) (304) (230)Non-current liabilities:Trade and other payablesBorrowings (268,075) (264,619) 3,456 (264,701) (264,596) 105 99 35 (64)DH Interim Revenue Support loan 0 (12,479) (12,479) 0 0 0 0 0 0DH Capital loan (22,632) (11,759) 10,873 (18,770) (12,509) 6,261 692 (889) (1,581)Provisions (2,379) (2,378) 1 (2,428) (2,426) 2 0 0 0Total assets employed 136,165 92,854 (43,311) 112,580 90,818 (21,762) 717 (1,158) (1,875)

Financed by taxpayers' equity:Public dividend capital 83,980 59,330 (24,650) 68,680 55,080 (13,600) 2,700 0 (2,700)Retained earnings (8,801) (13,462) (4,661) (7,446) (11,211) (3,765) (1,983) (1,158) 825Revaluation reserve 60,986 46,986 (14,000) 51,346 46,949 (4,397) 0 0 0

Total Taxpayers' Equity 136,165 92,854 (43,311) 112,580 90,818 (21,762) 717 (1,158) (1,875)

2015/16 Year To Date Month

• The TDA requested organisations to assess the scope to reduce capital expenditure in 2015/16 (due to pressures on the capital budget at a national level) and defer the draw down of loans into the following year. Capital Planning Review Group have identified a number of schemes where slippage is likely and expenditure can be deferred to 2016/17.

• An overall reduction of £10.9m on DH Capital loan (Current & Non-Current Liabilities) is due to the capital to revenue budget agreement. • DH interim revenue support loan has increased by £12.5m from plan, due to the Trust's revenue financing application being approved as an

interim support loan rather than the planned PDC. • The public dividend capital (PDC) reduction of £24.7m is due to the plan reflecting the revenue support required to cover the Trust's planned

deficit, being planned as PDC, however this has now been approved by the ITFF as an interim revenue support loan.

Efficiency Delivery Report | Key Headlines Reporting Month: February 2016

The Trust is forecasting delivery of £34.7m against a target of £34m, giving an over delivery of £700k: There are identified savings of £35.4m allowing delivery risk to be mitigated.

• Trust maintains its forecast delivery of £34.7m from month 10. • £31.6m savings delivered against a cumulative year to date plan of

£30.9m. • A slight improvement on Forecast delivery of £0.014m from previous

month giving a forecast over-delivery of £0.7m against Target of £34m.

• 8% of the identified savings are classified as opportunities. • 40% of the identified savings are expected from income streams; most

of which relates to commissioning contract income. • 37% of the identified savings are non recurrent.

• There is an overall Trust efficiency target of £21m set for 2016/17. £14.8m of the target has been allocated to the Groups as cost savings.

• A concerted effort is being made towards the identification of opportunities for CIP schemes in 2016/17. Groups are required to have fully identified and documented schemes by 22nd March.

• £6.3m of opportunities still to be found by Groups. • The Trust reports a balance to full-year effect value of £1.3m.

Against the 2016/17 CIP target of £21m the Groups have documented £14.7m of potential savings: This leaves 30% to be identified

14

Workforce Information | Headlines February


15

29th Feb 2016 TDA Plan

Variation from Plan

Last Month’s Variation from Plan ISS

WTE 6660.46 6608.40 -52.06 -40.77 618.40

WTE including ISS 7278.86

Headcount 7597 801

Headcount including ISS 8398

(excluding bank and ad-hoc locums) TDA/Monitor Rate Caps | Percentage of Shifts Booked Over Cap Rates

Starters & Leavers |Nursing

The Trust’s staff in post is 52.06 WTE ahead of the TDA plan of 6608.40 WTE. The Trust’s monthly staff in post has increased in WTE to 16.31 from January’s figures. Please note the decrease in Nursing and Midwifery Registered this does not take into account the increase of Newly Qualified staff who will sit under Additional Clinical services until the receipt of their NMC pin numbers.

With bank staff removed, there was an overall increase of 26 Registered Nurses February 2016. A cohort of 12 newly qualified nurses have commenced and are included in the total of 26. Bank only employees numbered three this month out of a total of 12 leavers.

Staff in Post | Variation from TDA Plan

Staff in Post | Monthly Variation

Staff Group Staff In Post WTE 31st Jan

2016

Staff In Post WTE 29th Feb

2016

Variance (WTE) % Variance

Add Prof Scientific and Technic 220.86 223.41 2.55 1.14%

Additional Clinical Services 1518.23 1528.60 10.37 0.68%

Administrative and Clerical 1145.54 1143.09 -2.45 -0.21%

Allied Health Professionals 372.02 374.92 2.90 0.77%

Estates and Ancillary 5.00 5.00 0.00 0.00%

Healthcare Scientists 320.68 318.71 -1.97 -0.62%

Medical and Dental 924.85 930.90 6.05 0.65%

Nursing and Midwifery Registered 2102.77 2096.64 -6.13 -0.29%

Students 34.20 39.20 5.00 12.76%

Totals 6644.15 6660.46 16.31 0.24%

ISS 621.90 618.40 -3.50 -0.56%

The above graph outlines the information from the weekly submissions by the Trust to the TDA on usage of agency staff with charge rates above the current TDA capped rates. The capped rates are being applied in stages and the next and final reduction in the capped rates will come into effect on April 2016. Work is being undertaken with agencies to reduce charge rates in line with the caps whilst ensuring quality and consistency of supply.

The above figures do not include 1094 bank only staff who do not have contracted hours. These employees will not be included in future staff in post figures.

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

RN

HCA

Medical

AHP/ODP

Healthcare Scientistst

A&C

Integrated Quality, Performance and Finance Reporting Framework 16

Workforce Information | Headlines February Pay Costs| Provided by Finance

Temporary costs equate to 16.39% of the Trusts total pay bill (28,997,620), this is an increase of 0.63% from last month. This represents:

An increase in Bank of 254k and Medical Agency 152k. An decrease in overtime and Agency Nursing/other of 262k.

Agency costs against total costs decreased from 11.20% to 10.92%, a decrease of 0.28% against last month which was driven by an decrease in the use of other agency spend of £238K. Bank usage increased from 4.21% to 5.13% of total spend. Overall, the pay bill has decreased by £256k over January 2016.

Mandatory Training |Topics

Absence| Specialty Group

Mandatory Training compliance is currently 87.45% an increase of 1.35% against January’s 86.10% . 4 topics are above 95% (Hand Hygiene Non Clinical, Equality and Diversity, Neonatal Life Support – Annual & Thromboprophylaxis) with 10 topics between 85% and 95% and 19 topics below 85%. 6 topics with the lowest compliance which are under 75% are Advanced Life Support 4 yearly 49.06%, Safeguarding Children Level 3 56.74%, Immediate Life Support 60.53%, Advanced Life Support Annual 64.71%, Paediatric Basic Life Support 72.73% and Paediatric Life Support Update 71.31%. The competency for Safeguarding Children Level 3 has been reviewed for the second time which has resulted in the increased compliance 56.74% against 44.54% in January. 72 medical locums who have not worked in 6 months have been removed from ESR. This has impacted on the February 2016 figures.

Absence| Staff Group -12 Months Rolling Period

Absence has reduced by 0.31% to 4.51% which is the lowest for four months but remains well above the target. In the past month there have been 44 long term sickness cases managed to either return to work (41) or have left the Trust (3), it is anticipated that this will result in a reduction in the absence figures for March 2016.

Specialty Group % Abs Rate (WTE)

Anaesthetics Specialty Group 6.37% Cardiac & Respiratory 3.53% Care of the Elderly 4.05% Clinical Support Services Specialty Group 4.74% Core Functions 3.54% Delivery Unit 2.70% Emergency Department Specialty Group 5.09% Hospital of St Cross 6.06% Imaging 2.31% Neurosciences Specialty Group 4.47% Oncology and Haematology 5.12% Pathology Network Cov & Warwicks 5.40% Renal Specialty Group 7.52% Specialist Medicine & Ophthalmology 3.50% Surgery Specialty Group 3.74% Theatres Specialty Group 4.96% Trauma & Orthopaedics Specialty Group 3.81% Women & Children Specialty Group 4.43%

Totals 4.51%


The figures reported above are submitted to the DoH via Unify on a monthly basis to support NHS England Safer Staffing along with the ten expectations from the NQB. These figures show the previous months Trust wide nurse staffing, along with exceptions and actions being taken. Patients are able to view this information on the Trust’s Internet Site.

