twentie th trust board meeting mon day 4 … · twentie th trust board meeting mon day 4 march 2013...

TWENTIETH TRUST BOARD MEETING

MONDAY 4 MARCH 2013

2:00 PM

WIRRAL COMMUNITY NHS TRUST

DUNCAN ROOM OLD MARKET HOUSE HAMILTON STREET

BIRKENHEAD CH41 5AL

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WIRRAL COMMUNITY NHS TRUST BOARD OF DIRECTORS MEETING

Monday 4 March 2013 at 2.00pm Duncan Room, Old Market House

AGENDA - PUBLIC

No Time Item Action Reference

PRELIMINARY BUSINESS: (45 minutes)

1. Apologies for Absence WCT 12/13-223 (v)

2. Invitation for Public Comments WCT 12/13-224 (v)

3. Chairman’s Announcements WCT 12/13-225 (v)

4. Declaration of Interests WCT 12/13-226 (v)

5. Minutes of the Previous Meeting:

7 January 2013 (Pages 1 – 10) To approve WCT 12/13-227 (d)

6.

Matters Arising

7 January 2013 (Pages 11 – 14)

To challenge progress

WCT 12/13-228 (d)

7. Patient Story – Self Care (Pages 15 – 17) To assure WCT 12/13-229 (d)

8.

Chief Executive’s Report – January/February 2013

(Pages 18 – 22) To assure WCT 12/13-230 (d)

9.

Committee Reports – January/February 2013

(Pages 23 – 29) To note WCT 12/13-231 (d)

STRATEGIC: (15 minutes)

10. 15 mins Foundation Trust Programme Update

(Director of Finance) (Pages 30 – 44) To assure WCT 12/13-232 (d)

BUSINESS: (90 minutes)

11. 20 mins Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry (Chief Executive) (Pages 45 – 54)

To assure WCT 12/13-233 (d)

12. 20 mins

Quarter 3 Assurance Reports: (Director of Quality & Governance) (Pages 55 – 121)

Infection Control & Control Assurance

Safeguarding

Quality & Patient Experience

Integrated External Assurance Report


13. 20 mins CQUIN Payment Framework – Self Care for Patients with Diabetes (Director of Quality & Governance) (Pages 122 – 138)

To assure WCT 12/13-235 (d/p)

14. 10 mins CQC Registration Proposed Changes to Registration Requirements (Director of Quality & Governance) (Pages 139 – 185)

To approve WCT 12/13-236 (d)

15. 10 mins Quality Handover Document (Director of Quality & Governance) (Pages 186 – 198)


16. 10 mins Membership Recruitment Update (Trust Board Secretary) (Pages 199 – 210)

To note WCT 12/13-238 (d)

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USE OF RESOURCES/GOVERNANCE: (30 minutes)

17. 15 mins Integrated Performance Report – Month 10 (Chief Executive) (Pages 211 – 236)

To challenge process

WCT12/13-239 (d)

18. 5 mins Board Terms of Reference (Trust Board Secretary) (Pages 237 – 241)


19. 10 mins High Level Organisational Risk Report (Trust Board Secretary) (Pages 242 – 248)


COMMITTEE REPORTS: (10 minutes)

20. Quality & Governance Committee: (Pages 249 – 262)

17 December 2012

21 January 2013


21. Education & Workforce Committee: (Pages 263 – 275)

17 December 2012

21 January 2013


22. Finance and Performance Committee: (Pages 276 – 288)

7 January 2013

28 January 2013


23. Staff Council: (Pages 289 – 310)

12 December 2012

23 January 2013


ITEMS FOR INFORMATION

24. Any Other Business WCT 12/13-246 (v)

25. Items for Risk Register WCT 12/13-247 (v)

Date and Time of Next Meeting:

The next Public Trust Board meeting will take place on Tuesday 2 April 2013 at 2.00pm.

WIRRAL COMMUNITY NHS TRUST

TRUST BOARD OF DIRECTORS MEETING

MINUTES OF MEETING

MONDAY 7 JANUARY 2013, at 14:00

DUNCAN ROOM, OLD MARKET HOUSE

Members:

Mrs Frances Street Chairman (Chair) (FS)

Mrs Chris Allen Non Executive Director (CA)

Ms Lisa Cooper Director of Quality & Governance (LC)

Dr Murray Freeman Non Executive Director (MF)

Mr Simon Gilby Chief Executive (SG)

Mr Garry Gray Director of Finance (GG)

Mr John Lancaster Director of Operations & Performance/Executive Nurse (JL)

Dr Ewen Sim Medical Director (ES)

Mr Brian Simmons Non-Executive Director (BS)

Mr Steve Wilson Director of Finance (SW)

In Attendance:

Mr Michael Games Trust Board Secretary (MG)

Mrs Diane Hill LINks (Chair) Representative (DH)

Ms Debbie Ollerhead Staff Council Chair (DO)

Mrs Heather Stapleton Board Support/FOI Officer (HS)

Reference Minute

WCT12/13-198

Apologies for Absence

The Board received apologies from:

Ms Jo Harvey, Director of HR & Corporate Affairs

Ms Fiona Johnstone, Director of Public Health

WCT12/13-

199

Invitation for Public Comments

No members of the public were present.

WCT12/13-

200

Chairman’s Announcements

The Chair welcomed all members to the nineteenth formal Board Meeting of Wirral Community NHS Trust.

The Chair made the following announcements:

Following a successful Board to Board on 28 November 2012, the SHA have confirmed the Trust’s Foundation Trust application was submitted to the Department of Health before the due date of 1 January 2013. A key aspect of the submission is the Quality Governance Assurance Framework (QGAF) score which was refreshed to 4.5 in November, the required level being 3.5. Following a concerted effort by staff across the Trust, the assessors (Deloitte) were able to confirm a score of 3.5 in

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December, commenting that a significant degree of progress had been made.

Andrea Spyropoulos, President of the Royal College of Nursing, visited St. Catherine’s Health Centre on the 11 December. She was accompanied on a tour of the new healthcare facility by JL and LC and was introduced to staff in the Sexual Health, Community Nursing and Health Visiting Teams. A question and answer session was held when she praised the work done by nurses and invited a number of staff to attend the next RCN Conference. LC asked if it would be possible to launch the Nursing Strategy at the conference.

Due to the unusually high demand at Arrowe Park Hospital on 17 December, the Trust worked with other NHS colleagues to relocate the GP Out of Hours, Walk in Centre and All Day Health Centre services to Eastham and Victoria Central Health Centres, enabling a second Primary Care Assessment Unit to operate from the Arrowe Park location. The Walk in Centre and GP Out of Hours services returned to normal from 8 am the following morning. The changes to local health services and a cross organisational approach ensured that the situation was resolved as quickly as possible and access to healthcare services continued to be provided.

Congratulations were extended to Chris Allen who had been awarded the BEM for services in the community, in the New Year Honours List.

ES proposed a vote of thanks to Amy Hinchliffe and Alison Hughes for their support and consistency towards making the Board to Board at the SHA a team effort. The Board supported this and FS expressed thanks to all Board members.

WCT12/13-201

Declaration of Interests

ES and MF declared an interest as practising General Practitioners on the Wirral.

WCT12/13-202

Minutes of the Previous Meeting

The minutes of the Board meeting held on 3 December 2012 were agreed as a true and accurate record.

WCT12/13-203

Matters Arising

The Board reviewed the action points from the previous Board meeting held in December 2012. (See separate actions/matters arising tracker).

The Board members were happy to see that progress is being made in all areas.

WCT12/13-

204

Patient Story – Pressure Ulcer

LC introduced an audio recording of a patient story in which a gentleman talked about his experience in accessing care from the Community Nursing Service and the Tissue Viability Service. The gentleman explained there was no consistency with the bank nursing staff as he was seeing a different nurse each visit. They did not always have the correct products and he often had to describe to them his wound treatment regime. He also stated that his health records (yellow folder) had been out of his home for a period of 10 days. The patient commented that he would like to know what time of day the nurses were going to visit. He stated that he did have a pressure relieving mattress and equipment, which was beneficial. GG asked if it was usual for one patient to be seen by a number of different people. JL advised that when the service experiences high periods of sickness, bank staff are used but this does not mean the patient was put at risk in any way. JL commented that an efficient IT system would ensure documentation and communication was up to date. GG stated that the issue of the patient being advised of the timing of the nurses visit was not on the action plan.

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LC advised that patients are advised as to whether the visit will be in the morning or the afternoon but specific times cannot be given. BS stated that the patient felt as though he did not matter due to the amount of different nurses treating him and he did not have control or was advised of his progress. The timing of visits is also important to an elderly patient. ES highlighted the concern in relation to the health records being missing for a period of time and queried if any notes were taken in that time, the notes being used as the clinical handover. MF asked at what stage does a community nurse take further action if a pressure ulcer is not healing. LC advised that the protocol is very clear and based on NICE guidance when to refer to either Tissue Viability or the GP. FS stated this patient story had helped to highlight areas to be improved upon and the actions will be monitored by the Quality, Patient Experience & Risk Group. LC advised that in future, a letter will be sent to the patient, thanking them for their involvement and asking if they would like to be part of further patient involvement in the organisation. The Board noted the action plan and were assured of the delivery of high quality, safe and effective services.

WCT12/13-205

Chief Executive’s Report – December 2012

The Board received the Chief Executive’s Report for December 2012 and the following key areas were highlighted:

National Developments:

Planning Guidance – The NHS Commissioning Board had published ‘Everyone Counts: Planning for Patients 2013/14’ which covers a set of outcomes against which to measure improvements. SG advised there was nothing in the guidance that the Trust was unaware of and arrangements will be made for a full briefing to be given to Board.

Autumn Statement – The Chancellor’s Autumn Statement on the economy confirmed continued protection for NHS funding levels. A copy of the Statement was attached for Board.

Aspirant Community Foundation Trusts – A meeting has been held with the Chief Executive of the NHS Trust Development Authority. In attendance were other aspirant Community FT Chief Executives. The meeting was broadly positive with the key message that Community Trusts are performing well.

Local:

Service continuity over the holiday period – Services performed well over the holiday period with some services experiencing significantly high demand. Thanks were expressed to staff on behalf of the Trust Board, for their hard work and commitment.

The Board noted the report.

WCT12/13-206

Committee Reports - December 2012

SG introduced the report from the Chairmen of Committees of the Board which had met since the last Board meeting with a brief update before the approved minutes were submitted to Board. This provided an early indicator on any key issues raised at Committees.

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Education & Workforce Committee – 17 December 2012 CA advised that development of the Organisational Development Strategy remained outstanding, however progress has been made as SG and HR are taking the lead. Managing attendance continues to be monitored. The Committee had approved the Criminal Record Bureau Report, the Criminal Record Bureau Policy and the Revalidation and Appraisal proposal. Finance & Performance Committee – 7 January 2013 GG advised that discussions had focussed on the financial position which is positive at the moment, with Cost Improvement Programmes on track. The Committee approved the submission to the SHA on FT progress. Quality & Governance Committee - 17 December 2012 MF advised that the RCAs were discussed together with their action plans. In particular the results around leg ulcer management were reviewed. SG suggested a section of formal recommendations, where appropriate, be included for each of the Committees for the Board to be aware of decisions taken. The briefing reports from the Committees of the Board were noted.

WCT12/13-207

Foundation Trust - Programme Update

SW presented the Trust’s current position in the Foundation Trust application process. The report outlines significant milestones and achievements made during the past month and provides an update on each of the five work streams established under the Trust’s programme management arrangements for the FT application. SW advised that following the successful Board to Board on 28 November 2012, the Strategic Health Authority made the submission, on the Trust’s behalf, to the Department of Health. This completed the first phase of the Foundation Trust process. Further information in relation to the timetable is awaited from the Department of Health. SW advised that the refreshed QGAF assessment score of 3.5 had been received from Deloitte, which was the required score to progress to the next stage of the FT process. Work will continue to further reduce this score as the Trust moves into the Monitor phase and the score reduction toward zero will be expected. The latest update with regard to the recruitment of public members to the end December, was that 3,235 had been recruited. The Trust’s current RAG rating with the SHA is still red as the TFA agreed submission date was missed. As the revised deadline had now been achieved, it was expected this will turn green in January 2013. SW informed the Board the scope of management that the Programme Management Office will deliver would be decided shortly and it is expected this will involve Cost Improvement Plans and the Service Transformation Team. Options for the managment of this will be discussed by the Senior Managemen Team. Further work has been undertaken with the Divisional Managers regarding Cost Improvement Plans. A final report was expected from Deloitte relating to the Strategic Efficiency Programme and this would be submitted to the Private Board when received. CA highlighted the QGAF score of 3.5 and recognised the work that had been undertaken to reduce the score from 6 in a short period of time. CA asked how the Board received information on QGAF to ensure it remains on track for further reduction. LC advised that Monitor will look for further evidence of consolidation and embedding and will speak to staff in relation to cultural change. FS suggested this could form part of Board Development to ensure there is no slippage in relation to QGAF and other matters. SW advised that this needs to be wider than QGAF in terms of the next steps and

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deadlines and a detailed programme and timeline will be brought to Board. The Board noted and were assured of the progress made by the Trust in its FT application process.

WCT12/13-208

Response to Wirral Clinical Commissioning Group Constitution MG provided the Board with a paper providing assurance that the Senior Management Team (SMT) had reviewed the draft constitution of the Wirral Clinical Commissioning Group (CCG). MG advised that the constitution was developed using a template provided by the National Commissioning Board, however some additional sections had been included to reflect the situation on Wirral. The constitution was reviewed by the SMT who concluded that the content of the constitution did not have any material impact on the Trust and agreed that a letter of support be provided to the CCG. The Board noted the letter of support.

WCT12/13-209

CQUIN Payment Framework – Harm Free Care Sandra Christie, Head of Nursing, Quality & Governance, was in attendance for this item. LC introduced a presentation to update the Board of progress to date for the Harm Free Care (Safety Thermometer) CQUIN. SC presented and advised that the thermometer CQUIN is the number of monthly data collections on one day provided within a financial quarter. Clinical staff have been involved in the development of this CQUIN. The data is collected by a nurse at the point of care and the survey data is uploaded to the national tool. When viewing the data, understanding the demographics and case mix of patients surveyed is important. The NHS Safety Thermometer measures patients and their harm burden and not organisations. The patients to be included is defined by the Department of Health and relates to patients receiving a home visit conducted by a member of staff, including visits by Community Matrons, on the data collection day. SC highlighted, with the use of graphs, the high volume patient safety issues measured by the tool:

Pressure ulcers

Falls

Urinary infection in patients with a catheter

Treatment for venous thromboembolsim SC advised that in relation to pressure ulcers, increased collaboration with nursing homes regarding shared care is being followed up. A pressure ulcer patient information leaflet is also being devised with the assistance of a gentleman featured in a Patient Story. ES highlighted the need to take into consideration the views of carers and SC advised involving members of the family in the care delivered is included in essential learning. The Board are assured of progress made to date with the CQUIN and that robust processes are in place to develop, test, implement and evaluate changes to achieve and maintain quality improvement in the organisation.

WCT12/13-210

Quality Assurance Action Plan for Non Medical Education LC presented a paper for approval for the Quality Assurance Action Plan for Non-Medical Education, which forms part of the Learning and Development Agreement the Trust has in place with NHS Northwest. This was a new requirement of the Learning and Development Agreement (LDA). LC advised that the Trust is required to submit a RAG rated self-assessment against the Practice Education Facilitator (PEF) outcomes each year. There is the requirement to have an action plan to address any areas which are rated as red or amber and this

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requires Board approval. CA asked how the Board gain a better understanding and monitor improvements going forward. LC advised there is a requirement to complete and demonstrate the development of actions rated red or amber and more detail will be recorded than previously, for example the number of accidents involving students. A detailed action will be monitored by the Education & Workforce Committee in April 2013. LC advised this does not apply to people undertaking non medical prescribing training or mentors and only applies to student nurses who will receive feedback when their student placement is completed. CA asked for further clarity in relation to understanding the headlines and tasks and the determining of categories prior to the information being submitted to the Education & Workforce Committee. LC agreed to arrange to meet with the Practice Education Facilitator to gain further information. The Board approved the Quality Assurance Action Plan for Non Medical Education.

WCT12/13-211

Quarterly Quality Strategy Implementation Plan Update LC presented a paper providing assurance of progress made to date regarding implementation of the Trust’s Quality Strategy. LC advised assurance is provided in three areas:

Actions contained within the implementation plan for the Quality Strategy

A summary of staff evaluations from Quality Forums for October, November and December 2012

Draft Quality Strategy Dashboard for reporting period 1 November – 30 November 2012.

The Quality Strategy dashboard will be included monthly in future Integrated Performance Reports. SW advised the dashboard included at the present time in the Integrated Performance Report is slightly out of date and this will replace it. The Board will need to consider whether any additional information is required. Discussion will take place at Quality & Governance Committee before submission to Board to ensure the appropriate information is captured. LC advised that the Board needs to be aware of how the Trust is performing in relation to the Quality Strategy goals and this will need to be included in the dashboard. The newly appointed Head of Business Intelligence will be key to pulling this information together and ensuring it is fit for purpose. CA referred to Appendix 1 (page 71 of the Board papers) where some actions have missed the deadline and asked how the Board will be alerted of slippage. The Executive Directors will look into this and advise. The Board are assured of the progress made regarding implementation of the Quality Strategy and approved the inclusion of Quality Strategy Dashboard in future monthly Trust Board Integrated Performance reports.

WCT12/13-212

Service Development Update JL presented a paper informing the Board of the progress of:

current service development initiatives

progress towards implementation of the Integrated Care Model and to highlight areas of significant risk.

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Reference Minute

JL advised that the Integrated Business Plan (IBP) identified a range of service developments which will have a significant impact on the wider integration whilst ensuring more effective long term delivery of the Trust’s services. The Trust is involved in a number of local and national initiatives including acceptance on the Aqua/Kings Fund Integrated Community Programme. £300,000 has been received from the SHA to assist in the development of a care home support pilot. JL informed the Board of the following:

Long Term Conditions Management - a Programme Board had been established which meets fortnightly and is chaired by the Trust. Localised work groups addressing each Aqua domain have been established and initial meetings of the groups will report back in late January. JL advised that the appointment of a Programme Manager will be a joint appointment and will work with managers and teams to support the actions of the domain groups.

Care Home Support - 10 care homes across Wirral have been identified to benefit from Community Services support to reduce hospital admissions. Care homes and GPs have been contacted to take part in the programme. In order to measure the success of the scheme, the Service Transformation Team (STT) are correlating the data. JL advised the homes are a combination of residential and nursing and on request agreed to forward a list of the homes to DH.

Centralised Booking - centralised booking for podiatry has commenced and will be rolled out to therapies late February, early March 2013.

PCAU Development - the integrated assessment pilot, in partnership with WUTH, went live in December 2012. Although the model is robust, bed pressures initially caused some problems and the model is constantly being re-evaluated.

Service Reviews - service reviews are routinely undertaken within all Community Trust services with triggers in place for an early review if necessary.

NHS 111 - NHS Direct has been chosen as the local provider of NHS 111 urgent care call centre with effect from April 2013. The new arrangements pose a number of potential challenges for the organisation and a Community Trust project group has been formed to provide a structured organisational approach to support the new model.

External Engagement – The Community Trust took part in a national workshop regarding the expectations of integrated care which was facilitated by National Voices.

The Board noted the report and agreed to receive the report on a regular basis as an update.

WCT12/13-213

Membership Recruitment Update MG provided the Board with a monthly update on membership recruitment for the Trust advising that as at 4 January 2013 a total of 3,300 members were registered on the database. MG informed the meeting that the membership profile remained largely unchanged from November 2012 but there remained plans in place to improve the under representation in South Wirral and Neston and the number of 13 – 16 year old members.

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It was noted that the independent provider to run the Governor election had now been chosen and that UK Engage will be undertaking this task on behalf of the Trust. Further Governor sessions are scheduled for January and February with two meetings scheduled at the end of February for those members considering standing for election. Flyers have been printed to promote the events and these will be placed in GP practices as well as on the web site and an advert in local paper. It was suggested that the Non-Executive Directors note the dates of the sessions and, if available, come along to meet with potential governors. The Board noted the update provided in the paper.

WCT12/13-214

Quarterly Update Leadership Safety and Patient Experience Walk Rounds SG made reference to the paper and commented that the recent commencement of the Walk Rounds by the Executive Directors and Non-Executive Directors has been extremely beneficial. He added that it is good practice to bring reports to the Board on regular basis. However, at this stage, it was difficult to draw any conclusions based on the data provided to date but the experience had been well received by staff and patients and comments have been largely positive. It was noted that the process and data collection may be refined over time to ensure that it remains worthwhile and helpful. A review of the questions will also be undertaken at either 6 months or 12 months. LC commented that that there is a need to ensure that the data captured is capable of being analysed appropriately for future reporting and so it was important that the forms are completed in full and the data sent back to Julie Sheldrick. In addition, any additional written comments are also to be provided. LC also made reference to the possibility of the Non-Executives seeing patients in their homes once the consent issues have been resolved. The Board noted the report and were assured of the provision of high quality patient focussed services arising from the Walk Rounds.

WCT12/13-215

Integrated Performance Report – Month 8 SG presented the Integrated Performance Report for Month 8 (period ended 30 November 2012) to provide assurance on the performance of services and the action plans in place to deliver improvements as required. SG stated that the Trust continues to perform well against the majority of indicators as detailed in the Report. One area of underperformance and red rated, related to Community Ophthalmology which was due to a cancelled clinic resulting in failure against the target. In addition, sickness and absence remained above target but was reducing over time and was considerably better than the corresponding month last year. The Trust remained in a sound financial position and was broadly on track against its targets at this stage of the year. Overall, the Board should be assured by the information contained in the report. CA made reference to page 99 of the Board pack and suggested that further information in relation to the litigation claims would be helpful. FS made reference to the increased costs relating to the use of agency staff and SW stated that there would need to be some further work undertaken to understand why the Trust continues to use Agency staff to the level being expereinced. JL commented that this increase may have been as a result of the additional bank holidays during December and the changes in GP Out of Hours. The Board noted the Trust’s performance and the assurances given in relation to the year-end financial forecast position.

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WCT12/13-216

High Level Organisational Risk Report MG presented the Trusts’s high level organisation report compiled from the BAF and the risk register, including the FT risk register, with a risk score of 15 or above. MG reported that following the discussions held at the Board meeting in December 2012, the process for reporting risks has been slightly adjusted. In future, the initial challenge and discussion of risks with a score over 15 will be considered by the Quality Patient Experience & Risk (QPER) Group. If the score then remains at 15 or more it will be escalated to the Quality & Governance Committee who will exercise their judgement as to whether to refer the risks to the Board or refer them back to QPER Group for further challenge. If a risk with a score over 15 arises between meetings, it will be brought to the attention of the relevant Executive Director who will determine whether it is appropriate to bring it to the attention of the Board. In respect of the current organisation risks, the result of the tender for the sexual health service would be known by end of January and for the IT related issues in Wirral Heart Support Service, a further review of the action plan was to be undertaken at IM&T meeting in January. MG reported that the two risks reported to Board last month in respect of Leasowe Primary Care Centre and the financial position for GP Out of Hours were considered by the Quality & Governance Committee who believed that the risks were scored too highly and have been referred back to QPER. It was also confirmed that the FT risks have been included on the Datix system and that risk training sessions have been scheduled for members of staff during January and February. The Board reviewed progress and noted the report.

WCT12/13-217

Committee Papers:

Quality & Governance Committee – 19 November 2012 MF advised there was nothing further to report. The Board noted the minutes approved by the Committee.

WCT12/13-218

Education & Workforce Committee – 19 November 2012 CA referred to page 138 of the Board pack and asked whether there would an update on the level of sickness absence within Community Nursing at the Committee’s meeting in January. SG stated that an update will be provided and added that it is the intention to work with each of the services to gain more of an understanding of the reasons for sickness absence and ascertain what the Trust can do to improve the situation. The Board noted the minutes approved by the Committee.

WCT12/13-219

Finance & Performance Committee – 26 November 2012 SW advised there was nothing further to report. The Board noted the minutes approved by the Committee.

WCT12/13-220

Staff Council – 21 November 2012 DO commented that the two way communication process has been beneficial to the staff and that they are looking forward to the future particularly in respect of the desire to obtain Foundation Trust status. BS remarked that whilst on the Leadership Walk Rounds there has been a positive atmosphere and members of staff have commented on the level of communications. . CA enquired about staff awards and asked for an update on the position. DO stated that information was shared prior to Christmas on the process and requests for nomination via the Staff Zone on the intranet. An update on the number of nominations received is due to be provided at the next Staff Council meeting. DO remarked that the Awards provide an opportunity for staff to feel valued and will have a benefit across the organisation. It was noted that the date of the event will need to be confirmed in order

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that the Non-Executive Directors can be advised. SG stated that consideration is being given to the format of the event but it is expected to be given a high profile. CA then referred to page 153 of the Board pack concerning the statement on the EMIS system and the effect this is having on staff morale. SW commented that a number of issues have been identified and a request has been put forward for a dedicated resource to be put in place to deal with the issues and challenged WHIS to do this at their cost. SW added that Staff Council is to establish a new staff user group to meet periodically with Executive Directors so that updates can be provided on progress and any further issues that may arise. CA sought and received confirmation that there will be information at the next E&W Committee meeting on the Staff Salary Sacrifice Scheme. FS enquired about the proposed staff magazine and SG stated that this was in draft form ready for the Chairman to review. ES asked about the concept of producing a clinical handbook and whether it was appropriate given that it can quickly go out of date. He suggested that a Directory of Services may be of more benefit to the Trust. DO stated that she would inform Staff Council of the comments and suggestion made. The Board noted the minutes approved by the Staff Council.

WCT12/13-221

Any Other Business

At the Chairman’s invitation, DH made reference to the recent media coverage and misconceptions in regard to the Liverpool Care Pathway. As a result of this Wirral Link was holding an event at the Floral Pavilion on 29 January 2013. It was noted that MF would be a key speaker and LC will be on the panel and it would give people the opportunity to ask questions and dispel the misconceptions that have arisen. To obtain wider coverage of the event a notice is to be placed in the local press and it was suggested that it could also be placed on the Trust’s website as well as being displayed at GP practices.

DH agreed to forward an electronic version of the flyer to MG so he could liaise with the Membership Manager.

WCT12/13-222

Items for Risk Register

None.

Date and Time of Next Meeting:

The next Formal Trust Board meeting will take place on Monday 4 February 2013 at 2.00 pm in Duncan Room, Old Market House.

Board - Chair Approval

Name: Date:

Signature:

The Board of Directors Meeting closed at 17.05.

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Page 14 of 307

Patient Story – Self Care

Agenda Item: 7 Reference: WCT12/13-229

Meeting Name: Trust Board Meeting Date: 4 March 2013

Lead Director: Lisa Cooper

Job Title: Director of Quality and Governance

Link to Business Plan: Community contract and comply with national standards for quality

Has an Equality Impact Assessment (EQIA) been undertaken & attached?

Yes No N/A

Has the Public & Stakeholders been consulted?

Yes No N/A

To Approve

To Note

To Assure

Financial Implications: E.g. What is the Impact on the Trust? Does it provide Value for Money? All costs should be clearly explained in the section below.

None identified

Overall Cost / Pressure:

£N/A Overall Income: £N/A

Additional Funding Required:

£N/A Funding Already Ring Fenced:

£N/A

Identified Risks:

None identified

Assurance to Board:

This patient story provides assurance to Wirral Community NHS Trust Board regarding the delivery of high quality, safe and effective patient services.

Publish on Website: Yes No Private Business: Yes No

Report History

Submitted to Date Brief Summary of Outcome

No history

Pat

ient

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Wirral Community NHS Trust

Patient Story – Self Care

Purpose

1. The patient story provides assurance to Wirral Community NHS Trust Board regarding the delivery of high quality, safe and effective services.

Executive Summary

2. Evidence demonstrates that involving patients in their care and treatment can:

Improve health outcomes

Boost satisfaction with services received

Increase patient knowledge and understanding of their health status

Increase patient adherence to a chosen treatment

Significant reductions in cost associated with the management of long-term conditions

3. People with Diabetes need to manage their Diabetes on a day-to-day basis. How they

manage their Diabetes can impact on their quality of life and influence the risk of developing complications.

4. This patient story involves a gentleman who attended the X-PERT Diabetes Patient

Programme which is facilitated by the Community Nutrition and Dietetics Service. 5. Positive areas identified:

Patient valued the self care plan to record his own health goals.

Patient stated that the X-PERT Diabetes Patient Programme supported him to lose weight.

Patient stated that he had learnt a lot from the programme.

Patient said he was very impressed by the NHS.

6. Less positive areas identified:

Constructive feedback on the repetitive approach to the beginning of each programme on topics previously covered.

Patient requested that all patients should be given a free blood glucose machine to promote self care.

7. An action plan relating to this patient story is included in Appendix 1.

8. All actions will be monitored via the Quality, Patient Experience and Risk Group, with

escalation to the Quality and Governance Committee if required.

