TRUST BOARD
A meeting of the Board of Directors will be held at 10.30am on Tuesday 25 September 2012, in Room 3, Education Centre, Queen Elizabeth Hospital
A G E N D A
1 Apologies for Absence:
2 To Sign the Attendance Register:
3 Chairman’s Business:
4 Minutes of the Previous Meeting: Enclosure To approve the minutes of the previous meeting of the Board of Directors held on 25 July 2012
5 Matters Arising from the Minutes:
Items for Decision:-
6 Charitable Funds Annual Report and Accounts: Enclosure To approve the Annual Report and Accounts presented by the Director of Finance and Information
7 Calendar of Board Meetings: Enclosure To approve the calendar of Board meeting dates for 2013 presented by the Trust Secretary
Items for Assurance:-
8 Performance Report: Enclosure To receive the routine briefing report presented by the Director of Transformation and Compliance
9 Finance and Activity Report: Enclosure To receive the Finance and Activity Report for the period ended 31 August 2012 presented by the Director of Finance and Information
10 Annual Management Letter 2011/12 Enclosure To receive the annual management letter from the Director of Finance and Information.
11 Healthcare Associated Infections: Enclosure To receive an update report from the Director of Nursing, Midwifery and Quality
12 PQRS Compliance Report: Enclosure To receive the report from the Director of Nursing, Midwifery and Quality
Items for Discussion:-
13 Audit Committee Annual Report Enclosure To receive the annual report from the Chair of the Audit Committee
14 Energy Conservation Update Enclosure To provide an update presented by The Director of Estates and Facilities
Items for Information:-
15 Trust Branding Enclosure To receive an update from the Head of Communications
16 South of Tyne and Wear Serious Incident Enclosure Reporting and Management Policy To be presented by the Director of Nursing, Midwifery and Quality
17 Minutes of Meetings: Enclosure To receive for information, the minutes of the following meetings:
i) Audit Committee held on 21 May 2012 ii) Charitable Funds Committee held on 14 June 2012 iii) Human Resources Committee held on 11 June 2012 iv) Patient, Quality, Risk and Safety Committee held on 20 July 2012 vi) Mental Health Committee held on 27 April 2012
18 Date & Time of the next Meeting The next meeting of the Board of Directors will be held at 10.30am on Thursday 25 October 2012 in Room 3, Education Centre, Queen Elizabeth Hospital
19 Exclusion of the Press and Public To resolve to exclude the press and public from the remainder of the meeting, due to the confidential nature of the business to be discussed.
Trust Board Minutes of a meeting of the Board of Directors held at 10.30am on Wednesday 25 July 2012, in Room 3, Education Centre, Queen Elizabeth Hospital
Present: Mrs J E A Hickey Chairman Dr D M Beaumont Medical Director Mr M Brown Non-Executive Director Dr J Bryson Non-Executive Director Mr J Connolly Director of Finance and Information Dr A Fairbairn Non-Executive Director Mr K Godfrey Deputy Medical Director Mr M Graham Non-Executive Director Mr P Harding Director of Estates and Facilities Mrs G MacArthur Director of Nursing, Midwifery and Quality Mrs Y Ormston Deputy Chief Executive Mr I D Renwick Chief Executive Mr R Simpson Non-Executive Director In Attendance: Mrs D Atkinson Trust Secretary Mrs D Renwick Strategic Lead for Performance (12/146) Miss D Waites Personal Assistant Apologies: Mr F Major Non-Executive Director (Deputy Chairman)
Agenda Discussion and Action Points Action Item by 12/141 Chairman’s Business:
The Board welcomed Mrs J E A Hickey to her first meeting as Chairman to the Trust.
She requested Board members present to report any revisions to their declared interests or any declarations in the items on the agenda.
The Chairman highlighted to the Board that the deadline for contacting the relevant Foundation trusts had passed, which indicated that the Trust would not be subject to an Annual Plan Stage 2 Review this year. Mr I D Renwick, Chief Executive, reported that the Trust had been contacted to arrange a Relationship visit in October 2012 which provides an opportunity to meet Jay Mistry, Senior Compliance Manager, and John Plumer, Compliance Manager.
Mr Renwick informed the Board that the Bigger Picture group had submitted a nomination for Partnership of the Year in the Leadership in Healthcare Awards.
12/142 Minutes of the Previous Meeting:
The minutes of the last meeting held on 27 June 2012 were approved as a true record.
1 Agenda Discussion and Action Points Action Item by 12/143 Matters arising from the Minutes:
The new Board Action Plan was updated accordingly to reflect matters arising from the minutes. It was agreed to separate the action plan in accordance with Part I and Part II of the meeting from September 2012.
12/144 Monitor Q1 Governance:
Mr I D Renwick, Chief Executive, presented the Quarter 1 2012/13 Governance Declaration and Quality Board Statement.
He informed the Board that some of the figures contained in the report may have changed since the time of writing the paper and asked the Board to refer to the figures presented in the Performance Report, Agenda Item 8, for the Trust’s definitive position. He added that these changes would not affect the recommendation to the Board.
The Board acknowledged that all targets had been achieved and following consideration, it was:
RESOLVED: i) to approve that the Trust signs Declaration 1 for the Quarter 1 Declaration for 2012/13 ii) to sign Declaration 1 of the Quality Board Statement at Quarter 1 of 2012/13.
12/145 Research & Development Operational Capability Statement:
Dr D M Beaumont, Medical Director, presented the Research and Development Operational Capability Statement for approval by the Board.
He explained that following approval, this statement will be available on the external website to attract more portfolio studies, industry studies and researchers which in turn will attract more research funding to the Trust.
The Board supported the need for further research but felt that the current template was difficult to read and queried how this would be presented within the website. Mrs Y Ormston, Deputy Chief Executive, agreed to discuss with YO Lucia Hiden, Head of Communications for her to clarify this with Alison Harvey, Governance, Research and Development Manager.
After further discussion, it was:
RESOLVED: to approve the Research and Development Operational Capability Statement.
12/146 Performance Report:
Mrs D Renwick, Strategic Head of Performance, updated the Board on performance against national and local targets.
Mrs Renwick reminded the Board of the detailed discussion at the last meeting in relation to the under performance against the A&E 4 hour waiting time target 2 Agenda Discussion and Action Points Action Item by and was pleased to report that despite this, the Trust has achieved quarterly compliance with a final position of 95.03%. She explained that fortnightly review meetings are taking place within the team and this has instigated work across the patch to fully understand this and provide detailed learning. Mr I D Renwick, Chief Executive, reported that all clinical Divisions within the organisation have worked together around this issue and an action plan is being developed and implemented. This is providing a positive impact within the decision support unit and easing the overall position.
She also highlighted that following the Medway/PAS implementation, ongoing data validation is being undertaken on a weekly basis to review the management of data quality and compliance across the suite of indicators.
The Chairman commented on the programme for Improving Clinical Performance and whether this work was still being focussed on following the introduction of the Strategic Transformation Improvement Programme. Mrs Y Ormston, Deputy Chief Executive reported that a framework is being developed and the Chairman felt that a focus paper would be beneficial to show the Board the type of data being collated and how this will be included within strategic developments.
Dr J Bryson, Non Executive Director, raised an issue to the Board on requests for orthopaedic and gynaecology intervention being referred through A&E rather than directly to the appropriate speciality and Mrs Ormston agreed to investigate YO this further.
Mr M Brown, Non Executive Director, also raised concerns on the percentage of Personal Development Plans falling from 53% to 48% and felt that the importance of completion may need to be reinforced across the organisation. Mrs Ormston highlighted that an action plan had been presented at the last Human Resources Committee and further details from managers will be requested.
The Board discussed the report in detail and acknowledged the hard work being undertaken by all those involved in achieving all the targets currently covered in the Compliance Framework. It was therefore:
RESOLVED: to receive the report as assurance of full compliance against the governance indicators in the Compliance Framework and local supporting measures of improvement management in Quarter 1
Mrs D Renwick left the meeting.
12/147 Finance and Activity Report:
Mr J Connolly, Director of Finance and Information, provided the Board with details of performance against activity and financial plans as at the end of June 2012 (Month 3).
Mr Connolly reported that the Trust had a planned surplus of £1,360k at Month 3 and Quarter 1 however the actual position is a surplus of £212.1k. He explained that this was mainly due to a fall in operating income.
The Board discussed the overspend in expenditure for temporary staff and Mr Connolly reported that the rate had fallen but still had a large impact on the 3 Agenda Discussion and Action Points Action Item by Efficiency Programme. The Chairman pointed out the work previously completed on ward staffing however Mrs G MacArthur, Director of Nursing, Midwifery and Quality, highlighted that a further review was being planned to be carried out from September 2012 and will be looked at in further detail at the Human Resources Committee in relation to recruitment problems.
Mr Connolly informed the Board that it is anticipated that the Trust will continue to maintain a Financial Risk Rating (FRR) of at least 3 over the next 12 months and it supported the self certification required by the Compliance Framework.
After further discussion and consideration, it was:
RESOLVED: i) to note the reported financial performance as at 30 June 2012 (Month 3) ii) to support the self-certification that the Board anticipates that the Trust will continue to maintain a FRR of at least 3 over the next 12 months.
12/148 Healthcare Associated Infections:
Dr D M Beaumont, Medical Director and Joint DIPC, updated the Board on the current status of HCAI within the Trust and advised on progress against the Annual Delivery Programme 2012/13.
He highlighted that the Trust remains below the trajectories set for MRSA and CDI. An intensive programme of work continues within the Trust with initiatives to improve signage for use of specialist clothing on entry to isolation rooms and environmental swabbing for Clostridium Difficile to commence on 18 July 2012.
The Board acknowledged the excellent work being carried out by the Infection Prevention and Control Team against tight targets and Dr Beaumont emphasised that the patient environment must remain under continuous scrutiny to assure the Trust.
Following further discussion, it was:
RESOLVED: to note current and forecast performance on Healthcare Associated Infections.
12/149 Clinical Audit Annual Report:
Dr D M Beaumont, Medical Director, provided the Board with the report on Clinical Audit activity for 2011/12 which drives improvements in patient care.
He highlighted that a comprehensive range of activities is monitored and coordinated via the SafeCare Department to improve quality and procedures within the Trust via both national and local audit programmes.
The Chairman pointed out that audit plans are generally risk based and indicated that it may useful for this to be linked to the Trust Risk Register. Mrs G MacArthur, Director of Nursing, Midwifery and Quality, agreed to discuss this with Gillian Appleby, Head of Risk Management, as part of her development GMac work with Divisional Managers. 4 Agenda Discussion and Action Points Action Item by After consideration, it was:
RESOLVED: to receive the report for information.
12/150 Minutes of Meetings:
RESOLVED: To receive for information the minutes of the following meetings:
• Patient, Quality, Risk and Safety Committee held on 18 May 2012
12/151 Date and Time of Next Meeting:
RESOLVED: that the next meeting of the Board of Directors be held at 10.30am on Tuesday 25 September 2012 in Room 3, Education Centre, Queen Elizabeth Hospital.
12/152 Exclusion of the Press and Public:
RESOLVED: to exclude the press and public from the remainder of the meeting due to the confidential nature of the business to be discussed.
5
Trust Board
Report Cover Sheet Agenda Item: 6
Date of Meeting: 25 September 2012
Report Title: Charitable Funds Annual Report and Accounts 2011/12
Purpose of Report: This paper presents the final audited accounts and annual report for the Gateshead Health NHS Foundation Trust Charitable Fund for consideration and formal adoption.
Decision: √ Discussion: Assurance: Information:
Corporate Objectives 2. Achieving the Trust’s financial plan report relates to: (Including reference to any specific risk)
Recommendations: To approve the Annual Report and Accounts for 2011/12. (Action required by Board of Directors)
Financial Implications: None
Risk Management None Implications:
Human Resource None Implications:
Equality and Diversity None Implications:
Author: Mrs T Preece, Deputy Director of Finance
Presented by: Mr J Connolly, Director of Finance and Information
GATESHEAD HEALTH NHS FOUNDATION TRUST draft CHARITABLE FUND
ANNUAL REPORT AND ACCOUNTS
2011-12
Reference and Administrative details Registered Charity No. 1086145
Address of Charity:
Queen Elizabeth Hospital Sheriff Hill Gateshead Tyne & Wear NE9 6SX Telephone No. 0191 482 0000
i
TRUSTEE ARRANGEMENTS
For 2011/2012 all Executive and Non Executive Members of Gateshead Health NHS Foundation Trust Board acted as Trustees of the charity.
Executive Membership of the Board and consequently Trustees throughout 2011/2012 were as follows:-
Mr Peter J Smith Chairman Mr Ian D Renwick Chief Executive Mrs Jacqui Parkin* Chair of Charitable funds sub-committee (To 30th June 2011) Mr Richard E Simpson* Chair of Charitable funds sub-committee (From 1st July 2011) Mr Frank Major* Non Executive Director Mr Mitchell J Brown* Non Executive Director Mr Malcolm Graham Non Executive Director Mrs Julia E A Hickey* Non Executive Director Mr Andrew Fairbairn Non Executive Director Dr J M Bryson Non Executive Director Mrs Lynne Hodgson* Director of Finance & Information (To 25th March 2011) Mrs Tracey Preece* Acting Director of Finance (From 26th March 2011) Dr David M Beaumont Medical Director Mr Peter Harding Director of Estates Mrs Gillian MacArthur Director of Nursing and Midwifery Mr R Allan Smith Director of Operations (To 31st December 2011) Mrs Yvonne A Ormston Director of Health Development Mr Keith Godfrey* Assistant Medical Director
* Member of Charitable funds sub-committee
BANKERS: Lloyds Bank PLC West Street Gateshead NE8 1DP
AUDITORS: Audit Commission 2nd Floor Nickalls House` Metro Centre Gateshead NE11 9NH
ii Structure, Governance and Management of the Charitable Funds
Gateshead Health NHS Foundation Trust charitable fund was formed on 1st April 2001 following the merger of Gateshead Hospitals NHS Trust charitable fund (1055236) and Gateshead Healthcare NHS Trust charitable fund (1061808). It was named Gateshead Health NHS Trust charitable fund up to 4th January 2005 when the name changed to mirror the Foundation Trust status gained by the Trust.
Following NHS organisational changes on 1st April 2002 some of the services operated by Gateshead Health NHS Trust transferred to Gateshead Primary Care Trust and South of Tyne and Wearside Mental Health Trust. The charity still holds some of the associated charitable funds for Gateshead Primary Care Trust. The Gateshead PCT funds are being held by this charity as they represent less than £10,000 and it is not recommended that a separate charity is set up to administer the funds. This is in line with the objectives of the Charity.
The Corporate Trustee is Gateshead Health NHS Foundation Trust, and the executive directors and the non-executive directors of the Trust Board share responsibility to ensure that the Foundation Trust fulfils its duties as Corporate Trustee when it manages the charitable funds.
The Board of Gateshead Health NHS Foundation Trust on behalf of the Corporate Trustee has delegated the responsibility to manage the charitable funds to the Charitable funds sub committee. The Director of Finance is responsible for the day to day management and control of the administration of the charitable funds. The Director of Finance has particular responsibility for ensuring that the spending is in accordance with the objectives of the Charity.
The Charitable funds sub committee is in place to oversee the work of, and to advise, or direct the Director of Finance. In addition the sub committee reviews the performance of the investments and ensures that the investment of the funds is ethical and compatible with the objective of improving health.
Within the Charity are a number of earmarked (designated) funds relating to particular wards and departments. The charity manages spending through departmental fund managers. Any item over £1,000 is passed to the Chief Executive or an Executive director for authorisation and a summary of these items is submitted to each charitable funds sub committee for review.
Public Benefit Statement
All our charitable activities focus on the advancement of health and the saving of lives.
Our main activities aim to provide support by enhancing patient’s stays, supporting staff and providing support for medical research projects. Further details can be found within the ‘Strategic Objectives and Activities’ section of this report.