17

Appendix 1

Cancer Information | January Headlines Two week wait standard:

Two week wait performance year to date is 96.7% (achieved and improving). The breast symptomatic 2ww target is met for January but year to date is not met. The team have over performed since failing badly in July and August due to a reduced Consultant workforce. Year to date performance is 91.8% - this trajectory now means that the year end figure is predicted to be 92.8% - ACTION to mitigate is that all January breaches are being reviewed and February data is now validated, so all February breaches will also be reviewed and a final predicted figure for year end will be provided to COG by w/e Friday 11th March.

62 Day Standard:

Urology: 5.5 breaches (7 patients) as expected for January

Colorectal: 4.0 breaches (lower than December). Delays due to Christmas, referral to specialist centre for an opinion and patient cancelling an appointment in diagnostic period

Lung: shared breach sent to UHCW on day 58 from SWFT

UGI: shared breach sent to UHCW on day 96 from SWFT

Head and Neck: 1.0 breach (complex and festive period delays)

Skin: 1.0 breach. First diagnostic test took 21 days to occur and then an additional lesion found which delayed primary treatment

Gynaecology: 1.0 breach. Multiple diagnostics required and festive period.

100 day plus patients:

All urology patients (1.5)

Two Week Referral Service 2015/16 YTD

100.

0%

93.6

%

94.5

%

96.8

%

98.8

%

95.1

%

97.2

%

97.8

%

100.

0%

96.1

%

98.9

%

92.0

%

71.4

%

95.7

%

93.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Brain/N

eurologic

al

Breast

Children

s

Gynae

colog

y

Haemato

logy

Head an

d Nec

k

Lower

GILu

ng

Sarcom

aSkin

Upper G

I

Urolog

ical

Other All

Tumour site

% c

ompl

iace

YTD Target

Time from decision to treat to treatment (31 day first treatment) 2015/16 YTD

98.4

%

100.

0% 99.2

%

100.

0%

100.

0%

100.

0%

99.6

%

100.

0%

100.

0% 96.9

%

100.

0%

99.3

%

96.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

101.0%

Brain/N

eurologic

al

Breast

Gynae

colog

y

Haemato

logy

Head an

d Nec

k

Lower

GILu

ng Skin

Upper G

I

Urolog

ical

Other All

Tumour site

%co

mpl

ianc

e

YTD Target

Time from urgent GP referral to treatment (62 day standard) 2015/16 YTD

100.

0%

97.3

%

83.7

%

81.5

%

62.8

%

77.3

%

79.4

%

92.9

%

78.4

%

71.1

%

84.6

%

82.5

%

85.0%

0.0%20.0%40.0%60.0%80.0%

100.0%120.0%

Brain/N

eurologic

al

Breast

Gynae

colog

y

Haemato

logy

Head an

d Nec

k

Lower

GILu

ng Skin

Upper G

I

Urolog

ical

Other All

Tumour site

%co

mpl

ianc

e

YTD Target

0

1

2

3

4

5

6

7n

um

ber

of p

atie

nts

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

month

Treated on or after day 100 / 104

Number referral to treated 100+ days Number referral to treated over 104 days

Integrated Quality, Performance and Finance Reporting Framework 18

This appendix contains the following additional scorecards which measure KPIs at Trust level.

Additional Scorecards

Appendix 3

19 Integrated Quality, Performance and Finance Reporting Framework

Page

Supplementary Scorecard – includes further national standards and key trust metrics 18

Finance and Performance Committee Scorecard – contains the main Trust level KPIs coming under the remit of this committee

20

Quality and Governance Committee Scorecard – contains the main Trust level KPIs coming under the remit of this committee

21

20

Trust Scorecard – (Supplementary) Reporting Month February 2016


21

Trust Scorecard – (Supplementary) Reporting Month February 2016


22

Trust Scorecard – Finance and Performance Committee Reporting Month February 2016


23

Trust Scorecard – Quality and Governance Performance Committee Reporting Month February 2016




Title MEDICAL EDUCATION REPORT TO UHCW TRUST BOARD – March 2016

Author Dr Sailesh Sankar, Associate Medical Director for Education


Professor Meghana Pandit , Chief Medical and Quality Officer

Date 31 March 2016

1. Purpose The Trust sees education, research and learning as central to improvement and it is our stated objective to be a Leading Training and Education Centre. We are the major undergraduate (UG) teaching partner to Warwick Medical School (WMS), and offer postgraduate (PG) training in almost all specialties. The Trust Board will be informed and updated on progress against this objective, and on substantial internal and external pressures that impinge upon Medical Education. We ask the support of the Board in maintaining the Trust’s focus on, and excellence in, Medical Education and Training. 2. Background and Links to Previous Papers

UHCW is one of the UK’s largest and busiest NHS University Teaching Trusts.

We have a mature and strengthened partnership with WMS, which allows us to combine excellence in teaching and research with high quality medical education. The Trust recognises that its association with Warwick has improved recruitment of high quality doctors at all levels.

The delivery of postgraduate education and training is recognised as a Trust core activity. Approximately 250 Foundation, Core and Specialty trainee doctors appointed by Health Education England West Midlands (HEEWM) undertake training, and patient care, within the Trust.

Both areas must operate in line with the General Medical Council (GMC) document ‘Promoting Excellence: Standards for Medical Education and Training’ which took effect January 2016.

Education impinges on many operational areas for the Trust; with regular reports to Patient Safety, Training, Education and Research, and Quality Governance Committees as well as Trust Board.

In October 2015 Dr Maggie Allen left the Trust to take up an exciting and challenging post in Qatar. In her place Dr Sailesh Sankar was appointed to the role of Associate Medical Director for Education, Training and Professional Development.

3. Narrative Medical Education has a Service Level Agreement with WMS and a Learning

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Development Agreement with HEEWM. These give us a clear framework for facilities, delivery, and in particular quality, of teaching and training, and of ‘working conditions’ for our learners. We are subject to frequent inspection, particularly of PG Training. Following Government recognition that more educational funds needed to be identified for nurse training and training of professions allied to medicine, but a restriction in central funding, there was a rebalancing of the education budget which has resulted in a considerable drop in funding for medical education in the past two years. This is likely to continue into the 2016-2017 budget with a further predicted drop of £800,000 for the UG income and on the PG side HEEWM now pays only 50% of trainees’ basic salaries and no ‘on call’; the Trust must fund the remainder. Education income now explicitly follows the learner, and learners may only be assigned if teaching and training is at least satisfactory. While income has dropped, the standards to be achieved for both UG and PG training are becoming more explicit and demanding. Thus we are operating in a much tougher climate. We stand to lose income if we do not meet standards, and of course our aim is excellence, but against this we face a number of important service challenges, which directly impact on our ability to provide excellent education. From July 2016 all Teaching Leads & Supervisors are required to have attained Full GMC Trainer Accreditation in order to be allowed to provide Educational supervision to trainees and students. The aim is that all trainers will be carefully selected, trained and supported by the Trust. Over the past two years we have made good progress against initial requirements for provisional registration by running a large number of tailored ‘in house’ courses, but full (and on-going) accreditation requires each trainer to maintain individual professional development in this area. We require increased emphasis on educational activity at appraisal and revalidation to support this. We return our data to HEEWM and WMS and may be asked by the GMC at any stage for our current status, which must be 100% compliance. We are on target to achieve this demanding standard. Specific Postgraduate Training Issues. There have been four Health Education England visits to inspect PG training since September 2015 (Paediatrics, Acute Medicine and Geriatrics at UHCW, Geriatrics at Rugby St Cross and Obstetrics and Gynaecology) with a further two due in the next four months (a revisit to Geriatrics at Rugby St Cross in May and a revisit to Acute Medicine in July). Such visits impose huge stress and workload upon the PG tutors and administration staff, particularly in data gathering/analysis. For past visits, two (Geriatrics at Rugby and Obstetrics and Gynaecology) were ‘level 3’, i.e. ‘triggered’ by significant criticisms or concerns, often over locally recognised issues, many of which are operational, rather than directly educational. The visit to Acute Medicine was a Level 4 (triggered by concerns with GMC input). Following their visit in March to Obstetrics & Gynaecology this specialty has now been graded back to standard visits. This is in recognition of the very substantial progress made by this specialty but the inspection team recognised that the service still has significant operational challenges (mainly associated with workload) to address. The operational issues in Acute medicine, again mainly linked to the high workload, are proving very challenging to solve but the Trust has responded and continues to work on the issues and is seen by HEEWM as being supportive of Education and Training. The problems identified with the Geriatric specialty at Rugby have been addressed and it is hoped that the follow up visit in May will confirm this. Therefore, in summary our progress is recognised but major ‘front door’ pressures