Board Action

9. Wirral Community NHS Trust Board is asked to be assured of the delivery of high quality, safe and effective services and that appropriate actions are in place to improve self care for patients with Diabetes.

Lisa Cooper Director of Quality and Governance Contributors: Sandra Christie, Head of Nursing, Quality and Governance

Page 16 of 307

A

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Page 17 of 307

`

Chief Executive’s Report – January/February 2013



Lead Director: Simon Gilby

Job Title: Chief Executive

Link to Business Plan:


Yes No N/A


Yes No N/A

To Approve

To Note

To Assure


None identified.


n/a Overall Income: n/a


n/a Funding Already Ring Fenced:

n/a

Identified Risks:

That the Board is not fully appraised of relevant national policy issues and local developments.

Assurance to Board:

As part of recommended good practice, the Chief Executive’s Report to Trust Board meetings covers national as well as local issues as a means to keep members informed.


Report History


This is a regular monthly report on topical policy, strategy and business related issues

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Chief Executive’s Report – January/February 2013 Purpose 1. The purpose of this report is to provide an update to the Board with regard to national policy

and local developments that affect the Trust. Introduction 2. A key focus of business in recent weeks has been our initial response to the publication of the

report of the public inquiry into events at Mid-Staffordshire NHS Trust. Inevitably, this has also influenced much of the recent output from the Department of Health in terms of policy and related issues. The report is dealt with under a separate agenda item (Item 11). Contract negotiations have been progressing with clinical commissioning groups, and other commissioners, and generally have gone well. In this context we have continued to work with commissioners and local partners to ensure that appropriate and growing focus in on the importance of having the right model and capacity for community services in Wirral. This has been supported by joint work we have progressed with other community trusts across the country. The following paragraphs provide more detail in relation to a number of specific areas.

National Monitor Provider Licence 3. Monitor launched its provider licence on 14 February 2013 following more than a year of

stakeholder engagement and consultation on the proposals. The licence is required by the Health and Social Care Act 2012 and is the mechanism by which Monitor will regulate licensed providers of NHS Services.

4. From April 2013, all Foundation Trusts will automatically be issued with a licence, and the

Health and Social Care Act 2012 specifies that they are to be treated as having met the licence criteria. Other types of providers will need to have a licence by April 2014 and in seeking a licence will need to demonstrate that they hold a Care Quality Commission (CQC) registration, and that their Governors and Directors, or those performing equivalent functions, are fit and proper.

5. The Trust Development Agency, whilst recognising that NHS Trusts would not be required to

be licenced in April 2013 has indicated that it will wish to assure itself, as part of the 2013/14 planning process, that NHS Trusts comply with key elements of the process in relation to pricing and choice.

Community Foundation Trust Network 6. Wirral Community NHS Trust is a member of the in the Aspirant Community Foundation Trust

Network (ACFTN) along with the other 17 aspirant community foundation trusts. 7. The Network has appointed a part-time network facilitator (to be hosted by Central London

Community NHS Trust) to lead on our agreed joint work programme and to ensure liaison with partner agencies such as the Trust Development Agency, NHS Confederation and Foundation Trust Network.

8. The ACFTN has developed a “Sector Led” Programme in Community Services covering policy

advice, financial payments for community services, quality metrics, benchmarking and community support to prevent admissions (linked to the Kings Fund initiative). We are engaged in each of these. Both the NHS Confederation and FTN have agreed to work with and provide funding to the programme.

Page 19 of 307

Public Health 9. A £5.45 billion two-year ring-fenced public health budget for local authorities has been

announced by the Department of Health. From April 2013, when local authorities take the lead for improving the health of their local communities, public health budgets will be protected. The policy intent is that this should help drive local efforts to improve health and wellbeing by tackling the wider determinants of poor health.

10. Building on advice from an independent expert group – the Advisory Committee on Resource

Allocation (ACRA) – funding is specifically targeted for the first time at those areas with the worst health outcomes.

11. In 2013/14, the total budget for local public health services will be just under £2.7 billion. In

2014/15, the budget will be just under £2.8 billion. Every Local Authority will receive a real terms increase in funding. Further information on these figures is available at: http://www.dh.gov.uk/health/2013/01/public-health-budgets/

12. We have now received written confirmation from Wirral Council that its Public Health grant for

2013/14 is sufficient to confirm existing contractual arrangements with this Trust into next year. Patient Led Assessments of the Care Environment (PLACE) 13. Jane Cummings, Chief Nursing Officer, has sent out a letter with arrangements for the new

system for assessing the quality of the hospital environment, which replaces Patient Environment Action Team (PEAT) inspections from April 2013. PLACE assessments will apply to all hospitals delivering NHS-funded care, including day treatment centres and hospices. NHS Chief Executives must ensure their hospitals are ready to engage with the PLACE process when it goes live in April 2013.

14. There are no immediate implications for this Trust as we provide beds nor day case

procedures. A copy of the letter is attached as Appendix A for information.

Local Wirral Public Service Board 15. The newly established Board met for the second time in January 2013. The Board

membership is the Chief Executives or their equivalents in the key public sector organisations in Wirral. It is currently chaired by the local authority Chief Executive, and the Local Authority also administers the Board.

16. Draft Terms of Reference are in development and will be brought to this Board for approval

before being finalised. In essence the Board provides and environment for public sector agencies to seek to work together where appropriate and to share information, not least in respect of individual financial positions, designed to ensure minimal duplication of effort and avoid unintended consequences of actions by one partner on another.

17. The Board is established to work alongside the local strategic partnership framework, including

the Local Strategic Partnership itself and the Health and Well-Being Board. Recommendations 18. The Board is asked to receive this report. Simon Gilby Chief Executive 27 February 2013

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20 February 2013 NHS Commissioning Board To: 1N05 Quarry House Chief Executives of NHS Trusts Quarry Hill Chief Executives of NHS Foundation Trust Leeds Chief Executives of Care Trusts LS2 7UE PCT Cluster Chief Executives SHA Cluster Chief Executives NHS Trust Board Chairs PCT Cluster Chairs Directors of Nursing Directors of Estates and Facilities Communication Leads ROCR/OR/2085/002VOLU Dear Colleague Patient-Led Assessments of the Care Environment (PLACE) This letter alerts you to the new system for assessing the quality of the hospital environment, which replaces the old Patient Environment Action Team (PEAT) inspections from April 2013. The assessment regime, which will be known as Patient-Led Assessment of the Care Environment (PLACE), applies to all hospitals delivering NHS-funded care, including day treatment centres and hospices. Like PEAT, it is an annual assessment covering acute, general, community, mental health and learning disabilities hospitals. The only hospital types that are excluded are those very small units (of fewer than 10 beds) that provide home-like accommodation. PLACE covers broadly the same areas as PEAT – namely privacy and dignity, wellbeing, food, cleanliness and general maintenance. It focuses entirely on the care environment and does not stray into clinical care provision or staff behaviours. It extends only to areas accessible to patients and the public (for example, wards, departments and common areas) and does not include staff areas, operating theatres, main kitchens or laboratories. It is important to note that this is a site-based assessment and organisations with more than one hospital will need to arrange separate PLACE assessments for each site. PLACE assessments are voluntary and not a requirement. In the past, all NHS providers have undertaken PEAT inspections and in the same way, PLACE will continue to provide an invaluable resource in assessing your care environment. This will directly support the provision of a high quality service to patients.

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A strong patient voice The key feature of PLACE is the central role of patients1 in carrying out the assessments. At least 50 per cent of the team must be patients, and local Healthwatch must be offered the opportunity to be involved. Recruiting and training patient assessors is carried out locally and hospitals will wish to start this process as soon as possible to assure themselves they have enough patients with the right qualities. The PLACE timetable The process is managed by the Health and Social Care Information Centre (HSCIC). In Year 1 (2013-14) the assessment period will run from April to June, but in subsequent years it will run from February to April. Year 1 results will be published in September 2013, with subsequent years’ results being published in July. For practical reasons PLACE cannot be entirely unannounced and hospitals will be given six weeks’ notice of their assessment week. However, only those people directly involved in the assessment should be informed. On no account should the areas being assessed be given any advance warning and no special preparation (for example extra cleaning) should be undertaken. Further information about the conduct of the assessment will be sent direct from the HSCIC. After the assessment Hospitals are required to publish their PLACE results (following analysis by HSCIC). They should also publish a short local improvement plan, indicating how they intend to use the PLACE report to drive improvements. Action required Chief executives will wish to ensure that their hospitals are ready to engage with the PLACE process when it begins in April 2013. In particular, I would ask that you, together with your Boards, review your arrangements for promoting, supporting and encouraging the involvement of local people in assessing the hospital environment, and consider how you might best support the steps being taken to ensure the revised process becomes genuinely patient-led. Further information can be obtained from: [email protected] 0113 254 5694 [email protected] 0113 254 5306 [email protected] 0113 254 7168 Jane Cummings Chief Nursing Officer for England, NHS Commissioning Board

1 The term ‘patient’ in this context includes relatives, visitors, advocates, members of the public and other patient representatives.

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Reports from Committees – January/February 2013

Agenda Item: 9 Reference: WCT 12/13-231






Yes No N/A


Yes No N/A

To Approve

To Note

To Assure


None identified.





n/a

Identified Risks:

Each Committee monitors risk within its remit, as identified in the BAF and Risk Register.

Assurance to Board:

These reports provide on early indicator of any key issues raised at Board Committee in advance of formal minutes being received by the Board.


Report History


Regular reports submitted each month.

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Wirral Community NHS Trust Briefing from the Chairman of Quality and Governance Committee

Purpose 1. This is a brief report from the Quality and Governance Committee meeting held on Monday 21

January 2013. The ratified minutes of that committee meeting will be presented formally to the Trust Board in due course.

2. The Trust Board is asked to note the key issues identified by the Quality and Governance

Committee for communication to the Board. Significant Agenda Items 3. Quality and Patient Experience Report was presented to the Committee for approval. This

report provides assurance to the Quality and Governance Committee and Trust Board of the delivery of safe, effective and quality services across the organisation and demonstrates how the Organisation is performing in relation to strategic objectives:

Improve quality outcomes & patient satisfaction

Ensure delivery of contract requirements

Improve patient safety & risk management

4. Action plan relating to single use medical devices was received and will be monitored via the committee on a monthly basis. The committee was assured of progress against the action plan.

5. Quality assurance report received in relation to the Podiatry Service.

6. Progress report received in relation to leg ulcer assessment and management.

7. MIAA review regarding Complaints Management and Processes was presented to the Committee with a rating of significant assurance.

8. One report was received by the committee that related to a claim settled via NHSLA. Resulting action plan will be monitored via Quality, Patient Experience and Risk Group.

9. Quarter 2 Risk Register was reviewed Outcomes and Actions Agreed 10. The following policy was were approved by the Quality and Governance Committee

Policy & Procedure for Withholding Care (GP3) Any Formal Recommendations 11. None Identified Dr Murray Freeman Chair Quality and Governance Committee 21 January 2013

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Wirral Community NHS Trust Briefing from the Chairman of Quality and Governance Committee

Purpose 1. This is a brief report from the Quality and Governance Committee meeting held on Monday 18

February 2013. The ratified minutes of that committee meeting will be presented formally to the Trust Board in due course.

2. The Trust Board is asked to note the key issues identified by the Quality and Governance

Committee for communication to the Board. Significant Agenda Items 3. Quality and Patient Experience Report was presented to the Committee for approval. This

report provides assurance to the Quality and Governance Committee and Trust Board of the delivery of safe, effective and quality services across the organisation and demonstrates how the Organisation is performing in relation to strategic objectives:

Improve quality outcomes & patient satisfaction

Ensure delivery of contract requirements

Improve patient safety & risk management

The Committee discussed the increased number of grade 2 & 3 pressure ulcers for the reporting period and requested that the Director of Quality & Governance and Director of Operations & Performance/Executive Nurse provide a more detailed report to April 2013 Committee.

4. Action plan relating to single use medical devices was received. It was noted that the final action to be completed is not due until 31 March 2013 and therefore the action plan will be presented to committee next in April 2013. The committee was assured of progress against the action plan.

5. Root Cause Analysis (W1532) Report & Action Plan was presented to the Committee for approval. The Committee discussed the content of the report and requested further information regarding how other agencies involved were notified of the findings. The Committee requested the Director of Operations & Performance/Executive Nurse present this to March 2013 Committee.

6. Root Cause Analysis (W1429) Report & Update on Action Plan was presented to the

Committee for approval. The Committee requested further updates on the relevant action plan at April 2013 Committee.

Outcomes and Actions Agreed 7. The following policy was referred to the Education & Workforce Committee for review and

approval.

Gifts & Hospitality (GP7) Any Formal Recommendations 8. None Identified Dr Murray Freeman Chair Quality and Governance Committee 18 January 2013

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Briefing from the Chairman of Finance and Performance Committee Purpose 1. This is a brief report from the committee meeting held on 28th January 2012. The ratified

minutes of that committee meeting will be presented formally to the Board in due course. 2. The Board is asked to note the key issues identified by the Committee for communication to

the Board, pending receipt of these formal minutes. Significant Agenda Items 3. The following significant agenda items were considered by the committee in February

Financial Plans 2013/14

Financial Performance Report - Month 9

Key Performance Indicators - Month 9

Divisional Performance Reports – Month 9

Podiatry service quality assurance report

FT Self-Certification

Fraud & Corruption policy and Bribery policy

4. The Trust’s IMT strategy was brought back to the committee for following a review 12 months after the original strategy was agreed. Following discussions and recommendations a revised version will be submitted to the April committee for final approval.

5. The SHA Self-Certification submission for December 2012 was presented to the Committee for

approval.

6. The committee received a report the quality of the podiatry service.

7. The committee received the Bribery and Fraud and Corruption policies for approval. Outcomes and Actions Agreed 8. The committee approved/noted the following:

(i) The Trust’s financial position at the end of month 9 of the financial year (December

2012) noting that the Trust is broadly performing in line with expectations and is on course to deliver the planned £900k surplus for 2012/13.

(ii) The KPI report for December 2013 noting that 7 KPIs were reporting red and 5 were amber.

(iii) The SHA Self-Certification submission for December 2013 was approved and noted that it will be presented to the board in February for noting by the full Trust Board

(iv) The IMT strategy was considered and subject to minor amendment s was agreed to be a good document. The final version will be brought back in March.

(v) The Fraud & Corruption and Bribery policies were reviewed and amendments recommended to be brought back in March

Any Formal Recommendations

9. There are no formal recommendations from the Finance and Performance Committee to the Trust Board.

Garry Gray Chair, Finance & Performance Committee, 27th February 2013

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Briefing from the Chairman of Finance and Performance Committee Purpose 1. This is a brief report from the committee meeting held on 25th February 2013. The ratified


the Board, pending receipt of these formal minutes. Significant Agenda Items 3. The following significant agenda items were considered by the committee in February

Nursing Strategy

Financial Performance Report - Month 10

Key Performance Indicators - Month 10

Divisional Performance Reports – Month 10

Estates Management Proposal – Month 10

FT Self-Certification

Community Nursing IT System – Positional Statement

4. The Trust’s draft Nursing strategy was brought to the committee for consideration and

comment. Following discussions and recommendations a revised version will be submitted to the Quality and Governance committee for recommendation to for future Trust board approval..

5. The SHA Self-Certification submission for January 20113 was presented to the Committee for

approval.

6. The committee received a report on the position in respect of the estates strategy including consideration of the next steps in delivering the estates efficiency savings.

Outcomes and Actions Agreed 7. The committee approved/noted the following:

(i) The Trust’s financial position at the end of month 10 of the financial year (January

2013) noting that the Trust is broadly performing in line with expectations and is on course to deliver the planned £900k surplus for 2012/13.

(ii) The KPI report for January 2013 noting that 3 KPI were reporting red and 8 were amber.

(iii) The SHA Self-Certification submission for January 2013 was approved and noted that it will be presented to the board in March for noting by the full Trust Board

(iv) The proposal to progress the estates strategic efficiency work was agreed

Any Formal Recommendations

8. There are no formal recommendations from the Finance and Performance Committee to the Trust Board.

Frances Street Acting Chair, Finance & Performance Committee, 27th February 2013

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Briefing from the Chairman of Education and Workforce Committee Purpose 1. This is a brief report from the committee meeting held on 21 January 2013. The ratified


the Board, pending receipt of the formal minutes. Significant Agenda Items 3. The following key agenda items were discussed:

Redeployment Policy

Integrated Identity Management & Registration Authority Policy

HR Balanced Scorecard

Managing Attendance Update

Quarter 3 Learning & Development Report Outcomes and Actions Agreed 4. Summary of key points to be reported to the Board, either for information or requiring Board

action:

The Committee were updated on the development of the Trust’s Redeployment Policy. The Committee were informed that the Policy would enable the Trust to proactively manage staff requiring deployment by cross referencing vacancies with natural staff turnover, reducing potential redundancies and retaining skills and knowledge within the workforce. The policy was approved subject to some minor changes.

The revised Integrated Identity Management and Registration Authority Policy was approved by the Committee.

The Committee noted the contents of the HR balanced scorecard which included data on sickness absence, staffing, employee relations cases including mediation, corporate and local induction and appraisal. A verbal update was provided in relation to sickness absence levels for December which were at 4.5%.

The Committee noted the Trust’s sickness absence rate for November 2012 which was 4.5%. This was a slight decrease on the October figure but a significant reduction on the figure for November 2011. The Committee noted the progress made in relation to the overall reduction in absence levels and the actions being taken to further address specific areas of high absence.

The Quarterly Learning & Development report was presented to the Committee. The Committee were informed that the Trust is failing to meet the mandatory training target set at 2.5% and at quarter 3 remains at 8%. Actions had been put in place to address this issue. The Committee approved the report.

Chris Allen Chair, Education and Workforce Committee 10 February 2013

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Briefing from the Chairman of Education and Workforce Committee Purpose 1. This is a brief report from the Committee meeting held on 18 February 2013. The ratified

minutes of that Committee meeting will be presented formally to the Board in due course. 2. The Board is asked to note the key issues identified by the Committee for communication to

the Board, pending receipt of these formal minutes. Significant Agenda Items 3. The following key agenda items were discussed:

HR Strategy Implementation Plan and Quarterly Scorecard

Organisational Development (OD) Plan

Pensions Auto-Enrolment

Support for Revalidation and Medical Staff Appraisal

Managing Attendance Update Outcomes and Actions Agreed 4. Summary of key points to be reported to the Board, either for information or requiring Board

action:

The Committee received the HR Strategy Implementation Plan and were assured on the progress of the Strategy through the new scorecard. Feedback was provided on the further development of the scorecard.

The Committee received an update on the progress to develop an OD Plan to support the delivery of the Trust’s vision and values, which will be part of the Integrated Business Plan. The OD Plan will be developed in consultation with the Board and wider staff groups during March and April and presented to the Board in May.

Developments in relation to the possibility of deferring the implementation date of auto-enrolment were discussed. The Committee asked for further information in relation to likely costs and implications to be brought to the next meeting to enable a final decision to be made.

The Committee were assured regarding the progress and new arrangements in relation to medical staff appraisal and revalidation.

The Trust’s position of 4.5% sickness absence for both December 2012 and January 2013 was noted and the continued improvement in performance welcomed. Sickness absence levels will continue to be monitored monthly until the target of 3.4% is achieved.

Any Formal Recommendations 5. No formal actions were agreed which require consideration or ratification by the Trust Board. Chris Allen Chair, Education and Workforce Committee 27 February 2013

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Foundation Trust Programme Update



Lead Director: Steve Wilson

Job Title: Director of Finance



Yes No N/A

Have the Public & Stakeholders been consulted?

Yes No N/A

To Approve

To Note

To Assure


Dependant on achieving Foundation Trust status.





n/a

Identified Risks:

Ability to deliver the organisational change to meet NHS policy within the financial envelope and timescales set by Department of Health.

Assurance to Board:

Programme management arrangements, overall timetable and risks to achieving FT status determined, as set out in this paper.


Report History


Regular report submitted each month

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Foundation Trust Programme - Update Purpose 1. The purpose of this paper is to provide an update with regard to the Trust’s progress with its

application for Foundation Trust status. General Programme Update 2. The programme plan and associated actions are on track to support continued delivery to the

agreed timetable, with all actions progressing to their due dates, led by a Director. The milestones and timeline are shown at Appendix 1.

3. The Trust’s formal Foundation Trust application was submitted to the Department of Health in December 2012.

4. The Trust was presented to Technical Committee at the end of January. Feedback was

received on a number of aspects of the application from the Committee, identifying areas of work that require progression before the application can progress to Monitor Stage. The Trust’s application has been awarded a ‘B’ category.

5. Following a meeting with the TDA to explore the feedback in more detail, the position in regard

to the work required to progress is clearer. However, the timescale for progression is not and confirmation is being sought via the TDA as to whether the Trust’s application will be considered by the meeting of the TDA Board in May or July 2013, subject to the outcome of the TDA Quality Visit discussed below.

6. The Trust is planning to adopt the May TDA Board date as the goal to work towards in order to

preserve momentum, and reflect the fact that a number of aspects of the work required are already on-going in the Trust.

7. The key areas of development for the application focus on:

An increase in detail detailed workforce plans, aligned with CIP and quality plans

A refreshed Board Governance Assurance Framework assessment. The original assessment was delivered during May-June 2012 the progress made since against the recommendations is required to be externally verified

Progressing delivery of compliance with the Data Completeness: Community Services Indicator.

8. These areas of work are reflective of the Trust’s own assessment of what needs to be delivered in preparation for the Monitor phase of the FT application. The Trust is committed to delivering to a high standard and will use the additional focus of this feedback to ensure this is achieved.

9. Following our initial submission to the TDA of our 2013/14 Operating Plan we received

feedback and a request for revisions to elements of the overview presentation. This feedback is shown at Appendix 2. The required changes have been made and the updated content submitted in line with the deadline of 28 February.

10. The final iteration of the whole plan is to be submitted in early April and work continues to

complete this. The work required on our workforce plans and BGAF refresh is considered to be timely as the outputs will inform the finalising of the TDA Operating Plan draft for 2013/14.

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Work Stream Updates Business Planning Work Stream

11. The Trust is planning a visit to Southport Hospital with other local interested parties to assess

the integrated care model in place at that Hospital.

12. The Trust attended the Age UK Workshop “Making Patients a Priority” on 28 February as part of the panel for question time and also discussion groups on a variety of subjects including Urgent Care and End of Life Care.

Quality Work Stream

13. Further contact was made with Bridgewater regarding their experience of the Quality Visit from

the TDA and Quality Challenge with the Executive Team prior to the Monitor stage of FT assessment.

14. This was a useful information sharing exercise in advance of the Trust’s own Quality Visit which is provisionally scheduled for April 2013, with a preparatory telephone call scheduled for early March.

15. The current timing of the visit could inject delay into the application process. This delay would be due to resource availability at the TDA rather than any performance issue on the part of the Trust. The situation is being kept under close review.

Governance Work Stream

16. Prospective Governor Development sessions for staff and public members have been held,

both well received and attended. Further sessions are being planned for the future to ensure that a wide range of prospective members stand in the Governor elections.

17. Provision is being made to write out to prospective Appointed Governors as part of the

Governor development programme of work. 18. Activity is underway to progress the Trust’s Organisational Development Plan, with a position

paper being submitted to Education and Workforce Committee in February. Over the coming months the plan will be reviewed with Divisional Managers to identify actions and gaps, with a fully developed plan to be taken to Trust Board in April/May for approval.

Communications Work Stream

19. The Staff Awards have been judged and are due to be awarded in March. This is the first time

staff awards have been used to recognise the contribution made to the Trust of our biggest resource and is a key element of our engagement activities.

20. Planning for the first formal stakeholder engagement event is underway, which will be used to focus on GP providers. Invitations have been sent and the programme for the afternoon is being finalised.

21. To date over 3,300 public members have been recruited. This means the Trust has almost

recruited its target figure of 3,600 public members, planned for April 2013.

Finance & Performance Work Stream

22. As part of the Strategic Efficiency Programme the Trust is establishing a Programme Management Office (PMO). SMT received a presentation from Deloitte which covered the following:

The key functions and benefits of a PMO.

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The programme management meeting schedule with particular emphasis on governance, frequency and purpose.

A depiction of how the PMO will operate over the course of the month.

The interdependencies between each of the projects and the commencement of savings.

The status of the project within each of the work streams and the identified CIP savings.

Draft terms of reference for Programme Management Board and CIP Operations.

The proposed PMO escalation principles. 23. It was noted that the next steps include final agreement of the CIP targets, a revised PMO

governance structure and the organisation of the programme management meeting schedules.

24. The successful formation and delivery of the PMO approach is a vital part of the Trust’s move to operating as a Foundation Trust. The approach will bring an additional layer of rigour and assurance to the delivery of programmes of work, allowing the Trust Board and relevant Committees to focus on matters requiring escalation rather than day-to-day delivery.

Latest Performance Monitoring as part of the Single Operating Model

25. Our monthly monitoring RAG rating as part of the Single Operating Model reporting arrangements to the SHA was turned back to Green in January. This followed the period from October 2012 where the Trust was rated as Red due to the missing of the TFA agreed submission date.

26. The self-certification templates for January (populated with December’s data) were completed

and sent to February Board in private session for noting.

27. The self-certification template for February (populated with January’s data) was completed and submitted to Finance and Performance Committee on 25 February.

Risk Register

28. The Trust’s latest risk register for its FT application is included as Appendix 3. Board Action

29. The Trust Board is asked to:

Note and to be assured on the progress made by the Trust in its FT application process and assure itself that the actions identified are consistent with existing timeframes.

Steve Wilson Director of Finance Contributors: Amy Hinchliffe, FT Programme Manager

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Our ref: IM/FH/Wirral/08022013 8 February 2013 Sent via e-mail Simon Gilby Chief Executive


Old Market House Hamilton Street Birkenhead CH41 5AL Dear Simon Thank you for submitting your 2013/14 Operating Plan following the publication of the NHS TDA Planning Guidance in December 2012. The first stage of the NHS TDA assessment process has been completed and set out below is the result of that assessment for your Trust. This first stage has focused on a high level assessment of the plans and if necessary whether to ask you to update them, in advance of a more detailed assessment the NHS TDA will be conducting. Feedback on the finance plans has not yet been completed and will follow in the next week. Common Themes All plans for the 19 NHS Trusts in the North of England were submitted on time and were generally of a high quality, particularly given the amount of time for completion. We have identified some common themes from the initial assessment that should be taken into account by all Trusts when completing your final version for 5 April 2013. 1. Improvement Priorities (Annex A) This section was included in the guidance for Trusts to reduce the variation to national benchmarks using comparative data, for example from the quality dashboard. For some Trusts, there is not a clear rationale and use of benchmarking to determine these priorities. The delivery of performance standards is expected to be described or compliance declared in other parts of the return and, therefore, should not be included as one of the five improvement priorities. Boards are expected to set their own improvement trajectories and monitor achievement. As part of the plan, we would expect to see these set out in a way that enables the Board to identify what is to be achieved, how it will be measured, who is responsible, when it will be delivered and how it will be reported. 2. Development Priorities (Annex B) The information provided has been very useful and will be used for devising development opportunities through the NHS TDA. It would be helpful if these suggestions could be specific in identifying how the NHS TDA might help.

NHS Trust Development Authority

Delivery and Development Team (North) 3 Piccadilly Place

Manchester M1 3BN

Tel: 0845 050 0194

www.ntda.nhs.uk

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Trust’s Specific Actions

Having looked at your plan we have identified some areas that we would like you to update and re-submit. Set out below are the issues we have identified and by when we would like these areas to be re-submitted.

Section Reason When

Annex A The rationale for choice of the improvement priorities is not explicit, benchmarking data and targets are not described. Please note the section overleaf- “Common Themes”.

By noon 28 February 2013

Further information and Contact Details The assessment of plans for 2013/14 are being co-ordinated by the Delivery and Development (North) Team, with technical assessments being undertaken centrally within the NHS TDA. The oversight meetings will provide an opportunity to ask for any further points of clarification about the planning process for 2013/14. The contact points for technical queries are contained in the Technical Guidance. In the meantime if you wish to discuss further please contact me on 07887-636334 or e-mail [email protected]. Board Sign Off NHS Trust Boards are required to sign off the submission of the 2013/14 Operating Plans and in doing so certify their forward plans. Where there are grounds to question the basis of the submission including the checklist responses, the NHS TDA may require further evidence regarding the statements made in order to fully assess governance within a trust. Where any gaps are identified in the evidence or the process, the NHS TDA may require a review of governance within a Trust. Next Steps 1. The Trust should update plans as required and resubmit them through the central email

addresses [email protected] for all except finance plans which should be submitted to [email protected]

2. The NHS TDA will complete a more detailed assessment of your plan by the 21 February, following which you will receive further feedback.