The main activities undertaken this year can be found in the ‘Review of the Finances, Activities, Achievements and Performance of the Charitable Funds’ section in this report.
iii Strategic Objectives and Activities
The Charity’s objectives are as follows:-
The Trustees shall hold the trust fund upon trust to apply the income, and at their discretion, so far as may be permissible, the capital for any charitable purpose or purposes relating to the National Health Service wholly or mainly for the service provided by Gateshead Health NHS Foundation Trust.
The charity is funded by donations and/or legacies received from patients, their relatives, staff, the general public and other external organisations. The overall strategy of the Charity is to provide support by the following means:-
Patients Expenditure -
• Purchase equipment and provision of goods or services to enhance a patient’s stay
Staff Expenditure -
• Support for training and development • Improving staff facilities and services
Capital Equipment -
• Equipment in addition to that normally provided by the Trust
Medical Research -
• To provide support for medical research projects
Whilst respecting the wishes of the donors, the corporate trustee has ultimate discretion to apply charitable funds, in accordance with charity law.
Relationships with Related Parties/External Bodies
Gateshead Health NHS Charitable fund works closely with Gateshead Health NHS Foundation Trust and Gateshead Primary Care Trust. Nearly all of the expenditure is to provide services and facilities to these two organisations or members of their staff.
Close links are also maintained with the Women’s Cancer Detection Society, the Friends of St Bedes and the WRVS. The Charitable fund acknowledges these links in the overall provision of charitable support to the related health provision of our patients.
iv Review of the Finances, Activities, Achievements and Performance of the Charitable Funds
The Charity started a successful year with assets valued at £1,415,000. The year has been active with a total expenditure of £327,000 and income of £343,000.
There has been a downturn in current market conditions which has resulted in a loss on equity investments of £13,000. However there has been an increase in the investment income of £9,000. The trustees continue to closely monitor the investments along with advisors from CCLA Investment Management.
The following major items of medical equipment have been bought:-
• OR1 Camera Stack & Network System • Sonicaid Antepartum Foetal Monitoring System • Micro-infiltration System
Funds were also spent on:
• Contributing to IPACS imaging system for cardiology • Purchase of centrifuge kits
Additionally funds were spent on:
• Staff training • Research • Other medical equipment
Many smaller items were also purchased all of which contributed greatly to the welfare of patients and staff.
Administration fees are always kept to the absolute minimum.
We were privileged to receive five legacies to purchase medical equipment and to support the surgical directorate and cancer services. Many people helped to raise funds by attending the staff Charity Balls and carrying out various sponsored events e.g. runs, walks, coffee mornings etc. and finally many people gave direct donations often in memory of a loved one.
The Charity is indebted to the generosity of patients, their families and carers, well wishers and friends who have donated so generously to the work of the charity. The Charity ended the year with total assets of £1,417,000.
v
Reserves Policy
The Charity maintains reserves to purchase items in the immediate future or when saving to buy special items.
Fund managers are encouraged to raise charitable funds and to spend them as soon as possible.
The Trustees through the Charitable funds sub committee regularly review and actively monitor the level of uncommitted reserves.
Investment Policy
The Trustees maintain a cautious investment policy. The investments in funds managed by CCLA Investment Management limited give a conservative balance between equity, cash and property.
Funds are invested to provide access for the short, medium and long term needs of the Charity. The investments aim to be socially and ethically responsible in line with the objectives and ethos of the National Health Service. During the year, CCLA split their investment fund into two parts, one with a slightly less ethical stance and one with a slightly more ethical stance. The trustees decided to move the investments into the more ethical investment fund as it was felt that this linked more closely with the objectives of the charity.
Risk Management Policy
Only one major risk has been identified by the Trustees i.e. that the value of the investments will fall due to the current economic climate of the country. This risk is mitigated by the Trustees regularly monitoring the performance of the investment funds.
Plans for future periods
The Trustees do not expect any changes in the objectives of the charity in the forthcoming year.
The charity does not currently actively fundraise and relies upon the generosity of patients, their relatives and other donors who are familiar with or have experienced the care of Gateshead Health NHS Foundation Trust. However, this policy is continually reviewed and may change in the future.
vi
Statement of trustees’ responsibilities
The law applicable to charities in England and Wales requires the trustees to prepare financial statements for each financial year which give a true and fair view of the charity’s financial activities during the year and of its financial position at the end of the year. In preparing financial statements giving a true and fair view, the trustees should follow best practice and:
• Select suitable accounting policies and then apply them consistently; • Make judgements and estimates that are reasonable and prudent; • State whether applicable accounting standards and statements of recommended practice have been followed, subject to any departures disclosed and explained in the financial statements; • Comply with all guidance published by the Charity Commission in pursuance of its public benefit objective; and; • Prepare the financial statements on the going concern basis unless it is inappropriate to presume that the charity will continue in operation.
The trustees are responsible for keeping accounting records which disclose with reasonable accuracy the financial position of the charity and which enable them to ascertain the financial position of the charity and which enable them to ensure that the financial statements comply with the Charities Act 2011, the Charity (Accounts and Reports) Regulations and the provisions of the trust deed. The trustees are responsible for safeguarding the assets of the charity and hence taking reasonable steps for the prevention and detection of fraud and other irregularities.
Signed ______Signed ______Chief Executive Director of Finance & Information
Date ______Date ______
vii Gateshead Health NHS Foundation Trust Charitable Fund Annual Accounts 2011/12
Statement of Financial Activities for the year ended 31 March 2012
2010-11 2011-12 Total Note Unrestricted Endowment Total Funds Funds Funds Funds £000 £000 £000 £000 Incoming resources Incoming resources from generated funds: Voluntary Income: 226 Donations 213 0 213 82 Legacies 82 0 82 308 Sub total voluntary income: 295 0 295
39 Investment income 2.3 48 0 48 347 Total incoming resources 343 0 343
Resources expended
Charitable activities: 102 Patients' welfare and amenities 100 0 100 66 Staff welfare and amenities 68 0 68 26 Medical research 22 0 22 20 Contributions to the Foundation Trust 10 105 0 105 214 Sub total direct charitable expenditure: 295 0 295
34 Governance costs 3 32 0 32 248 Total resources expended 327 0 327
99 Net incoming/(outgoing) resources before Transfers 16 0 16 Net incoming/(outgoing) resources before 99 other recognised gains and losses 16 0 16
Other recognised gains and losses: 20 Realised and unrealised gains/(losses) (12) (1) (13) on investment assets 119 Net movement in funds 4 (1) 3
Reconciliation of Funds: 1,296 Total funds brought forward 1,379 35 1,414
1,415 Total funds carried forward 1,383 34 1,417
Page 1 Gateshead Health NHS Foundation Trust Charitable Fund Annual Accounts 2011/12
Balance Sheet as at 31 March 2012
Total at 31 Notes Unrestricted Endowment Total at 31 March 2011 Funds Funds March 2012 £000 £000 £000 £000 Fixed Assets 1,419 Investments 2/6 1,285 34 1,319 1,419 Total Fixed Assets 1,285 34 1,319
Current Assets 8 Debtors 4 7 0 7 35 Cash at bank and in hand 140 0 140 43 Total Current Assets 147 0 147
Creditors: Amounts falling due (47) within one year 5 (49) 0 (49)
(4) Net Current Assets/(Liabilities) 98 0 98
1,415 Total Assets less Current Liabilities 1,383 34 1,417
Creditors: Amounts falling due 0 after more than one year 0 0 0
1,415 Total Net Assets 1,383 34 1,417
Funds of the Charity
35 Endowment Funds 6.1/6.2 0 34 34 1,380 Unrestricted income funds 6.3 1,383 0 1,383
1,415 Total Funds 1,383 34 1,417
The notes at pages 3 to 8 form part of these accounts.
Signed:
Name: Tracey Preece
Designation: Acting Director of Finance and Information
Date:
Page 2 Gateshead Health NHS Foundation Trust Charitable Fund Annual Accounts 2011/12
Notes to the Accounts
Accounting Policies 1 1.1 Basis of Preparation
These accounts have been prepared on the basis of historic cost (except that investments are shown at market value) in accordance with applicable United Kingdom accounting standards, the Statement of Recommended Practice (SORP 2005) "Accounting and Reporting by Charities" and the Charities Act 2011
1.2 Structure of funds
a) The vast majority of our funds are classified as unrestricted funds. These are funds which are not legally restricted but which the Trustees have chosen to earmark for set purposes. The largest funds held within this category are disclosed in note 6.3
b) Funds where the capital is held to generate income for charitable purposes and cannot itself be spent are accounted for as endowment funds, only the income will be spent in furtherance of the specified charitable purpose.
c) Where there is a legal restriction on the purpose to which a fund may be put, the fund will be classified in the accounts as a restricted fund. We do not currently hold any restricted funds.
1.3 Incoming Resources
All incoming resources are included in full in the Statement of Financial Activities as soon as the following three factors can be met:
i) entitlement - arises when a particular resource is receivable or the charity's right becomes legally enforceable;
ii) certainty - when there is reasonable certainty that the incoming resource will be received;
iii) measurement - when the monetary value of the incoming resources can be measured with sufficient reliability.
1.4 Incoming Resources from Legacies
Legacies are accounted for as incoming resources either upon receipt or where the receipt of the legacy becomes reasonably certain. This will be once confirmation has been received from the representatives of the estates that payment of the legacy will be made or property transferred and once all conditions attached to the legacy have been fulfilled and the amount of incoming resources is known with reasonable certainty.
1.5 Incoming Resources from Endowment Funds
The incoming resources received from the investment of endowment funds are wholly unrestricted but have been earmarked in accordance with the donor's stated wishes.
Page 3 Gateshead Health NHS Foundation Trust Charitable Fund Annual Accounts 2011/12
1.6 Resources expended and irrecoverable VAT
a) Expenditure All expenditure is accounted for on an accruals basis and has been classified under headings that aggregate all costs related to the category. All expenditure is recognised once there is a legal or constructive obligation committing the charity to the expenditure. Irrecoverable VAT is charged against the category of the resources expended for which it was incurred.
b) Costs of generating funds The costs of generating funds are those attributable to generating income for the charity, other than those costs incurred in undertaking charitable activities or the costs incurred in undertaking activities in furtherance of the charity's objects.
c) Charitable activities Costs of charitable activities comprise all costs identified as wholly incurred in the pursuit of the charitable objects of the charity.
d) Governance costs Governance costs comprise all costs identifiable as wholly or mainly attributable to ensuring the public accountability of the charity and its compliance with regulation and good practice. These costs include costs relating to the audit together with support costs received from Gateshead Health NHS Foundation Trust.
1.7 Fixed Asset Investments
Investment fixed assets are shown at mid-market price as at the balance sheet date. The statement of financial activities includes the net gains and losses arising on revaluation and disposals throughout the year.
1.8 Realised gains and losses
All gains and losses are taken to the Statement of Financial Activities as they arise. Realised gains and losses on investments are calculated as the difference between sales proceeds and opening market value (or date of purchase if later). Unrealised gains and losses are calculated as the difference between market value at the year end and opening market value(or date of purchase if later).
1.9 Pensions
No staff are employed by the Charity.
1.10 Change in the Basis of Accounting
There has been no change in the basis of accounting during the year.
1.11 Prior Year Adjustments
There has been no change to the accounts of prior years.
1.12 Pooling Scheme
No official pooling scheme is operated for investments.
Page 4 Gateshead Health NHS Foundation Trust Charitable Fund Annual Accounts 2011/12
Analysis of 2 2011 2012 Fixed Asset 2.1 £000 Fixed Asset Investments: £000 Investments 1,261 Opening Market value 1,419 138 Add: Acquisitions\(Disposals) at cost (87) 20 Net gain (loss) on revaluation (13) 1,419 Closing Market value 1,319
1,242 Historic cost at 31 March 1,110
2.2 2011 Market value at 31 March : Held Held 2012 Total in UK outside UK Total £000 £000 £000 £000
919 Investments in COIF Investment fund 951 0 951 300 Investment in Lloyds deposit fund 230 0 230 200 Investments in COIF deposit fund 138 0 138 1,419 1,319 0 1,319
Analysis of 2.3 Total gross income gross income 2010-11 Held Held 2011-12 from Total in UK outside UK Total investments £000 £000 £000 £000
36 Investments in COIF Investment fund 43 0 43 1 Investments in Lloyds deposit fund 4 0 4 2 Investments in COIF deposit fund 1 0 1 39 48 0 48
Analysis of 3 Governance 2010-11 2011-12 Costs
£000 £000 Auditor's remuneration: 2 External Audit fee 2 2 Internal Audit fee 2 30 Bought-in services from the Foundation Trust 28 0 Other 0 34 32
Page 5 Gateshead Health NHS Foundation Trust Charitable Fund Annual Accounts 2011/12
Analysis of 4 31 March 2011 31 March 2012 Debtors £000 Amounts falling due within one year: £000 Amounts due from 2 Gateshead Health NHS Foundation Trust 4 6 Trade debtors 3 0 Other debtors 0 0 Prepayments 0 8 Total debtors falling due within one year 7
Total debtors falling due after more 0 than one year 0
8 Total debtors 7
Analysis of 5 31 March 2011 31 March 2012 Creditors £000 Amounts falling due within one year: £000 (12) Trade creditors (14) Amounts due to (33) Gateshead Health NHS Foundation Trust (33) (2) Other creditors (2) (47) Total creditors falling due within one year (49)
Total creditors falling due after more 0 than one year 0
(47) Total creditors (49)
Page 6 Gateshead Health NHS Foundation Trust Charitable Fund Annual Accounts 2011/12
Analysis of 6 Funds 6.1 Endowment Funds Balance Incoming Resources Transfers Gains and Balance 31 March Resources Expended (Losses) 31 March 2011 2012 £000 £000 £000 £000 £000 £000 (list individually) AMoffitt 20000 2 BWorley 13000013 CJackson19000-1 18 DPatient Welfare10000 1 Total 35000(1)34
Details of 6.2 Name of fund Description of the nature and purpose of each fund material Moffitt Childrens services funds - Worley Childrens services endowment Jackson Childrens services funds Patient Welfare Patient Welfare - Mental Health
Details of 6.3 Name of fund Description of the nature and purpose of each fund material General fund - Trust wide General Purposes for the Foundation Trust funds- General QEH General Purposes for QEH designated Anaesthesia T & E General purposes for training and education in anaesthesia funds Breast Cancer R & D General Purposes for breast cancer research and development Breast Cancer T & E General Purposes training staff in Breast Cancer Browell/Cunliffe cancer res. General Purposes cancer research in surgery Cancer R & D General Purposes for Cancer Research and Development Cardiology General Purposes for Cardiology Chemo Day Unit General Purposes for Chemo Day unit Children General Purposes for Childrens services Critical Care General Purposes for Critical Care Diabetes General Purposes for Diabetes services Gynae/Oncology T & R General Purposes for Gynae/Oncology Training and Research Imaging General Purposes for Imaging Services Leukaemia/Haematology General Purposes for Leukaemia and Haematology Margaret Dryburgh Ward General Purposes for Elderly Care at Dunston Hill Hospital Maternity General Purposes for Maternity services MIRACLe General Purposes in cancer research Palliative Care General Purposes for Palliative care Pharmacy General Purposes for Pharmacy Prof. Development Obs. & Gynae. General Purposes in training staff in Obstetrics and Gynaecology Surgical Directorate General Purposes in Surgical Directorate Ultrasound General Purposes in Ultrasound Various ward funds General Purposes for wards Vascular R & D General Purposes Vascular Research and Development
7 Provisions for Liabilities and Charges
There were no provisions made in the current or previous year.
8 Transfer between funds
There were no fund transfers between the designated funds within the year.