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and associated patient safety issues, identified by trainees, continue to worry HEEWM. The Non-Executive support and oversight of education by the Trust Board is very helpful, and favourably viewed by the GMC and HEEWM. Mrs Brenda Sheils, the Non-Executive Board member with the lead for Medical Education has set up a series of regular meetings with our medical students and trainees (to take place throughout the spring) to get a better understanding of the issues that confront them. This additional connection between the Board and the shop floor helps to illustrate the Trust’s genuine commitment to education. To acknowledge good news, the Paediatrics specialty were very favourably reviewed and as noted before the Obstetrics and Gynaecology team worked hard to return their specialty to standard visiting status Dr Ed Simmonds a Consultant Paediatrician who for many years has made a very significant contribution to the development of education in the Trust both within his own specialty but also as Clinical Tutor across the Trust stood down from his role as Clinical Tutor in November 2015, but we hope will be persuaded to re-join the Educational team later in the 2016. Dr Marius Holmes has taken on full responsibility for all Clinical Tutor related tasks and is working closely with the Acute Medicine team and the Geriatrics team to help them reduce their inspection level status back to standard inspections. Dr Pijush Ray has relinquished his role as Deputy Clinical Tutor managing Foundation Year 1 doctors training and has now been appointed as the Trust Lead for Undergraduate Medical Education. He took over this new role in February 2016. Currently the Trust is seeking to appoint to the Simulation Lead role which Dr Sarah Ellis stood down from after a short but impressive stint. One of the genuine strengths of the Trust is the committed educationalists working within its ranks. Also the PG Education teams continue to run many nationally and internationally acknowledged external courses, greatly enhancing the Trust’s specialist reputation. Undergraduate WMS introduced a ‘refreshed’ curriculum from September 2013. For the last three years we have run the original and refreshed curricula alongside each other. This has caused a significant ‘bulge’ in UG teaching requirements and pressure on teachers and educational leads. They have stepped up to the mark to try and ensure neither original nor refreshed curriculum students suffer as the course runs in parallel for three years. However, student dissatisfaction with their course was reflected in the results of the National Student Survey in 2015 and the extra-large bulge over the Christmas and New Year has been particularly challenging. On the plus side the ‘extra work’ has ensured that the Trust has maintained its overall ‘share’ of UG teaching income over these years. We also have a better understanding of income against activity than previously possible. We have appointed Dr Pijush Ray as the Trust Lead for Undergraduate Medical Education and over the last few months we have made significant improvements in the communication and working relations with our partners. These had become suboptimal as a result of significant staffing changes both at the Trust and WMS but with the establishment of a new team at WMS and the replacement of two administration posts at UHCW (due to start in April). Both teams will be back to full strength and well placed to implement the strategy being developed by the

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Senior management team at UHCW under the guidance of the Associate Medical Director for Education Dr Sailesh Sankar. Over the next 6 months we will develop Education SLA’s (this will include both UG and PG education) with individual department/directorate. The Surgical Training Centre The Surgical Training Centre continues its exponential growth in scope and reputation, nationally and internationally. The team have won several prestigious awards and (ably led by Brian Burnett), are tireless in accepting new challenges and opportunities. Over 1500 surgeons, many from overseas, have trained there. Teaching is in place for groups from local schoolchildren through to highly specialised consultants, with emphasis on our local UG and PG learners, including innovative multi-professional courses. This is now a substantially self-funding enterprise. However, it has reached a stage where it has optimised its current facilities and the options for expansion are being explored. Resuscitation, Clinical Skills and Simulation Centre Our Clinical Skills and Simulation Centre are also well-equipped facilities, with Hi-Fidelity (i.e. near reality) simulation particularly suited to teaching on acute medical and surgical emergencies, non-technical skills under stress (e.g. team-working, leadership, communication skills, problem solving, situational awareness) applicable to all clinical disciplines, often as specialty multi-professional teams. Dr Carl Hillerman has taken on one of the two simulation lead roles and has the remit to develop the scenarios and the training packages. Currently we are recruiting the second lead who will take on the role of marketing and business management. This is very timely; there is a HEEWM led drive to increase availability of simulation training and a national emphasis to develop the area. The team lead by Catherine Baldock are developing excellent services in all three areas. We are grateful for Trust investment at a time of great financial stringency. This is potential source for income generation and would like to work with other partners to look at this opportunity 4. Areas of Risk

Clinical Risk. If we lose trainees due to unsatisfactory standards of training we lose high standard clinical staff and will need to employ (at full cost) other clinical staff to fill the gaps. We may not have as much assurance on the standard of those replacement staff. Due to current workload pressures our highest current risk areas are our most pressurised. The continued high level inspections of Acute Medicine are a high corporate risk because we have already had two middle grade Acute Medicine trainees taken away and adjoining Trusts have had trainees removed in other specialities. Therefore there is a substantial risk of losing further trainees from Acute medicine unless the inspectors see significant improvements in the issues they have highlighted as areas of concern.

Financial; as outlined above, funding now directly follows both medical students and PG trainees. Losing the ‘contract’ to teach and train will result in a reduction in income. Retaining that contract is dependent on maintaining high standards.

Business; the success of our outward reaching educational ventures is in part built upon our general teaching and training reputation.

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Reputation; It is unthinkable that we should not maintain our status as a major teaching and training hospital. This has brought many advantages and improvements to the Trust and our local population and health care community

Performance; as with clinical risk losing trainees will impact on performance in areas already under particular pressure

5. Governance The Governance of medical education at UHCW has been commended by HEEWM as having a well-structured and effective management system. The CMO oversees all functions. The Associate Medical Director for Education (AMDE) reports directly to the CMO and reports on medical education to the Training, Education and Research Committee, the AMDE reports on safety concerns related to education to the Patient Safety committee and provides a quarterly report to the Clinical Governance committee. The Clinical Tutor chairs the Post graduate Medical Education committee that oversees the provision of training for junior doctors and the Trust Lead for Undergraduate Medical Education chairs the Undergraduate Medical Education Committee which oversees the provision of education and training for Warwick Medical Students. This paper links to the Trust’s objective to become a Leading Training and Education Centre. 6. Responsibility Associate Medical Director for Education with UG and PG Education teams, reporting to Chief Medical Officer. 7. Recommendations The Board is invited to NOTE:

1. The on-going work in respect of UG and PG training and education 2. Continue to provide oversight particularly in respect of HEEWM visits.

Dr Sailesh Sankar. Associate Medical Director for Education Date: 14th March 2016.



Title Developing Sustainability & Transformation Plans

Author Rebecca Southall, Director of Corporate Affairs


Andy Hardy, Chief Executive Officer


1. Purpose To provide an update in relation to the development of the Sustainability & Transformation Plan (STP) for Coventry & Warwickshire and to seek delegated authority from the Trust Board to make a formally requested submission by 15th April 2016. 2. Background and Links to Previous Papers The Trust Board discussed the requirement for STPs to be developed at the February meeting and was advised that the Trust’s Chief Executive Officer was the lead and Senior Responsible Officer (SRO) for developing the STP for the Coventry & Warwickshire footprint.

3. Narrative Since the February Trust Board meeting, given the tight timescales for final submission of the STP (June 2016), a Project Board has been established comprising the Chief Executive Officers of the following organisations:

UHCW NHS Trust (plus Chief Finance & Strategy Officer)

South Warwickshire NHS Foundation Trust

George Eliot Hospital NHS Trust

Coventry & Rugby CCG

North Warwickshire CCG

South Warwickshire CCG

Warwickwickshire County Council

Coventry City Council

Representatives are also present from:

NHS England

Specialist Commissioning

It was also agreed at the inaugural meeting that the following organisations will be invited to join:

NHS Improvement

Healthwatch (Coventry & Warwickshire)

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The Project Board will meet on a fortnightly basis to ensure that the plan is developing in line with the trajectory and is underpinned by a Project Team that comprises a clinical lead and finance & strategy lead from each health partner organization within the local health economy. The Trust is also providing internal expertise to the project in terms of finance and efficiency, modelling, governance and programme management.

As a Project Board, members have already agreed that the following work-streams will be the key areas of focus for the STP:

1. Frailty

2. Maternity & Paediatrics

3. Mental Health

4. Musculoskeletal

The SRO for the STP is required to submit a response to the following two questions on 15th April 2016, together with a completed template that seeks to obtain some further, related information.