3. The Trust should complete final plans and submit in the same way as set out above by 5 April 2013.

Yours sincerely

Iain McInnes Head of Delivery and Development NHS Trust Development Authority Delivery and Development (North) Cc Frances Street, Chair

Steven Wilson, Director of Finance Amy Hinchliffe, FT Programme Manager

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Page 38 of 307

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Page 39 of 307

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Page 40 of 307

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Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry







Yes No N/A


Yes No N/A

To Approve

To Note

To Assure


To be identified as part of the more detailed action plan.





n/a

Identified Risks: The key risk is that the Trust does not fully understand the level of quality and patient safety issues within the organisation. The report is calling for cultural change at a time when there are significant financial and employment relation challenges facing employers, coupled with a system that is changing and which needs providers to build new relationships with commissioners of both services and education.

Assurance to Board:

Provider organisations have been charged with reviewing their processes and delivering The Francis report recommendations. This paper provides assurance to the Board of how this work will be taken forward within the Trust, how it will be monitored and how it will be reported.


Report History


The report of the first independent inquiry, also chaired by Robert Francis, was published in 2010 and reviewed care provided by Mid Staffordshire NHS Foundation Trust from January 2005 to March 2009. The report was considered by the Trust’s predecessor organisation, NHS Wirral.

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Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Purpose 1. The purpose of this report is for Wirral Community Trust Board to formally receive the second

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, to note the implications of the report and to agree next steps.

Introduction and background 2. The report of the first independent inquiry, chaired by Robert Francis QC, was published in

2010 and reviewed care provided by Mid Staffordshire NHS Foundation Trust from January 2005 to March 2009. The report focused on the quality of care provided by the Trust not the wider healthcare system.

3. The report of the second public inquiry published in February 2013 focuses on the wider

involvement of healthcare providers, commissioning bodies and regulatory agencies. 4. This report recognises that what happened in Mid Staffordshire was a system failure, as well as

a failure of the organisation itself. The report concludes that a fundamental change in culture is required to prevent this system failure from happening again, and that many of the changes can be implemented within the current system. It stresses the importance of avoiding a blame culture, and proposes that the NHS - collectively and individually - adopt a learning culture aligned first and foremost with the needs and care of patients.

5. The report makes 290 recommendations, which focus primarily on securing a greater cohesion

and culture across the system, which ‘will not be brought about by further “top down” pronouncements, but by the engagement of every single person serving patients’. However, no single recommendation should be regarded as the solution to the many concerns identified.

6. Full details of the report, including the Executive Summary, can be found at

http://www.midstaffspublicinquiry.com/report. 7. For ease of reference of briefing prepared by the Foundation Trust Network is attached at

Appendix A. 8. In his report, Robert Francis QC calls for a whole service, patient centred focus. His detailed

recommendations do not call for a reorganisation of the system, but for a re-emphasis on what is important, to ensure that this does not happen again. They are focussed on the following themes:

Emphasis on and commitment to common values throughout the system by all within it;

Readily accessible fundamental standards and means of compliance;

No tolerance of noncompliance and the rigorous policing of fundamental standards;

Openness, transparency and candour in all the system’s business;

Strong leadership in nursing and other professional values;

Strong support for leadership roles;

A level playing field for accountability;

Information accessible and useable by all allowing effective comparison of performance by individuals, services and organisation.

9. Specifically in relation to the patient and carer experience, the first Francis Report identified a constant failure to listen to patients, carers and staff concerns about the quality of care and safety issues that we repeatedly being identified within the organisations. The second Francis

Page 43 of 307

Report reaffirms this fundamental failure to involve, engage and communicate must not be repeated.

National Level 10. The government has indicated that it will respond in detail by early March, although a number

of specific actions were put in place in the short term, as set out in Section 3 of the attached briefing.

Implications for Wirral Community NHS Trust 11. The report’s first recommendation sets out requirements for oversight and accountability to

ensure implementation of its proposals, including:

All commissioning, service provision, regulatory and ancillary organisations in healthcare should reflect on the report and its recommendations and decide how to apply them to their own work;

Each organisation should announce at the earliest opportunity its decision on the extent to which it accepts the recommendations and what it intends to do to implement them;

Each organisation should publish, at least annually, a report on its progress in achieving its planned actions.

12. On the day of the report, the Secretary of State for Health and NHS Chief Executive wrote to all

NHS Chairs and all Chief Executives respectively, encouraging a considered but proactive response to the report, including specifically the request to hold internal events to listen to staff, and to patients, in the context of the report’s findings, and to engage with the local community to rebuild public confidence.

13. Separately, the Secretary of State for Health wrote to all NHS Chairs asking that all

employment contracts are reviewed to ensure they do not contain inappropriate confidentiality clauses.

Current Position 14. Following publication of the first Report in 2010, a review was undertaken by the then Provider

Services arm of NHS Wirral. Actions put in place included in relation to clinical audits, root cause analyses, review of policies and procedures, frontline focus and patient safety training.

15. Since its establishment as an NHS Trust in April 2011, Wirral Community NHS Trust has

undertaken significant development of its overall governance arrangements, and the structures and processes to underpin these, with a clear focus on strategy.

16. A key element of this has been a self assessment of the Quality Governance Assurance

Framework, produced nationally in the light of the first inquiry report, and externally validated as part of the Foundation Trust application process.

17. Patient and staff feedback consistently is that they have confidence in the level of care

provided and that they would recommend our services to family and friends. Board level engagement with frontline services, including formal Leadership Walkabouts, provides additional assurance.

18. At the time of the report’s publication, all staff were communicated with and specifically invited

to raise concerns if they had them about quality and patient safety issues. A small number of staff took the opportunity to raise issues, and all are being followed up. All were issues about which the Trust was already aware and taking action, and none indicated any fundamental concerns about patient safety.

19. None of the above should be allowed to detract from the importance of responding to the

specific recommendations of the Francis Report.

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Proposed Actions 20. An initial review of the 290 recommendations has been completed to enable the Board to

enable it to fulfil the requirement of the first recommendation (see paragraph 11 above) and make a clear statement on the extent to which it accepts the recommendations and what it intends to do to implement them. This will be validated in the context of the government’s response and form the basis of a detailed action plan to be agreed at the April Board meeting. It is proposed that the Board monitor implementation of the action plan.

21. The action plan should include a communication plan. It is proposed that a core element of this

will be a series of ‘listening events’ for staff, scheduled April - May 2013 and designed to enable the Board to engage with staff and receive their views on the quality of services, whilst sharing the key messages of the report.

22. A review of the current complaints and concerns process in the organisation is already

underway and an action plan to ensure the organisation has a complaints and concerns process in place that reflects the recommendations of the report will be submitted to the Quality and Governance Committee for approval in April 2013.

23. A review of the current incident reporting policy is proposed to ensure the processes in place

reflect the report and have been shared widely with all staff. The revised process will be submitted to the Quality and Governance Committee for approval in May 2013.

24. The Board should lead a process to ensure that care and compassion is central to the values

of the organisation and the way it discharges its responsibilities. 25. In this context, a draft nursing strategy has been produced that focuses on the culture of care

and the values, attitudes and behaviours the organisation expects nursing staff to demonstrate towards the well-being of patients and their care needs. This will be submitted to the April Board for approval and then shared with all nursing staff.

26. The Trust should ensure this work is the basis for a strategy to be agreed for all staff in the

organisation to ensure a culture of care and compassion, and embed the values, attitudes and behaviours the organisation expects all staff to demonstrate towards the well-being of patients and their care needs.

27. The Trust should also set out for the local community the ways in which we are listening to staff

and patients, to rebuild confidence in the safety and quality of NHS care. In the first instance, it is proposed that engagement be sought with our partner NHS providers in Wirral and, if possible, a joint communication plan agreed.

Recommendations 28. Wirral Community NHS Trust Board is asked to receive the Francis Inquiry report (2013), to

consider the issues raised in the report and to approve the proposed actions and, in so doing, to be assured that a review of the relevant processes within the Trust for delivering the recommendations is being implemented and that progress with this work will be monitored by Board and relevant sub-committees of the Board.

Simon Gilby Chief Executive 27 February 2013

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1

The Final Report of the Mid Staffordshire NHS Foundation Trust Public

Inquiry – Chaired by Robert Francis QC

On the day briefing by the Foundation Trust Network (FTN)

1. Background

The following briefing provides a summary of the Francis recommendations, the Government’s initial

reaction and an initial response from the FTN. We would encourage members to read the full

content of this significant report which raises serious issues about care quality for consideration by

trusts and the wider NHS.

2. Key proposals from today’s announcements

Today, Robert Francis QC delivered his report, followed by a statement from David Cameron in the

House of Commons. The very clear message from Robert Francis was that improvement should be

driven by cultural change putting patients first. A fuller summary of the detail is below however here

are the most important, high level proposals impacting on NHS trusts and foundation trusts:

Inspection and regulation:

• Single healthcare regulator (merging CQC and Monitor) dealing with corporate governance,

financial competence, viability and compliance with patient safety and quality for all trusts;

• Creation of a Chief Inspector for hospitals to be appointed by CQC in autumn 2013;

• Clearer and legal consequences for failure including a power for CQC to remove trust boards on

the basis of poor quality care;

• Poor scores on Friends and Family Test resulting in immediate CQC inspection;

• Sir Bruce Keogh to conduct an immediate investigation into care at hospitals with the highest

mortality rates, and check remedial action is being taken.

Employee duties:

• Statutory duty of candour, and fit and proper persons test for directors;

• Requirements on FTs to provide adequate training for directors;

• Provision of misleading information by providers to regulators to be a criminal offence;

• Regulation of healthcare workers;

• Nurses to be hired and promoted on the basis of compassion.

Authorisation:

• Transfer of FT authorisation process to CQC with support from the NHS Trust Development

Authority to develop the quality of care as a pre-condition for authorisation;

• Inspection should be strengthened as an element of the authorisation process. Trusts applying

for FT status should be subject to a ‘duty of utmost good faith.’

Local accountability:

• Proposals for strengthening support for governors, and for strengthening the role of governors

and NEDs including their accountability to the public.

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2

3. The Government’s initial reaction

The Prime Minister laid the Francis Report before parliament today. The government will respond in

detail next month, however David Cameron today committed to moving more quickly on:

Putting patients first:

• There will be a single failure regime covering care quality, finances and governance, meaning

the Care Quality Commission (CQC) will have the power to suspend provider Boards;

• Poor scores on the Friends and Family Test will result in immediate CQC inspection;

• Don Berwick (former Obama health adviser) will lead a review into making ‘zero harm’ a reality;

• Nurses should be hired and promoted on the basis of compassion as a vocation not just an

academic qualification. Cameron favours linking pay to care quality over length of service.

Accountability and transparency:

• The Secretary of State has asked the Nursing and Midwifery Council (NMC) and the General

Medical Council (GMC) to explain why no-one has been struck off for the failures at Mid

Staffordshire and to strengthen their systems of accountability. The Law Commission will

advise on updating the NMC’s decision making processes;

• Government will look at moving responsibility for conducting criminal prosecutions in the NHS

away from the Health and Safety Executive to CQC.

Regulatory action:

• CQC will have a new Chief Inspector of Hospitals to develop and implement a new hospital

inspection regime to start autumn 2013. It will examine the quality of care and make an explicit

judgement about the culture of trusts. Government will re-examine the inspection regime to

ensure judgements focus on whether a hospital is clean, safe and caring;

• Sir Bruce Keogh will conduct an immediate investigation into care at hospitals with the highest

mortality rates, and check remedial action is being taken;

• Ann Clwyd MP (Labour) and Tricia Hart (Chief executive, South Tees Hospitals NHS FT) will lead

a review into how hospitals in the NHS should handle complaints.

4. Initial Reaction from the FTN

In the run up to publication of the Francis Report, our Chair, Peter Griffiths and Chief Executive, Chris

Hopson wrote an open letter to members acknowledging that pockets of poor quality care can exist

in all types of trust, but emphasising that failures as serious, protracted and devastating as Mid

Staffordshire are rare and isolated.

We recognised that the FTN and the wider NHS need to do much more to identify and share best

practice on improving quality of care and to provide practical tools to support trusts in doing so. Our

work programme will identify how the FTN can help develop sector led support to complement

government led initiatives, focussing on:

• The drivers of quality identified through research such as culture, ward level leadership, team

effectiveness, staff satisfaction and support;

• The role of the board;

• Defining what support could be provided to trusts finding it difficult to meet standards;

• Exploring the link between increasing financial pressure and quality.

Clearly, today’s announcements and recommendations will have a major impact on everyone in the

NHS. We are committed to engaging fully in the evolving debate, and to consulting widely with

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members and stakeholders to address the issues raised. Therefore, any views presented here are

our initial responses to proposals.

We would welcome members’ views on the recommendations and our initial response. Please

contact [email protected]

5. Recommendations from the Francis Report

The report emphasises the need to avoid further structural change, and does not seek to scapegoat

individuals. It makes a total of 290 recommendations along the following four themes. For the full

detail, please refer to the report.

A STRUCTURE OF FUNDAMENTAL STANDARDS AND MEASURES OF COMPLIANCE

NHS Constitution and values:

• Strengthen NHS Constitution to place patients first as an ‘overriding value’ and to articulate

fundamental standards of staff behaviour;

Development of fundamental standards – of behaviour, safety and quality:

• List of clear, fundamental quality and safety standards, which any patient is entitled to expect,

and to permit any hospital service to continue;

• NICE should produce standard procedures and guidance to enable organisations and individuals

to comply with these fundamental standards. They should work with professional and patient

organisations to do so, and cover clinical outcomes as well as staff mix and cultural outcomes;

• ‘Enhanced standards’ should be developed and made available to commissioners to raise

standards. Clear focus on the role of commissioners in driving standards;

• Non-compliance should not be tolerated and any organisation not able to consistently comply

should be prevented from continuing a service;

• Causing death or serious harm to a patient by non-compliance without reasonable excuse of the

fundamental standards should be a criminal offence.

Regulation of standards:

• CQC should become the single regulator dealing with corporate governance, financial

competence, viability and compliance with patient safety and quality for all trusts (i.e.

combining CQC’s current role with Monitor’s previous role as an FT regulator);

• Consider transferring the regulation of governance, and fitness of persons to be directors,

governors etc. from Monitor to CQC;

• CQC should have a duty for monitoring the accuracy of the data providers supply and to require

providers to provide a fuller narrative about patient complaints. Provision of misleading

information to a regulator should become a criminal offence;

• CQC should expand its work with overview and scrutiny functions and foundation trust

governors as a valuable source of intelligence and feedback;

• Routine and risk based monitoring, notably inspection, is advocated as a key source of

regulatory information and regulators are encouraged to adopt ‘zero tolerance’ and ‘a low

threshold of suspicion.’ Regulators must have policies in place to intervene to protect patients

and to repeatedly review if intervention is necessary;

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• CQC must develop well trained, specialist inspectors, integrate patient representation into its

structures and consider formalising partnership input from professional bodies such as the

GMC;

• Government should look at moving responsibility for conducting criminal prosecutions in the

NHS away from the Health and Safety Executive to CQC;

• Providers to comply with risk schemes of equal rigour to the NHS LA. Various recommendations

for the NHS LA to consider how it evaluates elements of risk, including staffing levels;

• All regulators to improve information sharing;

• National Patient Safety Agency and Health Protection Agency functions to be protected and

potentially transferred to another regulator;

• Transfer of FT authorisation process to CQC with support from TDA in developing quality of care

as a pre-condition for authorisation. Inspection should be strengthened as part of the

authorisation process. Aspirant trusts should be subject to a ‘duty of utmost good faith’;

• However, any evolution of the CQC should be gradual and staged. The report explicitly states

the CQC should not be dissolved and replaced by another organisation.

Initial views from the FTN

We welcome moves to clarify the standards of care which patients can expect and the

recommendation that standards are developed in partnership with patients, the public and

clinicians. We also welcome the involvement of NICE within this process, and hope that this will

build naturally on their growing library of quality standards.

If a growing number of standards are to become mandatory, we would welcome sector input, and

indeed sector leadership of elements of this process to ensure healthcare professionals contribute

their expertise and to enable the NHS to take greater ownership for its own improvement.

We also agree that the consequences for non-compliance should be clear and form a deterrent at

organisational and individual staff member levels. However we will need to give careful

consideration to proposals for individuals to be at risk of criminal prosecution for failures in care. We

will undertake more research to understand how this compares to other industries, and to evaluate

the costs and benefits of what may risk becoming a ‘litigation culture’ within the NHS at odds with

the spirit of the Francis recommendations.

We would add as a general point, that many of the recommendations within the Francis Report are

aimed at secondary care. Poor quality care can occur in all sectors of the NHS, including primary

care, and we would like to see the spirit of the Francis recommendations enacted across the system.

We are keen to see, and have consistently lobbied for, greater synergy and co-operation between

the regulators to avoid issues of ‘double jeopardy’ (where providers are penalised twice by different

regulators for the same issue). Our members would welcome any streamlining of the regulatory

burden in the interest of patients and the best use of resources. However the inspections of care

quality and finance require very different skill sets and the potential merging of the regulators could

provide too broad a remit for one single organisation. While we are keen to see a strong, and

effective quality regulator in the CQC, we feel that some of Monitor’s existing responsibilities,

particularly around policing compliance with competition legislation and mergers and acquisitions,

may not sit well within a single regulator of trusts and that the regulation of individual organisations

(both quality and financial regulation) should be treated separately from regulation in terms of

compliance with competition law.

We recognise that the CQC has improved, and is a changing organisation. However, we would be

cautious about a large and hurried expansion of the CQC’s role at a time when they are consolidating

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their core and fundamental role as a regulator of essential quality standards. Further reform of what

is essentially a new regulatory framework will need to be a carefully managed process over time.

OPENNESS, TRANSPARENCY AND CANDOUR THROUGH THE SYSTEM, UNDERPINNED BY STATUTE

• A statutory duty to be truthful to patients where harm has or may have been caused;

• Staff to be obliged by statute to make their employers aware of incidents in which harm has

been or may have been caused to a patient;

• Trusts have to be open and honest in their quality accounts which will be consistent, publicly

available. Quality and risk profiles should also be made public;

• The deliberate obstruction of the performance of these duties and the deliberate deception of

patients and the public should be a criminal offence;

• It should be a criminal offence for the directors of trusts to give deliberately misleading

information to the public and the regulators;

• Proposals for strengthening support for governors, and for strengthening the role of governors

and NEDs including their accountability to the public;

• Complaints handling must be improved nationally and locally;

• There should be a consistent structure for local Healthwatch across the country;

• Each provider board should have a member responsible for information;

• The CQC should be responsible for policing these obligations.


We welcome measures to enhance transparency and openness within the culture of the NHS at local

and national levels and the principles behind the recommendations.

We would encourage trusts to act on, and respond to, local complaints which form an important

source of information about the quality of their care.

We have supported the organisational, contractual ‘duty of candour’ as all providers strive to act on

the information available to them to improve services, and protect patients. However we are

cautious that the development of some of the legal duties proposed at individual employee levels

may work against a culture in which staff feel empowered to highlight and act on issues of concern

by perpetuating, and exacerbating fear of blame and repercussions. We will take more time to

review the recommendations, and their legal implications in detail, and we welcome members’

views on this issue.

We look forward to contributing to the discussion about proposals to strengthen the role of

governors, and NEDs who play a crucial role in representing and being held to account by members,

and the wider community in the foundation trust accountability model.

IMPROVED SUPPORT FOR COMPASSIONATE, CARING AND COMMITTED NURSING

• Nurses should be assessed for their aptitude to deliver and lead proper care, and their ability to

commit themselves to the welfare of patients;

• Training standards need to be created to ensure that qualified nurses are competent to deliver

compassionate care to a consistent standard;

• Nurses need a stronger voice with suggestions NMC strengthens its role;

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• Healthcare workers should be regulated by a registration scheme, with a uniform description of

their role;

• Patients should be allocated a key nurse for each shift. Ward leaders should not be office-

bound. Particular attention should be given to care for the elderly.


We have welcomed developments to adopt a more value based approach to nursing, such as the

publication of ‘Compassion in Practice’ and are fully supportive of training and development

measures which enable nurses to fulfil their roles effectively and compassionately.

We remain of the view that it is for individual providers to ascertain the skills mix, and patient/staff

ratio for their services. While professional guidance on these issues is always welcome, we would

wish to resist a prescriptive approach which could undermine local innovation and provider

autonomy and fail to serve the best interests of patients.

We would also highlight the need for all staff within NHS settings in both primary and secondary care

to adopt and enact the values of compassion in their interactions with patients. While nurses form a

crucial interface with patients in relation to quality of care, we would not wish to see their

profession unduly singled out when all healthcare professionals have a central role to play.

STRONGER HEALTHCARE LEADERSHIP

• An NHS leadership college to offer potential and current leaders the chance to share in a

common form of training to exemplify and implement a common culture, code of ethics and

conduct;

• It should be possible to disqualify those guilty of serious breaches of the code of conduct or

otherwise found unfit from eligibility for leadership posts;

• A registration scheme and a requirement need to be established that only fit and proper

persons are eligible to be directors of NHS organisations;

• Requirements on FTs to provide adequate training for directors;

• Strengthened role for training organisations in providing safety information, for instance

recommended skill mix and staff ratios;

• Professional regulators to play a tougher role in relation to protecting patients and the public;

• Health Education England should have a medical director and a lay person on its board. LETBs

should have a post of medically qualified post graduate dean.


We remain cautious about measures to introduce regulation of managers, beyond what might be

expected in comparable industries outside of the NHS. It is for the provider board to assure

themselves of the quality of leadership and management within the trust and to act accordingly. We

are interested to hear further detail about how these recommendations might be implemented and

which organisation might fulfil this role.

We do however welcome moves to strengthen medical input to training plans nationally and locally.

FOUNDATION TRUST NETWORK

February 6 2013

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Infection Prevention and Control Assurance Report

(01 October 2012 – 31 December 2012)




Job Title: Director of Quality & Governance/Director of Infection Prevention & Control



Yes No N/A


Yes No N/A

To Approve

To Note

To Assure


None identified.


Overall Income:


Funding Already Ring Fenced:

Identified Risks:

Non-compliance with The Health and Social Care Act 2008 Code of Practice on the Prevention and Control of Infections and related guidance may affect the Trust’s registration with the Care Quality Commission.

Non-compliance increases the risk of Healthcare Associated Infections and associated litigation.

Assurance to Board:

This report provides assurance to Wirral Community NHS Trust Board in relation to the Trust’s requirements to implement The Health and Social Care Act 2008 Code of practice on the Prevention and Control of Infections and related guidance.


Report History


Regular report submitted quarterly

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Infection Prevention and Control Assurance Report (01 October 2012 – 31 December 2012)

Purpose 1. The purpose of this paper is to:

Provide assurance to Wirral Community NHS Trust Board of its requirements to implement the Code of Practice on the Prevention and Control of Infection (DH 2008) and to demonstrate compliance with the Care Quality Commission Outcome 8: Regulation 12 – Cleanliness and Infection Control.

Provide assurance to the Trust Board regarding implementation of the Code of Practice during the period 01 October 2012 – 31 December 2012.

Introduction

2. Reducing the risk of infection through robust infection control practice is a key priority for

Wirral Community NHS Trust and supports the provision of high quality services for patients and a safe working environment for staff.

3. Effective Infection Prevention and Control structures, the commitment of Wirral Community

NHS Trust Board and all employees is essential to the effective control of Healthcare Associated Infection (HCAI’s).

Wirral Community NHS Trust Update (01 October 2012 – 31 December 2012) 4. There have been no MRSA bacteraemia cases attributed to the Trust during the reporting

period.

5. The following staff numbers attended Infection Prevention & Control training during the reporting period (01 October 2012 – December 2012):

151 Clinical staff attended Essential learning

30 Staff attended Corporate Induction

92 Non-Clinical staff attended non-Clinical essential Learning programme

6. Eight Trust premises were audited against the Infection Prevention Society and local standards. Of the areas audited six demonstrated improvement on the previous year’s audit. The following areas demonstrated a reduction in the audit score in the previous year:

Leasowe Primary Care Centre (reported in Quarter 2 Board Assurance Report)

Unsatisfactory standards of cleaning where observed

Increased dust within environment

Non-adherence to Wirral Community NHS Trust sharps safety policy

Evidence of reuse of single use medical devices.

St George’s Medical Centre Ophthalmology Clinic

Inadequate provision of hand hygiene resources

No evidence that reusable patient equipment is decontaminated between each use. 7. Action plans have been issued to Cheshire & Wirral Partnership Trust and to relevant

Divisional Managers these will be monitored via the Infection Prevention & Control Group.

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8. Essential Steps is a framework that allows the Trust to measure compliance with Infection

Prevention and Control standards to ensure the quality and safety of clinical interventions. It is a requirement of the Trust’s Community Contract.

9. For the reporting period 01 October 2012 – 31 December 2012; 940 eligible staff completed the mandatory Hand Hygiene Observational Audit; this represents 76% of the eligible workforce and is a slight increase on the previous reporting periods.

10. Whilst there is an overall compliance of 100% reported with Tool One: Hand Hygiene, which

is sustained from the previous reporting period, direct observation of clinical staff in practice during service inspections does not support this level of compliance.

11. Both the Wheelchair Service and Parkinson’s Disease Service failed to complete the required observational audits. This has been escalated to the relevant Divisional Manager and Director. Assurance is given to the Trust Board by the Director of Operations & performance/Executive Nurse that there are action plans in place to ensure all requirements are met in Quarter 4. Compliance with Essential Steps has also been placed on Service and Divisional risk registers.

12. Non-adherence to Wirral Community Trust’s Hand Hygiene Policy (ICP2) remains on the

Trust risk register with a score of 12. Assurance is given by the Director of Operations & performance/Executive Nurse that robust action plans are in place at service and divisional level to support adherence to Trust Policy.

13. Four Community Trust premises were visited as part of the programme of Unannounced

Visits. Of the areas visited the Community Equipment Store demonstrated significant improvement from previous visit.

14. There have been ten inoculation incidents reported via Datix during this reporting period

compared to nine in the previous reporting period.

15. The Podiatry Service continues to report the highest number of inoculation incidents within the Trust. There have been a number of measures introduced to reduce risk within the Service which includes the implementation of a protocol for returning instruments to the Central Sterile Supply Service and the introduction of a safer blade removal device.

16. There have been six infection control incidents reported via Datix during this reporting

period.

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17. Increased activity at the Arrowe Park site (Walk In Centre/GP Out of Hours) due to the

relocation of GP’s from Riverside has impacted on the Primary Care and Unplanned Care Divisions’ ability to isolate patients presenting with suspected infectious disease e.g. measles, pertussis. A meeting has been arranged with the relevant Divisional Managers to agree an action plan and staff training within the services affected.

18. Infection control and Inoculation incidents are reviewed by the Infection Prevention and

Control Service and monitored by the Infection Prevention and Control Group. 19. The Infection Prevention and Control Nurses were Flu Champions and supported the

Trust’s staff flu vaccination programmes. Currently the Trust achieved over 61.9% uptake for the staff flu immunisation campaign.

20. Wirral Community NHS Trust continues to submit Northwest HCAI Assurance Framework

to NHS Wirral. Work for Other Agencies 21. Wirral Community NHS Trust does not have national HCAI objectives set for MRSA or

Clostridium Difficile. All community attributed cases are reported against NHS Wirral’s objective as it is NHS Wirral who retains responsibility for HCAI reduction across the Health Economy.

22. During the reporting period 01 October 2012 – 31 December 2012 there have been seven

community attributed case reviews (NHS Wirral) undertaken by the Infection Prevention and Control Service. The case reviews in each case did not identify that the care provided by Wirral Community NHS Trust was a contributory factor or root cause of infection.

23. The Infection Prevention and Control Service have managed five outbreaks of gastro-

intestinal illness within care homes. 24. The Infection Prevention and Control Service delivered the following education and training

programmes:

1 education sessions for Practice Nurse’s and Health Care Assistants

2 education session for adult health and social care providers

1 education session for the Admission Prevention and Facilitated Discharge Team

1 education session for the University of Chester as part of the NM6065 Infection Prevention and Control Module

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25. The Infection Prevention and Control Service were commissioned by NHS Wirral to

undertake a programme of practice visits to General Dental Practices. This work stream has contributed to the IPC cost improvement programme.

26. Wirral Community NHS Trust Infection Prevention and Control Service continues to provide

advice and support to the Department of Adult Social Services and Wirral Clinical Commissioning Group regarding Infection Prevention and Control issues within care home services.

Board Action 27. Wirral Community NHS Trust is asked to be assured of the processes in place to implement

the Code of Practice on the Prevention and Control of Infection (DH 2008) and to demonstrate compliance with the Care Quality Commission Outcome 8: Regulation 12 – Cleanliness and Infection Control.

Lisa Cooper Director of Quality & Governance/ Director of Infection Prevention & Control Contributors: Helen Oulton, Head of Infection Prevention & Control Service

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Quarter 3: Safeguarding Assurance Report

(01 October 2012 – 31 December 2012)




Job Title: Director of Quality & Governance/Director of Infection Prevention & Control



Yes No N/A


Yes No N/A

To Approve

To Note

To Assure


None identified


£ TBC Overall Income: n/a



n/a

Identified Risks:

Non-compliance with Working Together To Safeguard Children (2010), Statutory Guidance on Promoting the Health and Well-Being of Looked After Children (2009), Mental Capacity Act 2005 Code Of Practice (including Deprivation of Liberty Safeguards), Department of Health “No Secrets” (2000), MAPPA Guidance (2009), Wirral Local Safeguarding Children Board (LSCB) multi-agency policies/procedures, Wirral Safeguarding Adults Partnership Board (SAPB) multi-agency policies/procedures which may affect Wirral Community NHS Trust Care Quality Commission registration.