Page 7 Gateshead Health NHS Foundation Trust Charitable Fund Annual Accounts 2011/12
Connected 9 2010-11 2011-12 Organisations Turnover of Net Surplus/ Turnover of Net Surplus/ Connected (Loss) for the Connected (Loss) for the Organisation Connected Organisation Connected Organisation Organisation £000 £000 £000 £000 Gateshead Health NHS Foundation Trust 180,828 2,050 189,130 6,404
Related party 10 Related party transactions transactions During the year none of the Trustees or members of the key management staff or parties related to them has undertaken any material transactions with the Charity.
The charitable trust has made revenue payments for the administration of the charitable funds and capital payments, of £105,000 (£20,000 in 2001-11) to purchase medical equipment, to Gateshead Health NHS Foundation Trust. The Trustees of the Charity are also members of the Foundation Trust Board.
None of the Trustees claimed remuneration or benefits from the charity during the year.
Page 8
Trust Board
Report Cover Sheet Agenda Item: 7
Date of Meeting: 25 September 2012
Report Title: Calendar of Board Meetings
Purpose of Report: To inform the Board of the planned Board meeting dates for 2013.
Decision:9 Discussion: Assurance: Information:
Corporate Objectives report relates to: (Including reference to any specific risk)
Recommendations: To approve the calendar of Board meeting dates for 2013. (Action required by Board of Directors)
Financial Implications: None
Risk Management None Implications:
Human Resource None Implications:
Equality and Diversity None Implications:
Author: Mrs D Atkinson, Trust Secretary
Presented by: Mrs D Atkinson, Trust Secretary
Gateshead Health NHS Foundation Trust
Board of Directors Meetings 2013
During 2013 the Board of Directors will hold 8 public meetings in addition to the Annual General Meeting.
Date Venue Time 23 January Room 3 Trust HQ 10.30am
27 March Room 3 Trust HQ 10.30am
24 April Room 3 Trust HQ 10.30am
26 June Room 3 Trust HQ 10.30am
24 July Room 3 Trust HQ 10.30am
24 September Room 3 Trust HQ 10.30am (Tuesday)
24 October Room 3 Trust HQ 10.30am (Thursday)
27 November Room 3 Trust HQ 10.30am
Annual General Meeting 25 September To be confirmed To be confirmed
Extraordinary Meetings held in Private (To be confirmed) 15 May Approval of Annual Plan 10.30am
22 May Approval of Annual Report & Accounts 1pm
Trust Board
Report Cover Sheet Agenda Item: 08
Date of Meeting: 25th September 2012
Report Title: Performance Report
Purpose of Report: To provide an update on performance against national and local targets, ensuring the Board remains up to date with the Trust’s performance in light of national and local requirements. Decision: Discussion: Assurance: √ Information:
Corporate Objectives Achieving national targets and best in class performance. report relates to: (Including reference to any specific risk)
Recommendations: For Assurance (Action required by Board of Directors)
Financial None Implications:
Risk Management Implications:
Human Resource No Implications:
Equality and Diversity No Implications:
Author: Yvonne Ormston, Deborah Renwick
Presented by: Yvonne Ormston
1 Paper for Board of Directors Meeting Agenda Item: 08 Tuesday 25 September 2012
Gateshead Health NHS Foundation Trust
PERFORMANCE REPORT
1. Purpose of the Report
This report provides an update on performance against national and local targets at the end of August 2012, providing a summary of:
• Performance governance indicators measured against Monitor’s Compliance Framework; • Summary of current risks to performance and; • Care Quality Commission (CQC) performance dashboard, appendix A;
2. Performance Executive Summary
2.1 Compliance Framework
The Trust reported 3 cases of C.difficile in July and there have been no further incidences of Trust reportable cases in August; the Trust is therefore within the quarterly trajectory allowance of 5. There have been no cases of MRSA reported in July and August.
In July the Trust achieved compliance against the 18 week non admitted 95th percentile measure and the admitted 90th percentile measure at both Trust and specialty level. Whilst the Trust achieved compliance against these measures at Trust level in August, specialties reported as underachieving are urology and general surgery. In August the percentage of patients who are still waiting on incomplete 18 week pathways remains at 94.8%, above the national tolerance, although the reported number of patients waiting remain higer than the Trust’s historic average. Issues remain with data backlog and data quality issues following the recent PAS implementation. The management of data quality and on-going PAS training remains an important success factor in tracking 18 week pathways and ensuring that robust reports and reporting mechanisms are in place. The Trust continues to monitor and manage the risks pertaining to the PAS implementation and on-going data validation on a weekly basis to ensure compliance across the suite of indicators.
Despite the Trust’s historical trend to under-perform against the 4 hour target in July and August, the Trust has managed to achieve compliance reporting 95.1% in July and 95.2 in August. At the time of writing this report Q2 to-date performance stands at 95.4%.
The data relating to cancer performance measures are still subject to patchwide validation and is therefore provisional at the time of writing this report, however, despite the earlier difficulties relating to cancer reporting from Medway, the Trust reports compliance across the suite of access measures.
There are no delays to report against the measure monitoring the transfer of care for patients, who are currently on a mental health pathway.
The Trust is therefore currently on track to achieve compliance across the full suite of governance indicators in Quarter 2, as detailed in the Compliance Framework dashboard in Section 2.
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2.2 Local Supporting Measures
The Trust is slightly under the target which measures the proportion of women breast feeding at the time of delivery, reporting quarter 2 performance at 68.4% against a target of 68.8% as agreed with Commissioners under the CQUIN suite of indicators.
In quarter 2 the Trust has managed to improve the performance position published against the CQUIN quality measure, ‘smoking at time of delivery’, reporting compliance of 15.43% against a target which sets performance achievement at less than 16.65%.
In A&E pressures continue against 2 of the 5 quality measures which monitor the flow in the department. Difficulties persist in the measures which monitor time to initial assessment and time to decision to treat.
2.3 Local Systems Issues
Following the implementation of Medway, difficulties in PAS reporting, data quality issues and incomplete clinical coding have resulted in a ‘limited’ performance report for month 5. These issues are now being managed and escalated through a daily task force team to ensure that risks to performance are minimised and managed, and to also ensure that reporting and a robust informatics service is resumed, as soon as possible.
3. Performance Executive Summary
The Trust is on plan to achieve all targets currently covered in the Compliance Framework, subject to further validation of data relating to cancer performance. Management of A&E performance across the suite of performance indicators remains a high priority to the Trust.
4. Recommendations
The Board is requested to receive this report for information and assurance of compliance against the governance indicators in the Compliance Framework and local supporting measures of improvement management relating to performance in July and August.
Yvonne Ormston Deborah Renwick Director of Transformation & Compliance Strategic Head of Performance
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1. Compliance Framework Dashboard
Targets – weighted 1.0
Target/ Trajectory YTD Q1 Jul & Aug Target 2012/13 2012/13 Clostridium difficile 11 5 3 Annual trajectory allowance of 21 MRSA Objective 1 0 0 Annual trajectory allowance of 1 Referral to Treatment Maximum time of 18 weeks 90% 97.9% 95.2% - Admitted Referral to Treatment Maximum time of 18 weeks 95% 98.9% 97.1% - Non Admitted Referral to Treatment Maximum time of 18 weeks 92% 98.3% 93.7% - Incomplete pathways Total time in A&E - 4 hours 95% 95.03% 95.2%
Minimising mental health delayed transfers of care (national <=7.5% 0% 0% reporting) 98% 100% 100% Maximum waiting time of 31 day subsequent Drugs treatments for all cancers Surgery 94% 98.4% 95.7%
GP Referral 85% 89.6% 86.4% Maximum 62 day wait for first treatment Screening 90% 100% 100%
Referral to 50% 94.9% 90.5% Treatment Referral 50% 84.4% 100% Data completeness : Community dataset Information Treatment Activity 50% 76.4% 93.2% Information Patient (Shadow Monitoring) identifiable 50% 97.0% 98.4% information
Targets – weighted 0.5
Target /Trajectory Target Q1 Q2 2012/13 2012/13
Data completeness: identifiers 99% 99.6% 99.3%
Data completeness: outcomes for patients on CPA 50% 100% 100%
Maximum waiting time of 31 days from diagnosis to treatment for all 96% 99.7% 99.7% cancers
Maximum waiting time of 2 weeks from urgent GP 2ww 93% 94.3% 95.3% referral for all urgent suspect cancer referrals
4 Breast 93% 96.1% 95.7%
Certification against compliance for access to healthcare for people Yes/No Yes Yes with a learning disability
Based on the information and data currently available, the Trust has achieved all governance indicators, giving the Trust a performance Risk Rating of ‘GREEN’ for the year to date. Cancer data remains unvalidated.
2. Trust Activity Plan
This report is unable to publish the performance positions of actual activity against plan. Issues arising from the recent PAS implementation are: • clinical coding backlogs, • general data quality issues and; • issues in mandatory reporting and minimum data set production.
However, an estimate of month 5 activity can be obtained from August’s Finance & Activity Report.
3. Productivity & Efficiency
The programme for Improving Clinical Performance continues to progress work in areas to increase productivity and improve efficiency. Work-streams are progressing to reduce lengths of stay, readmissions and streamline the discharge process. However, unfortunately due to issues arising from the recent PAS implementation the Trust is unable to accurately report productivity and efficiency metrics in these areas.
4. Trust Performance
4.1 18 Week Waiting Times
Following the re-newed public interest to achieve the 18 week target, and subsequent Department of Health communications underlining the intention to review all waiting-times including planned waits, the following section provides an update to the Board, detailing current performance and local position. This section replaces the previous outpatient waiting times section, measuring access to outpatient services only.
The measures are as follows: the median and 95th percentile for admitted (completed) pathways, non-admitted (completed) pathways and incomplete pathways. The table below shows the national thresholds, and GHNFT’s performance against quarter 1, July and August. The measures are assessed monthly using aggregate Trust performance rather than at specialty level.
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4.12 Referral to Treatment Time Measures & Performance
Median 95th Completed Outpatient Pathways (Non-admitted) % Wait percentile National Thresholds 95% <6.6 <18.3 Total GHNT (all specialties) – Q1 98.9% 3.30 12.13 Total GHNT (all specialties) – July 99.4% 4.90 16.11 Total GHNT (all specialties) – August 97.6% 4.60 16.51 95th Completed Inpatient Pathways (Admitted Adjusted) % Median percentile National Thresholds 90% <11.1 <27.7 Total GHNT (all specialties) – Q1 97.9% 8.30 17.26 Total GHNT (all specialties) – July 98.5% 7.46 17.06 Total GHNT (all specialties) – August 95.5% 6.50 17.72
Incomplete pathways (combined admitted and non- 95th admitted) % Median percentile National Threshold 92% <7.2 <36 Total GHNT (all specialties) – Q1 98.3% 3.63 14.57 Total GHNT (all specialties) – July 96.4% 4.42 16.77 Total GHNT (all specialties) – August 94.8% 5.40 18.31 Figure 1 – Q1/Q2 RTT Measures & Performance
The table above demonstrates that the Trust’s performance is currently well within required parameters for all of these measures. At the time of writing this report the Trust did not however achieve compliance across all specialties in August.
4.13 Patients waiting over 18 weeks
The reported numbers of patients waiting over 18 weeks has increased at the end of July and August. The table and graphs below show the Trust-wide reported monthly position.
Total numbers of waiters and numbers over 18 weeks
Totals Apr May June July August Total Waiters 4,660 4,339 4,406 7,738 9,814 18+ Incomplete Pathways 82 71 75 274 512 Over 26 week Incomplete Pathways 27 16 17 51 77 Over 52 week Incomplete Pathways 0 0 0 0 0 Figure 2 – Q1 RTT Over 18 week waiters
The specialities with the highest numbers of patients waiting over 18 weeks at the end of August were General Surgery (269) and Trauma and Orthopaedics (82). Further validation is required to ensure accurate and robust reporting in all specialties.
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4.2 Mental Health Indicators
The three mental health measures included in the framework to assess the Trusts performance are:
Minimising Delayed Transfers of Care Data Completeness: identifiers Data Completeness: outcomes
4.21 Minimising Delayed Transfers of Care
This indicator is used as an overall measure of quality in assessing the impact of community-based care in facilitating timely discharge from hospital and the mechanisms in place within the hospital to facilitate timely discharge. People should receive the right care in the right place at the right time and primary care trusts must ensure, with acute trusts, non-acute trusts and social services partners that people move on from the acute environment once they are safe to transfer. The Community Care Delayed Discharges Act 2003 facilitates joint working with social services and requires partners to identify the causes of delay, and implement the actions required to tackle delays within their local system. Although this is an all adult indicator the vast majority of those delayed are patients aged over 75 years. Information regarding delayed transfers of care is now collected for non-acute and mental health as well as acute patients on the SITREP return. Therefore, the guidance now applies to non-acute and mental health, as well as acute patients.
Mechanisms are now in place to ensure robust data capture and compliance surrounding local and national data definitions.
In previous performance reports this measure has been highlighted as a specific risk, and although elements of the risk remain i.e.
(i) relatively small numbers of admissions and; (ii) beds commissioned by external organisations.
In quarter 2 the Trust reports no delays, the Trust is compliant against this measure.
4.22 Data Completeness - Identifiers
Monitor has included this indicator, with a 0.5 weighting as a measure of effectiveness in assessing mental health processes. Patient identity data completeness metrics from the mental health minimum dataset consist of:
• NHS number • Date of birth • Postcode (normal residence) • Current gender • Marital status • Registered General Medical Practice organisation code • Commissioner organisation code
The graph below depicts performance against the completeness criterion by quarter.
7 MHMDS Data Completeness 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Q1 Q2 Q3 Q4 Performance Target
Figure 3 – Q2 MHMDS data completeness
The table below depicts compliance against specific data sets requirements.
Identifiers - Monthly Monitoring Q2 -2012/13 Total demographic records 4720 NHS Number 4589 97.2% Date of birth 4720 100.0% Postcode (normal residence) 4716 99.9% Current gender 4720 100.0% Registered General Medical Practice Code 4690 99.4% Commissioner organisation code 4687 99.3% Performance 28122 99.3% Figure 4 – Q1 Data Completeness - Identifiers
The data quality group progresses areas for improvements in this area, overall performance at 99.3% indicates compliance against this measure.
4.23 Data Completeness - Outcomes
Monitor have included this indicator, with a 0.5 weighting as a measure of effectiveness in assessing mental health processes for adult patients with a Care Programme Approach (CPA). The measure applies to the adults aged between 18-69 who have received secondary mental health services, and have the following elements captured within their assessment within the past 12 months:
o HoNOS assessment o Employment status o Accommodation status
Q2 performance indicates 100% data completeness in the 3 data fields above.
8 4.3 Additional Quality Measures
4.31 A&E Indicators
The dashboard below represents performance to date relating to the new quality measures in A&E. These indicators were removed from the Compliance Framework in Q2 2011/12, although the Trust has chosen to continue monitoring arrangements as a supporting measure of quality and patient flow.
Target /Trajectory Target Q1 Q2 2012/13 2012/13 A&E Clinical Quality: 4 hours 4 hours 4 hours Total Time in A&E – 95th Percentile
A&E Clinical Quality: 15 mins 19 minutes 23 minutes Time to Initial Assessment -95th Percentile
A&E Clinical Quality: 1 hour 11 1 hour 6 60 mins Time to Treatment Decision - Median minutes minutes
A&E Clinical Quality: <5% 3.8% 2.7% Unplanned re-attendance rate
A&E Clinical Quality: <5% 4.5% 4.6% Left Without being seen Figure 5 – Q1 A&E Quality Indicators
It is anticipated that the implementation of Rapid Access and Treat (RAT), to commence in October will improve performance against the two ‘RED’ measures identified above.