1. What leadership, decision-making processes and supporting resources have you put into place to make progress?

2. What are the major areas of focus and big decisions you will need to make as a system to drive transformation?

Clearly, the response to question (1) is straightforward in that a governance structure has been agreed, resource identified (subject to on-going review) and the Project Board and Team are now operational. Whilst the work-streams identified above have already been agreed, some further discussion around question (2) will be required at the next Project Board meeting, which is scheduled for 29th March 2016. Given the time-scales involved, delegated authority is sought from the Trust Board for the Chief Executive Officer to make the required response in his capacity as SRO. It should be noted that whilst the production of an STP is a requirement, the proposed response on 15th April does not bind the Trust to any course of action at this stage. Further information around the STP will be provided to Board members as the plan develops over coming months and in advance of formal approval and sign off.

4. Areas of Risk If an STP is not agreed and developed then the health economy will not be eligible for transformation funding, which given the current state of NHS finances, will jeopardise the ability of the Trust and its partners to transform services and ensure that they are clinically sustainable for the future. This could impact negatively on services in the future and on the patient experience. The STP links to the Trust’s strategic objective ‘to deliver excellent patient care and experience’ and as such, a corresponding risk features on the Board Assurance Framework for 2016/17 in relation to service transformation.

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5. Governance The Trust Board will be required to approve the final Sustainability & Transformation Plan and will be kept updated as to progress in the intervening period. 6. Responsibility Andrew Hardy, CEO and Senior Responsible Officer David Moon, Chief Finance & Strategy Officer 7. Recommendations The Trust Board is asked to NOTE the progress that has been made in terms of the governance arrangements around the STP and to DELEGATE authority to the Chief Executive Officer to submit the required response on 16th April 2016.



Title Information Governance Toolkit Annual Submission – v13

Author Head of Information Governance


Chief Operating Officer

Date 31 March 2016

1. Purpose To seek Trust Board approval of the proposed Information Governance Toolkit submission (version 13) 2015/16. 2. Background and Links to Previous Papers The IG Toolkit is a Department of Health (DH) Policy delivery vehicle that the Health and Social Care Information Centre (HSCIC) is commissioned to develop and maintain. It draws together the legal rules, standards, best practices and central guidance set out by the DH that apply to the processing and handling of all information, which are presented in a single standard in the form of 45 comprehensive requirements. The IG Toolkit is fast establishing itself as the de facto standard for all information governance requirements as the annual assessment is applicable to all NHS organisations, local authorities, GP practices, dental practices, the voluntary sector, and commercial third parties who are health care providers. The purpose of the IG Toolkit assessment is to enable organisations to measure their compliance against the legislation and central guidance, and to ensure information is processed and handled correctly and protected from unauthorised access, loss, damage and destruction. The ultimate aim is to demonstrate that an organisation can be trusted to comply with all the rules regarding confidentiality and data protection and maintain information security. The Information Governance (IG) Toolkit requires Trusts to submit their final scores by 31st March each year. 3. Narrative The Trust is required to submit version 13 of the IG Toolkit to the HSCIC at the end of March; attainment at level 2 or 3 has been achieved against all requirements (subject to final confirmation around mandatory training), giving an overall score of 81% which is an improvement of 3% from last year’s score. The Trust will therefore achieve an overall rating of ‘Satisfactory’ on the IG Toolkit. The evidence that is collected against each requirement has been audited by the Trust’s Internal Auditor to provide assurance that the assessment against each standard is accurate. An interim review was carried out in November 2016, where any gaps in evidence were highlighted and a final review was undertaken in February 2016. The final report will be provided to the Audit Committee in April 2016.

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The toolkit results are published on the HSCIC website for any healthcare partner and service user/citizen to see. This is the second year in succession that the Trust has achieved the ‘Satisfactory’ rating on the IG Toolkit since the mandatory IG training target was introduced into the toolkit in version 8 (2010/11) and a significant amount of work has been undertaken by the IG Team to ensure that the target is met, through the development of alternative means of accessing the annual training. It should be noted that at the time of writing this report, compliance against the mandatory training requirement is 94.72% against the 95% target and confirmation of the final figure will be given at the Trust Board meeting. It is anticipated however that given the continued targeted focus of the IG team, compliance will be reached by the time that the Trust Board meets, which corresponds with the toolkit submission date. 4. Areas of Risk If the Trust does not achieve the 95% compliance with mandatory training target, then it will not attain the overall score of 81% and the rating of ‘satisfactory’. This gives rise to reputation risks and a potential loss of confidence in the organization. Compliance is being monitored on a daily basis and as previously mentioned, a targeted approach is being taken to ensure that it is met by 31st March 2016. 5. Governance The requirements of the toolkit increase year-on-year as the information governance agenda grows. An Improvement Plan is developed each year to ensure that standards continue to be met and compliance improves where possible. Progress against the action plan is overseen by the Information Governance Committee, which reports to the Quality Governance Committee. The Committee has recently been refreshed in terms of Chairmanship, membership and the work-plan to ensure that the IG agenda continues to be progressed across the Trust. 6. Responsibility Harjit Matharu, Head of Information Governance Rebecca Southall, Director of Corporate Affairs David Eltringham, Chief Operating Officer, Senior Information Risk Owner (SIRO) 7. Recommendations The Board is asked to RAISE any questions and APPROVE the 2015/16 IG Toolkit submission



Title Register of Interests and Gifts/Hospitality 2015/16

Author Rebecca Southall, Director of Corporate Affairs


Andrew Hardy, Chief Executive Officer

Date 31 March 2016

1. Purpose

To present the Register of Interests and Register of Gifts & Hospitality for the Board of Directors of the Trust, for the financial year 2015/16. 2. Background and Links to Previous Papers In accordance with the transparency, openness and accountability agenda, the Trust Board receives this report on an annual basis. 3. Narrative

In accordance with the NHS Code of Accountability, the Trust’s Standing Orders and the Business Conduct Policy, the Trust is required to hold and maintain a Register of Interests and a Register of Gifts and Hospitality, and to make these available for public inspection. In addition to meeting regulatory requirements, declaring any relevant interests, benefits and hospitality received in connection with an individual’s employment at the Trust is in keeping with the Trust’s openness value and supports the transparency agenda, thereby promoting public confidence in the organisation. It also evidences that there are processes in place to ensure compliance with statutory and regulatory requirements, including those of the Bribery Act 2010.

For the purpose of this report, the attached extract from the registers of interests, gifts and hospitality only details the interests of members of the Trust Board, although both registers contain relevant declarations made by other members of the Trust’s staff. Board members are asked to declare any interests that they have that are relevant to their role as a Board member upon appointment, at each meeting of the Trust Board and also on an annual basis. Board members are however reminded of their on-going responsibility to declare interests to the Director of Corporate Affairs at the point that they arise during their tenure. The attached extract from the register of Gifts and Hospitality details gifts and hospitality received by members of the Board during the period. All staff are however required to declare any gifts or hospitality received in the course of their employment and a corresponding entry is then made on the register. Staff are reminded of the requirement to declare interests, gifts and hospitality on an annual basis (see attached email) and the full registers are scrutinised at the Audit Committee on an annual basis. 4. Areas of Risk

There are no specific risks highlighted within the paper; the risk relates to failing to have processes for making declarations and registers in place, in that this does not comply

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with regulatory and statutory requirements and could adversely impact on the Trust’s reputation and standing.

5. Governance The Trust aspires to the highest standards in corporate governance, transparency and openness. Maintaining registers and reporting upon them periodically is in keeping with this and the responsibilities of the Board of Directors given that the Trust is a public body. 6. Responsibility

Andrew Hardy, Chief Executive Officer Rebecca Southall, Director of Corporate Affairs 7. Recommendations The Trust Board is asked to APPROVE the register of interests and register of gifts and hospitality and NOTE the requirement to declare interests and any gifts/hospitality received on an on-going basis.

of 2 I:\ corporate governance\register of interests

Register of Interests April 2015 - March 2016*NB All voting Trust Board members are corporate Trustees of the UHCW Charity

Name Job Title Directorships Ownership Shareholdings Charity or Voluntary Organisations NHS Service Contracts: Research Funding Pooled Funds Paid employment, office, profession:Moon, David Chief Strategy Officer Parent Governor Trinity Catholic School

Leamington Spa until 7th October 2015 then Associate Governor

None None Trustee of UHCW Charity None None None Very occasionally I do a lecture on MSC courses at Warwick University (max a twice per annum).