Assurance to Board: This report provides assurance to Wirral Community NHS Trust Board in relation to the Trust’s requirements to adhere to statutory documents listed above and demonstrates compliance with the Care Quality Commission Outcome 1: Respecting and involving people who use services, and Outcome 7: Safeguarding people who use services from abuse


Report History



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Wirral Community NHS Trust Safeguarding Assurance Report

(01 October 2012 – 31 December 2012) Purpose 1. The purpose of this document is to:-

Provide assurance to Wirral Community NHS Trust Board of its requirements to comply with Working Together To Safeguard Children (2010), Statutory Guidance on Promoting the Health and Well-Being of Looked After Children (2009), Mental Capacity Act 2005 Code Of Practice (including Deprivation of Liberty Safeguards), Department of Health “No Secrets” (2000), MAPPA Guidance (2009) Wirral Local Safeguarding Children Board (LSCB) multi-agency policies/procedures, Wirral Safeguarding Adults Partnership Board (SAPB) multi-agency policies/procedures.

Provide assurance to the Trust Board regarding implementation of the above statutory guidance and demonstrate compliance with the Care Quality Commission Outcome 1: Respecting and involving people who use services, and Outcome 7: Safeguarding people who use services from abuse, during the reporting period 01 October 2012 – 31 December 2012.

Executive Summary 2. Wirral Community NHS Trust is committed to ensuring that all staff are aware of their role in

relation to safeguarding vulnerable children and adults. The Safeguarding Service provides advice, support and training to staff and independent contractors.

3. The Safeguarding Service discharges the statutory duty placed on all agencies to provide a

“single point of contact” (SPOC) in relation to MAPPA (multi agency public protection arrangements) regarding the management of high risk offenders. The SPOC role ensures that information is shared when appropriate to ensure that public safety and also staff safety is maximised.

Wirral Community NHS Trust Update (01 October 2012 – 31 December 2012) 4. Safeguarding is recognised as a key organisational priority and is embedded from corporate

level to provide leadership across all areas of service provision. 5. Activity levels for the Safeguarding Service are provided in the table below:

Summary Safeguarding Activity Quarter 1 Quarter 2 Quarter 3

Mental Capacity Act/Deprivation of Liberty Safeguards (MCA/DOLS) - DOLS Supervisory Body requests approved and processed within nationally agreed timescales

100% 100% 100%

Number of staff receiving child protection supervision 76 65 54

Number of actual families supervision relates to 393 303 253

Number of Case Conferences attended 42 43 32

Number of Court reports provided 12 12 4

Number enquiries to Named GP 7 11 16

Average number of Looked after Children across reporting period

840 827 809

Number of MAPPA case meetings attended 42 40 40

Number of MARAC cases requiring WCT involvement 159 157 170

Number of Safeguarding Adults referrals made by WCT staff

23 20 21

Number of Safeguarding Children contacts made to Named Nurses by WCT Staff (exc supervision)

- - 321

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6. Safeguarding training packages are in the final stages of review. The Essential Learning

package for face to face practitioners has been reviewed to reflect national intercollegiate document requirements for health staff with particular emphasis on Level 3 competencies. The review is on target for completion with a view to rolling the new programme out during training sessions delivered commencing January 2012 when pilot sessions using the new content will be delivered. Feedback from delegates will then be assessed prior to the formal rollout of the new content.

7. For the reporting period 01 October 2012 – 31 December 2012:

151clinical staff attended Essential Learning

92 non-clinical staff attended Essential Learning 8. The Safeguarding Group has met in accordance with the set meeting schedule. Minutes have

been forwarded to the Quality & Governance Committee. The terms of reference for the group have being reviewed and accepted. In order to ensure maximum effectiveness the meeting frequency has been increased to bi-monthly. The rationale for the increase is to ensure that safeguarding processes and learning from safeguarding incidents/reviews is embedded in all areas of service provision, not only from a policy, pathway, procedure perspective, but also from an operational perspective.

9. Wirral Community NHS Trust is currently participating in three Domestic Homicide Reviews

(DHR). It is anticipated that findings will be published nationally within 18 months of the reviews commencing. The reviews are meeting Home Office requirements in terms of progress made to date. Wirral Community NHS Trust has submitted abridged IMR’s (individual management reviews) for all three of the cases to the effect that there no information regarding any of the subjects named in the review genograms. It was anticipated that the third case would require Wirral Community NHS Trust to submit a full IMR, however, once the timescale for review had been identified along with the genogram there was no such requirement. To this end an abridged IMR was submitted as with previous two cases.

10. Wirral Community NHS Trust is currently participating in one Serious Case Review (SCR) in

relation to a child death and is meeting all statutory requirements in relation to information submission. Progress of the SCR will be included in future quarterly assurance reports until the case has been submitted to the Local Safeguarding Children Board (LSCB), it will then be reported to Board with a required action for approval. Thereafter, the overarching action plan will be monitored via the LSCB. Wirral Community NHS Trust action plan and learning from this case will be monitored via the Trust’s Safeguarding Group. It is anticipated that the SCR will be finalised January 2013. The Local Safeguarding Children Board (LSCB) will release the report and will manage any media interest in the case.

11. Wirral Community NHS Trust continues representation at Wirral Local Safeguarding Children

Board (LSCB) and Wirral Safeguarding Adults Partnership Board (SAPB) and all associated sub groups and working parties.

12. The Service Specification for the Looked after Children (LAC) aspect of the service has been

amended. The Commissioner has allocated funding for new posts to reflect the requirements of the new specification. The posts have now been recruited to and new members of the team will commence in post from February 2013.

13. The Looked after Children clinical staff are meeting all Infection Prevention and Control

standards in relation to their contact with children/young people and have completed the required Essential Steps Tool for Hand Hygiene with 100% compliance.

14. Safeguarding evidence is collected and updated in relation to Wirral Community NHS Trust

CQC registration (specifically Outcome 1 and Outcome 7) on a monthly basis.

15. The Care Quality Commission inspected the Walk in Centre (Arrowe Park) on 05 November 2012 and declared the service compliant with Outcome 7: Safeguarding Children and Adults.

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16. The Safeguarding Service continues to provide core functions in an area of work which is

constantly changing from not only a local but also national perspective. Changes in the remit of partner agencies has a significant impact on how the services meets its objectives, and, to date, all demands for input in multi-agency processes have been met within timescales and the core business has not been affected.

Board Action 17. Wirral Community NHS Trust Board is asked to be assured of the processes in place to

implement all relevant statutory guidance and adopt best practice principles in all areas of safeguarding and that the processes in place provide evidence and demonstrate compliance with the Care Quality Commission Outcome 1: Respecting and involving people who use services, and Outcome 7: Safeguarding people who use services from abuse.

Lisa Cooper Director of Quality & Governance Contributors: Ann Marie Ratcliffe Head of Safeguarding Service

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Quarterly Quality and Patient Experience Trends/Themes Report (01 October 2012 – 31 December 2012)





Link to Business Plan: Meets NHSLA/CQC requirements. Provision of high quality services


Yes No N/A


Yes No N/A

To Approve

To Note

To Assure


None identified at present


£ Overall Income: £


£ Funding Already Ring Fenced:

£

Identified Risks:

None Identified at present

Assurance to Board:

The Quarterly Quality and Patient Experience Report provides assurance to the Trust Board of the delivery of safe, effective and quality services across the organisation.


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Quarterly Quality and Patient Experience Trends/Themes Report (01 October 2012 – 31 December 2012)

Purpose

1. The purpose of the quarterly Quality and Patient Experience Report is to provide assurance to the Trust Board of the delivery of safe, effective, quality services during the reporting period 01 October 2012 to 31 December 2012.

Executive Summary

2. Wirral Community NHS Trust Board recognises that quality is an integral part of their business strategy and for the Trust to be most effective; quality must become the driving force of the organisation’s culture.

3. We are committed to ensuring that quality forms an integral part of its philosophy, practices

and business plans and that responsibility for driving this is accepted at all levels of the organisation.

4. The Organisation’s Quality Strategy represents Wirral Community NHS Trust’s philosophy

towards quality improvement and is built on these principles. Included in the Quality Strategy are four quality themes:

Patient Experience

Delivering Care

Getting Staffing Right/Staff Experience

Measuring Impact

5. This report provides the Trust Board with assurance regarding trends and theme analysis relating to Quality and Patient Experience and demonstrates how the Organisation is performing in relation to the quality outcome goals relating to:

Patient Experience

Delivering Care

6. The reporting period for this Quality and Patient Experience trend/theme report is 01 October 2012 to 31 December 2012.

Board Action

7. Wirral Community NHS Trust Board is asked to be assured of the delivery of safe, effective, quality services across the organisation for the reporting period 01 October 2012 to 31 December 2012.

Lisa Cooper Director of Quality and Governance

Contributors: Sandra Christie Head of Quality and Governance

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Section One: Patient Experience

1. For the reporting period 01 October 2012 – 31 December 2012 the following were received

by the organisation:

77 Concerns (Decrease compared to Quarter 2)

465 Compliments (Increase compared to Quarter 2)

8 Complaints (Decrease compared to Quarter 2)

2 Claims (Decrease compared to Quarter 2)

2. Trends for Patient Experience reported during the reporting period are shown below.

3. Concerns reported have decreased during Quarter 3 due to estates issues with St

Catherine’s Health Centre being resolved. 4. Compliments have significantly increased with access/admissions/appointments and

treatment procedure being the most common. 5. The themes for Patient Experience for Quarter 3 are shown below:

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6. Reporting times for responding to Complaints are included within this report for the first time:

100% (8) complaints were acknowledged within the required 3 working days

50% (4) complaints received final response outside of agreed timescales

12.5% (1) complaint was responded to inside of agreed timescales

12.5% (1) complaint was not pursued by claimant

12.5% (1) response not due

12.5% (1) response outstanding 7. All action plans which result from complaints and concerns are monitored monthly at the

Quality, Patient Experience and Risk Group. Minutes of this group are received at the Quality and Governance Committee for scrutiny and provide assurance regarding the management and learning from complaints.

8. Themes from compliments are monitored monthly at the Quality, Patient Experience and

Risk Group. Minutes of this group are received at the Quality and Governance Committee for scrutiny and provide assurance regarding the management and learning from compliments.

Claims 9. Two claims were received during the reporting period (C43; C44). 10. During the reporting period the Trust received no Solicitors’ Risk Management Reports

(SRMRC).

11. No claims were settled during the reporting period. 12. All action plans resulting from claims are monitored monthly at the Quality, Patient

Experience and Risk Group. Minutes of this group are received at the Quality and Governance Committee for scrutiny and provide assurance regarding the management and learning from claims.

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5

Section Two: Delivering Care

13. For the reporting period all agreed CQUIN targets were achieved. The local CQUIN relating

to communication with GP practices has been revised in agreement with the Commissioners (October 2012). Data collection has commenced (December 2012) with reporting against this CQUIN commencing in February 2013.

14. For the reporting period (01 October 2012 – 31 December 2012):

655 Total incidents were reported (Decrease compared to Quarter 2)

2 Serious Untoward Incidents were reported (Same as Quarter 2)

224 Patient Safety (Near Miss) incidents were reported (Increase compared to Quarter 2)

15. Trends for incidents reported are shown below:

16. Top 5 themes for incidents for Quarter 3 are shown below, of which Pressure Ulcer remains

the most common incident reported. This is due to the requirement to report all pressure ulcers as per NICE guidance.

17. All grade 3/4 pressure ulcers which have occurred in the care of the Trust are subject to a

records review to determine if they were avoidable.

18. Those pressure ulcers deemed avoidable are subject to a Root Cause Analysis (RCA) investigation.

19. All grade 3/4 pressure ulcers are reported to the Strategic Health Authority as per STESIS process.

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6

20. Details of all reported pressure ulcers for Quarter 3 are shown below. Grade 2 Community Trust Acquired is the most common reported for Quarter 3.

21. Themes for Serious Untoward Incidents reported in Quarter 3 are shown below.

22. All Serious Untoward Incidents are reported in accordance with Strategic Health Authority

(STESIS) process.

23. All Serious Untoward Incidents are investigated using the Root Cause Analysis (RCA) investigation process.

24. All RCA investigations relating to Serious Untoward Incidents are reported to the Quality and Governance Committee, with action plans being monitored monthly at the Quality, Patient Experience and Risk Group. Minutes of this group are received at the Quality and Governance Committee for scrutiny and provide assurance regarding the management and learning from Serious Untoward Incidents.

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7

25. Trends for Patient Safety (Near Miss) incidents reported are shown below:

26. The top 5 themes for Patient Safety (Near Miss) Incidents reported in Quarter 3 are shown

below, of which discharge remains the most common (Quarter 1& 2).

27. Themes from all incidents/near misses are monitored monthly at the Quality and Governance

Committee.

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8

Section Three: Report Analysis

28. The graph below provides an analysis of the Trust’s top 5 incident categories correlated with

complaints and claims for the Quarter 3 reporting period. 29. The analysis demonstrates that for the Quarter 3 reporting period there are trends in

incidents/complaints/claims.

Lisa Cooper Director of Quality and Governance

Contributors: Sandra Christie Head of Nursing, Quality and Governance

Page 68 of 307



Yes No N/A

Has the Public & Stakeholders b een consulted?

Yes No N/A

To Approve

To Note

To Assure

Financial Implications : E.g. What is the Impact on the Trust? Does it provide Value for Money? All costs should be clearly explained in the section below.

None identified

Overall Cost / Pressure: £ Overall Income: £

Additional Funding Required: £ Funding Already

Ring Fenced : £

Identified Risks:

None identified

Assurance to Board:

This paper provides assurance to the Trust Board of organisational compliance with external standards required by the Care Quality Commission, Department of Health (Information Governance), NHS Litigation Authority (NHSLA) and National Patient Safety Agency (NPSA).

Publish on Website : Yes No Private Business : Yes No

Report History Submitted to Date Brief Summary of Outcome


Integrated External Assurance Report (Care Quality Commission, Information Governance , NHS Litigation

Authority and National Patient Safety Agency ) Quarter 3: 01 October �± 31 December 2012

Agenda Item : 12 Reference : WCT12/13-234

Meeting Name : Trust Board Meeting Date : 4 March 2013

Lead Director : Lisa Cooper


��

��

��

��

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Wirral Community NHS Trust Integrated External Assurance Report

(Care Quality Commission, Information Governance , NHS Litigation Authority and National Patient Safety Agency )

Quarte r 3: 01 October �± 31 December 2012

Purpose

1. The purpose of this integrated report is to provide the Trust Board with external assurance from Care Quality Commission (CQC), Department of Health (Information Governance) (IGT), NHS Litigation Authority (NHSLA) and National Patient Safety Agency (NPSA) regarding the quality and safety of the services provided by Wirral Community NHS Trust for the reporting period 01 October �± 31 December 2012.

Introduction

2. The aim of this report is to support the Trust Board to:

Maintain an oversight of risks to demonstrating compliance with the required external standards (CQC, IGT, NHSLA, and NPSA).

Review risk estimates contained in the CQC Quality and Risk Profiles.

Challenge any unexpected trends or outliers in th�H��P�D�L�Q��³�G�D�V�K�E�R�D�U�G�´��L�Q�G�L�F�D�W�R�Us and Quality

and Risk Profiles.

Review Trust progress against the �'�H�S�D�U�W�P�H�Q�W�� R�I�� +�H�D�O�W�K�¶�V��Information Governance standards (Information Governance Toolkit version 10).

Review compliance with the NHSLA Risk Management Standards.

Care Quality Commission (CQC)

3. The CQC Quality and Risk Profile (Appendix 1) assist�¶s the Trust in assessing where risks lie within the organisation.

4. The information presented in the profiles is organised using the 16 CQC Essential Outcomes of Quality and Safety. To build each Quality and Risk Profile the CQC has sourced and analysed a range of data sources, both qualitative and quantitative from a variety of agencies (NPSA/NHSLA/Audits).

5. The CQC Risk Profile is an evolving document and will contain more information on compliance with each of the Essential Standards as the Trust develops. The current Quality and Risk Profile (Appendix 1) demonstrates that the Trust is complaint with the CQC Essential Standards for Quality and Safety.

6. The Board is asked to note the latest risk estimate in this report:

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(November 2012)

The risk profile for Outcome 9 (Management of Medicines), has moved from no data to low yellow

The risk profile for Outcome 11 (Safety, availability and suitability), has moved from no data to low yellow

The risk profile for Outcome 16 (Assessing and monitoring the quality or service provision), has moved from high green to low yellow. This is due to the number of alerts completed outside of the required time period:

�ƒ MDA/2012/073 deadline 05 November 2012 responded to 06 November 2012 �ƒ MDA/2012/066 deadline 17 October 2012 responded to 19 October 2012 �ƒ These delays were a result of a switch over to the DATIX electronic safety alert

system. A robust system had been put into place to prevent a reoccurrence of this late reporting.

7. The Board is asked to note that work is continuing to improve the following measures:

Trust commitment to work life balance Staff using flexible working options Staff having health and safety training in last 12 months Staff experiencing physical violence from staff in last 12 months Staff experiencing harassment or bullying or abuse from staff in the last 12 months Staff reporting good communication between senior managers and staff in last 12 months Staff having equality and diversity training in last 12 months Staff able to contribute to improvements at work in last 12 months

This data is all drawn from the national NHS staff survey.

8. The Director of HR & Corporate Affairs is the Executive Director with responsibility for this area of

improvement. 9. Action plans are in place to ensure improvements are made and these are monitored via the

Education and Workforce Committee.

10. Compliance with the CQC Essential Standards of Quality and Safety is monitored on a monthly basis via the Compliance Group, with quarterly update reports provided to the Quality and Governance Group.

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Information Governance Standards (IG T version 10)

11. Information Governance relates to the way in which organisations process or handles information. It covers personal information, e.g. that relating to patients/service users and employees and corporate information, e.g. financial and accounting records.

12. The Trust is required to declare level 2 compliance with IGT by 31 March 2103 with a final score of 75%.

13. The baseline assessment score submitted on 24 August 2012 was 65%. The interim assessment score submitted on 31 October 2012 was 68%.

14. The Director of Quality and Governance is the Director with responsibility for completion of IGT (v10).

15. Action plans to support compliance with IGT (v10) �D�U�H�� L�Q�F�O�X�G�H�G�� L�Q�� W�K�H�� 7�U�X�V�W�¶�V��Information

Governance Improvement Plan and are monitored via the Information Governance Group.

16. Compliance with IGT (v10) is monitored on a monthly basis via the Information Governance Group, with reports provided to the Quality and Governance Committee regarding the Baseline, Interim and Final submissions of IGT (v10).

NHS Litigation Authority (NHSLA) Risk Management Standards

17. The core of the NHSLA risk management programme is provided by their Risk Management Standards and assessments.

18. Healthcare organisations providing NHS care are regularly assessed against these risk

management standards which have been specifically developed to reflect issues which arise in the negligence claims reported to the NHSLA.

19. Wirral Community NHS Trust is required to demonstrate compliance with the Acute, Community or

Mental Health and Learning Disability Standards. 20. Final assessment by the NHSLA took place on 31 October 2012 and Wirral Community NHS Trust

was assessed as achieving Level 1.

21. The Director of Quality and Governance is the Director with responsibility for NHSLA Compliance. 22. Compliance with the NHSLA Risk management Standards is monitored on a monthly basis via the

Compliance Group, with quarterly update reports provided to the Quality and Governance Group. National Patient Safety Agency (NPSA)

23. The NPSA leads and contributes to improved and safe patient care by informing, supporting and influencing organisations and people working in the health sector.

24. From 01 June 2012 the key functions and expertise for patient safety developed by the NPSA

transferred to the NHS Commissioning Board Special Health Authority.

25. All incidents reported through Wirral Community NHS Trust Datix incident reporting system are uploaded on a monthly basis to the NPSA National Reporting and Learning System (NRLS).

26. The NPSA uses this data to produce an organisational patient safety incident report (Appendix 2).

27. The report is produced six monthly retrospectively. The current report is for the period 01 October 2011 �± 31 March 2012.

Page 72 of 307

28. The Board is asked to note that the NPSA has classified the Trust as a Primary Care Organisation with in-patient provision which appears to skew that data presented. The Director of Quality and Governance is in on-going discussion with the NPSA to change this classification.

29. Wirral Community Trust�¶s patient safety incident reporting data for the quarter 3 reporting period to the NPSA is below:

NPSA Uploaded Inciden ts October 2012 264 November 2012 99 December 2012 125 Total 488

30. It is not possible to compare �W�K�H�� 7�U�X�V�W�¶�V reporting to other Trusts within the NPSA report as the

Trust has no inpatient provision.

31. The Board is able to compare �W�K�H�� 7�U�X�V�W�¶�V top 10 incident types with other organisations in the report and the degree of harm caused.

Board Action

32. Wirral Community NHS Trust Board is asked to be assured of compliance with external assessment standards relating to the CQC, IGT, NHSLA and NPSA and of the processes in place to support the management of compliance against these standards.

Lisa Cooper Director of Quality & Governance

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Appendix 1 : Care Quality Commission Quality and Risk Profile (December 2012 )

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Appendix 2: Organisational Patient Safety Incident R eport

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Quality and Risk Profiles (QRP) enable CQC to assess where risks lie and prompt front line regulatoryactivity, such as site visits. They do not direct front line regulatory activity. They support teams to makerobust judgments about the quality of services. They are used alongside CQC's guidance aboutcompliance, including the judgment framework, and additional information known to inspectors

Please see associated guidance on QRPs for the NHS when using this QRP.

Quality and Risk Profile (QRP)to support monitoring of compliance

30/11/12

RY7

This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes,provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The

source should be acknowledged, by showing the publication title and © Care Quality Commission 2011.

© Care Quality Commission 2011

Produced: 30/11/12

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NHS Quality and Risk Profile (QRP)

Provider Code Provider Name Version Version Date

RY7 Wirral Community NHS Trust 4.6 30/11/12

Introduction

As part of CQC's monitoring of providers' compliance with the essential standards of quality andsafety, we need up-to-date, relevant information about each registered provider. The Quality andRisk Profile (QRP) is a tool that gathers all we know about a provider in one place.

How CQC uses the QRP

The QRP enables us to assess where risks lie and prompt any front line regulatory activity, suchas an inspection. QRPs support our teams to make robust judgments about the quality of services,and will develop over time as we gather more information about a provider.

It is important to stress that the items of data contained in the QRP do not constitute a new set ofrequirements, and that low risk estimates in a QRP do not guarantee compliance.

How providers and commissioners can use the QRP

QRPs are also an important tool for providers and commissioners �� both to support continuousmonitoring of compliance, by ensuring that everyone is working from the same information, and toimprove the provision and commissioning of care.

Providers should find the QRP useful in supporting their internal monitoring of quality, byidentifying areas of lower than average performance and, where necessary, taking action toaddress them. Commissioners (including, in time, the GP commissioning consortia) should alsofind the QRP invaluable in holding to account the providers that they commission services from,and in improving their commissioning for quality.

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About this document

This document presents the latest version of the QRP for this organisation. We create a newversion each time we update the data sources that underpin the profiles. NHS trusts have hadaccess to their own profiles from September 2010 and lead PCT commissioners have had accessto relevant trust profiles from October 2010.

The information in the QRP is organised by the 16 essential outcomes of quality and safety. Itincludes the following components:

· Summary information �� which includes background information about a provider orlocation.

· Information about outcomes �� this includes risk estimates for the essential standards ofquality and safety and the data items that underpin the estimates. They are organised atsection level (which group together a number of essential standards) and at individualoutcome level (for each of the 16 key essential standards).

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Guidance

We recommend that you refer to the following guidance documents when reviewing the QRP:

· Quality and Risk Profiles: How to use the QRP �� information about how to interpret theinformation within a QRP.

· Quality and Risk Profiles: Data sources �� a detailed listing of all of the quantitativedata sources within the QRP.

· Quality and Risk Profiles: Statistical guidance �� information about the statistical modeland analytic methods we use to calculate risk estimates in respect of the essentialstandards of quality and safety. It is a technical guide and assumes some statisticalknowledge.

Further help and support

If you have any queries or want to provide feedback about the contents of this QRP, pleasecontact our Customer Services team by phone or email:

Telephone: 03000 616161Email: [email protected]

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Table of Contents

Introduction.........................................................................................................................................2About this document...........................................................................................................................3Guidance............................................................................................................................................4Table of Contents...............................................................................................................................5

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Quality and Risk Profile (QRP)

The Care Quality Commission's quality and risk profiles (QRPs) bring together information about a care provider and provide an estimate of risk of non-compliance against each of the 16 essential standards of quality and safety.

They are primarily intended as a tool to support the day to day work of CQC's inspectors. Clicking the boxes below provides more detail concerning that aspect of the QRP.

Summary information Latest risk estimates Risk estimates over time

Provider type: NHS Healthcare Organisation

Date registered with CQC 01/04/2011

Number of regulated activities 5

Number of locations 10

Total no. of data items in QRP 103

No. of qualitative data items 8

No. of quantitative data Items 95 No

Dat

a

Insu

ffici

ent D

ata

Low

Gre

en

Hig

h G

reen

Low

Yel

low

Hig

h Y

ello

w

Low

Am

ber

Hig

h A

mbe

r

Low

Red

Hig

h R

ed

Num

ber

of O

utco

mes

0

1

2

3

4

5

6

7

8

Month of Refresh

May

-12

Jun-

12

Jul-1

2

Sep

-12

Oct

-12

Nov

-12

Num

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of O

utco

mes

0

2

4

6

8

10

12

14

16

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Summary information

This page details the general information we hold about a provider or location such as theactivities they are regulated to undertake. It also contains details of items that provide us withimportant details about the organisation which don't necessarily relate to one of the essentialstandards for quality and safety.