4.4 Community data: Data Completeness
New to the compliance framework for 2012/13 are the standards surrounding data completeness for community services. The new standards cover the following three areas concerning data completeness:
o RTT times; o Community referral activity; o Community contact activity;
Failure against any threshold will result in a 1.0 score, with the overall impact capped at 1.0, however failure to meet three quarters will result in a red-rating. Monitor has also reserved the right to include two further data items later in 2012/13, comprising:
o Patient identifier information; o Patient’s dying at home;
This indicator is applicable to the Trust for the provision of MSK Physiotherapy services. The data below indicates the following levels of compliance:
9 % of fields % of fields Category Target populated Q1 populated Q2 Referral to Treatment >50% 94.9% 90.5% Community Referral >50% 84.4% 100% Community Treatment >50% 76.4% 93.2%
Figure 6 – Q1 Community Data Completeness
The indicator relating to patients dying at home is not applicable to the Trust, we do however shadow monitor the patient identifier information, performance against this indicator stands at 98.4% above the 50% target.
10 Appendix A CQC - Performance Indicator Director Monitor Target Q1 Q2 Year Anticipated Lead Risk 2012/13 2012/13 Year End Rating National Commitments Data Quality for Ethnic Group IP JC >=85% 90.96% 92.92% 93.03% Delayed Transfers of Care YO <=3.5% 1.12% 1.62% 1.32% 4 hour Maximum Wait YO >=95% 95.03% 95.19% 95.1% 2 Week Wait for RACP YO >=98% 100% 100% 100% Cancelled Operations – 28 days <=0.8% 0.22% 0.24% 0.23% PH Admitted 28 days >=95% 100% 100% 100% National Priority Indicators Breast Feeding Initiative JC >68.8% 68.3% 68.4% 68.3% Smoking During Pregnancy LH DRAFT <16.65% 16.67% 15.43% 16.17% Experience of Patients GMC Inpatient Survey Participation in Heart Disease Audits GMC To be confirmed Engagement in Clinical Audits GMC To be confirmed Stroke Care 90% on stroke Unit YO 80% 83.7% 81.5% 82.9% % Patients with TIA treated <24 YO 60% 75.0% 75.0% hours Maternity – Data Quality Indicators JC <=15% 1.09% 1.51% 1.30% MRSA bacteraemia GMac 1.0 < 4 0 0 0 MSSA GMac 2 2 4 E Coli (Data collection started June GMac 48 34 82 2011) Clostridium Difficile Incidence GMac 1.0 21 5 3 8 18 Weeks Admitted within 18 weeks YO 1.0 > = 90% 97.9% 98.2% 98.0% 18 Weeks Non Admitted within 18 YO 1.0 > = 95% 98.9% 97.1% 99.0% weeks 18 weeks Incomplete pathways within 1.0 > = 92% 98.3% 93.7% 97.6% 18 weeks 2 Week Wait Cancers GMac >=93% 94.3% 95.3% 94.5% 0.5 2 Week Wait Breast Symptoms GMac >=93% 96.1% 95.7% 96.0% 31 Day diagnosis to treatment GMac 0.5 >=96% 99.5% 99.7% 99.1% 31 Day diagnosis to treatment Drugs GMac 1.0 >=98% 100% 100% 100% 11 31 Day diagnosis to treatment Surgery GMac >=94% 98.4% 95.7% 96.3% 62 Day Referral to treatment GMac >=85% 89.6% 88.9% 89.4%
62 Day Referral to treatment GMac 1.0 >=90% 100% 100% 100% screening 62 Day Referral to treatment GMac >=85% 80% 91.7% 83.8% upgraded th Time in A&E (95 percentile) YO 1.0 4 hours 4 hours 4 hours 4 hours A&E Time to Initial Assessment YO 0.5 15 minutes 19 mins 23 mins 21 mins A&E Time to treatment decision YO 0.5 60 minutes 1h 11m 1h 06m 1h 09m A&E Unplanned Re-attendance Rate YO 0.5 <5% 3.8% 2.7% 3.4% A&E Left without being seen YO 0.5 <5% 4.5% 4.6% 4.5% Cellulitis – Cellulitis – A&E Ambulatory Care Conditions YO 0.5 35.1% 35.1% DVT – 14.3% DVT – 14.3% Mental Health Data Completeness – YO 0.5 99% 99.6% 99.3% 99.5% identifiers Mental Health Data Completeness - YO 0.5 50% 100% 100% 100% outcomes Mental Health Delayed Discharges YO 1.0 7.5% 0% 0% 0% National Reporting MRSA Elective Screening GMac >100% 195.94% 195.6% 195.8% Community dataset Data GMac 1.0 50% 94.9% 90.5% 93.1% Completeness – Referral to treatment Community dataset Data GMac 1.0 50% 84.4% 100% 88.3% Completeness – Referral Community dataset Data GMac 1.0 50% 76.4% 93.2% 78.9% Completeness – Treatment activity Community dataset Data GMac 1.0 50% 97.0% 98.4% 98.2% Completeness – Patient Id’s
Local Indicators Director Monitor Target Q1 Q2 Q3 Q4 Year Anticipated Lead Risk 2012/13 2012/13 Year End Rating th 18 week RTT Admitted 95 Percentile YO/JC/PH <23 weeks 17.26 18 week RTT Admitted Median YO/JC/PH <11.1 8.3 18 week RTT Non Admitted 95th YO/JC/PH <18.3 12.13 Percentile /GM weeks
12 YO/JC/PH 18 week RTT Non Admitted Median <6.6 3.33 /GM Admitted – Pain Admitted – Pain Mgt, RTT All specialties achieving % YO/JC/PH/ All Mgt, Non admitted N/A Non admitted Surgery, Plastics standards GM Specialties Surgery, Plastics Patients Waiting > 26 weeks YO/JC/PH N/A 60 128 188 Slot Issues YO/JC/PH/ N/A 4% 8% 8% GM Mixed Sex Accommodation breaches GMac N/A 0 0 0
Area New Director Monitor Target Commentary Risk Indicators for Lead Risk 2012/13 Rating 2012/13 Rating Quality A&E Service YO Service experience is now monitored and published quarterly Experience Quality A&E Consultant YO The Audit is now complete – findings will form part of the overall quality Sign-off improvement plan. Patient Self GMac 0.5 Assessment completed experience certification against compliance with requirements regarding access to healthcare for people with a learning disability ioQuality Minimum PH Ongoing NHSLA Level 1 compliance Quality CQC regulatory PH None currently action Quality Quality GMac Internal audit is completed – no significant risks identified. framework
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Trust Board
Report Cover Sheet Agenda Item: 9
Date of Meeting: Tuesday 25 September 2012
Report Title: Finance and Activity Report – June 2012
Purpose of Report: Decision: Discussion: Assurance:√ Information:
Corporate Objectives 3. To deliver the Trust’s financial plan report relates to: (Including reference to any specific risk)
Recommendations: The Board is asked to note the reported financial performance at 31 (Action required by Board August 2012 of Directors)
Financial Implications: As included in the report
Risk Management Potential risk if delay in achieving the planned efficiency saving in Implications: year
Human Resource None Implications:
Equality and Diversity None Implications:
Author: Mr Jon Connolly, Director of Finance and Information
Presented by: Mr Jon Connolly, Director of Finance and Information
Finance and Activity Report – August 2012 EXECUTIVE SUMMARY
The attached paper provides a summary of performance against plan for activity, income and expenditure as at August 2012. The implementation of Medway PAS during the month of July has resulted in a range of data quality issues, several of which still need to be resolved, relating to the accuracy of the activity information and therefore the income. The current position has significantly improved from the July report as an inpatient file was available this month, but a range of estimates have still been made for those remaining areas affected and commissioners have been notified of the situation.
Activity Activity information has improved this month with information available for most activity lines, including inpatients, and data validation is still ongoing with a number of areas have been identified within the report for further detailed validation. The plan and its phasing have been agreed in line with PCT/CCG commissioning intentions for South of Tyne & Wear Commissioning Consortium and other PCTs/CCGs. Work is ongoing with commissioners to understand variances from plan.
Income The cumulative clinical income to August is showing a positive variance of £16k although there are some significant movements between PCTs. Other Non-NHS clinical income is above plan with NHS Injury Scheme and TSS both above plan. Non-clinical income in the Divisions continues to be above plan.
Total over-recovery of income against plan at Month 5 is £143.4k.
Expenditure At month 5 the Trust is showing an over spend on total operating expenses of £2,190.2k with all of the clinical divisions overspending against plan, as detailed in the table in section 8 of the report. Clinical Supplies is the main area of overspend to date. The Wave Programme Management Tool is planned to be in place by mid October to support the progress, monitoring and performance management of the Efficiency Programme.
Total cumulative overspend against expenditure plans at Month 5 is £2,315.2k.
Summary against Plan The Trust had a planned surplus of £2,441.6k at month 5. The actual position is a surplus of £269.8k resulting in an unfavourable variance against plan of £2,171.8k. The position worsened against plan in month by £607.5k, reflecting a worsening in the reported income position, and to a lesser degree, an unfavourable movement in the expenditure position which includes the Efficiency Programme.
Statement of Position The cash position for August has decreased by £1.37m to £18.30m. Although Creditor payments were higher than forecast for the month, this included capital cash payments of £1m. The reduction in the cash position contributed to an overall decrease of £1.6m on Total Current Assets. Total Current Liabilities also decreased however, by £1.4m, resulting in an overall decrease of £0.1m on Net Current Assets.
Performance against Annual Plan Performance against the Trust’s Annual Plan submitted to Monitor plan is showing a unfavourable variance of £338.3k, which gives a Financial Risk Rating (FRR) for August of 3, which is as planned. The financial risk indicators introduced in the Compliance Framework are detailed in section 9.3 and show 2 areas of risk for the Trust, relating to: two changes in Finance Director within the last 12 months and capital expenditure is less than 75% of plan for the year to date.
Forecast Outturn Forecast outturns will be included in this report from Month 6/Quarter 2.
1 Summary & Balanced Scorecard
This paper provides the Board of Directors with details of Finance and Activity Performance to the end of Month 5 (31st August 2012).
Ref 1. Activity and Clinical Income Activity (Var) Amount £ (Var) 1.1 Clinical Activity/Income (In month) N / A Ø 1.1 Clinical Activity/Income (YTD) N / A × Ref 6. Summary Financial Performance In Month YTD (£000's) 6.1 Net I & E (Surplus) / Deficit (269.8) 6.1 Net I & E (Surplus) / Deficit - Variance 2,171.8 6.1.1 Private Patient Cap % 0.2% 6.2 Cash Position 18,299 6.3 BPPC- 30 days (on £) 97.7% 97.5% 6.3 BPPC- 30 days (count in month) 97.2% 97.2% 6.4 Trust Summary CRP removed from budget (3,574) 9 Monitor Financial Risk Rating 3
Ref 8. Net Divisional Position In Month (£000's) YTD (£000's) 8.1 Clinical Support and Screening Services 64 204 8.2 Medicine and Elderly 80 489 8.3 Surgical Services 17 1,359 8.4 Womens and Childrens Services 3 208 8.5 Non-Clinical Services (61) (322)
Ref 6.4 & 8. Divisional CRP achieved Achieved (£000's) Balance (£000's) Clinical Support and Screening Services (415) 507 Medicine and Elderly (726) 781 Surgical Services (685) 2,551 Womens and Childrens Services (86) 403 Non-Clinical and Corporate Services (1,660) 707
Ref Key Financial Risks Non-achievement of CQUIN target and application of financial penalties Income from commissioners varies significantly Mental health income levels Structural changes to commissioning process Replacement PAS system Failure to deliver efficiency target and programme Inflation estimates vary from planned Divisions overspend against budget Slippage or overspend on capital plan
KEY Significant risk of non delivery Medium risk of non delivery Low risk of non delivery
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1. Activity & Clinical Income
Total Operating Income is shown below analysed by source, including a detailed breakdown of NHS Clinical Income by commissioner.
1.1 Clinical & SLA Income Analysis - August 2012
2012/2013 2012/2013 2012/2013 Variance Actual to Date Prev. Month Revised Budget Budget To Date (Inc CQUIN) Variance £000's £000's £000's £000's £000's NOTE Clinical Income (by Commissioner) Operating Income Contracted Activity Gateshead ( 123,990.9) ( 51,117.7) ( 51,540.6) ( 422.8) ( 25.7) Gateshead Community Commissioning ( 260.9) ( 108.7) ( 108.0) 0.7 2.8 Gateshead MSK ( 110.2) ( 45.9) ( 75.5) ( 29.6) ( 15.2) Sunderland Teaching ( 16,989.2) ( 6,983.2) ( 7,185.4) ( 202.2) ( 106.6) County Durham ( 6,351.3) ( 2,624.3) ( 2,916.1) ( 291.8) ( 327.7) South Tyneside ( 5,834.7) ( 2,404.4) ( 2,692.4) ( 288.1) ( 319.7) Yorkshire SHA - BCSP Hub ( 1,556.9) ( 648.7) ( 519.0) 129.8 0.0 Yorkshire SHA - BCSP Centre ( 312.0) ( 130.0) ( 130.0) ( 0.0) ( 0.0) NHS Screening Breast ( 298.1) ( 124.2) ( 124.2) ( 0.0) ( 0.0) Northumberland Care Trust ( 1,631.0) ( 683.9) ( 437.7) 246.2 131.6 Norscore ( 1,969.2) ( 770.4) ( 761.7) 8.7 ( 91.0) Yorkshire and Humber SCG ( 2,658.7) ( 1,107.8) ( 890.1) 217.7 0.0 Newcastle ( 1,831.3) ( 762.4) ( 567.2) 195.1 123.5 North Tyneside ( 788.4) ( 330.6) ( 330.7) ( 0.1) ( 79.2) Cumbria ( 694.8) ( 294.6) ( 181.6) 113.0 46.6 Overseas ( 12.8) ( 5.4) ( 10.4) ( 5.1) ( 3.8) Darlington PCT Gateshead Distinction Awards ( 144.7) ( 60.3) ( 60.3) 0.0 0.0 Dept Of Health NHS North East ( 49.0) ( 49.0) SHA Drugs Pool ( 694.0) ( 274.1) ( 184.6) 89.4 27.9 Blackpool PCT ( 5.8) ( 5.8) Non-Contracted Activity NCA - England ( 1,195.0) ( 459.2) ( 212.0) 247.2 212.5 NCA - Scotland ( 95.8) ( 39.5) ( 11.8) 27.7 20.3 NCA - Wales ( 7.6) ( 3.2) ( 5.3) ( 2.1) ( 4.4) NCA - Ireland Other ( 21.6) ( 9.2) ( 4.2) 5.0 2.9 Gateshead Council South Tynside Council ( 0.2) ( 0.2) ( 0.2) Sunderland Council ( 0.6) ( 0.6) ( 0.6) Other Miscellaneous Income
Total NHS Clinical Revenue ( 167,449.8) ( 68,988.4) ( 69,004.4) ( 16.0) ( 405.0) General ( 431.9) ( 180.6) ( 11.6) 169.0 133.2 IVF ( 565.0) ( 235.4) ( 126.7) 108.7 56.9 Patients Charges ( 31.1) ( 13.0) ( 12.6) 0.4 ( 0.1) Total Private Patient Revenue ( 1,028.0) ( 428.9) ( 150.8) 278.1 189.9 6.1.1
Other non-NHS clinical revenue (NHS Injury Scheme) ( 891.8) ( 371.6) ( 460.5) ( 88.9) ( 84.3)
Total Non NHS Clinical Revenue ( 891.8) ( 371.6) ( 460.5) ( 88.9) ( 84.3) Other Operating Income Education and Training ( 5,590.5) ( 2,398.3) ( 2,396.4) 1.9 ( 0.5)
( 5,590.5) ( 2,398.3) ( 2,396.4) 1.9 ( 0.5) SLA Income Gateshead PCT SLA South Tyneside PCT SLA Northumberland, Tyne & Wear Trust SLA Newcastle Hospitals FT SLA ( 414.5) ( 172.7) ( 172.7) Northumbria FT SLA TSS ( 739.5) ( 303.5) ( 354.4) ( 50.9) ( 65.0) SPIRE National Osteoporosis Society City Hospitals FT SLA
Total SLA ( 1,154.0) ( 476.2) ( 527.1) ( 50.9) ( 65.0)
Total Clinical & SLA Income ( 176,114.1) ( 72,663.5) ( 72,539.2) 124.2 ( 364.8)
% Private Patient Income as a proportion of NHS Clinical Revenue 0.22%
3 It has not been possible to produce an analysis of income at POD level this month. It is hoped to be able to do this by next month.