Robinson, Trevor Non-Executive Director None None None Unpaid Independent Member of the Audit and Risk Committee of Ofqual (the examinations regulator)

None None None Trevor works senior adviser to the Gambling Commission on a fixed term paid contract from October 2013 to October 2015

Radford, Mark Chief Nursing Officer Holly Medical Services Ltd (GP Surgery)

Parent Governor - Sutton Coldfield Girls Grammer School

None None Trustee of Myton Hospice

Trustee of UHCW Charity

None NHS England Research Grant (staffing £100k)

None Visiting Professor of Nursing at Birmingham City University and Coventry University

Martin, Karen Chief Workforce and Information Officer

Director of QGOV Consultancy Services Ltd None None Trustee of UHCW Charity None None None None

Macalister-Smith, Ed Non-Executive Director None None None None None None None Chair, NIHR HS&DR Priorities Panel, and Board Member, Leadership Coaching, occasional sessional basis, HEE Thames Valley, Oxford Deanery PSU, CQC, occasional daily work as Independent Reviewer of Ratings (NHS Trusts)

Radford, Mark Chief Nursing Officer Holly Medical Services Ltd (GP Surgery)

Parent Governor - Sutton Coldfield Girls Grammer School

None None None None None None None

Eltringham, David Chief Operating Officer None None None Trustee of UHCW Charity None None None None

Buckley, Ian Non-Executive Director None None None Trustee of UHCW Charity

Leadership Trust, consultancy and advisor Chelsea Group, consultancy

Does not hold shares in either company

None None None None

Meehan, Andrew Chairman Lanthorne Ltd - Business Consultancy and Ramsdens Financial Ltd

Lanthorne Ltd - Business Consultancy

None CVQO -Trustee of charity providing vocational education


Trustee - Mayday Trust

None None None None

Poynton, David Non-Executive Director In-form Solutions Ltd - Consultancy, Healthcare and Government

Poynt One Enterprises

Poynt One Enterprises Ltd - Coaching and Consultancy (paid employment)

None Trustee of UHCW Charity None None None Coaching and mentoring; occasional lecturing University of Brimingham HSMC

Pandit, Meghana Chef Medical Officer Nominal director of JJ and M J Pandit Ltd - a company registered to receive private practice income

None None Trustee of UHCW Charity None None None Director of MSc at Warwick Manufacturing Group (paid to UHCW, not Professor Pandit)

Hardy, Andrew Chief Executive Officer None None None Trustee Health Link Malawi


Trustee-Healthcare Financial Management Association

Trustee - Right Step

Trustee - Albany Theatre Trust

None None None

Winstanley, Peter Non-Executive Director None None None Trustee of UHCW Charity None None None None

Sheils, Brenda Non-Executive Director Sheils Associates Ltd None None Trustee of UHCW Charity None None None None

Beal, Barbara Non-Executive Director Griffiths Beal Healthcare Consultancy Ltd Griffiths Beal Healthacre Consultancy Ltd

None Trustee of UHCW Charity None None None NHS and CQC Adviser but do not undertake employment this work in the Coventry and Warwickshire area as advised to the NHS TDA on employment at UHCW.

*All Trust Board members are Trustees of the UHCW Charity Page 2 of 2I:\corporate governance\ declaration of gifts

Name Job Title Date gift/benefit rec'd Source of Gift or benefit Nature of gift/benefit start/end date of visit Destination Event details Purpose of visit Annual leave taken for

visit (Y/N/NA)Study leave taken for

visit (Y/N/NA)

Eltringham, D Chief Operating Officer 09/07/2015 Interim Partners LtdBottle of wine (Chataeu Le Vivier) - regifted as part of Perfect Week celebration

n/a n/a n/a n/a n/a n/a

Moon, David Chief Finance and Strategy Officer n/a n/a n/a n/a n/a n/a n/a n/a n/a

Robinson, Trevor Non-Executive Director n/a n/a n/a n/a n/a n/a n/a n/a n/a

David Poynton Non-Executive Director n/a n/a n/a n/a n/a n/a n/a n/a n/a

Radford, Mark Chief Nursing Officer n/a n/a n/a n/a n/a n/a n/a n/a n/a

Hardy, Andrew Chief Executive Officer n/a n/a n/a n/a n/a n/a n/a n/a n/a

Karen Martin Chief Workforce and Information Officer n/a n/a n/a n/a n/a n/a n/a n/a n/a

Macalister-Smith, Ed Non-Executive Director n/a n/a n/a n/a n/a n/a n/a n/a n/a

Winstanley, Peter Non-Executive Director n/a n/a n/a n/a n/a n/a n/a n/a n/a

Buckley, Ian Non-Executive Director n/a n/a n/a n/a n/a n/a n/a n/a n/a

Meehan, Andrew Chairman n/a n/a n/a n/a n/a n/a n/a n/a n/a

Beal, Barbara Non-Executive Director n/a n/a n/a n/a n/a n/a n/a n/a n/a

Sheils, Brenda Non-Executive Director n/a n/a n/a n/a n/a n/a n/a n/a n/a

Pandit, Meghana Chief Medical Officer n/a n/a n/a n/a n/a n/a n/a n/a n/a

Declaration of Gifts April 2015 - March 2016

Register of Interests / Declaration of Gifts

As we are now approaching the close of the current financial year, it is important that if you have not done so already, you register any interests, gifts or hospitality relevant to 2014/15 using the eforms below where applicable. Procedurally, the Register of Interests and Register of Hospitality for 2014/15 will be presented at the April 2015 Trust Board meeting for noting. Register of Interests - 2014/15 In line with the Trust’s Standing Orders, employees are required to declare at least annually any external business interests or positions of authority in any charity or voluntary body which are relevant to the Trust using the eform below.

Register of Interests eform Please declare any interests which may influence, or may be perceived to influence, your judgement in light of your role within the Trust (it is important to note that registering of interests does not imply any wrongdoing). This could include (but is not limited to):

Directorships, including non-executive directorships held in private companies or PLCs;

Ownership, or part ownership, of private companies, businesses or consultancy, likely or possibly seeking to do business with the NHS;

Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS;

A position of authority in a charity or voluntary organisation in the field of social and health care;

Any connection with a voluntary or other organisation contracting for NHS services;

Research funding / grants that may be received by an individual or their department in the course of their official duties;

Interests in pooled funds that are under separate management;

Paid employment, office or profession in which you continue to have a financial interest

Declaration of Gifts - 2014/15 Under the Bribery Act 2010, which repeals previous corruption legislation, it is a criminal offence to:

http://webapps/forms_live/forms/form.aspx?ftid=111

Bribe another person by offering, promising or giving a financial or other advantage to induce them to perform improperly a relevant function or activity, or as a reward for already having done so, and;

Be bribed by another person by requesting, agreeing to receive or accepting a financial or other advantage with the intention that a relevant function or activity would then be performed improperly, or as a reward for having already done so.

These offences can be committed directly or by and through a third person and, in many cases, it does not matter whether the person knows or believes that the performance of the function or activity is improper. It is, therefore, extremely important that staff adhere to this when considering whether to offer or accept gifts and hospitality and/or other incentives. All Trust employees are required to register any gifts, benefits or hospitality received in connection with your role in the Trust using the eform below.

Declaration of Gifts, Benefits and Hospitality eform Staff may accept token gifts of low value from patients or suppliers (i.e. calendars, pens, diaries, chocolates, etc.) up to the value of £25. However, more substantial gifts should be formally declared. It is important to note that acceptance by staff of commercial sponsorship for attendance at relevant conferences or courses is only acceptable where

The employee seeks permission in advance from their Line Manager or Director;

The employee completes a study leave form and declaration of gifts form;

Where acceptance will not compromise purchasing decisions in any way.

For more information, please refer to the Trust Code of Business Conduct Policy. If you are in any doubt whether to declare an interest or gift please err or the side of caution and register the item or contact Becky Southall, Director of Corporate Affairs.

http://webapps/forms_live/forms/form.aspx?ftid=112

http://webapps.walsgrave.nhs.uk/eLibrary/filecon/download.aspx?Doc=107286&VERI=jjmcbmv6

mailto:[email protected]?subject=Declaration%20of%20interests/gifts



Title Audit Committee Terms of Reference Author Rebecca Southall, Director of Corporate Affairs Responsible Chief Officer

David Moon, Chief Finance and Strategy Officer

Date 31st March 2016 1. Purpose To present the revised terms of reference for the Audit Committee for approval. 2. Background and Links to Previous Papers The Audit Committee reviews it terms of reference on an annual basis taking into account best practice and any issues arising out of the Audit Committee self-assessment that is undertaken each year. 3. Narrative The terms of reference were reviewed at the February Audit Committee meeting. The predecessor document was felt to be generally fit for purpose and in keeping with the Audit Committee handbook, although one amendment was made to strengthen arrangements around the Internal Audit plan. The Audit Committee is now required to approve any proposed amendments to the audit activity set out within the plan.