Locations and regulated activities

Locations Location Code Regulated Activity

Old Market House Hamilton Street Wirral CH41 5FL RY7Y3 Diagnostic and screening procedures

Family planning

Nursing care

Surgical procedures

Treatment of disease, disorder or injury

Oxton Emergency Dental Service 40 Balls Road Wirral CH43 5RE RY7X9 Diagnostic and screening procedures

Surgical procedures


Victoria Central Hospital Dental Service Victoria Central Hospital Wallasey CH44 5UF RY7X6 Diagnostic and screening procedures

Surgical procedures


Victoria Central Hospital Walk In Centre Victoria Central Hospital Wallasey CH44 5UF RY7X2 Diagnostic and screening procedures


Leasowe Primary Care Centre Hudson Road Wirral CH46 2QQ RY7X5 Diagnostic and screening procedures

Family planning

Surgical procedures


Arrowe Park Walk In Centre Arrowe Park Hospital Wirral CH49 5PE RY7X3 Diagnostic and screening procedures


Wirral Primary Care Assessment Unit Arrowe Park Hospital Wirral CH49 5PE RY7X4 Diagnostic and screening procedures

Family planning


Arrowe Park Dental Service General Anaesthetic Sedation Service Ground Floor Maxillofacial Department Wirral CH49 5PE RY7X7 Diagnostic and screening procedures

Surgical procedures


Eastham Walk In Centre Eastham Clinic Eastham, Wirral CH62 9AN RY7X1 Diagnostic and screening procedures


Clatterbridge Dental Service Clatterbridge Hospital Wirral CH63 4JY RY7X8 Diagnostic and screening procedures

Surgical procedures


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Background information

Item Ref Data Source Item Description Data Value

ASMS01 NHS Security Management Service (NHS SMS): ASMS contact list

Area Security Management Specialist

The Area Security Management Specialist for this organisation is John Mytton, who can be contacted at [email protected]

CDAO01Care Quality Commission: Register of accountable officers at 30th September 2012

Controlled Drugs Accountable Officer

This organisation's Controlled Drugs Accountable Officer is listed as Lisa Cooper

CSCR02 Primary Care Trusts Notifications received by CQC of organisations involved in Child Protection Serious Case Reviews

The Care Quality Commission was notified on 30/05/2012 by NHS Western Cheshire of a Child Protection Serious Case Review involving Wirral Community NHS Trust

OMBUD15

Parliamentary and Health Service Ombudsman: Review of complaint handling by the NHS in England 2011-12

Number of complaints received by the PHSO in 2011/12

This trust received 1 complaint in 2011/12

OMBUD16


Number of complaints resolved through intervention in 2011/12

The number of complaints resolved through intervention in 2011/12 was0

OMBUD17


Number of complaints accepted for investigation in 2011/12

The number of complaints accepted for investigation in 2011/12 was 0

OMBUD18


Number of investigated complaints reported on in 2011/12

The number of investigatedcomplaints reported on in 2011/12 was 0

SUB01 Care Quality Commission Registered service user band Whole Population (Data from Old Market House)

SUB01 Care Quality Commission Registered service user bandWhole Population (Data from Oxton Emergency Dental Service)

SUB01 Care Quality Commission Registered service user bandWhole Population (Data from Victoria Central Hospital Walk In Centre)

SUB01 Care Quality Commission Registered service user bandWhole Population (Data from Eastham Walk In Centre)

SUB01 Care Quality Commission Registered service user bandWhole Population (Data from Arrowe Park Walk In Centre)

SUB01 Care Quality Commission Registered service user bandWhole Population (Data from Wirral Primary Care Assessment Unit)

SUB01 Care Quality Commission Registered service user bandWhole Population (Data from Leasowe Primary Care Centre)

SUB01 Care Quality Commission Registered service user bandWhole Population (Data from Clatterbridge Dental Service)

SUB01 Care Quality Commission Registered service user band

Whole Population (Data from Arrowe Park Dental Service General Anaesthetic Sedation Service)

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Item Ref Data Source Item Description Data Value

SUB01 Care Quality Commission Registered service user bandWhole Population (Data from Victoria Central Hospital Dental Service)

SVTY01 Care Quality Commission Registered service typeDoctors treatment service (Data from Wirral Primary Care Assessment Unit)

SVTY01 Care Quality Commission Registered service type

Doctors consultation service (Data from Leasowe Primary Care Centre)


Doctors consultation service (Data from Wirral Primary Care Assessment Unit)

SVTY01 Care Quality Commission Registered service typeDiagnostic and/or screening service (Data from Old Market House)

SVTY01 Care Quality Commission Registered service type Dental service (Data from Old Market House)

SVTY01 Care Quality Commission Registered service typeDental service (Data from Oxton Emergency Dental Service)

SVTY01 Care Quality Commission Registered service typeUrgent care services (Data from Arrowe Park Walk In Centre)

SVTY01 Care Quality Commission Registered service typeUrgent care services (Data from Victoria Central Hospital Walk In Centre)

SVTY01 Care Quality Commission Registered service typeUrgent care services (Data from Eastham Walk In Centre)

SVTY01 Care Quality Commission Registered service typeDoctors treatment service (Data from Old Market House)

SVTY01 Care Quality Commission Registered service typeDoctors treatment service (Data from Leasowe Primary Care Centre)

SVTY01 Care Quality Commission Registered service typeDental service (Data from Clatterbridge Dental Service)


Dental service (Data from Arrowe Park Dental Service General Anaesthetic Sedation Service)

SVTY01 Care Quality Commission Registered service typeDental service (Data from Victoria Central Hospital Dental Service)

SVTY01 Care Quality Commission Registered service typeDental service (Data from Leasowe Primary Care Centre)


Community based servicesfor people with a learning disability (Data from Old Market House)

SVTY01 Care Quality Commission Registered service typeCommunity healthcare service (Data from Old Market House)

WRITCOM03 Information Centre: Data on Written Complaints in the NHS Written Complaints by Organisation in 2011/12

There were 62 written complaints made by (or on behalf of) patients about this organisation in 2011/12

WRITCOM04 Information Centre: Data on Written Complaints Upheld in the NHS

Written Complaints Upheld in 2011/1275.8% of written complaintsagainst this organisation were upheld in 2011/12

Information relevant to many outcomes

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Item Ref Data Source Item Description Data Value RAG

STAFFSURCTX02

Department of Health: Surveyof NHS Staff 2011/2012

Key Finding: Staff job satisfaction

This trust was worse than average when compared toother trusts for this key finding

AMBER

STAFFSURCTX07


Key Finding: Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month

This trust was worse than average when compared toother trusts for this key finding

AMBER

STAFFSURCTX01


Key Finding: Staff feeling satisfied with the quality of work and patient care they are able to deliver

This trust was better than average when compared toother trusts for this key finding.

GREEN

STAFFSURCTX03


Key Finding: Staff recommendation of the trust as a place to work or receive treatment


GREEN

STAFFSURCTX04


Key Finding: Percentage of staff experiencing discrimination at work in last 12 months

This trust was average when compared to other trusts for this key finding

GREEN

STAFFSURCTX05


Key Finding: Percentage of staff agreeing that their role makes a difference to patients


GREEN

STAFFSURCTX06

Department of Health: Surveyof NHS Staff 2011/2012 Key Finding: Effective team working


GREEN

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A key to the dials in QRP

Reducing risk of non-compliance Increasing risk of non-compliance

Some data is available, but itis not sufficient to calculate arisk estimate.

There is no data availableto inform this outcome orgroup of outcomes.

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Latest risk estimates

The Care Quality Commission's quality and risk profiles (QRPs) bring together information about a care provider and provide an estimate of risk of non-compliance against each of the 16 essential standards of quality and safety.

They are primarily intended as a tool to support the day to day work of CQC's inspectors. The table below lists the two most recent risk estimates for each of the 16 standards.

Section 1 - Involvement and information

Outcome Previous Risk Estimate Latest Risk Estimate Latest Data Summary

Outcome 1 (R17) Respecting and involving people who use services

Total number of data items: 4

Number of qualitative data items: 1Number of quantitative data items: 3

Outcome 2 (R18) Consent to care and treatment



Section 2 - Personalised care


Outcome 4 (R9) Care and welfare of people who use services



Outcome 5 (R14) Meeting nutritional needs



Outcome 6 (R24) Cooperating with other providers



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Latest risk estimates (continued)

Section 3 - Safeguarding and safety


Outcome 7 (R11) Safeguarding people who use services from abuse



Outcome 8 (R12) Cleanliness and infection control



Outcome 9 (R13) Management of medicines



Outcome 10 (R15) Safety and suitability of premises



Outcome 11 (R16) Safety, availability and suitability of equipment



Section 4 - Suitability of staffing


Outcome 12 (R21) Requirements relating to workers



Outcome 13 (R22) Staffing



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Outcome 14 (R23) Supporting staff



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Latest risk estimates (continued)

Section 5 - Quality and management


Outcome 16 (R10) Assessing and monitoring the quality of service provision



Outcome 17 (R19) Complaints



Outcome 21 (R20) Records



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Outcome 1 (R17) Respecting and involving people who use services

These are details of the individual pieces of data that contributes towards the risk estimate for the outcome.

Quantitative Items Qualitative Items

Much worse thanexpected

Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards

better than expected

Better thanexpected

Much better than expected

Negative Comment

Positive Comment

Number of Items 0 0 0 0 0 1 2 0 1

Item ID Description Data SourcePeriod Start

Period End

Comparison with Expected

Data Quality

Patient Experie

nceRelevance

-34 Intelligence from Compliance Review -

Care Quality Commission, Compliance Review

09/01/12 Positive comment High Low High

8041

The Trust ensures that patients are asked before their personal information is used outside of theircare and that patients decisions torestrict disclosure of this information are respected. -

Department of Health, Information Governance Toolkit

01/04/11 31/03/12 Much better than expected Low Med Med

8044

The Trust has appropriate procedures for recognising and responding to patient requests for access to their health records. -


01/04/11 31/03/12 Better than expected Low Med Med

12524The trust informs individuals aboutthe proposed uses of their personal information. -



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Outcome 2 (R18) Consent to care and treatment




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 0 0 0 0 0 0


Period End


Data Quality

Patient Experie

nceRelevance

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Outcome 4 (R9) Care and welfare of people who use services




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 0 1 0 1 0 2


Period End


Data Quality

Patient Experie

nceRelevance




-25 Intelligence from Children's Services Inspection -

Care Quality Commission/Ofsted, Children's Services Inspection reports

11/03/11 Positive comment Low High Med

12529

The trusts business continuity plans are up to date and tested forall critical information assets and service - specific measures are in place -


01/04/11 31/03/12 Tending towards better than expected Low Med Med

13016

Proportion of patients spending more than 4 hours in A&E from arrival to discharge, transfer or admission -

Department of Health, Aggregated weekly A&E SitReps

01/07/12 30/09/12 Much better than expected Med High High

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Outcome 5 (R14) Meeting nutritional needs




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 0 0 0 0 0 0


Period End


Data Quality

Patient Experie

nceRelevance

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Outcome 6 (R24) Cooperating with other providers




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 0 0 0 0 0 1


Period End


Data Quality

Patient Experie

nceRelevance

-25Intelligence from Children's Services Inspection -



Page 95 of 307




Outcome 7 (R11) Safeguarding people who use services from abuse




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 0 0 0 0 0 1


Period End


Data Quality

Patient Experie

nceRelevance




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Outcome 8 (R12) Cleanliness and infection control




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 1 0 1 0 0 1


Period End


Data Quality

Patient Experie

nceRelevance




11271 Key finding 19: Availability of handwashing materials -

Department of Health, Survey of NHS Staff

03/10/11 16/12/11 Similar to expected Med Low High

12798

Proportion of Health Care Workers with direct patient care that have been vaccinated againstseasonal influenza. -

Department of Health, HCW Seasonal Influenza Vaccination Programme

01/09/11 31/01/12 Better than expected Med Low Med

Page 97 of 307




Outcome 9 (R13) Management of medicines




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 5 0 0 0 0 0


Period End


Data Quality

Patient Experie

nceRelevance

12471

Does the NHS body have a fully accredited or nominated Local Security Management Specialist (LSMS) making adequate progress through the accreditationprocess? -

Counter Fraud and Security Management Service, SecurityManagement Service compliance data

01/04/12 30/06/12 Similar to expected Med Low Low

12472

Does the NHS body have a designated person to take a responsibility for security management matters as a Security Management Director (SMD) with voting board membership? -



12473

Does the NHS body have a designated person to promote security management measures as a Non - Executive Director (NED) with Specialist Responsibility for Security Issues?-



12474

Has the Local Security Management Specialist (LSMS) has submitted an annual workplanof projected work for that financial year? -



12475

Does the Local Security Management Specialist (LSMS) sufficiently attend the CFSMS quarterly regional LSMS meetings? -



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Outcome 10 (R15) Safety and suitability of premises




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 7 0 0 0 0 0


Period End


Data Quality

Patient Experie

nceRelevance

7547

Proportion of disabled car parking spaces available to total number of car parking spaces available foruse. -

Department of Health, Estates Return Information Collection (ERIC)

01/04/11 31/03/12 Similar to expected Med Med Med

7550

The organisation has a Board Approved Estates Development Strategy which is currently being implemented to improve the quality, efficiency and effectiveness of the estates and facilities services. -

Department of Health, Estates Return Information Collection (ERIC)

01/04/11 31/03/12 Similar to expected Med Low Med

12471




12472




12473




12474




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Item ID Description Data Source Period Start

Period End


Data Quality

Patient Experie

nceRelevance

12475




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Outcome 11 (R16) Safety, availability and suitability of equipment




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 5 0 0 0 0 0


Period End


Data Quality

Patient Experie

nceRelevance

12471




12472




12473




12474




12475




Page 101 of 307




Outcome 12 (R21) Requirements relating to workers




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 0 1 0 0 0 0


Period End


Data Quality

Patient Experie

nceRelevance

11290

Key finding 37: Staff believing trust provides equal opportunities for career progression or promotion -


03/10/11 16/12/11 Tending towards better than expected Med Low Low

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Outcome 13 (R22) Staffing




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 0 1 1 0 0 0


Period End


Data Quality

Patient Experie

nceRelevance

11260 Key finding 8: Staff working extra hours -



12798

Proportion of Health Care Workers with direct patient care that have been vaccinated againstseasonal influenza. -

Department of Health, HCW Seasonal Influenza Vaccination Programme

01/09/11 31/01/12 Better than expected Med Low Med

Page 103 of 307




Outcome 14 (R23) Supporting staff




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 7 13 7 0 1 0 1


Period End


Data Quality

Patient Experie

nceRelevance




11247Percentage of available working time lost due to sickness absence -

Information Centre for Health& Social Care (IC), NHS Staff Sickness Absence

01/06/12 30/06/12 Similar to expected Med Med Low

11254 Key finding 3: Staff feeling valued by their work colleagues -



11256Key finding 4: Quality of job design (clear content, feedback and staff involvement) -



11257 Key finding 5: Work pressure felt by staff -


03/10/11 16/12/11 Tending towards better than expected Med Low Med

11259 Key finding 7: Trust commitment to work-life balance -


03/10/11 16/12/11 Tending towards worse than expected Med Low Low

11261 Key finding 9: Staff using flexible working options -



11262Key finding 10: Staff feeling there are good opportunities to develop their potential at work -



11263Key finding 11: Staff receiving job-relevant training, learning or development in last 12 months -


03/10/11 16/12/11Tending towards better than expected Med Low Med

11264Key finding 12: Staff appraised in last 12 months -


03/10/11 16/12/11Tending towards better than expected

Med Low Med

11265Key finding 13: Staff having well structured appraisals in last 12 months -


03/10/11 16/12/11 Tending towards better than expected

Med Low Med

11266Key finding 14: Staff appraised with personal development plans in last 12 months -


03/10/11 16/12/11Tending towards better than expected Med Low Med

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Period End


Data Quality

Patient Experie

nceRelevance

11267 Key finding 15: Support from immediate managers -


03/10/11 16/12/11 Similar to expected Med Low High

11268Key finding 16: Staff having healthand safety training in last 12 months -


03/10/11 16/12/11 Tending towards worse than expected

Med Low Med

11270Key finding 18: Staff suffering work-related stress in last 12 months -



11276Key finding 24: Staff experiencing physical violence from staff in last 12 months -


03/10/11 16/12/11Tending towards worse than expected Med Low Low

11278Key finding 26: Staff experiencing harassment, bullying or abuse from staff in last 12 months -



11279

Key finding 27: Perceptions of effective action from employer towards violence and harassment -



11281Key finding 29: Staff feeling pressure to attend work when feeling unwell in last 3 months -



11282Key finding 30: Staff reporting good communication between senior management and staff -


03/10/11 16/12/11Tending towards worse than expected Med Low Low

11289Key finding 36: Staff having equality and diversity training in last 12 months -


03/10/11 16/12/11 Tending towards worse than expected Med Low Med

12471




12472




12473




12474




12475




Page 105 of 307





Period End


Data Quality

Patient Experie

nceRelevance

12517

Key finding 23: Staff experiencing physical violence from patients/relatives in last 12 months -



Med Low Low

12518

Key finding 25: Staff experiencing harassment, bullying or abuse from patients/relatives in last 12 months -



12523

The trust has in place InformationGovernance awareness and mandatory training procedures and all staff are appropriately trained -


01/04/11 31/03/12Much better than expected Low Med Med

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Outcome 16 (R10) Assessing and monitoring the quality of service provision




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 1 4 1 0 1 0 0


Period End


Data Quality

Patient Experie

nceRelevance

8254Consistency of reporting to the National Reporting Learning System (NRLS) -

National Patient Safety Agency (NPSA), NationalReporting Learning System(NRLS)


11273 Key finding 21: Staff reporting errors, near misses or incidents -



11274

Key finding 22: Fairness and effectiveness of procedures for reporting errors, near misses or incidents -



11284Key finding 31: Staff able to contribute towards improvements at work -



12533The trust has undertaken a multi-professional audit of clinical records across all specialties -


01/04/11 31/03/12Much better than expected

Low Low Low

12885

Proportion of alerts completed out of total number of alerts issued and due for completion within the time-period. (Report 2A) -

Medicines and Healthcare products Regulatory Agency (MHRA),Central Alerting System


12886

Proportion of alerts acknowledgedwithin deadline out of total numberof alerts issued to the organisation. (Report 2) -

Medicines and Healthcare products Regulatory Agency (MHRA),Central Alerting System


Page 107 of 307




Outcome 17 (R19) Complaints




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 0 0 0 0 0 0


Period End


Data Quality

Patient Experie

nceRelevance

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Outcome 21 (R20) Records




Worse than

expected

Tending towards

worse thanexpected

Similar to expected

Tending towards


Better thanexpected


Negative Comment

Positive Comment

Number of Items 0 0 0 1 5 16 11 0 1


Period End


Data Quality

Patient Experie

nceRelevance



11/03/11 Positive comment Low Med Med

8027

The Trust has adequate governance in place to support the current and evolving Information Governance agenda. -


01/04/11 31/03/12 Much better than expected Low Low Med

8028

How would you assess your Trust's ability to access expertise across the Confidentiality & Data Protection Assurance agenda? -



8029

How would you assess your Trust's ability to access expertise across the Information Security agenda? -


01/04/11 31/03/12 Better than expected Low Low Med

8030

How would you assess your Trust's ability to access expertise across the Information Quality andRecords Management Agenda? -


01/04/11 31/03/12Tending towards better than expected Low Low Med

8035

The Trust ensures that staff and those working on behalf of the Trust comply with the terms and conditions set out on the RA01 form. -


01/04/11 31/03/12 Much better than expected

Low Low Med

8036

The Trust ensures that it has formal contractual arrangements that include compliance with information governance requirements, with all contractors and support organisations. -



8037

The Trust ensures that all individuals carrying out work on behalf of the Trust have employment contracts which require compliance with information governance standards. -



Page 109 of 307





Period End


Data Quality

Patient Experie

nceRelevance

8040

The Trust has a Confidentiality Code of Conduct that provides staff with clear guidance on the disclosure of patient personal information. -


01/04/11 31/03/12Much better than expected Low Med Med

8045

The trust has established appropriate confidentiality audit procedures in line with the requirements of the National Programme for IT. -


01/04/11 31/03/12 Tending towards better than expected Low Low Med

8046

The trust has agreed protocols governing the sharing of patient-identifiable information with other organisations where this is required. -



8050

The Trust has a formal informationsecurity risk assessment and management programme that is implemented and regularly reviewed. -



8059

The Trust has procedures in placeto prevent information processing being interrupted or disrupted through equipment failure, environmental hazard or human error. -



8060

The Trust ensures that its Information systems are capable of the rapid detection, isolation and removal of malicious code and unauthorised mobile code. -



8062

The Trust has appropriate procedures in place to ensure thatcommunication networks under the Trust's control operate in a secure manner. -



8063

The Trust has appropriate procedures for ensuring that mobile computing and teleworkingare conducted in a secure manner. -


01/04/11 31/03/12Much better than expected Low Low Med

8065

The Trust has a strategy to ensurethe correct NHS number is recorded for each active patient and that it is used routinely in clinical communications. -


01/04/11 31/03/12 Much better than expected

Low High Med

8070

The Trust has processes and procedures in place to enable it to regularly monitor, measure and trace paper health records. -



8073

The Trust ensures that NHS standard definitions, values and validation programmes are incorporated within key systems and that local documentation is updated as standards develop. -


01/04/11 31/03/12Much better than expected Low Low Med

8078

The Trust has a documented procedure and a regular audit cycle for accuracy checks on patient data. -


01/04/11 31/03/12Tending towards better than expected Low Low Med

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Period End


Data Quality

Patient Experie

nceRelevance

8080

The Trust is involving clinical staff in validating information derived from the recording of clinical activity. -


01/04/11 31/03/12 Similar to expected Low Med Low

8086

The Trust has publicly available documented and implemented procedures to ensure compliance with the Freedom Of Information Act 2000. -


01/04/11 31/03/12 Better than expected Low Low Low

8087

The Trust has carried out an audit of its corporate records and information as part of the records lifecycle management strategy. -



Low Low Low

12525

New processes, services, information systems and assets that are developed and implemented comply with IG security accreditation, information quality, confidentiality and data protection requirements -


01/04/11 31/03/12 Better than expected Low Low High

12526

The trust has documented information security incident / event reporting and management procedures that are accessible to all staff -



12527

The trust has established business processes and procedures that satisfy the organisation's obligations as a Registration Authority -



12528

The trusts operating and application information systems support appropriate access control functionality and documented and managed accessrights are in place for all users of these systems -



12530

The trust ensures that all information assets that hold, or are, personal data are protected by appropriate organisational and technical measures -



12531

The trusts ensures that the confidentiality of service user information is protected through use of pseudonymisation and anonymisation techniques where appropriate -


01/04/11 31/03/12 Tending towards better than expected Low Med Med

12532

The trust has in place procedures to ensure the accuracy of service user information on all systems and /or records that support the provision of care -


01/04/11 31/03/12 Better than expected Low High Med

12533The trust has undertaken a multi-professional audit of clinical records across all specialties -



Page 111 of 307





Period End


Data Quality

Patient Experie

nceRelevance

12534

The trust has in place documented and implemented procedures for the effective management of corporate records-


01/04/11 31/03/12 Better than expected Low Low Low

12535

The trust has approved and comprehensive Information Governance Policies with associated strategies and/or improvement plans -


01/04/11 31/03/12 Much better than expected Low Low High

12538

All transfers of hardcopy/digital person identifiable and sensitive information have been identified, mapped and risk assessed; technical and organisational measures adequately secure these transfers -



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Risk estimates over time

The Care Quality Commission's quality and risk profiles (QRPs) bring together information about a care provider and provide an estimate of risk of non compliance against each of the 16 essential standards of quality and safety.

They are primarily intended as a tool to support the day to day work of CQC's inspectors. The graph and table below present the risk estimates from the six most recent QRP refreshes

Month of refresh

May-12 Jun-12 Jul-12 Sep-12 Oct-12 Nov-12

Num

ber

of O

utco

mes

0

2

4

6

8

10

12

14

16


High Red 0 0 0 0 0 0

Low Red 0 0 0 0 0 0

High Amber 0 0 0 0 0 0

Low Amber 0 0 0 0 0 0

High Yellow 0 0 0 0 1 0

Low Yellow 1 1 0 3 3 7

High Green 2 2 3 3 3 2

Low Green 3 3 3 4 4 4

Insufficient Data 4 4 4 0 0 0

No Data 6 6 6 6 5 3

Page 113 of 307




Risk estimates over time by section

The Care Quality Commission's quality and risk profiles (QRPs) bring together information about a care provider and provide an estimate of risk of non compliance against each of the 16 essential standards of quality and safety.

They are primarily intended as a tool to support the day to day work of CQC's inspectors. The graphs and tables below present the risk estimates by section from the six most recent QRP refreshes.

Section 1 �� Involvement and information


Outcome 1Outcome 2

Dial Key d

High Red .

Low Red .

High Amber .

Low Amber .

High Yellow .

Low Yellow .

High Green .

Low Green .

Insufficient Data .

No Data .

Outcome May-12 Jun-12 Jul-12 Sep-12 Oct-12 Nov-12

Outcome 1 Low Green Low Green Low Green Low Green Low Green Low Green

Outcome 2 No Data No Data No Data No Data No Data No Data

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Risk estimates over time by section (continued)

Section 2 - Personalised care


Outcome 4

Outcome 5

Outcome 6

Dial Key d

High Red .

Low Red .

High Amber .

Low Amber .

High Yellow .

Low Yellow .

High Green .

Low Green .

Insufficient Data .

No Data .




Outcome 6 Insufficient Data Insufficient Data Insufficient Data Low Yellow Low Yellow Low Yellow

Section 3 - Safeguarding and safety


Outcome 7

Outcome 8

Outcome 9

Outcome 10

Outcome 11

Dial Key d

High Red .

Low Red .

High Amber .

Low Amber .

High Yellow .

Low Yellow .

High Green .

Low Green .

Insufficient Data .

No Data .


Outcome 7 Insufficient Data Insufficient Data Insufficient Data Low Yellow Low Yellow Low Yellow

Outcome 8 Low Yellow Low Yellow High Green High Green High Green High Green

Outcome 9 No Data No Data No Data No Data No Data Low Yellow

Outcome 10 No Data No Data No Data No Data High Yellow Low Yellow

Outcome 11 No Data No Data No Data No Data No Data Low Yellow

Page 115 of 307




Risk estimates over time by section (continued)

Section 4 - Suitability of staffing


Outcome12

Outcome13

Outcome14

Dial Key d

High Red .

Low Red .

High Amber .

Low Amber .

High Yellow .

Low Yellow .

High Green .

Low Green .

Insufficient Data .

No Data .


Outcome 12 Insufficient Data Insufficient Data Insufficient Data High Green High Green High Green

Outcome 13 Insufficient Data Insufficient Data Insufficient Data Low Green Low Green Low Green

Outcome 14 High Green High Green High Green Low Yellow Low Yellow Low Yellow

Section 5 - Quality and management


Outcome16

Outcome17

Outcome21

Dial Key d

High Red .

Low Red .

High Amber .

Low Amber .

High Yellow .

Low Yellow .

High Green .

Low Green .

Insufficient Data .

No Data .


Outcome 16 High Green High Green High Green High Green High Green Low Yellow



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0 20 40 60 80 100 120 140 160

Highest 25% of reporters

Median = 43.7 incidents reported per 1,000 bed days

Lowest 25% of reporters

Middle 50% of reporters

Reported incidents per 1,000 bed days

75th Percentile 25th Percentile50th Percentile

**Your organisation's reporting rate = 0.0 incidents reported per 1,000 bed days

Organisation type: Primary care organisation with

Organisations that report more incidents usually have a better and more effective safety culture. You can't learn and improve if you don't know what the problems are.

Are you actively encouraging reporting of incidents?

The comparative reporting rate summary shown below provides an overview of incidents reported by your organisation to the National Reporting and Learning System (NRLS) between 1 October 2011 and 31 March 2012. 425 incidents were reported during this period.


Location: North West SHA

inpatient provision

Figure 1: Comparative reporting rate, per 1,000 bed days, for 19 primary care organisations with inpatient provision.

Organisation Patient Safety Incident Report

1 October 2011 to 31 March 2012

Your organisation reported incidents to the National Reporting and Learning System (NRLS) in 6 out of the 6 months between October 2011 and March 2012.

Report regularly: Incident reports should be submitted to the NRLS at least monthly.

Fifty percent of all incidents were submitted to the NRLS more than 33 days after the incident occurred. In your organisation, 50% of incidents were submitted more than 28 days after the incident occurred.

Report serious incidents quickly: It is vital that staff report serious safety risks promptly both locally and to the NRLS, so that lessons can be learned and action taken to prevent harm to others.

** The reporting rate for this organisation was set to zero, please see data handling notes at www.nrls.npsa.nhs.uk for further details.

How regularly do you report? Q3

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The NRLS helps the NHS to understand why, what and how patient safety incidents happen, learn from these experiences and take action to prevent future harm to patients. National data can be found at: www.nrls.npsa.nhs.uk/patient-safety-data/.

Further information for you

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

Patient accident

Implementation of care and ongoing monitoring / review

Treatment, procedure

Medication

Access, admission, transfer, discharge

Documentation (including records, identification)

Infrastructure (including staffing, facilities, environment)

Medical device / equipment

Consent, communication, confidentiality

Disruptive, aggressive behaviour

All others categories

28.0%

24.0%

10.1%

9.6%

8.2%

3.8%

3.3%

2.3%

2.1%

1.4%

7.3%

2.6%

54.1%

8.5%

7.5%

13.6%

0.5%

0.9%

4.5%

2.4%

0.0%

5.4%

What type of incidents are reported in your organisation?

Figure 2: Top 10 incident types

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

None

Low

Mod

erat

e

Sever

e

Death

50.3%

34.0%

14.8%

0.7% 0.1%

32.5%

24.9%

42.4%

0.2% 0.0%

Per cent of incidents

Per

cen

t of i

ncid

ents

occ

urrin

g

All primary care organisations with inpatient provision

Your organisation

Figure 3: Incidents reported by degree of harm for primary care organisations with inpatient provision

Do you understand harm?

Nationally, 68 per cent of incidents are reported as no harm, and just under 1 per cent as severe harm or death.

However, not all organisations apply the national coding of degree of harm in a consistent way, which can make comparison of harm profiles of organisations difficult.

Organisations should record actual harm to patients rather than potential degree of harm.

Degree of harm

Your organisation

All primary care organisations with inpatient provision

If your reporting profile looks different from similar organisations, this could reflect differences in reporting culture, the type of services provided or patients cared for. It could also be pointing you to high risk areas. The response system is more important than the reporting system.

None Low Moderate Severe Death138 106 180 1 0

Your figures:

Ref: Yourdata_RY7_September2012

Page 118 of 307

Commissioning for Quality and Innovation (CQUIN) Payment Framework

Self Care for Patients with Diabetes

Agenda Item : 13 Reference : WCT12/13-235

Meeting Name : Trust Board Meeting Date : 4 March 2013

Lead Director : Lisa Cooper


Link to Business Plan: Community contract and comply with national standards for quality


Yes No N/A


Yes No N/A

To Approve

To Note

To Assure

Financial Implications : E.g. What is the Impact on the Trust? Does it provide Value for Money? All costs should be clearly explained in the section below.

Achievement of this CQUIN will provide Wirral Community NHS Trust with £ £279,918 additional income via CQUIN payment framework.

Overall Cost / Pressure: £ Overall Income: £

Additional Funding Required: £ Funding Already

Ring Fenced : £

Identified Risks:


Assurance to Committee :

This presentation provides assurance to Wirral Community NHS Trust Board regarding the progress to date and achievement of the Self Care for Patients with Diabetes CQUIN.