2. A&E Activity
The 2012-13 plans for A&E are based upon figures from the PCT. As at August, activity in A&E was under plan by 356 attendances (6.5%) and the cumulative year to date position is 1,356 attendances under plan (4.9%). Income is also under plan in August, making cumulative year to date income down by £164.4k. As with last year, activity in low value attendances was down by 788 attendances (30.8%) in the month (3,712 year to date) but partly offset by increases in other more complex attendances. One of the reasons for this is the use of the PCT’s activity plan which has a lower value casemix. There are currently 643 un-coded attendances. As with all other activity types data validation is ongoing as a result of the Medway PAS implementation.
The graph below depicts monthly activity variation against activity baseline.
A&E Activity vs Baseline Variance 2012/13 4,000
3,000
2,000
1,000 521 11 111
Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 (1,000) Attendances (2,000)
(3,000)
(4,000)
CAT 0 CAT 1 CAT 2 CAT 3 CAT 5 #N/A
3 Elective & Day Case
This includes long stay elective income and day case activity but excludes Excess Bed Days which are analysed separately in section 5.5.
Inpatient activity has been provided this month and has been refreshed April-August. The outstanding major issues on inpatient activity are:
• Endoscopy unit data is not yet available so an estimate has been made for the 6 weeks outstanding based on first three months casemix. This issue is still ongoing with Medway. • Elective activity is currently not split by inpatient and daycase but simply recorded as inpatient. This issue has now been resolved and will be correct going forward. • Clinical coding has approximately 1,200 un-coded spells outstanding. Work is ongoing on this backlog but for August reporting the income system has pro-rated the un-coded activity across the current actual casemix as an estimate of its value.
In August, total elective activity (based on discharge activity) is above plan by 364 spells (14.3%); with the cumulative year to date position under plan by 193 spells (1.5%). In August long stay elective is over plan by 1,023 spells (213.8%) which is due to the activity not being split between daycase and inpatient. This makes the cumulative position 3,726 spells over plan (149.6%). Daycase activity in August is below plan by 659 spells (32.0%), with a cumulative position of 3,920 spells below plan (36.5%).
4 Electives ‐ Activity vs Plan 3,500
3,000
2,500
2,000
Spells Actual 1,500 Plan
1,000
500
4 Non Elective Care
This excludes Excess Bed Days which are analysed separately in section 5.5. Changes in Payment by Results (PbR) have led to a number of reclassifications this year. Consequently our non elective baseline has been rebased in line with these changes and agreed with the PCT.
Total non-elective activity in August was above plan by 447 spells (21.5%), with a cumulative year to date position of 2,003 spells (19.4%) above plan. Non elective income in August is below plan by £246.4k (6.9%), with a cumulative year to date position of £438.9k (2.5%) above plan.
An analysis at specialty level shows some significant variances, with over activity in Paediatrics of 630 spells (39.4%) and Gynaecology of 550 spells (329.0%) being offset by underperformance in Obstetrics of 595 spells (28.5%) and General Medicine of 305 spells (4.9%). Some of this variation is down to known data recording issues which are currently being worked upon.
The graph below depicts non-elective spell performance.
Non Electives ‐ Activity vs Plan 3,500
3,000
2,500
2,000 Actual Spells 1,500 Plan
1,000
500
Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13
5 5 Other Activity
5.1 Outpatient Activity
Changes in PbR have introduced a new category of activity – Non Elective Same Day (NELSDOP) for Ambulatory Care activity. This activity is recorded in outpatients and is identified separately for the first time this year. The plan has been agreed in conjunction with the PCT and covers a range of conditions which previously would have been a non elective admission.
For August, Outpatient activities are under plan by 4,512 attendances or 24.0%. New activity is under plan by 717 attendances or 16.4%; follow-up appointments are down against plan by 2,521 attendances or 20.5% and outpatients with procedures are down against plan by 1,273 attendances or 60.6%. NELSDOP activity is sourced via inpatient PAS and not available for this month.
5.2 Consultant Outpatient Activity Cumulative as at August Consultant led attendances are 5,536 (9.3%) below plan New attendances – 4,180 (19.6%) below plan Follow up attendances – 406 (1.2%) below plan National Tariff procedures – 950 (27.2%) below plan
5.3 Non Consultant Led (Nurse Led) Attendances Cumulative as at August Nurse Led attendances are 3,181 (9.9%) below plan New attendances – 1,966 (440.4%) above plan Follow up attendances – 3,213 (17.5%) below plan Local tariff procedures – 1,934 (36.3%) below plan
5.4 Non Elective Same Day NELSD activity is currently 389 attendances.
The table below highlights both the in-month and year to date position.
Month of August Year To Date Plan Actual Variance % Variance Plan Actual Variance % Variance Consultant Led New 4,288 3,136 (1,152) (26.9%) 21,325 17,145 (4,180) (19.6%) Follow up 7,085 5,665 (1,420) (20.0%) 34,905 34,499 (406) (1.2%) Nat. Procedures 739 234 (505) (68.3%) 3,492 2,542 (950) (27.2%) Total Consultant Led 12,112 9,035 (3,077) (25.4%) 59,722 54,186 (5,536) (9.3%) Non Consultant Led New 88 523 435 494.6% 447 2,413 1,966 440.4% Follow up 5,238 4,137 (1,101) (21.0%) 26,444 23,231 (3,213) (12.2%) Local. Procedures 1,362 594 (768) (56.4%) 5,333 3,399 (1,934) (36.3%) Total Non Consultant Led 6,689 5,254 (1,435) (21.4%) 32,224 29,043 (3,181) (9.9%) NELSDOP NELSDOP 389 389 Total NELSD 389 389 Grand Total 18,801 14,289 (4,512) (24.0%) 91,946 83,618 (8,328) (9.1%)
Procedures 2,101 828 (1,273) (60.6%) 8,826 5,941 (2,885) (32.7%) New 4,376 3,659 (717) (16.4%) 21,771 19,558 (2,213) (10.2%) Follow Up 12,323 9,802 (2,521) (20.5%) 61,349 57,730 (3,619) (5.9%) NELSDOP 389 389 Total 18,801 14,289 (4,512) -24.0% 91,946 83,618 (8,328) -9.1%
5.5 Excess Bed Days
Overall, excess bed days are over performing against plan by 387 days (85.6%) for the month of August. Elective excess bed days are under performing against plan by 35 days (36.4%), and non-elective excess bed days are also under performing against plan by 352 days (98.7%). Year to date position shows an under performance on elective beddays of 24 (4.8%) and over performance on non elective of 1,194 (69.7%).
6 5.6 Day Care
As at August Palliative Medicine is under plan by 12 attendances (15.8%), Psycho-geriatrics is under plan by 102 attendances (26.0%) and Geriatric Medicine is under-plan by 59 (33.0%) attendances. The year to date position is under plan by 54 attendances (16.7%) for Palliative Medicine, 358 attendances (17.7%) for Psycho-geriatrics and 217 attendances (26.5%) for Geriatric Medicine.
5.7 High Cost/Live Bed Days
Changes in the PbR now dictate that inpatient Palliative Medicine is recorded as high cost bed days and the analysis now includes this specialty. In August high cost bed days are under plan by 75 bed days (0.3%). Income is over against plan by £67.2k (0.8%), with under performance in Old Age Psychiatry and Geriatric Medicine offset by over performance in Critical Care, SCBU & Palliative Medicine. The year to date position is shown below:
Activity Income (£) Aug-12 Plan Actual Variance Plan Actual Variance 192 - Critical Care 1,827 1,901 74 2,890,310 3,011,315 121,005 315 - Palliative Medicine 906 1,094 188 285,706 301,797 16,091 422 - Neonatology (SCBU) 974 1,286 312 421,123 547,423 126,300 430 - Geriatric Medicine 13,538 13,085 (453) 2,887,279 2,750,008 (137,271) 715 - Psycho-geriatrics 5,239 5,043 (196) 1,569,889 1,510,990 (58,899) Total 22,484 22,409 (75) 8,054,307 8,121,533 67,226
5.8 CQUIN (Commissioning for Quality and Innovation)
The High Quality Care for All Framework made a proportion of the providers’ income conditional on the delivery of key targets on quality and innovation. This is known as a CQUIN payment (Commissioning for Quality and Innovation). For 2012/13 the planned level is now 2.5% and the Trust has an agreed schedule with the PCT which sets out indicators to achieve the level of 2.5% of income. CQUIN income is shown included within each Point of Delivery. As at August our estimation of the percentage of the CQUIN scheme achieved is 2.28% and our income reflects this figure.
7 6. Summary Financial Performance
Statement of Comprehensive Income - August 2012
2012/2013 2012/2013 2012/2013 2012/2013 Variance Prev. Month Variance Draft Opening Current Annual Budget To (Budget - Annual Plan Budget Date Actual to Date Actual) £000's £000's £000's £000's £000's £000's Operating Operating Income A&E (attendances) ( 6,434.0) Elective Income (Long Stay)(inc. xbd) ( 16,988.0) Daycases ( 15,115.0) Non-Elective Income (inc. xbd) ( 44,293.0) Outpatients (New, Follow Up & Proc) ( 27,911.0) Other ( 56,589.0) Total NHS Clinical Revenue ( 167,330.0) ( 167,449.8) ( 68,988.4) ( 69,004.4) ( 16.0) ( 405.0) Private Patient Revenue ( 1,010.0) ( 1,028.0) ( 428.9) ( 150.8) 278.1 189.9 Other non-NHS clinical revenue ( 891.6) ( 891.8) ( 371.6) ( 460.5) ( 88.9) ( 84.3) Total Non NHS Clinical Revenue ( 1,901.6) ( 1,919.8) ( 800.5) ( 611.3) 189.2 105.6 Other Operating Income Education and Training Income ( 5,858.2) ( 5,590.5) ( 2,398.3) ( 2,396.4) 1.9 ( 0.5) Misc. Other Operating Income Divisional Income ( 8,651.0) ( 8,373.2) ( 4,024.8) ( 4,268.3) ( 243.5) ( 197.1) Donations & Grants Received ( 125.0) ( 125.0) ( 52.1) 52.1 41.7 SLA Income ( 1,154.0) ( 476.2) ( 527.1) ( 50.9) ( 65.0) Total Other Operating Income ( 14,634.2) ( 15,242.7) ( 6,951.4) ( 7,191.8) ( 240.4) ( 220.9)
Total Operating Income ( 183,865.8) ( 184,612.3) ( 76,740.3) ( 76,807.6) ( 67.3) ( 520.2)
Operating Expenses Drugs 12,674.9 10,041.4 5,308.6 5,177.0 ( 131.7) ( 85.9) Clinical Supplies 19,244.4 16,687.1 7,139.0 7,432.6 293.6 356.2 Non-Clinical Supplies 11,940.7 13,125.2 5,612.5 5,582.5 ( 30.0) ( 21.3) Total Raw Materials & Consumables 43,860.0 39,853.6 18,060.1 18,192.1 131.9 249.0
Employee Benefits, Permanent Staff 118,472.1 120,375.2 50,364.1 49,405.4 ( 958.7) ( 548.6) Employee Benefits, Agency + Contract Staff 1,246.0 33.4 33.7 960.1 926.4 708.6 Total Employee Benefits Expenses 119,718.1 120,408.6 50,397.8 50,365.5 ( 32.3) 160.0
Education and training expense 1,012.8 543.4 246.1 183.5 ( 62.6) ( 36.1) Consultancy Expense 493.2 182.3 96.9 92.3 ( 4.6) ( 25.9) Misc. other Operating expenses 10,422.0 9,060.5 3,756.5 3,852.2 95.7 25.6 Cost Improvement Programme (Divisional) ( 4,948.9) ( 2,062.1) 2,062.1 1,667.0 Reserves 10,981.2
Total Operating Expenses 175,507.0 176,080.7 70,495.4 72,685.6 2,190.2 2,039.7
(Profit)/Loss from Operations ( 8,358.8) ( 8,531.6) ( 6,244.9) ( 4,122.0) 2,122.9 1,519.4
Non Operating Non-Operating Income Finance Income ( 152.0) ( 152.0) ( 63.3) ( 114.5) ( 51.2) ( 38.5) Other Non - Operating Income (PCT) ( 399.9) ( 400.0) ( 400.0) ( 424.9) ( 24.9) ( 24.9) Other Non-Operating Income ( Profit on Disposal ) ( 1,800.0) ( 1,800.0) Total Non-Operating Income ( 2,351.9) ( 2,352.0) ( 463.3) ( 539.5) ( 76.1) ( 63.5) Non-Operating Expenses Interest Payable 60.3 50.3 50.3 0.0 0.0 Interest Expense on Finance Leases 36.0 46.9 25.9 17.0 ( 8.9) ( 7.1) Depreciation and Amortisation 3,609.6 3,819.4 1,606.7 2,532.3 925.6 690.7 Depreciation and Amortisation - assets held under finance leases 110.4 26.4 26.4 26.4 PDC dividend expense 3,300.0 3,300.0 1,375.0 1,355.8 ( 19.2) ( 15.3) Total Finance Costs [for non-financial activities] 7,056.0 7,226.7 3,057.9 3,981.9 924.0 694.8 Other Non-Operating Expenses Impairment Losses 4,944.6 4,945.0 1,208.7 325.2 ( 883.5) ( 662.5) Restructuring Costs Other Non-Operating expenses 84.5 84.5 76.0 Total Non-Operating Expenses 12,000.6 12,171.7 4,266.6 4,391.6 125.0 108.3
(Surplus) Deficit After Tax from Continuing Operations 1,290.0 1,290.0 ( 2,441.6) ( 269.8) 2,171.8 1,564.3
Total Income ( 186,217.7) ( 186,964.3) ( 77,203.6) ( 77,347.0) ( 143.4) ( 583.7)
Total Expenses 187,507.6 188,252.3 74,762.0 77,077.2 2,315.2 2,148.0
EBITDA ( 8,233.8) ( 8,406.6) ( 6,192.8) ( 4,122.0) 2,070.8 1,477.8
8 Statement of Position - August 2012
2011/2012 2012/2013 2012/2013 2012/2013 2012/2013
March EoY Draft Annual Variance - Prior 2012Plan July 2012 August 2012 Month £000's £000's £000's £000's £000's NOTE Assets Non-Current Assets Intangible Assets, Net Property, Plant and Equipment, Net 105,770.2 121,629.0 106,929.5 106,983.4 53.9 Trade and Other Receivables, Net 3,440.9 3,353.0 3,479.8 3,491.7 12.0 Total Non Current Assets 109,211.0 124,982.0 110,409.3 110,475.2 65.8 7 Current Assets Inventories 2,116.6 2,011.0 2,037.0 2,049.8 12.8 Trade and Other Receivables, Net 5,076.8 4,778.0 5,701.0 5,475.5 ( 225.6) Prepayments 1,145.1 1,145.0 2,001.3 2,008.8 7.5 Cash and Cash Equivalents 20,823.8 28,319.0 19,673.4 18,298.6 ( 1,374.8) Accrued Income 189.7 190.0 310.8 338.9 28.1 Total Current Assets 29,352.0 36,443.0 29,723.4 28,171.5 ( 1,551.9) Liabilities Current Liabilites Deferred Income 5,348.3 5,500.0 4,437.5 4,524.4 86.8 Provisions 962.5 773.0 899.4 839.5 ( 59.9) Current Tax Payables 2,307.0 2,343.0 2,282.3 2,242.9 ( 39.4) Trade and Other Payables 7,731.5 9,073.0 8,257.0 6,080.1 ( 2,176.9) Other Financial Liabilities(Accruals) 4,197.5 3,500.0 2,302.5 2,816.8 514.3 Other Financial Liabilities(Finance Leases) 103.3 103.0 76.9 76.9 Other Liabilities (PDC Dividend) 1,084.7 1,355.8 271.2
Total Current Liabilities 20,650.0 21,292.0 19,340.3 17,936.4 ( 1,403.9)
NET CURRENT ASSETS (LIABILITIES) 8,702.0 15,151.0 10,383.2 10,235.1 ( 148.0)
Non-Current Liabilities Provisions 2,742.0 2,159.0 2,909.7 2,909.7 Loans Non Commercial FTFF 2,000.0 14,600.0 4,600.0 4,600.0 Other Financial Liabilities(Finance Leases) 199.3 199.0 199.3 199.3 Other Financial Liabilities (Lennartz) 1,239.6 733.0 980.6 980.6 Total Non-Current Liabilities 6,181.0 17,691.0 8,689.6 8,689.6
TOTAL ASSETS EMPLOYED 111,732.0 122,442.0 112,102.9 112,020.7 ( 82.2)
Tax Payers' and Others' Equity Minority Interest Taxpayers Equity Public Dividend capital 99,515.2 111,515.0 99,515.2 99,515.2 Retained Earnings (Accumulated Losses) ( 5,234.9) ( 6,525.0) ( 4,867.0) ( 4,937.0) ( 70.0) Donated Asset Reserve Other Reserves Revaluation Reserve 17,352.7 17,353.0 17,355.7 17,343.5 ( 12.2) Miscellaneous Other Reserves 99.0 99.0 99.0 99.0 Total Other Reserves
TOTAL TAXPAYERS EQUITY 111,732.0 122,442.0 112,102.9 112,020.7 ( 82.2) TOTAL ASSETS EMPLOYED 111,732.0 122,442.0 112,102.9 112,020.7 ( 82.2)
6.1 Summary Financial Performance
At the end of August the Statement of Comprehensive Income is showing a net operating surplus of £269.8k year to date, which is a £2,171.8k unfavourable variance against plan (previous month £1,564.3k). Total operating income is showing a surplus against budget of £67.3k, with clinical contract income (NHS clinical revenue) showing a surplus of £16.0k.