4. Areas of Risk The Trust is required to establish an Audit Committee by statute, to provide independent scrutiny around the Trust’s system of risk and internal control. If the terms of reference are not fit for purpose this could undermine public and regulatory confidence in the Trust, which could lead to regulatory intervention and damage to the Trust’s reputation. 5. Governance The Terms of Reference will continue to be reviewed on an annual basis to ensure that they are optimal. 6. Responsibility David Moon, Chief Strategy & Finance Officer Rebecca Southall, Director of Corporate Affairs 7. Recommendations These need to clearly state what you are asking the Board to consider e.g. The Trust Board is invited to APPROVE the Audit Committee terms of reference.

UNIVERSITY HOSPITALS COVENTRY & WARWICKSHIRE NHS TRUST

AUDIT COMMITTEE TERMS OF REFERENCE

Constitution: The Board of Directors (“the Board”) hereby resolves to establish a standing committee of the Board to be known as the Audit Committee (“the Committee”). The Committee is a non-executive committee of the Board had has no executive powers other than those specifically delegated to it via these terms of reference. The Standing Orders adopted by the Trust Board are applicable to this Committee in as far as they are relevant. Authority: The Committee is authorised by the Board to investigate any activity within its terms of reference and is authorised to seek any information that it requires from any member of staff. All members of staff are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain legal or other independent professional advice and to secure the attendance of others from outside of the Trust with relevant experience and expertise if it considers this necessary. Purpose of the Committee: The purpose of the Committee is to focus upon establishing and ensuring the effectiveness of over-arching systems of integrated governance, risk management and internal control and to provide assurance to the Board thereon Membership & Quorum: Membership of the Committee will comprise 4 Non-Executive Directors who will be appointed as committee members by the Trust Board. A quorum shall be two of the four Non-Executive Directors. One of the members will be appointed as Chair of the Committee and another member will be appointed as Vice Chair by the Trust Board. The Chairman of the Trust Board shall not be a member of the Committee. The Chairs of the Quality Governance Committee and Finance & Performance Committees shall be members of the Committee to reflect the assurance function that these committees provide to the Audit Committee. Meeting dates will be agreed with committee members at the start of each calendar year. Members should make every effort to attend all meetings of the Committee but should maintain an 80% attendance level in order to ensure quoracy and consistency. In attendance: The following will be in regular attendance at Committee meetings unless the Chair of the Committee requests for them to be excluded.

Feb 2016 v1.1 Page 1 of 6


• Chief Finance & Strategy Officer • Director of Corporate Affairs • Associate Director of Finance, Corporate Services • Representatives from the Trust’s external audit function • Representatives from the Trust’s internal audit function • The Trust’s Local Counter Fraud Specialist (required to attend at least 2

meetings per year) • The Trust’s Local Security Services Manager (required to attend at least 2

meetings per year) The Chief Executive Officer shall attend on an annual basis to discuss the process that supports the Annual Governance Statement (AGS), the annual accounts and annual report. Other Chief Officers and senior members of staff will be invited to attend at the request of the Chair to discuss matters relating to their portfolio. Access: The Head of Internal Audit, representatives of external audit and the Trust’s Counter Fraud Specialist and Local Security Management Specialist shall have a right of direct access to the Chair of the Committee. Members of the Committee will meet in private with the internal and external auditors at least once per year. Frequency: Five ordinary meetings of the Committee will be held per year and these will be scheduled in line with the business that the Committee is required to consider. One additional extraordinary meeting will take place to consider and approve the annual accounts and annual report each financial year. The Trust’s External Auditor or Head of Internal Audit may request a meeting if they consider this to be necessary. Reporting to the Board: The Chair of the Committee will report in writing to the Board at the Board meeting that follows the Committee meeting. This report will summarise the main issues of discussion and the Chair of the Committee will ensure that attention is drawn to any issues that require Board or Executive action or disclosure to the full Board. The minutes of the meeting will be submitted to the private session of the Trust Board once approved by the Committee. Responsibilities: The Audit Committee will have responsibility for the following:



• Governance, risk management and internal control • Internal Audit • External Audit • Other assurance functions • Financial reporting.

Governance, Risk Management & Internal Control The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the spectrum of the Trust’s activities that supports the achievement of the Trust’s corporate objectives. In particular, the Committee will review the adequacy of:

• all risk and control related disclosure statements (in particular the Annual Governance Statement and declarations of compliance with the requirements for Care Quality Commission registration), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to submission to the Board;

• The Board Assurance Framework, ensuring that it identifies all key strategic risks that affect the Trust, that the controls in place are adequate and reasonable and that the Internal Audit Plan and Clinical Audit Plan remain appropriate in light of new and emerging risks.

• The underlying assurance processes that indicate the degree of the achievement of the corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements;

• The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and any related reporting and self-certifications;

• The policies and procedures for all work related to counter fraud and security as required by NHS Protect, including approval and monitoring of the Counter Fraud Annual Work Plan.

The Committee will primarily utilise the work of internal and external audit and other assurance functions to carry out these duties but will not be limited to these. Reports and assurances will also be sought from Chief Officers and other managers as appropriate in relation to over-arching systems of integrated governance, risk management and internal control. In addition, the Committee will review the work of other Board committees within the Trust, whose work provides assurance to the Committee’s own scope of work. This will be achieved through the Chairs of the Quality Governance and Finance & Performance Committees being members of the Committee and the provision of an annual committee report detailing the effectiveness of the committee’s work.



Internal Audit The Committee shall ensure that the Trust has an effective internal audit function that meets mandatory Public Sector Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Executive Officer and Board. This will be achieved by:

• Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal;

• Review and approval of the Internal Audit Annual Plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation as identified in the Assurance Framework;

• Approval of any proposed changes to the Internal Audit Annual Plan • Consideration of the major findings of internal audit work (and

management’s response), and ensuring co-ordination between the Internal and External Auditors to optimise audit resources;

• Ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the organisation;

• Monitoring the effectiveness of internal audit and carrying out an annual review.

Counter Fraud The Audit Committee shall satisfy itself that the Trust has adequate arrangements in place for counter fraud and security that meet the standards set by NHS Protect. This will be achieved by:

• Receiving reports and progress updates from the LCFS in relation to counter fraud

• Approval of the Fraud Policy drafted by the LCFS. • Approval and monitoring of the LCFS Annual Plan and approval of the

Annual Report External Audit The Committee shall review and monitor the external auditors’ independence and objectivity and the effectiveness of the audit process. In particular, the Committee will review the work and findings of the External Auditor and consider the implications and management’s responses to their work. This will be achieved by:

• Consideration of the appointment and performance of the External Auditor, as far as the rules governing the appointment permit

• Discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan.

• Discussion with External Auditors their evaluation of audit risks and assessment of the Trust and associated impact on the audit fee;



• Reviewing all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work carried outside the annual audit plan, together with the appropriateness of management responses.

• Ensuring that there is in place a clear policy for the engagement of external auditors to supply non-audit services

Other Assurance Functions The Audit Committee shall review the findings of other significant assurance functions, both internal and external to the Trust, and consider the implications to the governance of the Trust.

• These will include, but will not be limited to, any reviews by Department of Health Arms-Length Bodies or Regulators/Inspectors (e.g. Care Quality Commission, NHS Litigation Authority, etc.), professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges, accreditation bodies, etc.)

• In reviewing the work of the Quality Governance Committee the Audit Committee should satisfy itself on the assurance that can be gained from the Trust’s clinical audit function. This will be achieved through bi-annual submission of the Clinical Audit Plan to the Audit Committee to ensure its adequacy and to monitor that audits are taking place in line with the plan.

• The Committee will also review the content of the Quality Account prior to submission to the Board to ensure that it is generally consistent with the Committee’s knowledge and understanding

• The Audit Committee may request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control.

Financial Reporting The Audit Committee shall monitor the integrity of the financial statements of the Trust and any formal announcements relating to its financial performance. The Committee should ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to the completeness and accuracy of the information provided. The Committee shall review the annual report and financial statements before submission to the Board, particularly focusing on:

• The wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the Committee;

• Changes in, and compliance with, accounting policies and practices; • Unadjusted mis-statements in the financial statements; • Significant judgments in preparation of the financial statements



• Letters of representation • Explanations for significant variances.