Publish on Website : Yes No Private Business : Yes No

Report H istory Submitted to Date Brief Summary of Outcome

No history

��

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��

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Wirral Community NHS Trust Commissioning for Quality and Innovat ion (CQUIN) Payment Framework

Self Care for Patients with Diabetes Purpose

1. The purpose of this presentation is to update Wirral Community NHS Trust Board of the progress to date for the Self Care (Diabetes) CQUIN. The reporting period for this report and presentation is 01 April 2012 �± 31 December 2012.

Executive Summary

2. The CQUIN payment framework makes a proportion of providers' income conditional on quality and innovation and aims to support the delivery of high quality services.

3. The aim of this CQUIN is to promote discussion between health professionals and

individuals with Diabetes regarding what options there are for self care and to record the outcome of the care planning discussion (Appendix 1) .

4. The quality goals to be achieved are:-

Percentage increase in number of newly diagnosed adult patients with type two diabetes controlled by diet and medication taken on the caseload of the dietetic, podiatry or heart support community based teams with a written self-care plan.

Percentage increase in number of newly diagnosed adult patients with type two

diabetes controlled by diet and medication taken on the caseload of the dietetic, podiatry or heart support community based teams with a written self-care plan who achieve self-care goal by next appointment.

5. For the reporting period 01 April 2012 �± 31 December 2012 these quality goals were

achieved. Board Action

6. Wirral Community NHS Trust Board is asked to be assured of the progress to date with the achievement of the Self Care (Diabetes) CQUIN and that robust processes are in place to develop, test, implement and evaluate changes to achieve and maintain quality improvement in the organisation.


Page 120 of 307

Appendix 1: Self Care Plan The self-care plan card folds into the size of a credit card and can fit easily into wallet/purse

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SELF

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Page 123 of 307

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Page 135 of 307

Care Quality Commission

Proposed Changes to Registration Requirements

Agenda Item: 14 Reference: WCT12/13-236 Meeting Name: Trust Board Meeting Date: 4 March 2013 Lead Director: Lisa Cooper Job Title: Director of Quality and Governance



Yes No N/A


Yes No N/A

To Approve

To Note

To Assure



Overall Cost / Pressure: £ Overall Income: £ Additional Funding Required: £ Funding Already

Ring Fenced: £

Identified Risks:

Inaccurate registration with the Care Quality Commission can result in the organisation not being registered with Care Quality Commission which is a requirement of the Health and Social Care Act.

Assurance to Board: This paper provides assurance to Wirral Community NHS Trust Board of compliance with the Care Quality Commission registration requirements.


Report History Submitted to Date Brief Summary of Outcome

No history

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Wirral Community NHS Trust Care Quality Commission

Proposed Changes to Registration Requirements Purpose

1. The purpose of this paper is to seek approval from Wirral Community NHS Trust Board for changes to be made to the Trust’s registration submitted to the Care Quality Commission (CQC).

Executive Summary

2. The Care Quality Commission (CQC) is the regulator of health and adult social care in England and ensures that the care people receive meets Essential Standards of Quality and Safety and encourage ongoing improvements by those who provide or commission care.

3. Wirral Community NHS Trust is registered with the Care Quality Commission to carry out

the following regulated activities included in the Health and Social Care Act (Regulated Activities) Regulations 2009 as follows (Appendix 1):

• Treatment of disease, disorder or injury • Surgical Procedures • Diagnostic and screening procedures • Nursing care • Family planning service • Transport services, triage and medical advice provided remotely

4. The Trust currently declares compliance against each regulated activity at each location

(Appendix 1). A location is a place where regulated activities are provided and where a type of service is carried out. Wirral Community NHS Trust is registered to provide regulated activities from the following locations:

• Eastham Walk In Centre • Victoria Central Health Centre Walk In Centre • Arrowe Park Walk In Centre • All Day Health Centre • Primary Care Access Centre • Leasowe Primary Care Centre • Victoria Central Health Centre Dental Service • Arrowe Park Dental Service • Clatterbridge Dental Service • Oxton Emergency Dental Service • Old Market House • St Catherine’s Health Centre • Riverside Park Call Centre

5. Wirral Community NHS Trust has been registered without conditions with the Care Quality

Commission since 01 April 2011 and submitted a declaration of compliance against the Essential Standards of Quality and Safety to the Care Quality Commission.

6. In preparation for planned service developments and potential business opportunities it is proposed that the following changes (Appendix 2) are made to Wirral Community NHS Trust’s registration with the Care Quality Commission:

• Wirral Brook Advisory Centre and Wirral University Teaching Hospital (Sexual Health)

to be added as new locations for regulated activities: Diagnostics & Screening Procedures; Treatment of Disease, Disorder and Injury; Family Planning (Appendix 3).

Page 137 of 307

• Registered individual for the Trust to be amended from Lisa Cooper, Director of Quality & Governance to Simon Gilby, Chief Executive (Appendix 4).

Board Action

7. Wirral Community NHS Trust is asked to approve the proposed changes to the Trust’s registration with the Care Quality Commission.


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A

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Page 139 of 307

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Application to vary a condition of registration by adding a location: Application by a service provider 1 20120302 100453 v10.00

Application to vary a condition of registration by adding a location to an approved regulated activity Application by a service provider

Page 141 of 307


Applications under section 19 of the Health and Social Care Act 2008 This form must only be used by: Existing service providers to apply to vary a condition of registration by adding a location to an approved regulated activity. It must not be used by: • service providers (‘providers’) to apply for registration; • providers, to add or remove a regulated activity; • providers, to cancel their registration; • managers, for any purpose. Providers are registered to carry on regulated activities. Conditions of registration apply to each regulated activity separately. It is an offence under section 33 of the Health and Social Care Act 2008 for registered providers to fail to comply with any condition of registration attached to that regulated activity without reasonable cause. If you commit such an offence you could be prosecuted, and it could lead to the cancellation of your registration. There is more information about registration to carry on regulated activities and guidance on how to apply to remove or vary conditions of registration on our website: www.cqc.org.uk. Fees Before you complete Section 3 of this form, we strongly advise you to read the guidance about service types on page 13 of the Guidance about compliance: Essential standards of quality and safety. You should also read our guidance for providers about fees. Both of these documents are available on our website. You must check or tick the boxes for the services you will provide at each new location in this application. The service type(s) you select are used to calculate your annual fee. The service types you declare should match the description of your service in your Statement of Purpose. You can read more information about annual fees on our website.

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Confidential personal information Please make sure that your application does not include any confidential personal information about the people who will use your service or your staff. This includes any information that can identify a person. We will reject any application form that includes such information. Your registered managers All:

• partnerships;

• organisations (excluding NHS bodies in relation to healthcare regulated activities), and

• providers who are individuals who will not be in day-to-day charge of carrying on the regulated activity in this application

must have a registered manager in respect of the regulated activities carried on at each location. Managers can sometimes manage more than one regulated activity and/or location (see the relevant guidance on our website). If any location added in this application already exists, and:

• is being transferred or sold to you by an existing registered provider, and

• has an existing registered manager who you intend to employ to manage the same regulated activity(s) with the same conditions on their registration at the same location(s), then

the manager(s) does not have to submit the normal full application forms. They can use a fast track process that uses a shorter form to both cancel their existing registration and apply for new registration with you as provider. If you intend any registered managers already working for you to manage the regulated activity(s) at the location(s) in this application, they must submit forms to add (and if necessary remove) regulated activities and/or locations, as needed. All other managers must submit a full new registered manager application form, even if they are registered as a manager elsewhere or have been in the past. Managers should download and fill in the appropriate forms. Our website form finder pages will help them to do so. You must submit all required manager’s form(s) with this application. Filling in this form You must provide an answer to every field marked with an asterisk (*). Other fields are optional but if you have the information please provide it. We will have to reject an incomplete application and return it. You must complete the declaration of compliance section for each regulated activity at each location where it will be provided. You can fill in and submit this form either on paper or on a computer. If you fill it in on a computer you can submit it by attaching it to an email – this is the best way to make applications to the Care Quality Commission.

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This form has been prepared as a ‘protected’ Word document. This means that if you use a computer you can easily move from answer to answer using your ‘tab’, down arrow, and ‘page down’ keys. You can also click from answer to answer using a mouse. You can put an ‘X’ in checkboxes using your space bar or mouse when the box is highlighted. If you need to make a change to your answers, use your ‘page up’ key, up arrow key, or mouse to go backwards. You can’t use the spell check function or format text with bullet points in protected Word documents. If you want to check spelling or use bullet points, type or paste your text into a blank new document, correct any spelling errors, add any bullet points, and then copy and paste it into the appropriate part of your application form. You can fill in this form on a computer using ‘Microsoft Word’ or ‘Open Office’. Open Office is a free programme you can download from www.openoffice.org. The spaces for answers expand while you type, if needed. If you are filling in this form on paper and need more space to answer any questions, please submit additional clearly numbered sheets and mark them with the question number from this form. Additional sections If you are applying to add more than one location you need to download additional location section(s), fill them in and submit them with this form (see the information about this at the relevant point in this form). If you are submitting this application by email, you must attach all of the required additional sections and manager application forms, as well as this main form, to your application email. If you are submitting your application by post you must enclose all of the forms in your application envelope. If you do not attach or enclose all the additional location sections required we will have to return your application.

Contents Page Statement on Data Protection Act 1998 5 Section 1: Application details 6 Section 2: Statement of purpose 8 Section 3: New location details 9 Section 4: Details of any non-compliance and action plan for a location 18 Section 5: Application declaration 21 How to submit this application 23

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Statement on the Data Protection Act 1998 You must sign the statement below. If you don’t, we will have to return your application. I understand that the Care Quality Commission will use the information provided on this form (including personal data), and other relevant information that we obtain or receive, for the purposes of performing our regulatory functions. In particular, this information will be used to make regulatory judgements in relation to the registration of individuals and providers and in relation to monitoring compliance with relevant regulations. This includes publication of:

• A register of providers

• Conditions of registration

• Reports relating to compliance with regulations

• Other information that we may publish to assist the public in understanding the quality of services and the regulatory actions of the Commission.

Information (including personal data) may also be shared with other regulators and public bodies where necessary or expedient to assist in the exercise of public functions. Registration application forms are processed on behalf of CQC. Personal data is processed in accordance with the Data Protection Act 1998. If you are submitting this form electronically we will accept a typed-in name as your signature.

*Applicant’s signature Lisa Cooper

*Applicant’s name Lisa Cooper

*Date (dd/mm/yy) 25/02/13

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Section 1: Application details

1.1 Details of the service provider

*CQC service provider ID† RY7

*Name Wirral Community NHS Trust

Name you trade under if this is different to the above

*Business address line 1 Old Market House

*Postcode CH41 5AL

Email address [email protected]

Telephone 0151 651 - 3939

† Your provider ID is found at the top right-hand side of your certificate of registration. You have already supplied CQC with an address for service of documents in accordance with Sections 93 and 94 of the Health and Social Care Act 2008. If your current address for service of documents is not an email address: The Care Quality Commission has decided that its preferred method of sending statutory notices, including Notices of Proposal and Decision about applications, is by email. Email ensures fast and efficient delivery of important information. By submitting this application, you are confirming your willingness for us to use the email address shown at 1.1 above for service of documents and for sending all other correspondence to you in relation to this application and all existing regulated activities. If you do not want to receive documents by email, please check or tick the box below. We will not share this email address with anyone else.

I do NOT wish to receive notices and other documents from CQC by email

It is vital that the postal and email addresses you supply are valid, clear and accurate, and that you keep us up to date with any changes. You can supply alternative contact details at 1.2 below if this would be helpful. We will only use these details while processing this application. We will not use this address for service of documents or other correspondence.

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1.2 Alternative correspondence address

Name

Address line 1

Address line 2

Town/city

County

Postcode

Email address

Telephone

*1.3 Purchase or transfer of existing service(s)

Is this application the result of the sale or transfer of service(s) for which a different provider is already registered under the Health and Social Care Act 2008?

Yes

No

*1.4 Start date

It takes CQC up to eight weeks to process most applications, sometimes more. You must not begin to provide regulated activity at any new location until you are registered to do so.

*When would you like to begin carrying on regulated activity at the location(s) in this application (dd/mm/yy)? 01/04/13

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Section 2: Statement of purpose The law says that your statement of purpose must be up to date. You are changing the details of your registration, so you must send us an amended copy of the statement of purpose that covers the locations in this application. If you don’t, we will have to return your application. Every service provider is required by law to have a statement of purpose for each of the regulated activities they carry on. If you carry on more than one regulated activity you can either have separate statements or combine them into one. By law, the statement of purpose must include: 1. The aims and objectives of the service provider in carrying on the regulated activity. 2. The kinds of services provided for the purposes of carrying on the regulated activity and

the range of service users’ needs that those services are intended to meet. 3. The full name of the service provider and of any registered manager, together with their

business address, telephone number and, where available, email addresses. 4. The legal status of the service provider. 5. Details of the locations at which the services provided for the purposes of the regulated

activity are carried on. Statements of purpose should provide: • An overview of the regulated activity and the locations you carry it on from. • Information that is detailed enough to enable us to understand what happens at each

location, so that we can assess the risks involved. For example, instead of saying “we carry out surgery at hospital x” the statement should say what type of surgery is provided and who it is for: ''The surgery we carry out at xx includes specialist surgery such as cardiac and neurosurgery. Cardiac surgery is provided for children as well as adults”.

• The lines of accountability for the regulated activity and contact details for the registered

person(s) carrying on and managing it.

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Section 3: New location details

*3.1 The new location(s) and the regulated activities and service types provided at them

Please provide details about the regulated activities and services you will provide at the new locations if your application is approved. We need information about services because your registration fees are based on the services you provide. If you are applying to add more than one new location, you can download additional copies for Section 3 from the website page where you found this form. If you are filling in this form on paper and need extra space, please add extra numbered sheets as needed and mark them with the question number from this form. If you don’t give us full information about all of your new locations we will have to return your application.

The information below is for new location number: 1 of a total of: 2 new locations where I / we will carry

on regulated activity

*Name of location Wirral Brook Advisory Centre (Sexual Health Services)

CQC location No. (if already registered by existing provider)

*Location address line 1 14 Whetstone Lane

*Location address line 2

*Town / city Birkenhead *County Merseyside

*Postcode CH41 2QR *Telephone 0151 670 0177

*No of places or beds (not NHS) Fax

Email

Website www.brook.org.uk

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*3.2 The regulated activities you will carry on at this location

Please check / tick the regulated activities you want to carry on at this location. These are defined in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, Schedule 1. You can only carry on activities at this location that you are already registered to provide. A different form is available if you want to register to provide a new regulated activity.

Personal care

Accommodation for persons who require nursing or personal care

(Please also see section 3.8 below if you have checked / ticked this activity)

Accommodation for persons who require treatment for substance misuse

Accommodation and nursing or personal care in the further education sector


Assessment or medical treatment for persons detained under the 1983 Act (The Mental Health Act 1983)

Surgical procedures

Diagnostic and screening procedures

Management of supply of blood and blood derived products etc

Transport services, triage and medical advice provided remotely

Maternity and midwifery services

Termination of pregnancies

Services in slimming clinics

Nursing care

Family planning service

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Day-to-day management of regulated activity at this location

Where required, you must submit applications for registration from managers in respect of this location, including from existing managers to continue their registration to manage it under your registration, with this application.

The services provided at this location

Please check or tick in the sections below to show the service types that will be provided at this location. Before you continue, we strongly advise you to read the guidance about service types on page 13 of the Guidance about compliance: Essential standards of quality and safety, and our guidance for providers about the fees scheme. The service types you select may decide your annual fee once you are registered. It is therefore important that you only select the service types that apply to this location. Please work through the questions in order, starting with question 3.4.

*3.3 Prison Healthcare Services (PHS)

Do you ONLY provide Prison Healthcare Services (PHS)?

Yes

No

If YES now go to question 3.7 If NO now go to question 3.4

*3.4 Acute Services (ACS)

Do you ONLY provide Acute Services (ACS)?

Yes

No


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*3.5 Further information about Acute Services (only)

Only answer this question if you checked or ticked that you provide ONLY Acute Services (ACS) in question 3.5. Where you provide ONLY ONE of the activities below at this location and it is the sole or main activity carried on there, please check or tick it. If you provide other services at this location as well as Acute Services (ACS), or more than one of the activities below at this location, do not complete this section. Instead, go to question 3.6.

(a) dental treatment carried out under general anaesthesia

(b) obstetric services and, in connection with childbirth, medical services

(c) the termination of pregnancies

(d) cosmetic surgery

(e) haemodialysis or peritoneal dialysis

(f) refractive eye surgery involving use of a laser or intense pulsed light

(g) activities to which the service type DSS (diagnostics and or screening services) applies

(h) procedures carried out under anaesthesia or intravenous sedation where those procedures are associated with in vitro fertilisation or assisted conception

*3.6 Acute services together with other services

Do you provide Acute Services with overnight beds?

Yes

No

Now go to question 3.8

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*3.7 Service types

Please check or tick ALL of the service types that will be provided at this location

Acute services (ACS)

Prison healthcare services (PHS)

Hospital services for people with mental health needs, learning disabilities, and problems with substance misuse (MLS)

Hospice services (HPS)

Rehabilitation services (RHS)

Long-term conditions services (LTC)

Residential substance misuse treatment and/or rehabilitation service (RSM)

Hyperbaric chamber (HBC)

Community healthcare service (CHC)

CHC: Please also tick if you are a nursing agency only

Community-based services for people with mental health needs (MHC)

Community-based services for people with a learning disability (LDC)

Community-based services for people who misuse substances (SMC)

Urgent care services (UCS)

Doctors consultation service (DCS)

Doctors treatment service (DTS)

Mobile doctor service (MBS)

Dental service (DEN)

Diagnostic and or screening service (DSS)

Care home service without nursing (CHS)

(Please also see section 3.8 below if you have checked / ticked this service type)

Care home service with nursing (CHN)

Specialist college service (SPC)

Domiciliary care service (DCC)

Supported living service (SLS)

Shared Lives (SHL)

Extra Care housing services (EXC)

Ambulance service (AMB)

Remote clinical advice service (RCA)

Blood and Transplant service (BTS)

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*3.8 Accommodation for persons who require nursing or personal care

Only answer this question if you checked / ticked: ‘Accommodation for persons who require nursing or personal care’ as a regulated activity you intend to provide at this location at section 3.2 above, AND

‘Care home service without nursing (CHS)’ at section 3.8 above (If this does not apply to you please go straight to section 3.10 below).

The regulated activity(s) you selected at 3.2 above and the service types you selected at 3.8 above show that you are not applying to provide nursing care at this location. Please tick below to confirm that you are agreeing in writing to a condition of registration that says “The provider must not provide nursing care under the ‘accommodation for persons who require nursing or personal care’ regulated activity at this location”.

I agree to the condition shown above

*3.9 Service user bands

Please check or tick all of the descriptions / service user bands for the people that will use this location. If you will provide a service to everyone you can check or tick ‘The whole population’.

Adults aged 18-65 Adults aged 65+

Mental health Sensory impairment

Physical disability People detained under the Mental Health Act

Dementia People who misuse drugs or alcohol

People with an eating disorder Learning difficulties or autistic spectrum disorder

Children aged 0 – 3 years Children aged 4-12 Children aged 13-18

The whole population Other (please specify below)

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*3.10 Location readiness Is the location ready to meet the needs of the people who will use it?

Yes

No

If ‘No’, please describe any building work, conversions, or planning applications that are currently underway, and the date this is expected to be finished.

Yes this location is currently registered with the CQC via Wirral Brook Advisory Centre registration

*3.11 Accessibility

Is the location accessible to all people, including people with disabilities?

Yes

No

If ‘No’, please describe in what way it is not accessible, why it is impossible to make the premises fully accessible, and the reasonable adjustments that you have been able to make.

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*3.12 Other businesses at the location

Are any other businesses carried on or going to be carried on at the location?

Yes

No

If ‘Yes’, please describe the other business carried on and the impact this has or will have on people.

*3.13 Security of records

Will records be kept in a way that meets the requirements of the Data Protection Act 1998?

Yes

No

If ‘No’, please describe how records are processed and stored.

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*3.14 Security of the premises

Are the premises secure and do they prevent access to people with no reason to be there?

Yes

No

If ‘No’, please describe how people are kept safe and their privacy and property protected.

3.15 Declaration of compliance at this location Before you make this declaration, you must refer to the Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which set out the legal obligations on a person or organisation registered to provide regulated activities. You must be sure you have understood their requirements. The Guidance about Compliance for providers shows how the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 regulation can be met. You may decide to comply with relevant regulations in another way. If you do, you should be ready to explain how and why you comply with the relevant regulation(s), and provide evidence where necessary about how your alternative approach will be just as or more effective in making sure that the regulations are met. You must have regard to Regulation 26(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which requires registered persons to have regard to the Guidance about Compliance. You must declare compliance with all of the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to the regulated activities you will carry on at this location. We declare that we will comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 for each regulated activity that we will carry on at this location:

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Yes

No

If you answered ‘YES’ to 3.14 above for all the locations you are applying to add to your registration please now go to Section 5 If you answered ‘NO’ to 3.14 above you must now complete a Section 4 declaration and action plan in relation to this location.

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Section 4: Details of non-compliance and action plan for a location You must tell us which essential standards regulation(s) you will not be compliant with at relevant locations. You must also submit an action plan to show how you will achieve compliance with the relevant regulation(s). If you will be non-compliant at more than one new location, you must download additional copies of Section 4 from the website page where you found this form. If you are filling in this form on paper and need extra space, please add extra numbered sheets as needed, mark them with the question number from this form. You must quote the location number you gave the relevant location in Section 3 so that we can match the right information with the relevant location. If you don’t submit an action plan for the locations that will be non-compliant, we will have to return your application.

The information below is for location number: 1 in this application to add locations

*Location details * CQC Location ID (where relevant)

* Location name

* First line of the address

* Postcode

Regulation Check / tick if you will NOT be compliant with this regulation

17: Respecting and involving service users (Outcome 1) 18. Consent to care and treatment (Outcome 2) 9. Care and welfare of service users (Outcome 4) 14. Meeting nutritional needs (Outcome 5) 24. Cooperating with other providers (Outcome 6) 11. Safeguarding service users from abuse (Outcome 7) 12. Cleanliness and infection control (Outcome 8) 13. Management of medicines (Outcome 9) 15. Safety and suitability of premises (Outcome 10) 16. Safety, availability and suitability of equipment (Outcome 11) 21. Requirements relating to workers (Outcome 12) 22. Staffing (Outcome 13) 23. Supporting workers (Outcome 14) 10. Assessing and monitoring the quality of service provision (Outcome 16) 19. Complaints (Outcome 17) 20. Records (Outcome 21)

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Compliance action plan

You must submit separate Section 4 action plans telling us how you will become compliant with each relevant Essential standards regulation for each regulated activity at each location where you have declared non-compliance. If you are non-compliant with more than one regulation or at more than one location, you must download additional action plan sections from the website page where you found this form. If you are filling in this form on paper and need extra space, please add extra numbered sheets as needed, mark them with the question number from this form. Please give each action plan a number so that we know you have sent us an action plan for each regulation and each location where you have declared that you are not compliant. If you don’t include all the action plans required, we will have to return your application.

This is action plan number: 1

This action plan relates to achieving and maintaining compliance with:

Regulation (number and title):

At (Location Name)

CQC Location ID:

*4.1 Describe how you are not compliant with this regulation

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*4.2 Describe how you will achieve compliance with this regulation

*4.3 When will you achieve compliance with this regulation (dd/mm/yy)?

*4.4 Describe how you will maintain compliance with this regulation

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Section 5: Application declaration This declaration must be signed by the applicant. If the applicant is an organisation, the person who signs must be duly authorised to do so. If the applicant is a partnership, it must be signed by each member of the partnership. I/we hereby declare that the information detailed in this application is true and accurate. I/we understand that Section 37 of the Health and Social Care Act 2008 makes it an offence to knowingly make a statement which is false or misleading in a material respect in this application, or in any of the documents submitted with this application. I/we understand that to knowingly make a false declaration could render me/us liable to prosecution and could lead to the refusal of this application. I/we understand that it is my/our responsibility to inform the Care Quality Commission of any information that is relevant to my /our application and which may not have been requested, and to update this information accordingly. I/we have kept a copy of all the information submitted in my/our application for my records. I/we understand that if I/we change my/our postal or email address for service of notices and delivery of other documents I/we must notify CQC using the specific form for this purpose. In making this application for registration with the Care Quality Commission, I/we agree to comply with the Health and Social Care Act 2008 and associated regulations. Once registered, I/we agree to inform the Care Quality Commission if there are any changes to compliance with the regulations I/we understand that non-compliance with the relevant legislation could lead to the refusal of this application or cancellation of registration if I/we do not comply once registered. I/we agree that the information contained in this form may be used as conditions of registration.

Please check or tick this box to confirm that the appropriate number of registered managers have also submitted applications for registration (where applicable)

IF YOU ARE AN NHS TRUST (only), please check or tick this box to confirm that the trust’s board members have seen and agreed the contents of this application

*Applicant’s signature Simon Gilby

*Applicant’s name Simon Gilby

*Date (dd/mm/yy) 25/02/13 If you are submitting this form electronically, we will accept a typed-in name as your signature. There is space for more partners to sign on the next page.

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Partnerships ONLY – additional partners: Each member of a partnership must sign this declaration. If they do not do so, we will have to return your application.

*Partner’s signature

*Partner’s name

*Date (dd/mm/yy)


* Partner’s name

*Date (dd/mm/yy)


* Partner’s name

*Date (dd/mm/yy)


* Partner’s name

*Date (dd/mm/yy)


* Partner’s name

*Date (dd/mm/yy)


* Partner’s name

*Date (dd/mm/yy)

If you are submitting this form electronically we will accept typed-in names as signatures.

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How to submit this application and accompanying documents Please submit this application to the Care Quality Commission, making sure that all required additional forms and documents are included. The checklist below lists the documents that you need to include with your application: Form or document Done

Statement of purpose A template is available on our website for you to use if you prefer

Additional location sections as needed

Number of locations I/we are applying to add to my/our registration

2

Number of additional location sections submitted with this application

1

Registered manager application forms (where applicable)

Number of locations in this application that will have a registered manager

0

Number of manager application forms of all types submitted with this application:

0

Additional declaration of non compliance and action plan sections as needed

Number of declarations of non compliance with a regulation at any location in this application

0

Number of additional non-compliance sections submitted with this application

0

Number of additional action plan sections submitted with this application

0

Where to send your application: You should, wherever possible, email completed form(s) and accompanying documents to: [email protected] You must attach all forms and documents to the same email. If you are unable to send us your application by email, you should print and sign your completed form(s) and post them with any accompanying documents in the same envelope to: CQC HSCA Registrations Citygate Gallowgate Newcastle upon Tyne NE1 4PA If you do not submit all required forms and information your application will be returned to you. You can read more information on our website www.cqc.org.uk or call our National Customer Service Centre on 03000 616161. © Care Quality Commission 2012

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20120314 800021 v2 00 Add a location – Action plan – application from a provider 1

Additional section 3: New location details

*3.1 The new location(s) and the regulated activities and service types provided at them

Please provide details about the regulated activities and services you will provide at the location shown below. We need information about services because your registration fees are based on the services you provide. If you are filling in this form on paper and need extra space, please add extra numbered sheets as needed and mark them with the question number from this form. If you don’t give us full information about all of your new locations we will have to return your application.

The information below is for new location number: 2 of a total of: 2 new locations where I / we will carry

on regulated activity

*Name of location Wirral University Teaching Hospital Sexual Health Services

CQC location No. (if already registered by existing provider)

*Location address line 1 Arrowe Park Hospital

*Location address line 2 Arrowe Park Road

*Town/ city Upton *County Merseyside

*Postcode CH49 5PE *Telephone 0151 678 5111

*No of places or beds (not NHS) 0 Fax

Email

Website

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*3.2 The regulated activities you will carry on at this location

Please check / tick the regulated activities you want to carry on at this location. These are defined in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, Schedule 1. You can only carry on activities at this location that you are already registered to provide with this kind of application.

Personal care

Accommodation for persons who require nursing or personal care

(Please also see section 3.8 below if you have checked / ticked this activity)

Accommodation for persons who require treatment for substance misuse

Accommodation for persons who require nursing or personal care in the FE sector


Assessment or medical treatment for persons detained under the 1983 Act (The Mental Health Act 1983)

Surgical procedures

Diagnostic and screening procedures

Management of supply of blood and blood derived products etc

Transport services, triage and medical advice provided remotely

Maternity and midwifery services

Termination of pregnancies

Services in slimming clinics

Nursing care

Family planning service

If you are a partnership or an organisation you do not need to answer question 3.3. Please move straight on to ‘The services provided at this location’ below.

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Day-to-day management of regulated activity at this location

Where required, applications for registration from managers in respect of this location, including from existing managers to continue their registration to manage it under your registration, must be submitted with this application.