The net position against divisional budgets income & expenditure is showing an over spend of £1,937.9k. A detailed divisional position is shown in section 8 and progress against the Efficiency Programme plan in section 6.4.
9 6.1.1 Private Patient Income
At the end of month 5, the Trust’s income from private sources stands at 0.2% of relevant income, which is within our current private patient cap of 0.3%, and the majority of this is still IVF income. The Trust has planned an increase in this income following the change in legislation which greatly increases the scope for Trusts to earn additional private patient income. This increase was planned from Q2 but will now not be in place until 1st October following confirmation of the implementation timetable for the Act. The Central Team are considering the parameters for this to enable the policy to be updated and implemented and a paper with options, reporting changes and resource requirements will be presented in September.
6.2 Cash/Debtors
The actual cash position for August 2012 was £18.30m. Total Current Assets have decreased in total by £1,551.9k this month, due to decreases in cash of £1,374.8k and Trade and Other receivables of £225.6k which are offset by increases in Inventories of £12.8k, Prepayments of £7.5k and Accrued Income £28.1k. The decrease in cash reflected an increase in capital cash payments in August and a general trend of higher paybills compared to last financial year in some areas.
Interest Organisation Nature Of Deposit Rate Amount Santander Fixed Term To 03.11.2012 1.60 % £ 3,500,000 Nat West / RBS Fixed Term To 28.03.2013 3.00 % £ 3,000,000 Lloyds Fixed Term To 09.10.2012 1.50 % £ 5,000,000 Citibank Bank £ 6,595,898 Lloyds Bank £ 184,766 Petty Cash, Franking Machines, un- Cash in hand presented cheques and un banked deposits £ 17,956 Total £ 18,298,620
The graph below shows the movement in cash position over August 2012:
6.2 Cash Flow Graph - August 2012
40000000
35000000
30000000
£
25000000
20000000
15000000 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 05 04 03 02 01 31 30 29 28 27 26 25 24 23 22 Date ACTUAL (INC INVESTMENTS) FORECAST ANNUAL PLAN‐QUARTER 2
10 6.3 Creditors & Better Payments Practice Code
In the month, Total Current Liabilities have decreased by £1,403.9k, including decreases of £2,176.9k relating to Trade and Other Payables, Provisions £59.9k and Current Tax Payables £39.4k. These are offset by increases in Deferred Income £86.8k, Accruals £ 514.3k and PDC Dividend £271.2k.
The Trust is complying with the request from Monitor to pay non-NHS, local small to medium-sized suppliers within 10 days to support the economy at this time. Performance against the Better Payments Practice Code (30 days) is currently excellent as a result and is as follows:
2012/13 % Bills Paid Month Volume Value April 98.1% 97.3% May 96.4% 95.4% June 98.0% 98.8% July 96.2% 97.6% August 97.2% 97.7% Total Cumulative 97.2% 97.5%
6.4 Efficiency Programme
The Trust Efficiency Programme for 2012/13 is monitored on a monthly basis with the Trust target being a total of £8.523m. The table below shows progress against this target to date. The ‘Total Removed’ indicates the annual amount removed from the 2012/13 budgets, £3.574m as at month 5. The full target has now been allocated directly to all Divisions but still on an interim basis as work continues on defining the benefits realisation of the large transformational initiatives.
Total Balance Target CRP Removed Remaining (£000's) (£000's) (£000's)
Clinical Support & Screening Services 923 ( 415) 507
Medicine and Elderly 1,508 ( 726) 781
Surgical Services 3,236 ( 685) 2,551
Womens and Childrens Services 490 ( 86) 403
Non Clinical and Corporate Services 2,367 ( 1,660) 707
Total 8,523 ( 3,574) 4,949
7. Non-Current Assets
Capital additions have increased by £605k in August to a total of £4,078k. The main areas of increase in August are Emergency Care Centre and associated works (£84k), Pathology (£45k), Chemotherapy (£110k), Palliative Care (£16k), Endoscopy (£42k), Call Centre relocation (£108k), IP Telephony (£46k) and Pharmacy upgrade (£26k).
11 8. Divisional Budgets
Divisional Income and Expenses Analysis - August 2012
Current Workforce In Month Cumulative Annual Contracted Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget WTE WTE WTE WTE £000 £000 o.s/(u.s) £000 £000 o.s/(u.s) £000 (A-B) £000 £000 NOTE
CLINICAL SERVICES
Clinical Support & Screening Services 35,254.4 660.3 713.4 648.3 ( 65.1) 2,939.1 3,003.0 63.9 14,703.9 14,908.0 204.1 8.1
Medicine & Elderly 40,250.5 791.2 818.4 819.7 1.3 3,635.4 3,715.2 79.7 17,663.9 18,152.5 488.6 8.2
Surgical Services 39,691.6 642.6 677.2 652.5 ( 24.7) 3,403.9 3,420.9 17.0 16,729.3 18,088.1 1,358.8 8.3
Womens & Childrens Services 10,390.5 207.8 217.9 206.6 ( 11.3) 873.6 876.1 2.6 4,338.6 4,546.9 208.3 8.4
TOTAL CLINICAL SERVICES 125,587.0 2,301.8 2,426.8 2,327.0 ( 99.8) 10,852.0 11,015.2 163.2 53,435.7 55,695.5 2,259.8
NON CLINICAL SERVICES
Chief Executive 2,031.1 28.0 30.4 28.6 ( 1.8) 169.5 158.0 ( 11.5) 847.2 809.4 ( 37.7)
Estates & Facilities 18,792.5 323.3 363.9 343.1 ( 20.8) 1,572.1 1,502.1 ( 69.9) 7,863.9 7,761.4 ( 102.5)
Finance & Information 6,526.2 163.4 168.7 174.9 6.2 571.4 604.0 32.6 2,796.4 2,752.2 ( 44.2)
Health Development 3,037.0 62.4 66.0 58.5 ( 7.5) 259.6 240.6 ( 19.0) 1,218.2 1,087.2 ( 130.9)
Nursing & Midwifery 3,530.4 84.1 86.9 87.6 0.7 284.5 291.6 7.0 1,458.6 1,452.1 ( 6.6)
TOTAL NON CLINICAL SERVICES 33,917.2 661.3 715.8 692.7 ( 23.1) 2,857.1 2,796.3 ( 60.8) 14,184.2 13,862.4 ( 321.9) 8.5
TOTAL EXPEND. & DEPT. INCOME 159,504.2 2,963.1 3,142.6 3,019.7 ( 123.0) 13,709.1 13,811.5 102.5 67,619.9 69,557.8 1,937.9
Divisional Position Variance (000's) ‐600 ‐400 ‐200 0 200 400 600 800 1000 1200 1400 1600
Clinical Support & Screening Services
Medicine and Elderly Jun‐12 Jul‐12 Aug‐12 Surgical Services Division
Womens and Childrens Services
Non‐Clinical Services
At the end of the August delegated budgets showed a net over-spend of £1,937.9k. All of the clinical divisions have a cumulative overspend at month 5 of £2,259.8k. All of the non-clinical divisions are under spent. The financial positions for the Divisions, together with a commentary, are as follows:
12
8.1 Clinical Support & Screening Services (£204.1k deficit)
Discussion of the Current Financial Position
The Divisional allocation of the Trust Efficiency Programme balance outstanding remains at £507k, 5/12ths of this is £223k, which accounts for the majority of the Divisions cumulative overspend position at August. Overall Directorates continue to perform well against budget. The main issues to highlight continue to be: Radiology overspend of £127k, an in month movement of £59k, driven mainly by the use of a Locum Radiologist, Waiting List Work and off-site Reporting. This is compounded by the additional planned spend required for the Locum Ultrasonographer covering maternity leave, however this is being closely monitored to ensure that a balanced budget is achieved by year end. Endoscopy continues as previous months and is now £28k overspent due to increased activity. These pressures continue to be offset by smaller underspends across the Division, which may be identified as non recurrent CRP opportunities to support the 2012-13 position until bigger workstream savings can be identified and quantified.
Future Action Points
Efficiency schemes identified and actioned amount to £415k (£383k Recurrently, £32k Non Recurrently). The annual balance outstanding is £507k, towards which the Division continues to scope a range of potential opportunities:- • Following successful notification of their successful pilot site bid for Flexible Sigmoidoscopy Screening, the phased implementation plan is being scoped and the 1st lists are currently profiled to commence in June 2013. • AAA North West programme is progressing, the phased implementation plan schedules the 1st lists to start from January 2013. • PLICS work streams have been established for Radiology and Endoscopy and are developing mechanisms for the allocation of costs per test / procedure to support the wider SLM/SLR plans. • The ST&T work stream are meeting regularly to develop plans and, in conjunction with this work, establishment reviews are ongoing across a number of staff areas which are being closely monitored on a monthly basis. • The Clinic Management Workstream (Outpatients) is also meeting regularly and the project structure has been defined. Work is progressing to analyse potential opportunities within this work stream. • The Division continues to await the outcome of two Any Qualified Provider (AQP) bids for the provision of Community Based Anti Coagulation Services for Non-Complex Patients and also a bid for the Direct Access Adult Hearing Service.
Clinical Support & Screening Services ‐ Year to Date 2012‐13
12,000,000
10,422,845 10,321,108 10,000,000
8,000,000
6,000,000 5,689,457 5,210,004 £
4,000,000
2,000,000
0
‐928,954 ‐1,102,565 ‐2,000,000
PAY YTD Budget PAY YTD Actual NON PAY YTD Budget NON PAY YTD Actual INCOME YTD Budget INCOME YTD Actual
13 8.2 Medicine and Elderly (£488.6k deficit)
Discussion of the Current Financial Position
Divisional staffing is currently overspent by £193.4k which is a positive movement of £0.6k on the previous month. This overspend is in relation to £185.8k for Nursing, £21.3k for Senior Medical, due mainly to Agency and locum waiting list payments, and a small Junior Medical overspend of £1.1k, this being offset by underspends elsewhere in the Division relating mainly to PTB staff of £17.9k due to vacant posts. In addition, drugs are now under spent by £33.4k which is an increase of £11.0k in the month (due mainly to non recurrent slippage on the ICAR Unit), and Medical and Surgical Equipment is currently underspent by £0.4k with other non pay items overspending by £3.5k. The CRP target for the Division is £1,507.6k of which £726.4k has been actioned to date (£816.1k recurrently), the shortfall being reflected in the deficit reported above.
Future Action Points
The Division continues to scope CRP schemes currently identified within the programme, and investigate other potential areas of efficiency in 2012/13 and future years. Work streams have been set up to look at efficiencies in relation to NEIP and OP schemes and identify opportunities. Bank staff spend continues to be actively monitored and in addition to the on-going nurse bank working group, ward meetings continue to be held with the Divisional manager with a view to identifying areas of expenditure reduction in order to meet the £65k target identified. The Division remains focused on all areas of possible tendering, both internal and external, in order to maximise potential income streams.
Medicine & Elderly‐ Year to Date 2012‐13
16,000,000
13,824,906 14,032,222 14,000,000
12,000,000
10,000,000
8,000,000 £
6,000,000
4,224,542 3,926,889 4,000,000
2,000,000
0 ‐87,905 ‐104,251
‐2,000,000
PAY YTD Budget PAY YTD Actual NON PAY YTD Budget NON PAY YTD Actual INCOME YTD Budget INCOME YTD Actual
8.3 Surgical Services (£1,358.8k deficit)
Discussion of the Current Financial Position
Surgical Services had an adverse move in August of £17k, which can be attributed to a number of areas. Medical staff budgets have had an adverse move of £6.1k which is locum consultant costs in Anaesthetics and Surgery and a locum SHO post in Trauma and Orthopaedics. The locum spend is offset in August by a credit for an overcharge of PGI medics in June and July. The unachieved efficiency plan also contributes £212.5k to the adverse move in August. Nursing budgets are showing a favourable move of £1k due to vacancies of £70.6k offset by nurse bank usage of £69k. This is an improvement in previous months due to the monitoring and visits of senior staff around the wards. Clinical services and supplies contributed £149.2k favourable move due to low spend in prosthetics and MSE which is aligned to activity and theatre lists for August with 115 cancelled lists for annual leave and sickness. 14
The CRP target for the Division is £3235.7k and £403.3k has been achieved year to date, the shortfall being reflected in the deficit reported above.
Future Action Points
Surgical Services continues to constantly review its financial position in order to identify and scope potential areas for efficiency. Current work streams within the Division include the following: - Prosthetics Workshop - the work stream involves a multi disciplinary team which has now met six times to resolve problems in prosthetics ordering and reconciliation of expenditure to activity. The group are currently testing quarter one data through August and are confident that they will be able to match expenditure on elective prosthetics to the patient and therefore the activity income. Supplies and Procurement efficiencies continue to be achieved within the division through competitive tendering; £20k has already been achieved on one tender to date which has contributed to the efficiency programme. The division is continuing to address consultant and theatre productivity with monitoring of theatre start times and activity in order to gain further efficiencies. Currently Surgical Services have managed to restrict the use of Third party providers and achieved a saving in April - July of £418.5k which has been allocated against the efficiency target and is a continued trend through August.
Surgical Services ‐ Year to Date 2012‐13
14,000,000 12,876,394 12,250,489 12,000,000
10,000,000
8,000,000
£ 6,000,000 5,365,647 4,589,948
4,000,000
2,000,000
0 ‐111,145 ‐153,966
‐2,000,000
PAY YTD Budget PAY YTD Actual NON PAY YTD Budget NON PAY YTD Actual INCOME YTD Budget INCOME YTD Actual
8.4 Women and Children’s Services (£208.3k deficit)
Discussion of the Current Financial Position
Women's and Children's had an adverse move in the month of August of £2.6k. Paediatrics contributes £10.2k to the adverse move and the main reason behind this is the unachievement of the efficiency plan. Women’s Services had a favourable move in month of £7.6k due to vacancies across the wards. The efficiency target for the Division is £489.6k and £86.4k has been achieved to date, the shortfall being reflected in the deficit reported above.