The Committee will review and approve all losses and special payments. The Committee will review all instances where the Trust’s Standing Orders, Standing Financial Instructions and Scheme of Reservation and Delegation have been waived. The Committee will review all proposed changes to the Trust’s Standing Orders, Standing Financial Instructions and Scheme of Reservation and Delegation prior to submission to the Trust Board. Raising Concerns (Whistleblowing) The Committee shall review the effectiveness of the arrangements in place for allowing staff to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns are investigated proportionately and independently. This will be achieved through approval of the related Policies and monitoring of its usage. Delegation By approval of these terms of reference the Board delegates the following functions to the committee:

• Ratification of Trust Policies that fall within the remit of the committee and that are not reserved to the Trust Board.

• Approval of the Internal Audit Annual Plan and any changes thereto • Approval of the Counter Fraud Annual Work Plan and Annual Report

Appraisal The Committee will carry out an annual appraisal of its performance and will report this to the Trust Board via an Annual Report. The content of the Annual Report to the Trust Board will be in keeping with the requirements of the Audit Committee Handbook Administration: The Director of Corporate Affairs will act as Committee Secretary and will agree the agenda with the Chair of the Committee. Review These terms of reference will be reviewed in February 2017 unless there is a requirement to do so earlier. Date of Audit Committee Approval 24th February 2016 Date of Trust Board Approval




Title Establishing an Auditor Panel Author Rebecca Southall, Director of Corporate Affairs Responsible Chief Officer

David Moon, Chief Finance and Strategy Officer

Date 31st March 2016 1. Purpose To present the recommendation of the Audit Committee in relation to establishing an Auditor Panel to the Trust Board, for discussion and approval. 2. Background and Links to Previous Papers Following the abolition and subsequent closure of the Audit Commission on 31st March 2015, which was the body previously responsible for the appointment of auditors to NHS Trusts, each NHS Trust is now required to make arrangements to appoint their external auditors for the financial year commencing 2017/18. This paper sets out a proposal which was considered and approved by the Trust’s Audit Committee and is recommended to the Trust Board. 3. Narrative The Trust’s current contract with KPMG expires in April 2017 and the Trust is required to have undergone a process to appoint its external auditor for the financial year 2017/18 and beyond, by 31st December 2016. Given that the external audit function provides an important service that is a key part of the Trust’s governance mechanism and a source of assurance around the stewardship of public funds, the decision making around the appointment must be properly and appropriately carried out.

To this end, the Local Audit and Accountability Act 2014 requires all public bodies covered by this legislation (including NHS organisations) to appoint an auditor panel to advise governing bodies/boards on the selection, appointment and removal of auditors and on maintaining an independent relationship with them

The auditor panel is responsible for advising the governing body/board on all matters in connection with the appointment, removal and independence of external auditors and must comprise a minimum of 3 members, the majority of who must be independent, Non-Executive members of the organisation’s governing body/board. Membership can also include a minority of members who are not members of the governing body or who are not independent. The Chair of the panel must also be an independent Non-Executive member of the organisation’s governing body/board.

Given that the Trust’s Audit Committee comprises 4 Non-Executive directors, it is proposed that the existing members of the Audit Committee form the auditor panel for the Trust, together with the Chief Finance & Strategy Officer who is in attendance at Audit Committee meetings. Support to the panel will be provided by the Director of Corporate

Affairs. The proposal satisfies the requirement around both numbers and independence, although it is suggested that the panel meet separately to the Audit Committee in order to ensure that there is the necessary focus.

The Trust Board is required to formally approve these arrangements and if approved, it is anticipated that the panel will meet early in the new financial year to commence the process.

4. Areas of Risk If the Trust does not appoint an Auditor Panel then it will be in breach of a statutory duty and could face regulatory action and the associated reputation damage. Failing to appoint an auditor by the deadline will also expose the Trust to similar risk. The proposal is intended to mitigate against these risks and ensure that the panel is established in sufficient time to allow the necessary procurement processes to take place ahead of the 31st December 2016 deadline. 5. Governance The Trust is required by virtue of the Local Audit and Accountability Act to put appropriate arrangements into place to ensure the proper appointment of an external auditor by 31st December 2016. The Audit Panel will report back to the Trust Board periodically in relation to its progress. 6. Responsibility David Moon, Chief Strategy & Finance Officer Alan Jones, Associate Director of Finance Rebecca Southall, Director of Corporate Affairs 7. Recommendations These need to clearly state what you are asking the Board to consider e.g. The Trust Board is invited to APPROVE the establishment of an Auditor Panel comprising members of the Audit Committee and the Chief Finance & Strategy Officer, with the Director of Corporate Affairs in support.

Page 2 of 2



Title Report of January Private Trust Board Meeting Author Rebecca Southall, Director of Corporate Affairs Responsible Andy Meehan, Chairman Date 31 March 2015 1. Purpose To report in public the substantive business that was transacted in the section of the February Board meeting that members of the public and the press were excluded from pursuant to Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, and the Public Bodies (Admissions to Meetings) (NHS Trusts) Order 1997. 2. Background and Links to Previous Papers The Trust Board is at liberty to exclude members of the public and the press from board meetings when the nature of the business that is prejudicial to the public interest due to its confidential nature. In the interests of transparency however, the Chairman provides a report on the substantive items that were discussed to the next public meeting of the Trust Board. 3. Narrative The following substantive items were discussed and/or approved at the February private session of the Trust Board:

• Priorities for 2016-2017 (for Quality Account 2015-2016) • Draft Capital Programme 2016/17 and Outline Capital Programme 2017/18 to

2020/21 • Corporate Objectives 2016/17 • Business Case for Interventional Radiology Suite

4. Areas of Risk There no specific areas of risk to highlight arising out of the matters discussed. 5. Governance A further report will be submitted to the April Trust board detailing the business transacted in the March Trust Board. Reporting in this way ensures that we are fulfilling our obligations around transparency and openness. 6. Responsibility Andrew Meehan, Chairman Rebecca Southall, Director of Corporate Affairs 7. Recommendations The Trust Board is asked to NOTE the report.


INTERIM COMMITTEE REPORT TO BOARD Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Audit Committee Committee Meeting Date: 24th February 2016 Quoracy: Yes Apologies: Ed Macalister-Smith Chair: David Poynton, Non-Executive Director Report submitted by: David Poynton, Non-Executive Director 1. Audit Plan of Work The Committee RECEIVED the strategic plan of internal audit coverage for the period April 2016 to March 2019 with the aim of delivering a focused audit programme through detailed risk assessment and commercial recommendations to save resources and enhance controls. External Auditors will work with Internal Audit to ensure a targeted strategy to delivering the assignments set out within the strategic plan. 2. Internal Audit Report – Financial Delivery Including CIP An overall conclusion of ‘significant assurance’ was provided on the design and operation of the system’s internal controls to prevent risks from impacting on achievement of the system’s objectives. Further consideration will be given to how cost and volume of productivity financial reporting is presented to the Finance and Performance Committee. It was noted that the Trust Development Authority had commended the Trust’s approach to CIP as best practice. 3. Internal Audit Report – Board Assurance Framework (BAF) – Interim Review

2015/16 An overall conclusion was that the refreshed and considerable strength of the current version of the BAF, provides the Board with greater oversight on the actions in place and whether they have yielded the desired effect in reducing strategic risk. A further review of the BAF will be undertaken in the Spring when a formal opinion on the BAF is required. 4. Counter Fraud Progress Report The Committee DELEGATED to the Quality Governance Committee to review in greater detail the mechanisms and controls in place for quality assuring agency nurse bookings and to seek assurance as to the rigour of the process in place. 5. Annual Counter Fraud Plan The Committee RECEIVED and APPROVED the plan designed to meet requirements of the Standards of Providers relating to fraud, bribery and corruption. Case studies to prevent and deter temptation to commit crime against the NHS will be displayed on the webpage and feature in the internal staff magazine. 6. Review of Standing Orders (SOs), Scheme of Reservation & Delegation (SoRD)

and Standing Financial Instructions (SFIs) The Committee APPROVED the amendments to the SOs/SoRD and SFIs SUPPORTED the proposal to delegate minor changes to the Director of Corporate Affairs and Chief Finance/Strategy Officer and RECOMMENDED approval to the Trust Board. 7. External Audit Panel Proposal The report set out the requirements around establishing Auditor Panels. The Committee APPROVED the proposal for the UHCW Auditor Panel to comprise the current Non-Executive Director Audit Committee members plus the Chief Finance and Strategy Officer. 8. Medical Agency Locums Process – matter delegated by Trust Board The report provided an overview of the current process for booking medical agency locums. It demonstrated areas of compliance and also highlighted several areas for improvement. The Committee RECEIVED ASSURANCE that the implementation of the

247Time Integrated Booking System will provide increased functionality that will address the areas for improvement identified. It is anticipated that the system will be in place by the end of the financial year. The Committee DELEGATED to the Quality Governance Committee to consider at what point medical agency locums are required to complete mandatory training. The outcome of this should feed into the ‘Process for the Authorisation and Appointment of Locum Medical Staff’ currently under review. 9. Review of Committee Terms of Reference The Committee APPROVED the revised Terms of Reference and RECOMMENDED approval to the Trust Board. 10. Annual Work Plan The Committee APPROVED the Annual Work subject to the following amendments:-

• Inclusion of reference cost submission and methodology for presentation to the Committee in July

• Removal of the Charitable Funds Audit Plan as this will feature within the overall External Audit Plan presented to the Committee in November

• Accelerate presentation of the Quality Account to the Committee in June The Board is asked to NOTE the business transacted at the meeting and to RAISE any questions in relation to the same.