*The services provided at this location

Please check or tick in the sections below to show the service types that will be provided at this location. Before you continue you are strongly advised to read the guidance about service types on page 13 of the Guidance about compliance: Essential standards of quality and safety, and our guidance for providers about the fees scheme. The service types you select may decide your annual fee once you are registered. It is therefore important that you only select the service types that apply to this location. Please work through the questions in order, starting with question 3.4

*3.3 Prison Healthcare Services (PHS)

Yes

No


*3.4 Acute Services (ACS)

Yes

No


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*3.5 Further information about Acute Services (only)

Only answer this question if you checked or ticked that you provide ONLY Acute Services (ACS) in question 3.5. Where you provide ONLY ONE of the activities below at this location and it is the sole or main activity carried on there, please check or tick it. If you provide other services at this location as well as Acute Services (ACS), or more than one of the activities below at this location, do not complete this section. Instead, go to question 3.7.

(a) dental treatment carried out under general anaesthesia

(b) obstetric services and, in connection with childbirth, medical services

(c) the termination of pregnancies

(d) cosmetic surgery

(e) haemodialysis or peritoneal dialysis

(f) refractive eye surgery involving use of a laser or intense pulsed light

(g) activities to which the service type DSS (diagnostics and or screening services) applies

(h) procedures carried out under anaesthesia or intravenous sedation where those procedures are associated with in vitro fertilisation or assisted conception

*3.6 Acute Services together with other services

Do you provide Acute Services with overnight beds?

Yes

No

Now go to question 3.8

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*3.7 Service types

Please check or tick ALL of the service types that will be provided at this location

Acute services (ACS)

Prison healthcare services (PHS)

Hospital services for people with mental health needs, learning disabilities, and problems with substance misuse (MLS)

Hospice services (HPS)

Rehabilitation services (RHS)

Long-term conditions services (LTC)

Residential substance misuse treatment and/or rehabilitation service (RSM)

Hyperbaric chamber (HBC)

Community healthcare service (CHC)

CHC: Please also tick if you are a nursing agency only

Community-based services for people with mental health needs (MHC)

Community-based services for people with a learning disability (LDC)

Community-based services for people who misuse substances (SMC)

Urgent care services (UCS)

Doctors consultation service (DCS)

Doctors treatment service (DTS)

Mobile doctor service (MBS)

Dental service (DEN)

Diagnostic and or screening service (DSS)

Care home service without nursing (CHS)

(Please also see section 3.8 below if you have checked / ticked this service type)

Care home service with nursing (CHN)

Specialist college service (SPC)

Domiciliary care service (DCC)

Supported living service (SLS)

Shared Lives (SHL)

Extra Care housing services (EXC)

Ambulance service (AMB)

Remote clinical advice service (RCA)

Blood and Transplant service (BTS)

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*3.8 Accommodation for persons who require nursing or personal care

Only answer this question if you checked / ticked: ‘Accommodation for persons who require nursing or personal care’ as a regulated activity you intend to provide at this location at section 3.2 above, AND

‘Care home service without nursing (CHS)’ at section 3.8 above (If this does not apply to you please go straight to section 3.10 below)

The regulated activity(s) you selected at 3.2 above and the service types you selected at 3.8 above show that you are not applying to provide nursing care at this location. Please tick below to confirm that you are agreeing in writing to a condition of registration that says

‘The provider must not provide nursing care under the accommodation for persons who require nursing or personal care regulated activity at this location’.

I agree to the condition shown above

*3.9 Service user bands

Please check or tick all of the descriptions / service user bands for the people that will use this location. If you will provide a service to everyone you can check or tick ‘The whole population’.

Adults aged 18-65 Adults aged 65+

Mental health Sensory impairment

Physical disability People detained under the Mental Health Act

Dementia People who misuse drugs or alcohol

People with an eating disorder Learning difficulties or autistic spectrum disorder

Children aged 0 – 3 years Children aged 4-12 Children aged 13-18

The whole population Other (please specify below)

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*3.10 Location readiness Is the location ready to meet the needs of the people who will use it?

Yes

No

If ‘No’, please describe any building work, conversions, or planning applications that are currently under way, and the date this is expected to be finished.

This location is currently registered with the CQC under Wirral University Teaching Hospitals NHS Foundation Trust registration

*3.11 Accessibility

Is the location accessible to all people, including people with disabilities?

Yes

No

If ‘No’, please describe in what way it does not do so, why it is impossible to make the premises fully accessible, and the reasonable adjustments that you have been able to make.

C

QC

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atio

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CT

12/1

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6

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*3.12 Other businesses at the location

Are any other businesses carried on or going to be carried on at the location?

Yes

No

If ‘Yes’, please describe the other business carried on and the impact this has or will have on people.

This is also an acute hospital Trust and is registered with the CQC via Wirral University Teaching Hospitals NHS Foundation Trust

*3.13 Security of records

Will records be kept in a way that meets the requirements of the Data Protection Act 1998?

Yes

No

If ‘No’, please describe how records are processed and stored.

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*3.14 Security of the premises

The premises are secure and do not allow access to people with no reason to be there?

Yes

No

If ‘No’, please describe how people are kept safe and their privacy and property protected.

3.15 Declaration of compliance at this location Before you make this declaration you must refer to the Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which set out the legal obligations on a person or organisation registered to provide regulated activities. You must be sure you have understood their requirements. The Guidance about Compliance for providers shows how the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 regulation can be met. You may decide to comply with relevant regulations in another way. If you do you should be ready to explain how and why you comply with the relevant regulation(s), and provide evidence where necessary about how your alternative approach will be just as or more effective in making sure that the regulations are met. You must have regard to Regulation 26(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which requires registered persons to have regard to the Guidance about Compliance. You must declare compliance with all of the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to the regulated activities you will carry on at this location. We declare that we will comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 for each regulated activity that we will carry on at this location:

Yes

No

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If you answered ‘NO’ to 3.14 above you must now complete declaration of non compliance and action plan sections as needed. You can download an additional non compliance and action plan sections from the web page where you found the main form application form to add a location.

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PoC1B 100091 4.00 Notification: Changes affecting a service provider or manager 1

Statutory notification Regulation 15, Care Quality Commission (Registration) Regulations 2009 Changes affecting a provider or manager

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Provider’s notification reference:

Statutory and other notifications about changes affecting the provider or manager of a regulated activity

Care Quality Commission (Registration) Regulations 2009, Regulation 15 Health and Social Care Act 2008, section 94

Please read our guidance for providers about making statutory notifications and our Guidance about compliance: Essential standards of quality and safety for detailed advice on how and when to make statutory notifications, available at www.cqc.org.uk. You must complete section 1 for all notifications of changes, and then (as needed): Section 2 for changes of service provider Section 3 for changes of registered manager Section 4 for changes to a registered individual’s name Section 5 for changes to the membership of a partnership Section 6 for changes to an organisation’s name or address Section 7 to notify the appointment of a new nominated individual Section 8 for changes to an organisation’s officers or directors Section 9 to notify the appointment of a trustee in bankruptcy, a receiver, or liquidator Section 10 to notify the sequestration of a registered person’s estate Section 11 to provide any other relevant information

Non-statutory notifications NHS bodies should use section 8 to tell us about changes of chief executive. All providers can use this form to tell us about changes to your main contact telephone number. Please enter dates in the format dd/mm/yyyy

Please email the completed form back to: [email protected]

Page 177 of 307


1. Provider and relevant location details

Provider: Wirral Community NHS Trust

CQC provider number: RY7

Form filled in by: Lisa Cooper Date submitted 26/02/2013

Contact for more information (where different):

Telephone number: 0151 643-5316

Email address: [email protected] Where the change affects just one location:

Location name and address:

Location postcode:

CQC location number: Where the change affects regulated activities carried on at more than one location:

The change affects all locations where regulated activities are carried on

The change affects some locations where regulated activities are carried on

List the affected locations and their CQC location numbers in section 11

2. Change of service provider A new provider will carry on, or is carrying on, regulated activity(ies) previously carried on by the provider shown in section 1

The provider shown in section 1 plans to stop, or has stopped, carrying on regulated activity(ies)

3. Changes involving a registered manager A new manager will manage, or is managing, regulated activity(ies) carried on by the provider shown in section 1

A registered manager plans to stop, or has stopped, managing regulated activity(ies) carried on by the provider shown in section 1

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4. Change of name of a registered person who is an individual

I am:

A service provider who is an individual

A member of a partnership

A registered manager

My date of birth:

My previous name:

My new name:

5. Changes to a registered provider that is a partnership

A new partner is joining the partnership

The new partner’s name

A partner is leaving the partnership

The leaving partner’s name

6. Changes of name and address of a registered provider that is an organisation

The organisation is changing or has changed its name

The organisation’s new name:

The business address of the organisation is changing or has changed

The new address:

The new postcode:

Page 179 of 307


7 An organisation appoints a new nominated individual

The organisation is appointing or has appointed a new nominated individual (NI)

New NI’s name: Simon Gilby

The NI’s date of birth: 15/10/1957

The NI’s business address: Old Market House Hamilton Street Birkenhead

The NI’s postcode: CH41 5AL

The NI’s job title: Chief Executive

The NI’s email address: [email protected]

The NI’s telephone number: 0151 651 - 3939

The regulated activity or activities they act as NI for:

Diagnostic and Screening Procedures Family Planning Nursing Care Surgical Procedures Transport Services, triage and medical advice provided remotely Treatment of disease, disorder or injury

8 Changes to an organisation’s directors or similar officers

(use this section to tell us about changes to an NHS body’s chief executive)

A new director, secretary or other officer is joining or has joined an organisation

The new person’s name:

The new person’s role:

The new person is now the organisation’s primary contact for CQC

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Where the new person is the primary contact for CQC

The primary contact’s business address: OId Market House Hamilton Street Birkenhead

The primary contact’s postcode: CH41 5AL

The primary contact’s email address: [email protected]

Where a director or similar officer leaves an organisation

A director, secretary or other similar officer is leaving or has left an organisation

The leaving person’s name: Lisa Cooper

The leaving person’s role: Director of Quality & Governance

9 The appointment of a trustee in bankruptcy, a receiver, liquidator or provisional

liquidator A trustee in bankruptcy has been appointed for an individual who is a registered service provider

A trustee in bankruptcy has been appointed for a member of the partnership

The affected partner’s name:

A receiver, liquidator or provisional liquidator has been appointed for a partnership or organisation

10 The sequestration of an individual’s estate

The estate of a registered provider who is an individual has been sequestrated

The estate of a member of a partnership has been sequestrated

The affected partner’s name:

11 Any further relevant information

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Continue on additional numbered sheets if necessary. Box will expand if used on a computer. Email back to: [email protected] For CQC use only, please leave blank

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Quality Handover Document




Job Title: Director of Quality & Governance



Yes No N/A


Yes No N/A

To Approve

To Note

To Assure


None identified





n/a

Identified Risks:

Potential risks identified are contained within document

Assurance to Board:

This document provides assurance to the Trust Board of the provision of a Quality Handover document to NHS Cheshire, Warrington and Wirral, which meets all requirements stated by NHS Cheshire, Warrington and Wirral Cluster.


Report History


No history

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Quality Handover Document

Purpose

1. The purpose of this document is to provide assurance to the Trust Board of the provision of a Quality Handover document to NHS Cheshire, Warrington and Wirral. This document meets the requirements stated by NHS Cheshire, Warrington and Wirral for a quality handover document

Executive Summary 2. Implementation of the Health and Social Care Act 2012 requires a transition programme for the

NHS. As SHAs and PCTs will be abolished from 01 April 2013 their existing functions will need to be separated out and handed over to the organisations that will form the new landscape e.g. Clinical Commissioning Groups.

3. As part of the process all Trusts are required to submit a Quality Handover document to their

respective PCT Clusters for handover to Clinical Commissioning Groups from 01 April 2013.

4. Wirral Community NHS Trust submitted its Quality Handover document to NHS Cheshire, Warrington and Wirral by 31 January 2013.

5. The Director of Quality & Governance and Director of Operations & Performance/Executive

Nurse presented the Trust’s Quality Handover document to representative from NHS Cheshire, Warrington and Wirral, Wirral Clinical Commissioning Group, Local Area Team of National Commissioning Board and Local Authority Public Health on 15 February 2013.

6. Wirral Community NHS Trust’s Quality Handover document is contained within Appendix One.

Board Action

7. Wirral Community NHS Trust Board is asked to approve the Trust’s Quality Handover document for NHS Cheshire, Warrington and Wirral.

Lisa Cooper Director of Quality & Governance

Page 184 of 307

NHS Cheshire, Warrington and Wirral Quality Handover Document March 2013

Provider Organisation Responsible PCT Responsible CCG

Wirral Community NHS Trust NHS Wirral Wirral Clinical Commissioning Group

Area(s) of Concern

• Named GP post • Community CQUIN for 2013/14

Summary of Risk/Actions to mitigate

Discussions with NCB regarding recruitment to Named GP post Discussions with CCG progressing regarding CQUIN aiming for agreement mid February 2013 Areas of Good Practice

• Quality Strategy/Dashboards • Leadership/Patient Experience walk rounds

Francis 1

Recommendations implemented (yes): Yes Board assurances received (yes): Previous NHS Wirral Board

Outstanding issues and mitigation – All actions completed

Actions in anticipation of Francis 2

Actions documented (no): Trust Board reviewed report on 11 February 2013

Plans or further action: Action plan in process of development. Report to Trust Board March 2013. Report shared with all staff via email/staff intranet. Plans to hold events for staff throughout March/April 2013 to discuss report. Review of Patient Experience Service and Complaints underway to ensure implementation of specific Francis recommendations. Airedale / Norris Inquiry

Recommendations implemented (yes/no):Those relevant to CT - Yes

Outstanding issues and mitigation: None Identified. QGAF assessment and score (3.5) demonstrates quality & governance systems and processes in place which address recommendations above report Winterbourne View Report

Recommendations implemented (yes/no): Those relevant to CT - Yes

Outstanding issues and mitigation None Identified. QGAF assessment and score (3.5) demonstrates quality & governance systems and processes in place which address recommendations above report Patient Survey

Recommendations Actions identified (yes/no): None identified

Board received (yes/no): Board receives quarterly information relating to internal patient survey of services and also annual Patient Experience report.

NHS Choice Website

Issues identified (yes/no): none identified Plan to address in place (yes/no): n/a

Friends and Family Test

State of Readiness reviewed (yes/no): Yes commenced collection September 2012 Proposed local CQUIN for 2013/14

Sign Off – Lead Commissioner Date

Test

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Sign Off – Associate Commissioner (s) Date

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lity

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Page 187 of 307

Wir

ral C

omm

unit

y N

HS

Trus

t Q

ualit

y Pr

ofile

Ch

air:

Fran

ces

Stre

et

Chie

f Exe

cuti

ve:

Si

mon

Gilb

y

Qua

lity

Lead

:

Lisa

Coo

per

Gov

erna

nce

Arr

ange

men

ts

for Q

ualit

y:

Evid

ence

hel

d by

Wir

ral C

T: R

isk

Man

agem

ent S

trat

egy;

Com

mitt

ee te

rms

of re

fere

nce;

min

utes

of B

oard

/com

mitt

ees/

grou

ps.

Qua

lity

&

Gov

erna

nce

Ass

essm

ent F

ram

ewor

k (s

core

3.5

) – e

xter

nal a

sses

smen

t as

requ

irem

ent o

f Fou

ndat

ion

Trus

t pro

cess

Gen

eral

Des

crip

tion

: Lo

go

Wir

ral C

omm

unity

NH

S Tr

ust i

s lo

cate

d in

Wir

ral i

n N

orth

Wes

t Eng

land

, on

the

Wir

ral

Peni

nsul

a. W

e pr

ovid

e a

rang

e of

hig

h qu

ality

com

mun

ity b

ased

hea

lthca

re s

ervi

ces

to th

e po

pula

tion

of W

irra

l and

som

e ar

eas

of C

hesh

ire

and

Live

rpoo

l; 30

9,37

2 re

side

nts

acro

ss

145,

000

hous

ehol

ds b

ased

in 2

011

cens

us p

roje

ctio

ns.

We

have

no

inpa

tient

bed

s.

Our

ser

vice

s ar

e gr

oupe

d in

to fi

ve c

ore

divi

sion

s:

Nur

sing

, Th

erap

ies,

Pr

imar

y Ca

re

Unp

lann

ed C

are

Life

styl

e se

rvic

es

The

maj

ority

of o

ur s

ervi

ces

are

prov

ided

thro

ugh

bloc

k co

ntra

cts

with

NH

S W

irra

l, w

ith a

3

year

con

trac

t sig

ned

with

the

PCT

(Pri

mar

y Ca

re T

rust

) end

ing

in M

arch

201

4. T

he T

rust

has

a

plan

ned

net s

urpl

us fo

r 201

2/13

of £

0.9m

and

em

ploy

ed 1

,077

WTE

(who

le ti

me

equi

vale

nts)

as

at 3

1st M

arch

201

2. W

e ha

ve n

o in

patie

nt b

eds,

wit

h 85

% o

f the

wor

kfor

ce in

pat

ient

-fac

ing

role

s, d

eliv

ered

thro

ugh

com

mun

ity b

ased

ser

vice

s. W

e ar

e re

gist

ered

with

the

CQC

(Car

e Q

ualit

y Co

mm

issi

on) w

ith n

o co

nditi

ons.

Page 188 of 307

Wir

ral C

omm

unit

y N

HS

Trus

t Q

ualit

y Pr

ofile

O

ur s

trat

egic

vis

ion

is c

lear

, and

we

belie

ve b

ecom

ing

an F

T (F

ound

atio

n Tr

ust)

will

hel

p us

to

achi

eve

it. W

e w

ant:

“t

o be

the

outs

tand

ing

prov

ider

of h

igh

qual

ity,

inte

grat

ed c

omm

unity

car

e se

rvic

es to

Wirr

al

and

beyo

nd”.

Serv

ices

Pr

ovid

ed:

Com

mun

ity S

ervi

ces

incl

udin

g:

Nur

sing

: Com

mun

ity N

ursi

ng/H

ealth

Vis

iting

/Spe

cial

ist N

ursi

ng

Ther

apie

s: P

hysi

othe

rapy

/Occ

upat

iona

l The

rapy

/Die

tetic

s/Sp

eech

& L

angu

age

Ther

apy/

Podi

atry

/Equ

ipm

ent &

Whe

elch

air S

ervi

ces

Life

styl

e: P

ublic

Hea

lth S

ervi

ces/

Sexu

al H

ealth

Ser

vice

s U

npla

nned

Car

e: W

alk

in C

entr

es/P

hleb

otom

y Pr

imar

y Ca

re: G

P O

ut o

f Hou

rs/A

ll D

ay H

ealth

Cen

tre/

Prim

ary

Care

Ass

essm

ent U

nit/

Leas

owe

Prim

ary

Care

Cen

tre/

Com

mun

ity D

enta

l Ser

vice

Sa

fegu

ardi

ng: L

ooke

d af

ter C

hild

ren/

Nam

ed G

P In

fect

ion

Prev

enti

on &

Con

trol

for N

HS

Wir

ral/

Loca

l Aut

hori

ty P

ublic

Hea

lth

Le

ad

Com

mis

sion

er:

Wir

ral C

linic

al C

omm

issi

onin

g G

roup

Repo

rtin

g to

G

over

ning

Bod

y:

• N

ot fo

rmal

ly W

irra

l CT

gove

rnin

g bo

dy

Com

mun

ity C

ontr

act 2

012/

13

Mon

thly

con

trac

t mon

itori

ng m

eetin

gs

Evid

ence

hel

d by

CCG

(Ann

a Ro

bert

s): C

opy

of C

omm

unity

Con

trac

t; M

inut

es o

f mee

tings

; ter

ms

of re

fere

nce

Qua

lity

Han

dove

r W

CT

12/1

3-23

7

Page 189 of 307

Wir

ral C

omm

unit

y N

HS

Trus

t Q

ualit

y Pr

ofile

20

11/1

2 Q

ualit

y A

ccou

nt:

Subm

itted

to N

HS

Choi

ces

by 3

0 Ju

ne 2

012

Ev

iden

ce h

eld

by W

irra

l CT:

Cop

y of

Qua

lity

Acc

ount

201

1/12

2011

/12

Qua

lity

Sche

dule

:

CQU

IN s

chem

es a

gree

d w

ith c

omm

issi

oner

s an

d on

trac

k as

per

qua

lity

sche

dule

Ev

iden

ce h

eld

by C

CG (A

nna

Robe

rts)

: Cop

y of

mon

thly

con

trac

t qua

lity

repo

rts;

min

utes

of m

eetin

gs

Evid

ence

hel

d by

Wir

ral C

T: C

opy

of m

onth

ly in

tern

al q

ualit

y re

port

s; m

inut

es o

f mee

tings

W

orkf

orce

Is

sues

incl

: •

Staf

f to

bed

rati

o •

Staf

f Sur

veys

Benc

hmar

king

aga

inst

oth

er N

HS

Org

anis

atio

ns li

mite

d du

e to

pro

file

of W

irra

l CT

(no

in-p

atie

nt p

rovi

sion

). S

taff

exp

erie

nce

mea

sure

d vi

a na

tiona

l st

aff s

urve

y an

d m

onth

ly m

ini e

lect

roni

c su

rvey

s on

spe

cific

topi

cs e

.g. a

bsen

ce, I

nfor

mat

ion

Gov

erna

nce,

repo

rtin

g co

ncer

ns

Evid

ence

hel

d by

Wir

ral C

T: Q

uart

erly

Boa

rd A

ssur

ance

repo

rt; M

inut

es o

f Boa

rd m

eetin

gs; S

taff

Sur

vey

repo

rt; r

esul

ts o

f min

i sur

veys

Qua

lity

Impa

ct

of C

ost

Impr

ovem

ent

Plan

All

CIP

plan

s qu

ality

impa

ct a

sses

sed

and

appr

oved

by

Dir

ecto

r of Q

ualit

y &

Gov

erna

nce/

Med

ical

Dir

ecto

r Ev

iden

ce h

eld

by W

irra

l CT:

Exa

mpl

es o

f pro

cess

of C

IP s

chem

es a

nd q

ualit

y im

pact

ass

essm

ents

; Boa

rd re

port

s

Qua

lity

Info

rmat

ion:

Spec

ific

Elem

ents

O

verv

iew

O

utst

andi

ng Is

sues

RA

G

Safe

ty

SUI

2011

/12:

8 re

port

ed

2012

– to

dat

e: 4

repo

rted

Ev

iden

ce h

eld

by W

irra

l CT:

Inci

dent

repo

rtin

g po

licy;

exa

mpl

es o

f SU

I re

port

ing;

RCA

revi

ews

and

actio

ns p

lans

; min

utes

of m

eetin

gs; q

ualit

y re

port

s

Non

e Id

entif

ied

Gre

en

Safe

guar

ding

Lead

Exe

cutiv

e D

irec

tor

of Q

ualit

y &

Gov

erna

nce

Part

icip

ate

in a

ll m

ultia

genc

y re

view

s as

requ

ired

Qua

rter

ly u

pdat

es p

rese

nted

to T

rust

Boa

rd a

nd C

omm

issi

oner

s Ev

iden

ce h

eld

by W

irra

l CT:

Qua

rter

ly u

pdat

es to

Tru

st B

oard

and

Co

mm

issi

oner

s; R

CA a

ctio

ns p

lans

and

repo

rts;

Pol

icie

s an

d Pr

oced

ures

Non

e Id

entif

ied

Gre

en

Page 190 of 307

Wir

ral C

omm

unit

y N

HS

Trus

t Q

ualit

y Pr

ofile

Infe

ctio

n,

Prev

entio

n &

Co

ntro

l

Dir

ecto

r of I

nfec

tion

Prev

entio

n &

Con

trol

is D

irec

tor

of Q

ualit

y &

G

over

nanc

e Tr

ust a

gree

d ta

rget

of Z

ero

tole

ranc

e of

avo

idab

le h

ealth

care

infe

ctio

ns

attr

ibut

able

to th

e se

rvic

es p

rovi

ded

by W

irra

l Com

mun

ity N

HS

Trus

t. N

o H

CAI a

ttri

buta

ble

to W

CT to

dat

e Q

uart

erly

upd

ates

pre

sent

ed to

Tru

st B

oard

and

Com

mis

sion

ers

Evid

ence

hel

d by

Wir

ral C

T: Q

uart

erly

upd

ates

to T

rust

Boa

rd a

nd

Com

mis

sion

ers;

Qua

lity

repo

rt a

nd m

inut

es; a

nnua

l wor

k pl

an; p

olic

ies

and

proc

edur

es

Non

e Id

entif

ied

Gre

en

Nev

er E

vent

s N

one

repo

rted

. Ze

ro ta

rget

agr

eed

by T

rust

Boa

rd a

nd re

port

ed m

onth

ly

to T

rust

Boa

rd a

s pe

r DH

Gui

danc

e Ev

iden

ce h

eld

by W

irra

l CT:

Mon

thly

qua

lity

repo

rt; m

inut

es o

f mee

tings

Non

e Id

entif

ied

Gre

en

<Add

mor

e as

re

quir

ed>

Effe

ctiv

enes

s

Aud

it

Clin

ical

aud

it pr

ogra

mm

e ag

reed

with

com

mis

sion

ers

and

on tr

ack

for

2012

/13

Evid

ence

hel

d by

Wir

ral C

T: A

ppro

ved

clin

ical

aud

it pl

an 2

012/

13; a

udit

polic

y; m

inut

es/t

erm

s of

refe

renc

e au

dit c

omm

ittee

; six

mon

thly

upd

ate

to a

udit

com

mitt

ee/c

omm

issi

oner

s

Non

e Id

entif

ied

Gre

en

Com

plia

nce

with

N

ICE

Gui

danc

e

Com

plia

nce

decl

ared

with

NIC

E gu

idan

ce a

pplic

able

to W

irra

l Com

mun

ity

NH

S Tr

ust

Evid

ence

hel

d by

Wir

ral C

T: P

olic

y fo

r NIC

E gu

idan

ce; m

inut

es o

f re

leva

nt g

roup

and

term

s of

refe

renc

e

Non

e Id

entif

ied

Gre

en

CQC

Com

plia

nce

Com

plia

nce

with

CQ

C de

clar

ed

Insp

ectio

n of

Com

mun

ity D

enta

l Ser

vice

s in

Dec

embe

r 201

1 –

full

com

plia

nce

give

n In

spec

tion

of W

alk

in C

entr

e, A

rrow

e Pa

rk in

Nov

embe

r 201

2 –

full

com

plia

nce

give

n

Non

e Id

entif

ied

Gre

en

Qua

lity

Han

dove

r W

CT

12/1

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Page 191 of 307

Wir

ral C

omm

unit

y N

HS

Trus

t Q

ualit

y Pr

ofile

Re

gist

ratio

n re

view

ed a

nd u

pdat

ed to

incl

ude

•

New

pre

mis

es -

St C

athe

rine

’s H

ealth

Cen

tre

and

Gre

enw

ay

Road

, Com

mun

ity D

enta

l Sur

gery

(rep

laci

ng D

enta

l Em

erge

ncy

Out

of H

ours

at O

xton

Clin

ic) S

ite in

spec

tions

con

duct

ed b

y CQ

C an

d pr

emis

es a

sses

sed

as s

uita

ble

for t

he d

eliv

ery

of s

ervi

ces.

•

New

act

ivity

of T

rans

port

ser

vice

s, tr

iage

and

adv

ice

prov

ided

re

mot

ely

Evid

ence

hel

d by

Wir

ral C

T: D

enta

l and

WIC

APH

CQ

C re

port

; Tru

st

Boar

d pa

pers

. Reg

istr

atio

n A

ppro

val T

rust

Boa

rd P

aper

and

CQ

C re

gist

ratio

n do

cum

ents

. Q

uart

erly

Rep

ort t

o Q

ualit

y an

d G

over

nanc

e on

CQ

C co

mpl

ianc

e.

CQU

IN

CQU

IN s

chem

es a

gree

d w

ith c

omm

issi

oner

s an

d on

trac

k as

per

con

trac

t.

Evid

ence

hel

d by

CCG

(Ann

a Ro

bert

s): C

opy

of m

onth

ly c

ontr

act q

ualit

y re

port

s; m

inut

es o

f mee

tings

Ev

iden

ce h

eld

by W

irra

l CT:

Cop

y of

mon

thly

qua

lity

repo

rts;

min

utes

of

mee

tings

Non

e Id

entif

ied

Gre

en

Pres

sure

Ulc

ers

Repo

rt a

ll gr

ade

2 an

d ab

ove

pres

sure

ulc

ers

via

inci

dent

repo

rtin

g sy

stem

. Re

port

gra

de 3

and

abo

ve p

ress

ure

ulce

rs a

s SU

I to

SHA

. All

pres

sure

ulc

ers

subj

ect t

o re

cord

s re

view

to d

eter

min

e if

avoi

dabl

e/un

avoi

dabl

e. A

ll gr

ade

4 pr

essu

re u

lcer

s su

bjec

t to

RCA

. M

onth

ly re

port

ing

on p

ress

ure

ulce

rs in

qua

lity

repo

rt.

Part

of j

oint

w

orki

ng w

ith W

UTH

and

saf

ety

ther

mom

eter

/exp

ress

initi

ativ

e.