Future Action Points
Women’s and Children’s are constantly striving to complete new plans in order to achieve their efficiency program. They have had very progressive ideas for the future and are currently working to make them reality, schemes such as the 4D scanning in maternity and the Digi pens for midwives. This will have the effect of bringing in income as well as saving on admin and clerical time in the Division.
15 Women & Childrens ‐ Year to Date 2012‐13
4,500,000 4,261,429 4,199,726
4,000,000
3,500,000
3,000,000
2,500,000
£ 2,000,000
1,500,000
1,000,000
546,911.00 500,000 292,827
0
‐215,660 ‐199,760 ‐500,000
PAY YTD Budget PAY YTD Actual NON PAY YTD Budget NON PAY YTD Actual INCOME YTD Budget INCOME YTD Actual
8.5 Non Clinical Services (£321.9k surplus)
Discussion of the Current Financial Position
All of the non-clinical services are under-spending:
- Chief Executive £37.7k – The divisional position shows a favourable movement of £11.5k in August, reflecting continued under-spends on non staff expenditure and vacant posts within Projects and Non-Executive Directors. The Division’s CRP target of £125.3k has been fully achieved. - Estates & Facilities £102.5k – The combined Division had a favourable movement of £69.9k this month. This position reflects lower expenditure against Building & Engineering Maintenance schemes in the month, but is still predominantly driven by staff vacancies within the ancillary staff groups which are generating significant under-spends. Cumulatively, income targets within Facilities are also overachieving against budget and there are under-spends in non staff areas in Catering, CSSD, Laundry and Transport. The overall interim CRP target for the Division is £1,037.4k, of which £465.1k has been achieved to date. - Finance & Information £44.2k – The adverse movement of £32.6k in August is due to consultancy fees incurred to maximise VAT savings (£12k), continued spend on bank staff within Health Records (£3k), audit fees (£9k) and the unachieved element of the CRP target (£9k). Cumulatively, under- spends on both staff and non-staff budgets within Finance, Information and IT are offsetting the current overspend within Health Records and the unachieved element of the CRP target. Income recovery within Finance is also well ahead of plan. The CRP target allocated to the Division is £446.6k, of which £338.8k has been achieved to date and further savings are planned to be actioned for quarter 2. - Health Development £130.9k – Under-spends due to staff vacancies and reduced hours throughout the Division, along with under-spends on SIFT and other non staff spend, are offsetting the unachieved element of the CRP target. These factors, along with reduced expenditure on study leave applications, led to a favourable movement of £19.0k in the month. Further CRP schemes have been identified in August, reducing the outstanding balance to £26.7k, from an initial target of £187.8k. - Nursing & Midwifery £6.6k – For the year-to-date position, vacancies have led to under-spends on staff budgets (notably in Risk Management), and there are currently non-staff under-spends within 16 Control of Infection and Nursing Admin. The Division has seen an adverse movement of £7.0k in August, reflecting the under-recovery of income within the Day Nursery. The CRP target allocated to the Division is £159.1k, and this has now been fully achieved, although £69.5k is from non- recurrent measures.
Future Action Points
All non-clinical service areas continue to develop their efficiency plans, working towards achievement of the stretch targets that have now been allocated to divisions. Some of the efficiency measures being proposed within Estates & Facilities require further examination to understand the risks and agree the full implications of the schemes, and discussions around this are continuing.
Further work will be undertaken to understand the budget position in relation to energy costs as budgets were increased for 2012/13 for projected pressures. The energy budget position has shown only a slight movement from last month.
Following implementation of the new charging structure in the Day Nursery, this budget continues to be closely monitored in respect of staffing, occupancy and income levels.
The non-clinical Divisions are also taking forward a number of Trust-wide initiatives which should increase efficiency and produce savings, including an Accelerating the Bigger Picture work stream around Back Office functions, the print strategy project currently underway, a review of the provision of maintenance agreements and reviewing existing arrangements for estates and facilities.
Non‐Clinical Divisions ‐ Year to Date 2012‐13
12,000,000
10,000,000 9,638,143 8,936,031
8,000,000 7,634,125 7,227,237
6,000,000
£ 4,000,000
2,000,000
0
‐2,000,000
‐2,681,144 ‐2,707,777 ‐4,000,000
PAY YTD Budget PAY YTD Actual NON PAY YTD Budget NON PAY YTD Actual INCOME YTD Budget INCOME YTD Actual
Whole Time Equivalents
An analysis of Whole Time Equivalents (WTE) for month 5 shows that the actual WTE for the month is lower than the budgeted WTE with a difference of 123 WTE.
17 Monthly WTE (Paid/Worked)
WTE (Budget) WTE (Contracted) WTE (Actual) WTE (Budget) 11‐12 WTE (Actual) 11‐12
3,250
3,200
3,150
3,100
3,050
WTE 3,000
2,950
2,900
2,850
2,800 Dec Jan Feb Mar Apr May Jul Jun Aug Sep Oct Nov ‐ ‐ ‐ 12 ‐ ‐ ‐ ‐ ‐ ‐ ‐ 13 ‐ 12 12 12 13 ‐ 12 12 12 12 13 12
Month
9. Monitor
The Trust submitted its Annual Plan for 2012/13 to Monitor on 31st May 2012 and received feedback on 31st July. The Trust has also now received feedback from Monitor on the Quarter 1 submission and this has been shared widely with Divisional and senior management.
9.1 Financial Risk Rating
The table below shows the Financial Risk Rating at the end of August being a 3, which is in line with the planned risk rating. As at the end of August, the variance against the Monitor plan is an unfavourable variance of £338.3k.
Underlying performance EBITDA Margin rating 3 EBITDA % of plan achieved rating 5
Financial Efficiency Net return after financing rating 3 IS Surplus margin rating 2
Liquidity Liquidity days rating 4
Financial Risk Rating 3
The Compliance Framework states that the Trust must self-certify that the Board anticipates that the Trust will continue to maintain a Financial Risk Rating (FRR) of at least 3 over the next 12 months. This will be done on a quarterly basis to coincide with the quarterly returns made to Monitor.
18 9.2 August Performance against the Plan submitted to Monitor
The income and expenditure position for August can be seen in the table on the following pages. This shows a £269.8k surplus, which gives rise to a unfavourable variance of £338.3k against the Monitor year to date plan.
9.3 Compliance Framework Financial Risk Indicators
The Compliance Framework includes various national targets and standards that Monitor use as triggers to identify whether a trust is at risk of breaching its terms of authorisation. The Compliance Framework includes a set of proposed financial risk indicators which are designed to highlight the potential for any future material financial risk. Where Monitor believes that one or more of these indicators are present, they will consider whether an earlier meeting to discuss them is appropriate. Following this meeting, Monitor may request the preparation of plans, or the provision of other assurances as to the Trust’s capacity to mitigate the potential risk. The use of the indicators will not form part of the formal regulatory framework or Monitor’s approach to the potential use of its statutory powers of intervention.
These indicators are included as a separate sheet in the Quarterly Monitoring to Monitor. For the current month, two indicators have been triggered by the Compliance Framework as shown below: - Two or more changes of Finance Director in a 12 month period - Clarification has been received from Monitor that a period of ‘acting’ Director is applicable, hence this will remain a ‘risk’ until the end of March 2013. - Capital expenditure is less than 75% of plan for the year to date – This reflects slippage on major schemes, particularly the Emergency Care Scheme and Pathology.
Please note that if the status of an indicator is left blank it is deemed that the Trust has no significant risk in that category and it is where the indicator is ‘TRUE’ that risk is present, hence the highlighting of these in red.
Compliance Framework Indicator Status Unplanned decrease in (quarterly) EBITDA margin in two consecutive quarters Quarterly self-certication by trust that FRR may be less than 3 in the next 12 months
FRR 2 for any one quarter Working capital facility (WCF) agreement includes default clause. Debtors more than 90 days past due account for more than 5% of total debtor balances Creditors more than 90 days past due account for more than 5% of total creditor balances Two or more changes in Finance Director in a twelve TRUE month period Interim Finance Director in place over more than one quarter end Quarter end cash balance less than 10 days of operating expenses Capital expenditure is less than 75% of plan for the TRUE year to date Capital expenditure is greater than 125% of plan for the year to date
19 9. Monitor - Performance against Annual Plan - August 2012
2012/2013 2012/2013 2012/2013 VARIANCE
Opening Annual Actual to Plan Plan to date Date (Plan-Actual) £000's £000's £000's £000's Operating Operating Income A&E (attendances) ( 6,434.0) Elective Income (Long Stay) (inc .xbd) ( 16,988.0) Day Cases ( 15,115.0) Non-Elective Income (inc. xbd) ( 44,293.0) Outpatients (New and Follow up) ( 27,911.0) Other ( 56,589.0) Total NHS Clinical Revenue ( 167,330.0) ( 69,194.0) ( 69,004.4) 189.6 Private Patient Revenue ( 1,010.0) ( 322.0) ( 150.8) 171.2 Other non-NHS clinical revenue ( 891.6) ( 371.5) ( 460.5) ( 89.0) Total Non NHS Clinical Revenue ( 1,901.6) ( 693.5) ( 611.3) 82.2 Education and Training Income ( 5,858.2) ( 2,440.0) ( 2,396.4) 43.6 Donations & Grants Received ( 125.0) ( 52.1) 52.1 Misc. Other Operating Income ( 8,651.0) ( 3,604.6) ( 4,795.5) ( 1,190.9) Total Other Operating Income ( 14,634.2) ( 6,096.7) ( 7,191.8) ( 1,095.2)
Total Operating Income ( 183,865.8) ( 75,984.2) ( 76,807.6) ( 823.4) Operating Expenses Drugs 12,674.9 5,045.4 5,177.0 131.6 Clinical Supplies 19,244.4 7,036.5 7,432.6 396.1 Non-Clinical Supplies 11,940.7 4,731.2 5,582.5 851.3 Total Raw Materials & Consumables 43,860.0 16,813.1 18,192.1 1,379.0 Employee Benefits, Permanent Staff 118,472.1 50,388.3 49,405.4 ( 982.9) Employee Benefits, Agency + Contract Staff 1,246.0 524.0 960.1 436.1 Total Employee Benefits Expense 119,718.1 50,912.3 50,365.5 ( 546.8) Education and training expense 1,012.8 422.0 183.5 ( 238.5) Consultancy Expense 493.2 205.5 92.3 ( 113.2) Misc. other Operating expenses 10,422.0 4,130.0 3,852.2 ( 277.8) Reserves Total Operating Expenses 175,507.0 72,482.9 72,685.6 202.7
(Profit)/Loss from Operations ( 8,358.8) ( 3,501.3) ( 4,122.0) ( 620.7) Non Operating Non-Operating Income Finance Income ( 152.0) ( 63.4) ( 114.5) ( 51.2) Other Non - Operating Income (PCT) ( 399.9) ( 399.9) ( 424.9) ( 25.0) Total Finance Income ( 551.9) ( 463.3) ( 539.5) ( 76.2) Other Non-Operating Income Other Non-Operating Income (Profit on Disposal) ( 1,800.0) Total Non-Operating Income ( 2,351.9) ( 463.3) ( 539.5) ( 76.2)
Non-Operating Expenses Interest Payable on Non-commercial borrowings 50.3 50.3 Interest Expense on Finance Leases 36.0 15.0 17.0 2.0 Depreciation and Amortisation 3,609.6 1,504.0 2,532.3 1,028.3 Depreciation and Amortisation - assets held under finance leases 110.4 46.0 26.4 ( 19.6) PDC dividend expense 3,300.0 1,375.0 1,355.8 ( 19.2) Total Finance Costs [for non-financial activities] 7,056.0 2,940.0 3,981.9 1,041.9 Other Non-Operating Expenses Other Non-Operating expenses 84.5 84.5 Restructuring Costs Impairment 4,944.6 416.5 325.2 ( 91.3) Total Non-Operating Expenses 12,000.6 3,356.5 4,391.6 1,035.1
(Surplus) / Deficit After Tax from Continuing Operations 1,290.0 ( 608.0) ( 269.8) 338.3
Total Income ( 186,217.7) ( 76,447.4) ( 77,347.0) ( 899.6)
Total Expenses 187,507.6 75,839.4 77,077.2 1,237.8
EBITDA ( 8,233.8) ( 3,449.2) ( 4,122.0) ( 672.8)
20
10 Forecast Outturn
Detailed forecast outturns will be included in this report from Month 6/Quarter 2 onwards, when trends and patterns of spend and income streams become clearer, but it is anticipated at this stage that the Trust will achieve the financial plan in 2012/13.
11 Recommendations
The Board is asked to:
• Note the reported financial performance at 31st August 2012.
Mr Jon Connolly Director of Finance & Information
21
Trust Board
Report Cover Sheet Agenda Item: 10
Date of Meeting: 25 September 2012
Report Title: Annual Management Letter 2011/12
Purpose of Report: The Trust receives an Annual Management Letter each year from our External Auditors which summarises the main issues resulting from the audit. The attached report for our 2011/12 audit has already been considered by the Trust’s Audit Committee at its meeting on 20 September 2012.
Decision: Discussion: Assurance: √ Information:
Corporate Objectives 2. Achieving the Trust’s financial plan report relates to: (Including reference to any specific risk)
Recommendations: The Board is asked to receive the report for information. (Action required by Board of Directors)
Financial Implications: None
Risk Management None Implications:
Human Resource None Implications:
Equality and Diversity None Implications:
Author: Mr Cameron Waddell, Engagement Lead
Presented by: Mr J Connolly, Director of Finance and Information
Management Letter Gateshead Health NHS Foundation Trust Audit 2011/12
Contents
Key messages ...... 3 Audit opinion and financial statements ...... 3 Value for money...... 3 Limited assurance opinion on the Quality Report ...... 3
Financial statements and Annual governance statement ...... 4 Overall conclusion from the audit...... 4 Significant weaknesses in internal control ...... 4
Securing economy, efficiency and effectiveness ...... 5
Other activity ...... 8 Payment by Results Data Assurance Framework...... 8 Ongoing independent support during the year...... 9
Closing remarks ...... 10
Appendix 1 – Fees...... 11
Appendix 2 – Glossary ...... 12
Audit Commission Management Letter 2
Key messages
This report summarises the findings from my 2011/12 audit. My audit comprises three elements: ■ the audit of your financial statements; ■ my assessment of your arrangements to achieve value for money in your use of resources; and ■ review of your quality report, including testing of two indicators.
Audit area Our findings Value for money Unqualified audit opinion I undertook work in line with the Audit Code for Foundation Trusts, and issued an unqualified certificate on 30 May 2012. Proper arrangements to secure value for money Limited assurance opinion on the Quality Report Limited assurance opinion on the Quality Report I issued a limited assurance opinion on the Quality Report on Audit opinion and financial statements 30 May 2012. This concluded that: ■ the Quality Report was prepared in line with Monitor's guidance and I issued an audit report including an unqualified opinion on the financial was not inconsistent with information specified by Monitor; and statements on 30 May 2012. My audit progressed smoothly, and ■ the two indicators in the Quality Report subject to my limited identified only a small number of errors. assurance work were reasonably stated.
Audit Commission Management Letter 3
Financial statements and Annual governance statement
The Trust’s financial statements and Annual governance statement are an important means by which the Trust accounts for its stewardship of public funds.
Overall conclusion from the audit I issued an audit report including an unqualified opinion on the financial statements on 30 May 2012. My audit progressed smoothly, and identified only a small number of errors. I identified no significant issues in the course of my audit. The two material errors that I identified were corrected by the Trust, and the draft financial statements were of a good quality overall; as were the standard of supporting working papers. The Trust's finance team were, once again, very cooperative whilst I undertook my work.