Page 1 of 2 Interim Report to Board


INTERIM COMMITTEE REPORT TO BOARD Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Finance and Performance Committee Committee Meeting Date: 17th February 2016 Quoracy: No Apologies: David Eltringham, Karen Martin, David Moon, Brenda Sheils, Barbara Beale Committee Chair: Ian Buckley Report submitted by: Ian Buckley, Vice Chair 1. Minutes

The minutes of the January meeting were approved in principle as an accurate record but as the meeting was not quorate the minutes will be presented to the meeting in March for final approval.

2. Integrated Performance Report The Committee debated the areas of challenge that require improvement and focused attention; noting that achievement of the referral to treatment incomplete pathway and Emergency Department 4-hour wait targets continue to present a challenge. The Committee requested a month by month trajectory versus the position, broken down for each Group to better understand the critical issues that are preventing Groups from hitting key targets.

3. Integrated Finance Report As a result of Trust Development Authority (TDA) transacting capital to revenue funding transfers, the Trust changed its plan by £8m from a £19.4m control total deficit to £11.4m deficit in December. It was noted that in response to a subsequent request from the TDA to Providers seeking further slippage; the Trust has a revised control total of circa £10m. Overdue creditors increased by £0.6m during December mostly due to an increase in the 61-90 day creditors. The movement in creditors mainly reflects fluctuations in the timing of payment runs and the receipt of invoices from suppliers. The Committee conveyed concern in relation to invoices overdue by >90 days which increased by £0.04m to £2.1m in December. Discussion ensued in relation to Chief Officers taking a more centralised approach to setting deliverable performance targets for each of the groups based upon historical intelligence and Group ability to control expenditure. The Committee sought assurance that this method would provide the vehicle to hold Groups to account and requested further details at the next meeting of the Finance and Performance Committee in relation to the implications for organisational shift in adopting this strategy and assurance around how performance will be managed.

4. Referral to Treatment (RTT) Trajectories at Specialty Level The report was received following a request from the Committee in January to receive assurance around the current RTT position broken down by specialty and actions underway to achieve delivery by 31st March 2016. Delivery of RTT performance remains a significant challenge and is not without risk and the Committee was assured that this was being micromanaged on a daily basis. Trust performance as at 8th February 2016 was 86.33% against a standard of 92%. During the

month of January, despite high pressures on emergency admissions and capacity, the size of the waiting list has shown a reduction, with performance showing a steady increase in delivery of 0.45% per week for the last three weeks.

5. Workforce Information Report The Committee commended the reduction in the average time to hire over the last 12 months from 65 days to 29 days. It was noted that further reduction is expected in February. The Committee was assured that the Groups have developed improvement trajectories and supporting action plans to reduce the level of sickness absence to achieve a target of 4% by April 2016. The Committee requested a report highlighting long-term sickness absence by specialty group and trajectories for absence in 2016/17 to be presented to the Committee in March.

6. Operational Plan The Committee retrospectively supported the draft operational plan for 2016/17 submission to the TDA. The Committee requested, that prior to submission of the final plan, that the Trust seek an agreement from Commissioners regarding key planning assumptions across Coventry and Warwickshire and assurance of this provided to the Board at the Board Seminar on 29th March 2016.

The Board is asked to note the business discussed at the meeting and to raise any questions in relation to the same.

Page 1 of 2 Interim Report to Board


INTERIM COMMITTEE REPORT TO BOARD Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Finance and Performance Committee Committee Meeting Date: 23rd March 2016 Quoracy: Yes Apologies: Karen Martin & David Moon, Committee Chair: Ian Buckley Report submitted by: Ian Buckley, Vice Chair 1. Minutes

The minutes of the January and February meetings were approved. 2. Delivery of Referral to Treatment Target

The Committee was advised that whilst performance had improved and was at circa 91.4% the 92% target would not be met and the TDA had been informed of this. Discussion was held in relation to the various issues that contributed to the non-achievement of RTT, their interrelated nature and the plans that are in place to address these. RTT targets have been more closely aligned to the Group Operational Delivery Plan (ODPs) for 2016/17 and the current schedule of monthly performance meetings would continue. Further discussion will take place at the seminar on 29th March 2016. The detail within the report and its clarity was commended by members.

3. Theatre Efficiency The Committee received a report detailing theatre efficiency and the reasons why the targets were not being met. Concern was raised that given that there was no mechanism for cross- charging in respect of internal resources in place, there was no penalty for not adhering to efficiency targets. Assurance was given that theatre efficiency and consultant productivity would be more closely linked to the OPD process for 2016/17 and issues such as support for business cases and additional resource would be linked to performance. The Committee requested the detail of lost theatre time by Group in order to better understand where the issues lay.

4. Cost Improvement Programmes The Committee was assured that the CIP target for 2015/16 had been exceeded and that close to 100% of the target for 2016/17 was expected to have been identified by the time that the Trust Board met in March 2016. It was acknowledged that this was a far better position than had been achieved in previous years and signalled very good progress.

5. Integrated Finance Report The Committee received a summary of non-pay variances and it was agreed that areas with a higher variance in terms of spend would be the subject of further discussion during 2016/17 pending the Lord Carter work that would also have an impact on procurement.

6. Agency Cap The Committee discussed the impact of the agency cap in the context of the Safer Staffing standards and sought further information within the work-force report in relation to the level of control that the Trust actually had around agency spend given the requirement to adhere to the standard.

The Board is asked to note the business discussed at the meeting and to raise any questions in relation to the same.


INTERIM QGC COMMITTEE REPORT TO BOARD Purpose: This report has two purposes; firstly to ASSURE the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to ADVISE Board Members of the business transacted at the most recent meeting and to INVITE questions from non-committee members thereon. The Board is asked to note the business discussed at the meeting and to raise any questions in relation to the same. Committee Name: Quality Governance Committee Committee Meeting Date: 21st March 2016 Quorate: Yes Apologies: Peter Winstanley Chair: Ed Macalister-Smith 1. Never events: Review work completed into recent theatre never events, no common connection found. 2. Governance relationship to Audit Committee: two issues for QGC from Audit Committee for Executives

to respond to had not been effectively communicated. Chair to initiate better liaison, Dir Corporate Affairs to raise within Execs.

3. Violence against Staff: a report was received in response to issues raised in the Staff Survey. Analysis of incidents showed that the large majority were related to patients without mental capacity. QGC was concerned to ensure that staff felt fully and visibly supported by the Trust. Dir Operations was taking on responsibility for this, and would review the current position and report back. Security staff now had body cameras for incidents in A&E, or involving carers or visitors.

4. Patient Safety Thermometer Report: UHCW Trust is performing well against the components of the safety thermometer, and performance in January was the best since data collection began (96.88%). The target is to achieve 97% harm free care by the end of 2015/16 as featured on the Board Assurance Framework.

5. Children in Looked After Services; the Committee received the CQC report issued following the inspection in Coventry in May 2015 together with the multi-agency action plan which focused on bringing about improvements across the city. UHCW has clearly identified lead clinicians.

6. Mortality Update; the report demonstrated that the HMSR for November 2015 was within expected limits and there has been 6 confirmed NCEPOD E deaths since April 2015 which is significantly under the threshold of 15 for 2015/16. Mortality Review Committee continues to meet and scrutinise deaths and the Trust’s processes have been held up as best practice by the TDA.

7. Medical Education Report; the report demonstrated that good progress is being made in many areas following the appointment of the new Associate Medical Director - Education, Sailesh Sankar. The primary area of focus is on improving satisfaction levels in the National Student Survey (NSS), and preparing for the Acute Medicine Deanery visit in July 2016.

8. CQC Action Plan; the Committee was advised that all ‘must-do’ actions identified in the CQC report have now been completed. A future report will cover the “should-do” actions.

public trust board meeting to be held at on thursday 31 march 2016 … papers... · 2017-09-08 ·...

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