Evid

ence

hel

d by

Wir

ral C

T: C

opy

of m

onth

ly q

ualit

y re

port

s; m

inut

es o

f m

eetin

gs; R

CA re

port

s/ac

tion

plan

s/SU

I rep

ortin

g

Non

e Id

entif

ied

Gre

en

Page 192 of 307

Pa

tien

t Exp

erie

nce

Inpa

tient

Sur

veys

No

inpa

tient

s U

nder

take

pat

ient

sur

veys

dur

ing

2012

/13

a 10

0 re

spon

ses

per s

ervi

ce

will

be

colle

cted

D

ata

pres

ente

d to

Tru

st B

oard

and

Com

mis

sion

ers

Evid

ence

hel

d by

Wir

ral C

T: A

nnua

l Pat

ient

Exp

erie

nce

repo

rt; P

atie

nt

Expe

rien

ce S

trat

egy;

qua

rter

ly u

pdat

es to

com

mitt

ees;

qua

lity

repo

rt

http

://w

ww

.nhs

.uk/

serv

ices

/tru

sts/

over

view

/def

aultv

iew

.asp

x?id

=296

73

Non

e Id

entif

ied

Gre

en

Com

plai

nts

Colle

ct d

ata

rega

rdin

g co

mpl

aint

s/co

mm

ents

/con

cern

s/co

mpl

imen

ts.

Ev

iden

ce h

eld

by W

irra

l CT:

Com

plai

nt A

nnua

l Rep

ort;

Mon

thly

repo

rt

and

min

utes

, Qua

rter

ly Q

ualit

y Re

port

and

min

utes

, Mon

thly

ass

uran

ces

to T

rust

Boa

rd, A

nnua

l ext

erna

l aud

it (M

IAA

), Bi

-ann

ual i

nter

nal

com

plia

nce

audi

t, Co

mpl

aint

Pol

icy.

Non

e Id

entif

ied

Gre

en

Mix

ed S

ex

Acc

omm

odat

ion

App

licab

le to

Pri

mar

y Ca

re A

sses

smen

t Uni

t – fu

ll co

mpl

ianc

e de

clar

ed

with

elim

inat

ion

of m

ixed

sex

acc

omm

odat

ion;

no

brea

ches

to d

ate

Evid

ence

hel

d by

CCG

(Ann

a Ro

bert

s): M

onth

ly s

ubm

issi

ons

to C

CG

decl

arin

g co

mpl

ianc

e

Non

e Id

entif

ied

Gre

en

2 ar

eas

of

posi

tive

chan

ge

(for

mal

/inf

orm

al)

Intr

oduc

tion

of p

atie

nt s

tori

es a

t Boa

rd/u

se in

sta

ff tr

aini

ng

Lead

ersh

ip a

nd P

atie

nt E

xper

ienc

e w

alk

roun

ds b

y Bo

ard

Intr

oduc

tion

of P

atie

nt a

nd S

taff

Qua

lity

Gro

ups

Evid

ence

hel

d by

Wir

ral C

T: P

atie

nt S

tori

es/B

oard

min

utes

/Min

utes

of

Patie

nt &

Sta

ff Q

ualit

y G

roup

s/Bo

ard

pape

rs re

gard

ing

lead

ersh

ip w

alk

roun

ds

Fam

ily a

nd

Frie

nd te

st

Repo

rted

in p

atie

nt fe

edba

ck c

ards

; lea

ders

hip/

patie

nt e

xper

ienc

e w

alk

roun

ds; f

ront

line

focu

s vi

sits

. Ev

iden

ce h

eld

by W

irra

l CT:

Pat

ient

Sto

ries

/Boa

rd m

inut

es/M

inut

es o

f Pa

tient

& S

taff

Qua

lity

Gro

ups/

Boar

d pa

pers

rega

rdin

g le

ader

ship

wal

k ro

unds

/Qua

lity

& G

over

nanc

e Co

mm

ittee

min

utes

Qua

lity

Han

dove

r W

CT

12/1

3-23

7

Page 193 of 307

Risk

s an

d A

ssur

ance

s

Key

Risk

M

itig

atin

g Fa

ctor

s Ri

sk S

core

Fina

ncia

l Via

bilit

y Co

ntra

ct e

xpir

es in

201

4 In

com

e ge

nera

tion

via

othe

r sou

rces

Co

ntra

cts

with

oth

er c

omm

issi

oner

s

Robu

st C

IP p

lans

in p

lace

with

qua

lity

impa

ct a

sses

smen

ts

Ri

sk S

core

4 x

3 =

12

Org

anis

atio

nal S

ize

(via

bilit

y if

serv

ices

dec

omm

issi

oned

) A

ppro

ved

AQ

P in

oth

er a

reas

St

rong

rela

tions

hips

with

Com

mis

sion

ers

Prov

en tr

ack

reco

rd o

f res

pond

ing

to C

omm

issi

oner

requ

irem

ents

Pr

oven

qua

lity

perf

orm

ance

incl

udin

g ac

hiev

emen

t of C

QU

IN

sinc

e 20

09/1

0 In

vest

men

t in

busi

ness

dev

elop

men

t opp

ortu

nitie

s

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ners

hip

wor

king

with

oth

er p

rovi

ders

(Hea

lth &

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ial C

are)

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ad o

rgan

isat

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in d

evel

opin

g in

tegr

ated

car

e m

odel

/pat

hway

s

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sk S

core

3 x

3 =

9

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gnat

ion

of N

amed

GP

for

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guar

ding

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com

men

ced

recr

uitm

ent t

o po

st

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sk S

core

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eem

ent w

ith C

CG re

gard

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pre-

qual

ifica

tion

fram

ewor

k fo

r CQ

UIN

and

agr

eem

ent o

f CQ

UIN

20

13/1

4

Pre-

qual

ifica

tion

docu

men

t com

plet

ed a

nd s

ubm

itted

to C

CG.

D

iscu

ssio

ns re

gard

ing

CQU

IN (l

ocal

var

iatio

ns o

f nat

iona

l CQ

UIN

s)

on g

oing

aim

for c

ompl

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n ea

rly

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ch 2

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sk S

core

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rall

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val:

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ad C

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gned

:

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ate:

Page 194 of 307

Agr

eed

wit

h Pr

ovid

er

Sign

ed: L

isa

Coop

er, D

irec

tor o

f Q

ualit

y &

Gov

erna

nce

D

ate:

20

Feb

ruar

y 20

13

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cuss

ed w

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iona

l Co

mm

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dove

r W

CT

12/1

3-23

7

Page 195 of 307

Membership Update



Lead Director: Jo Harvey

Job Title: Director of Human Resources & Corporate Affairs



Yes No N/A


Yes No N/A

To Approve

To Note

To Assure


N/A





n/a

Identified Risks:

Recruiting and engaging 3600 members, representative of the Wirral and Neston population, is essential to our application to become a foundation trust. Also essential is having an elected shadow Council of Governors at the point of authorisation. Not doing so would jeopardise our application.

Assurance to Board: Our current member profile is representative of the Wirral population with deviations identified along with plans to address them. We are within 300 members of our target. Governor elections are being planned and potential governors have been engaged through a series of events, with over 30 people interested in the governor roles.


Report History


Regular report submitted each month

Mem

bers

hip

Rec

ruitm

ent

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238

Page 196 of 307


Membership Update

Purpose 1. This paper provides members of Wirral Community NHS Trust Board with an update on

progress in the planning for governor elections and recruitment of members. Executive Summary 2. Recruiting and engaging 3600 members, representative of the Wirral and Neston population,

and having successful elections for public and staff governors are both prerequisites for the Trust’s approval as a foundation trust.

3. Based on the current level of interest for becoming a governor (demonstrated by attendance at

the 22 February ‘Standing for Election’ workshop) all constituencies would have contested elections.

4. At the end of February 2013 there are another 300 members to recruit to reach our authorisation target. The membership is generally representative of the wider population.

Governor elections

5. Governor elections need to be held so that a shadow council of governors is in place at the earliest point Wirral CT may be authorised by Monitor.

6. There is a requirement for governor elections to be run by an independent provider. UK

Engage has been selected to run the elections and the Membership and Communications teams have been working with UK Engage to develop election materials.

7. Successful elections are defined by having contested elections in each constituency. The

introductory Governor Information sessions held in November 2012, January and February 2013 in Birkenhead, Wallasey, West Kirby and Bromborough were well attended by 60 people.

8. Thirty one members attended, or gave apologies, for the Standing for Election workshop on 22

February 2013, suggesting a high level of interest for the governor roles.

Constituency Number of seats on Council

of Governors Number of attendees at Standing for Election session, inc apologies

Birkenhead 3 8

Wallasey 3 5

Wirral West 2 9

Wirral South & Neston 2 4

Staff 3 5

Total 13 31

9. The election process will officially begin once Wirral CT’s application is passed from the

Department of Health to Monitor for final assessment. 10. The uncertainty with regard to the timing of elections creates a challenge. We must be ready

for the earliest possible date whilst making sure that potential governors do not lose interest if it takes longer. The membership team is addressing this by having regular contact with potential governors, including specific invitations to attend member events to help them better understand the Trust.

Page 197 of 307

Membership

11. Relatively few new members have been added since the last update - the current total is 3303.

12. The front loading of member recruitment during 2012 meant that, over the past six weeks, the membership team have been able to focus on engaging with potential governors and related activities. The recruitment events planned during March 2013 should allow us to meet our target of 3600 within the next month (see Appendix 1).

13. The membership profile is essentially unchanged since the last update. The key categories examined, with any areas of significant deviation, are noted in table below:

Category Exceptions to representative member profile?

Action plan

Constituency area

South Wirral and Neston underrepresented by 7% (230 people)

Further recruitment event in Sainsbury’s, Neston

Socioeconomic and Health profile

No, within 2% across all groups

Ethnic origin

No, within 1%

Age

60-74 year olds overrepresented by 9% (300 people); 13-16 year olds underrepresented by 3% (100 people)

Staff recruitment incentive re-launched with a focus on increasing numbers of younger members.

All schools on Wirral contacted re membership

Work experience pilot scheme starting April 2013 with potential for new, younger members

Gender

Women overrepresented / men underrepresented by 11% (360 people)

Encouraging husbands and wives to each join when recruiting

14. An analysis of the membership according to the key categories is included in Appendix 2.

15. NB The average cost of recruiting each new public member by the membership team and other trust employees (staff time, attending events, staff recognition etc) remains approx. one quarter of the cost of employing an external company to carry out recruitment activity on behalf of the trust. This will avoid approx. £27,000 in potential recruitment costs.

Conclusion

16. Wirral Community NHS Trust’s current membership profile is generally representative of the Wirral population.

17. Our target to achieve 3600 by FT authorisation is highly achievable.

18. Though the timing of governor elections is unpredictable, the Trust has a cohort of members very interested in becoming governors.

Board Action

19. The Board is asked to note the update position as outlined in the report and provide any further recommendations to support membership recruitment.

Author Michael Games Trust Board Secretary

David Hammond Membership Manager

Mem

bers

hip

Rec

ruitm

ent

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238

Page 198 of 307

Appendix 1

Activity plan for member recruitment, March 2013

Month Date Activity

February 27 Birkenhead ASDA with Public Health team - recruitment Membership talk with Ashville Lodge (Blind and Partially Sighted)

28 Birkenhead ASDA - recruitment

March 1 Woodchurch ASDA - recruitment

4 VCHC - recruitment

8 Liscard ASDA - recruitment

11 All Day Health Centre - recruitment

12 Membership talk with Advocacy in Wirral

14 Child Support Agency with Public Health team - recruitment

15 All Day Health Centre - recruitment

19 St Catherine’s Health Centre - member tour

22 Sainsbury’s Neston - recruitment

NB In addition to the activity noted above, the Membership and Volunteering Team are simultaneously delivering:

ongoing engagement with members and potential governors

the Trust’s pilot work experience scheme

management of the Trust’s existing volunteer scheme

planning for expansion of the Trust’s volunteer scheme

a new volunteer Welcome Team at St Catherine’s Health Centre

Page 199 of 307

Wirra

l C

om

mu

nity

NH

S T

ru

st -

Me

mb

ersh

ip

U

pd

ate

,

Ap

pe

nd

ix

2

Based

on

3303 m

em

bers

@ 2

5 F

eb

2013

Mem

bers

hip

Rec

ruitm

ent

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238

Page 200 of 307

Mem

ber

pro

file

–

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Page 201 of 307

Mem

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24

Mem

bers

hip

Rec

ruitm

ent

WC

T12

/13-

238

Page 202 of 307

Loca

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32

Page 203 of 307

Ethn

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0.6

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14.7

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020406080100

120

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14.2

84.3

Mem

bers

hip

Rec

ruitm

ent

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T12

/13-

238

Page 204 of 307

Mem

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Age

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Page 205 of 307

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011

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lati

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25

10

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26

Mem

bers

hip

Rec

ruitm

ent

WC

T12

/13-

238

Page 206 of 307

Mem

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pro

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hart

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62

0

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63

Page 207 of 307

Integrated Performance Report – Month 10 (January 2013)





Link to Business Plan: N/A


Yes No N/A


Yes No N/A

To Approve

To Note

To Assure


Performance against key indicators is core to the organisations aim of provision of high quality services within an financially sustainable organisation


£ Overall Income: £


£ Funding Already Ring Fenced:

£

Identified Risks:

Individual risks are identified in the appropriate sections of the report

Assurance to Board:

To assure the Board of the performance of services and action plans in place to deliver improvement as required.


Report History


No history

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Integrated Performance Report – Month 10 (January 2013)

Purpose

1. This report presents the board with an overview of the Trust’s performance across all key

performance areas at the end of the tenth month of the 2012/13 financial year, January 2013.

2. The report describes the Trust’s performance against the 4 strategic themes agreed as part our strategic vision and values. These are:

Patient, Community and Commissioners;

Care Delivery;

People and Resources;

Enabling functions.

3. The report includes a balanced scorecard which has been developed following work to agree the strategic objectives of the organisation.

4. The report summarises the individual reports received by the Finance and Performance,

Quality and Governance and Education and Workforce Committees. Individual scorecards for the 5 clinical divisions have also been submitted to the Finance and Performance committee.

Executive Summary 5. The Trust continues to perform well against most indicators in January. The Trust is delivering

on the majority of key performance indicators within its contract with commissioners and doing so with a good financial position which is reported as on track to deliver year end targets.

6. The Trust continues to perform well against the indicators set out in our quality strategy which has now been formally launched to all staff.

7. The Trust’s sickness and absence rate remains higher than the Trust’s target of 3.4% standing

at 4.5% for January. This is the same as the position in December. The corresponding period in 2011/12 saw a rate of 5.0%.

8. The Trust financial position is a year to date surplus of £758k, this is in line with the planned

surplus at this stage of the financial year which is £751k. The run rate at month 10 is in line with that required to deliver the forecast outturn and the Trust’s cash position is strong with cash balances of £3.1m at the end of January. All other financial indicators are positive at this stage of the year.

9. The Trust is performing well against the quality targets set within the CQUIN framework and is

expecting to deliver all CQUIN requirements for 2012/2013.

Month 8 Performance Overview

Strategic Theme 1 – Patients, Community & Commissioners

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Introduction 10. The Trust continues to perform well against this strategic theme and is achieving all targets for

the year to date. Access Targets 11. The Trust is delivering on both its duty to treat non admitted patients within certain relevant

services (mainly therapies) within 18 weeks (100% achievement in January) and ensuring that at least 95% of patients visiting our walk in services are treated within 4 hours (January performance 99.3%).

Quality Indicators 12. The Trust’s Quality Dashboard (Appendix 1) highlights the Trust’s performance against the

individual quality indicators set out in the Quality Strategy. The strategy outlined 4 quality themes which are as follows:

Patient Experience

Delivering Care

Getting Staffing right

Measuring Impact

13. The Quality Dashboard is in a revised format following work undertaken by the Quality and Governance team and consideration and discussions at the Quality and Governance Committee.

Patient Experience - Comments, Concerns, Compliments and Complaints

14. The graph below shows the number of comments, concerns, compliments and complaints

received in month order. Twelve months of data are shown to enable the run rate to be understood.

Source: Patient Experience service Assurance: Annual Compliance Audit

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Litigation 15. There were no new litigation claims received for the reporting period 1January 2013 – 31

January 2013.

Incidents

16. There were a total of 252 incidents reported in the month of January 2013. The graph below

shows the number of incident forms received from April 2012. Figures for 2011/2012 are given for comparison

Source: WCT Datix System Assurance: Annual Compliance Audit

Serious and Untoward Incidents Reported by Month 17. There were no serious and untoward incidents reported for January 2013.

National Never Events 18. There were no nationally defined Never Events reported for the month of January 2013.

Local Never Events (LNEs) 19. There were three avoidable pressure ulcers under the care of the community Trust’s in

January. These are the subject of SBAR investigations.

20. There were 8 Information Governance Incidents in January. These are being investigated and will be considered at the appropriate committee.

21. Infection Control incident trends are monitored in the Infection Prevention and Control Group. If any incidents are escalated to a Root Cause Analysis the action plans and any organisational learning is monitored and shared at the Infection Control Group.

2011/12 CQUIN Quality Indicators

22. The Trust expects to deliver against all the targets identified by commissioners for CQUIN

payments in 2012/13.

Strategic Theme 2 – Care Delivery

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Introduction 23. This section provides the board with an overview of performance against contract KPI’s during

December 2012. 24. The Trust is achieving a green rating against 77 of the 88 service KPIs within its contract with

commissioners. There are 7 amber performing indicators and 3 red indicators for the month, these are shown in detail appendix 2.

25. Appendix 2 also highlights the Trust’s performance against the national performance target

which are applicable to a community provider. Exception Reports 26. Lifestyle Services – Two red indicators, two amber and all of which are cumulative. The service

is confident that targets will be delivered over the full year.

27. Healthy Settings Team – This indicator is dependent on school engagement. The commissioned training provider left the course and is being replaced, resulting in a delay in service delivery. A skill mix review as part of public health service redesign will ensure this doesn’t happen again in the future.

28. Healthy Child Programme – Performance against this indicator is dependent on breastfeeding initiation levels, which are under the control of the acute trust. Low initiation levels for breastfeeding make performance against this continuation target very challenging. This issue is currently being discussed through contract negotiation meetings for 2013/14.

29. Out of Hours – Whilst performance is steady, during specific days poor performance was

recorded and is being reviewed by the service to underpin learning and improvement. These poor days resulted in amber for the month.

30. Specialist Palliative Care Team – as indicated previously, arrangements are now in place to renegotiate this indicator in the context of a whole system rather than service specific indicator. LPCC requires GP intervention to initiate, and the team continues to develop and maintain relationships with all key stakeholders to ensure appropriate patient management.

Strategic Theme 3 – People & Resources

Introduction

31. The purpose of this section is to present to the board the workforce and financial performance of Wirral Community NHS Trust for the period ended 31st December, it highlights performance against a number of key indicators including the statutory financial duties of an NHS Trust and the financial risk rating areas applicable to NHS Foundation Trusts.

Workforce 32. The current monthly sickness rate for the Trust is 4.5%, this is the same as last month’s figure

but significantly lower than last year’s figure for January which was 5.0%. The figure below shows the trend in 2012/13 compared with that seen in 2011/12 and highlights what is now a sustained improvement on the levels seen in 2011/12.

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Source: ESR System Assurance: Annual Compliance Audit

33. The Trust continues to show excellent levels of appraisal across the organisation. 34. The overall Trust position for local induction as at December remains Green with 100% of

relevant inductions completed and completed within the required timescales. This continues the improvement seen last month.

Financial Performance Summary of Financial Performance 35. The Trust is showing a YTD net surplus of £758k for the period ending 31st January 2013. This

is marginally ahead of the planned budget at this stage of the financial year which is £751k. All cost improvement targets have been removed from budgets and this YTD position is net of the reduction of £2.8m to budgets in relation to the required efficiencies for the Trust.

36. The Trust is performing in line with expectations against the other statutory duties of an NHS trust, namely, maintaining cash expenditure within its External Financing Limit (EFL), maintaining capital expenditure within its Capital Resource Limit (CRL) and achieving a capital absorption rate of at least 3.5%. The Trust is achieving the planned levels of performance for all these targets and is forecasting full delivery against these duties at the year end.

37. The Trust has identified the full year CIP requirement for 2012-13 of £2.8m, and has received project initiation documents for individual schemes in excess of the required target.

38. The identified schemes continue to be RAG rated against likelihood of delivery as well as against the risks identified on a monthly basis by Finance, HR, Quality and Performance leads for the projects.

39. The Trust has spent £172k against its identified £500k capital programme, all of which it expects to spend by the end of the financial year. However failure to spend all of the Trust’s 2012/13 CRL will not have a negative impact on future plans as all capital investment funding is internally generated by the Trust.

40. The Trust is also delivering its additional administrative target of paying 95% all bills within 30 days.

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41. An executive dashboard highlighting the key aspects of financial performance for the year is shown in Appendix 1.

NHS Trust Statutory Duties 42. The Trust’s performance against its statutory duties is shown below:

Statutory Duty Target YTD Forecast

Break Even Duty Break-even £758k Surplus £900k Surplus

Capital Cost Absorption Rate 3.5% 3.5% 3.5%

Capital Resource Limit £500k £172k £500k

External Financing Limit £471k £646k £470k

Foundation Trust Financial Risk Ratings (FRR) 43. The Trust has formally entered into agreement with the Strategic Health Authority and the

Department of Health to work towards achieving foundation trust (FT) status by April 2014. A key test of the Trusts application for FT status will by its performance against the FT finance risk ratings set by monitor in the FT compliance framework 2011/2012. There are 5 risk ratings against which the Trust will be assessed and it is considered good practice to begin the monitoring of performance against these ratings during the application period. The 5 FRRs and their relative weighting in the overall calculation of risk are detailed below:

a. Underlying Performance – 1 rating weighted 25 which measures the Trusts earnings

before interest, taxation, depreciation and amortisation (EBITDA) as a percentage of income.

b. Achievement of plan – 1 rating weighted 10 which measures the achievement of EBITDA against the planned achievement for that year.

c. Financial efficiency – 2 ratings each weighted 20 which measure the Trust’s surplus

against its overall level of income and against its net asset base.

d. Liquidity – 1 Rating weighted 25 which measures the Trust’s liquidity in terms of available days liquid resources (cash plus debtors less creditors plus agreed working capital facility)

44. The Trust’s performance against the shadow FT risk ratings is shown in Appendix 2. The ratings are given a score from 1 to 5 with 5 representing the lowest risk and 1 the highest. It is expected that the Trust will be achieving at least a 3 in each category at the point of FT authorisation.

45. Current performance is in line with the required level of 3 with a weighted average of 3.6 for the Trust. The liquidity rating remains healthy due to the inclusion of a working capital loan facility equivalent to that which would be available to an FT.

46. The Trust is rated at 2 against the underlying performance indicator and expects to remain at this level given its low asset base, which will remain the case even after transfer of assets from the PCT. Delivery of full year surplus in line with the Trust’s plans will ensure all other indicators are at 3 or above.

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Income and Expenditure Position 47. A breakdown of the performance by division is shown in Appendix 3 and a summary income

and expenditure account is show in Appendix 4. The key movements and variances are highlighted below

a. Nursing - £240k above budget driven by non pay over spend partly off set by

favourable pay and income variances.

b. Primary Care - £879k above budget, driven by agency over spend in GP OOH and the All Day Health Centre.

c. Therapies - £110k above budget resulting from non pay overspend on supplies and

travel partially offset by favourable pay and income variances.

d. Corporate, Ops/Performance & Other - £1,080k below budget, with Asset Financing & Reserves the largest element.

e. Estates & SLA’s - £41k under spend.

f. Lifestyle - £155k below budget arising from under spend on pay as vacancies are

held pending restructure.

g. Unplanned Care - £113k above budget. An over spend on agency costs offset by additional income from Phlebotomy.

Statement of Financial Position (Balance Sheet) 48. The Trust’s statement of financial position (also known as the balance sheet) is shown in

Appendix 5.

49. The balance reflects the fact that legal asset transfer will not happen until April 2013 in line with stated DH policy.

Cash Position and Cashflow Forecasts 50. The Trust’s cash flow forecast for the financial year is shown in Appendix 6. The figures for the

first few month of the year are based on actual cash movements and the forecasts for the remaining year have been updated in line with latest expectations.

51. The Trust currently holds cash balances of £3.1m which is higher than expected at this stage of the financial year. The main reason for the variance is that the plan assumes all creditors are paid inside 1 month but most creditors are paid 1 month in arrears.

Analysis of Outstanding Debt 52. Appendix 7 shows the aged debt for the Trust. The level of debt outstanding for more than 90

days now stands at £475k. Capital Expenditure 53. The Trust’s YTD and forecast capital expenditure against the agreed capital programme are

outlined in Appendix 8.

54. It is expected that most of the Trust’s capital expenditure will not take place until the final months of the financial year, any underspend against the planned investments will be rolled forward to 2013/14 and is expected to be incurred early next year.

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CIP Position 55. The Community Trust established a Cost Improvement Programme (CIP) of £2.8m for the

financial year. This represented around 4.5% of total revenue and is in line with the DH operating framework assumed efficiency requirements of all NHS provider organisations.

56. This target has been allocated across the 5 clinical divisions along with an appropriate share to the corporate and other departments within the Trust.

57. The CIP governance process outlined to the board last October is now firmly in place and all schemes identified by managers and budget holders will be assessed, approved, monitored and reported through the processes approved by the board.

58. Project initiation documents (PIDs) have now been received for a total of 59 individual schemes that are expected to deliver in excess of the required target.

59. Of the 59 schemes proposed 8 have so far been rejected for quality or other issues and have been removed from the Trusts plans. Of the remaining schemes 8 are non recurring schemes with a value approaching £240k.

60. The latest position against divisional totals is shown in Appendix 9

61. The Trust’s Financial Performance and Efficiency Group (FPEG) continues to meet fortnightly and will be a crucial source of assurance for the finance and performance committee in a number of areas but in particular in relation to delivery of CIP both this year and next.

62. A summary of the CIP position is shown in the table below:

Description Amount % of Target

Opening Target 2,787 100%

Green Rated PIDs 2,313 83%

Amber Rated PIDs 1,012 36%

Red Rated PIDs 345 12%

Total PIDs 3,670 131%

Additional Schemes 240 9%

Total Proposals 3,911 140%

63. As the Committee are aware, all schemes undergo a quality impact assessment prior to commencement. Within the QIA the clinical sponsor for the project assesses the potential risk against the 3 domains of quality: patient safety, clinical effectiveness and patient experience. The QIA process scores each scheme against these indicators using the Trust’s standard risk scoring process. The QIA’s also identify the quality indicators which could be at risk following commencement of the scheme.

64. The table below shows the schemes assessed to date which have scores more than 10 on the

QIA risk assessment.

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Scheme Division Score Indicators Affected QIA Status

PCT Additional Activity Charging

Nursing 12

Getting staffing right

Delivering Care

Measuring Impact

Approved

Heart Support Additional Activity

Nursing

12 Getting staffing right

Delivering Care

Approved

Speech & Language Staffing

Therapies 20 Getting staffing right

Patient Experience

Rejected

Provision of Medical Syringes

Therapies 10 Getting staffing right

Patient Experience

Rejected

Heart Support Staffing Reductions

Nursing 11 Getting staffing right

Delivering Care

Rejected

Better Payment Practice Code (BPPC) 65. Appendix 10 shows the Trust’s performance against its administrative duty to pay 95% of

creditors within 30 days. Historically the Trust performs well against this duty and is currently delivering above target in all areas.

WTE analysis 66. Appendix 12 shows the split of WTE by staff group for the first ten months of the financial year

and 2012/13. Conclusion 67. The Trust is broadly performing in line with expectations and is on course to deliver the

planned £900k surplus for 2012/13. Continued close attention will support actions required to ensure delivery of the Trust’s duties.

68. The Trust is forecasting it will achieve all other statutory financial duties

69. The Trust is monitoring performance against shadow FT risk ratings and is performing in line with expectations at this stage of the financial year.

70. The Trust is forecasting it will fully deliver the required CIP’s for 2012/2013.

Strategic Theme 4 – Enabling Functions

71. Our fourth strategic theme is Enabling Functions. This covers the requirements we place on our supporting functions to enable the delivery of high quality integrated care.

72. The key indicators monitored against this theme are as follows:

FT Pipeline Following the submission of the Trust’s FT application to the Department of Health at the end of December our rating has returned to green as anticipated.

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PO Coverage The Trust is further rolling out i-procurement and reviewing its procurement strategy.

LD The Trust is now reporting green against monitor’s self-assessment for delivering services to people with learning disabilities.

Community Dataset The trust is on track to deliver the requirement to implement the Community Information Dataset in full by April 2014

IT Systems The Trust is on track to implement full coverage of IT systems within clinical services

Board Action

73. The Trust Board is asked to note the Trust’s performance for January 2013 and the assurances given in relation to the year-end forecast position.

Simon Gilby Chief Executive

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