Significant weaknesses in internal control I identified no significant issues in respect of internal control.
Audit Commission Management Letter 4
Securing economy, efficiency and effectiveness
I assessed your arrangements for securing economy, efficiency and effectiveness in your use of resources.
Use of resources
To inform my work in this area I drew upon: ■ my audit work on the Annual governance statement as part of the audit of the financial statements; ■ my review of the Trust’s Quality Report; and ■ the results of the work of regulatory bodies, including Monitor and the Care Quality Commission. My work in these areas allowed me to satisfy myself that the Trust has maintained proper arrangements in securing economy, efficiency and effectiveness in its use of resources.
Annual Governance Statement
There were no issues arising from my review of the Trust’s Annual Governance Statement that led me to consider the Trust did not have proper arrangements in securing economy, efficiency and effectiveness.
Review of the Trust’s Quality Report
The foundation trust regulator (Monitor) defines the extent of the work auditors carry out on Quality Reports. On 15 March 2012 it published 'Detailed Guidance for External Assurance on Quality Reports 2011/12'. I based my work on that guidance.
Audit Commission Management Letter 5
Monitor's guidance required NHS foundation trusts to: ■ include a brief description of the key controls in place to prepare and publish a Quality Report in the Annual Governance Statement in the published accounts; ■ sign a Statement of Directors’ Responsibilities in respect of the content of the Quality Report and mandated indicators for inclusion in the annual report; ■ sign a Statement of Directors’ Responsibilities in respect of all other indicators included within the Quality Report to provide to their auditors; ■ include the signed limited assurance report provided by their auditors on the content of the Quality Report and the mandated indicators in the annual report; and ■ submit a copy of their auditors’ report on the outcome of the external work performed on the content of the Quality Report, and the mandated and local indicators, to Monitor and to the NHS foundation trust’s board of governors. Monitor required auditors to: ■ review the content of the Quality Report against the requirements set out in the 2011/12 NHS Foundation Trust Annual Reporting Manual; ■ review the content of the Quality Report for consistency against the other information sources detailed in section 2.1 of the Monitor guidance; ■ provide a signed limited assurance report in the Quality Report on whether anything had come to the attention of the auditor that led them to believe that the Quality Report had not been prepared in line with the requirements set out in the NHS Foundation Trust Annual Reporting Manual or was not consistent with the other information sources detailed in section 2.1 of the Monitor guidance; ■ undertake substantive sample testing of two mandated performance indicators and one locally selected indicator, to include, but not necessarily be limited to: − an evaluation of the key processes and controls for managing and reporting the indicators; and − sample testing of the data used to calculate the indicator back to supporting documentation; ■ provide a signed limited assurance report in the Quality Report on whether there was evidence to suggest that mandated indicators had not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual; and ■ provide a report (the ‘governors’ report’) to the NHS foundation trust board of governors of their findings and recommendations for improvements concerning the content of the Quality Report, the mandated indicators and the local indicator.
I therefore planned my work to: ■ review whether the content of your Quality Report was in line with Monitor guidance and not inconsistent with other specified information; and ■ test two performance indicators mandated by Monitor and one indicator selected by Governors from the Quality Report.
Audit Commission Management Letter 6
I issued a limited assurance opinion on the content of the Quality Report and testing of the two mandated indicators on 30 May 2012. This concluded that the Quality Report was prepared in line with Monitor's guidance and was not inconsistent with the information specified by Monitor, and that the two mandated indicators were reasonably stated. I reported my findings from my review and testing of the performance indicators to the Trust in the ‘governors’ report’. As I undertook my review on a draft version of the Trust’s Quality Report the Trust considered my findings and made a minor amendment before final publication.
Audit Commission Management Letter 7
Other activity
Payment by Results Data Assurance Framework The Audit Commission has managed an assurance framework for Payment by Results (PbR) at the request of the Department of Health since 2006/07. For 2011/12 the work programme included: ■ a national data assurance audit at the Trust; and ■ follow-up of all previous local work delivered by the assurance framework to ensure actions agreed have been completed and improvements secured.
National Assurance Audit
In previous years the PbR assurance framework has reviewed the accuracy of clinical coding and reported on the accuracy of the Healthcare Resource Group (HRG) assignment. In addition to reviewing clinical coding this year the audit looked at the accuracy all data items that affect the price commissioners pay the Trust for a spell under PbR rules. The new data items are: ■ age on admission; ■ admission method; ■ sex; and ■ length of stay (LoS).
From the audit sample, the Trust had 13.6 per cent of spells with an error that affected the price. This means that 13.6 per cent of spells had either a clinical coding error affecting the HRG or a data entry error (or both). Either error means the price that the commissioner was charged for that spell was wrong. If all the errors are added together there is a gross financial error of £18,068. The commissioners were overcharged by £7,016 for the errors in the audit sample.
Audit Commission Management Letter 8
Follow-up of previous work
The follow-up work covered the most recent recommendations from the different audits and reviews at the Trust. The audits and reviews were: ■ the inpatient clinical coding audit in 2009/10; ■ the outpatient data quality review in 2009/10; and ■ the reference costs review in 2010/11. The Trust has worked well to address the recommendations made in the three action plans for inpatients, outpatients and reference costs. Evidence of progress has been provided for all recommendations, ensuring a positive contribution to improvements in the quality of data supporting the Payments by Results regime: ■ all of the ten recommendations in the 2009/10 inpatients action plan have been addressed and are now complete; ■ all of the five recommendations within the outpatient action plan have been addressed and completed; and ■ one of the five recommendations from the Reference costs audit has been addressed and completed. Two of the recommendations have been partly superseded by the work ongoing following the introduction of a Patient Level Information Costing System (PLICS). The remaining two recommendations are expected to be actioned as part of the 2011/12 reference cost submission.
Ongoing independent support during the year During the year my team and I have continued to support the Trust in other ways, including: ■ attendance at Audit Committees. At these meetings, I inform the Committee about progress on the audit, report my key findings, and update it about developments in the NHS, foundation trusts, and the wider environment; ■ hosting seminars and events for trust staff, such as popular NHS Accounts workshops; and ■ facilitating quarterly meetings of the North East Audit Committee Chairs' network. This supports sharing of information and views, and encourages audit committee development across NHS bodies in the North East.
Audit Commission Management Letter 9
Closing remarks
I have discussed and agreed this letter with the Director of Finance. I will provide copies to all Board members. Further detailed findings, conclusions and recommendations in the areas covered by my audit are included in the reports issued to the Trust during the year.
Report Date issued
Strategic audit plan September 2011 External Audit Progress Report and Briefing To each Audit Committee meeting, as and when held Update to Audit Plan March 2012 Annual Governance Report May 2012 External assurance on the Trust’s Quality Report May 2012 Audit Opinion on the Financial Statements May 2012 Limited Assurance Report on the Quality Report May 2012
The Trust has continued to take a positive and constructive approach to my audit. As a result of the externalisation of the Audit Commission’s Audit Practice this will be the Audit Commission’s last Management Letter. I wish to thank the Trust for its support and co-operation during my audit in the past year and previous years.
Cameron Waddell, Engagement Lead June 2012
Audit Commission Management Letter 10
Appendix 1 – Fees
Actual 2011/12
Fees for work undertaken under the Audit Code: ■ Opinion on the Financial Statements, review of Annual Governance Statement, and 3Es conclusion; £37,500 ■ Work to support Whole of Government Accounts; and £1,400 ■ Review of Quality Report. £6,100 Total audit fees £45,000 Non-audit work £0 Total £45,000
Audit Commission Management Letter 11
Appendix 2 – Glossary
Annual Governance Statement
Public bodies must provide assurance that they are appropriately managing and controlling their money, time and people. The Annual Governance Statement (AGS) is an important document for communicating these assurances to Parliament and citizens. The AGS is the means by which the Chief Executive Officer declares his or her approach to and responsibility for, risk management, internal control and corporate governance. It is also used to highlight weaknesses which exist in the internal control system within the organisation. It forms part of the Annual Report and Accounts.
Audit opinion
On completion of the audit of the financial statements, I must give my opinion on the financial statements, including: ■ whether they give a true and fair view of the financial position of the audited body and its spending and income for the year in question; and ■ whether they have been prepared properly, following the relevant accounting rules. If I agree that the financial statements give a true and fair view and that the spending and income was regular, I issue an unqualified opinion. I issue a qualified opinion if: ■ I find the statements do not give a true and fair view; or ■ I cannot confirm that the statements give a true and fair view; or ■ I find that some spending or income was irregular.
Audit Commission Management Letter 12
If you require a copy of this document in an alternative format or in a language other than English, please call: 0844 798 7070 © Audit Commission 2012. Design and production by the Audit Commission Publishing Team. Image copyright © Audit Commission.
The Engagement Letter, issued by the Audit Commission, explains the respective responsibilities of auditors and of the audited body. Reports prepared by engagement leads are addressed to governors, members, non-executive directors, directors or officers and are prepared for the sole use of the audited body. Auditors accept no responsibility to: ■ any member, governor, non executive director, director or officer in their individual capacity; or ■ any third party.
www.audit-commission.gov.uk June 2012
Trust Board Report Cover Sheet Agenda Item: 11
Date of Meeting: 26th September 2012
Report Title: Healthcare Associated Infections
Purpose of Report: To update the Board on the current status of HCAI in Gateshead Health NHS Foundation Trust and advise the Trust Board of progress against the Annual Delivery Programme 2012-13
Decision: Discussion: Assurance: 9 Information:
Corporate Objectives Objective 3: Deliver of strategies focused on sustaining and report relates to: improving quality of service for all Trust patients to reflect best in class, reduction of harm and compliance with all CQC for standards (Including reference to any specific risk) quality and safety.
Recommendations: To note current and forecast performance on Healthcare (Action required by Board Associated Infections of Directors)
Financial Implications: Yes
Risk Management Yes Implications:
Human Resource No Implications:
Equality and Diversity No Implications:
Author: Viv Atkinson, Head of Infection Prevention and Control
Presented by: Gillian MacArthur, Director of Nursing and Midwifery and Joint DIPC
1. INTRODUCTION
Intensive work has been continued across the infection prevention and control team (IPCT) to support ward staff in root cause analysis (RCA) related to Clostridium difficile and E.coli bacteraemia patient management. It must be acknowledged that E.coli rates for the Trust present a challenge and discussions across the North East health economy recognise the importance of RCA. The Director of Infection Prevention and Control has introduced monthly Matron meetings which will provide a regular forum for in depth discussions related to the patient experience and best practice infection control. The Matrons play an important facilitating role in ensuring that the ward and departmental environment remains appropriate for patient care and staff are adequately supported regarding the IPC agenda and Trust expectations.
2. PERFORMANCE INDICATORS- Infection Prevention and Control (IPC)
Individual ward dips in performance against the IPC indicators are currently being supported by the IPC and relevent Matrons. Ward team performance remains under scrutiny with many wards achieving 100% compliance. The Standard precaution indciator will now feature as an additional measure for the Trust Board from October 2012.
Trust % Compliance Hand Hygiene 100.00 95.00 90.00 85.00 80.00 07/11/2011 14/11/2011 21/11/2011 28/11/2011 05/12/2011 12/12/2011 19/12/2011 26/12/2011 02/01/2012 09/01/2012 16/01/2012 23/01/2012 30/01/2012 06/02/2012 13/02/2012 20/02/2012 27/02/2012 05/03/2012 12/03/2012 19/03/2012 26/03/2012 02/04/2012 09/04/2012 16/04/2012 23/04/2012 30/04/2012 07/05/2012 14/05/2012 21/05/2012 28/05/2012 04/06/2012 11/06/2012 18/06/2012 25/06/2012 02/07/2012 09/07/2012 16/07/2012 23/07/2012 30/07/2012 06/08/2012 13/08/2012 20/08/2012 27/08/2012
Trust % Compliance Uniform Policy 100.00 95.00 90.00 85.00 80.00 07/11/2011 14/11/2011 21/11/2011 28/11/2011 05/12/2011 12/12/2011 19/12/2011 26/12/2011 02/01/2012 09/01/2012 16/01/2012 23/01/2012 30/01/2012 06/02/2012 13/02/2012 20/02/2012 27/02/2012 05/03/2012 12/03/2012 19/03/2012 26/03/2012 02/04/2012 09/04/2012 16/04/2012 23/04/2012 30/04/2012 07/05/2012 14/05/2012 21/05/2012 28/05/2012 04/06/2012 11/06/2012 18/06/2012 25/06/2012 02/07/2012 09/07/2012 16/07/2012 23/07/2012 30/07/2012 06/08/2012 13/08/2012 20/08/2012 27/08/2012
Trust % Compliance Intraveneous Cannula 100.00
95.00
90.00
85.00
80.00 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 03/10/ 10/10/ 17/10/ 24/10/ 31/10/ 07/11/ 14/11/ 21/11/ 28/11/ 05/12/ 12/12/ 19/12/ 26/12/ 02/01/ 09/01/ 16/01/ 23/01/ 30/01/ 06/02/ 13/02/ 20/02/ 27/02/ 05/03/ 12/03/ 19/03/ 26/03/ 02/04/ 09/04/ 16/04/ 23/04/ 30/04/ 07/05/ 14/05/ 21/05/ 28/05/ 04/06/ 11/06/ 18/06/ 25/06/ 02/07/ 09/07/ 16/07/ 23/07/ 30/07/ 06/08/ 13/08/ 20/08/ 27/08/
2 Trust % Compliance Indwelling Catheter
100.00 95.00 90.00 85.00 80.00 75.00 70.00
07/11/2011 14/11/2011 21/11/2011 28/11/2011 05/12/2011 12/12/2011 19/12/2011 26/12/2011 02/01/2012 09/01/2012 16/01/2012 23/01/2012 30/01/2012 06/02/2012 13/02/2012 20/02/2012 27/02/2012 05/03/2012 12/03/2012 19/03/2012 26/03/2012 02/04/2012 09/04/2012 16/04/2012 23/04/2012 30/04/2012 07/05/2012 14/05/2012 21/05/2012 28/05/2012 04/06/2012 11/06/2012 18/06/2012 25/06/2012 02/07/2012 09/07/2012 16/07/2012 23/07/2012 30/07/2012 06/08/2012 13/08/2012 20/08/2012 27/08/2012
Trust % Compliance Clean Equipment
100.00 95.00 90.00 85.00 80.00 31/10/2011 07/11/2011 14/11/2011 21/11/2011 28/11/2011 05/12/2011 12/12/2011 19/12/2011 26/12/2011 02/01/2012 09/01/2012 16/01/2012 23/01/2012 30/01/2012 06/02/2012 13/02/2012 20/02/2012 27/02/2012 05/03/2012 12/03/2012 19/03/2012 26/03/2012 02/04/2012 09/04/2012 16/04/2012 23/04/2012 30/04/2012 07/05/2012 14/05/2012 21/05/2012 28/05/2012 04/06/2012 11/06/2012 18/06/2012 25/06/2012 02/07/2012 09/07/2012 16/07/2012 23/07/2012 30/07/2012 06/08/2012 13/08/2012 20/08/2012 27/08/2012
3. SURVEILLANCE –Mandatory alert organisms
3.1 Meticillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia
The Trust continues to date with no MRSA bacteraemia from 1st April 12 reflecting the regional and national picture. This is against an ambition of 1 post 48 hour case for 2012-13.
3.2 Meticillin Sensitive Staphylococcus Aureus (MSSA) Bacteraemia
Pre 48 hour MSSA data shared at a recent meeting of the HCAI sub group acknowledged that Gateshead had the most source or cause of bacteraemia information available. The recent introduction of MSSA root cause analysis for every patient should also assist in a more thorough understanding of the reasons for this organism related blood stream infection. During July and August 12, 1 Trust attributed case occurred each month. In July the source was skin and soft tissue related, non device related and unavoidable. The August case was a urinary source, non device related and unavoidable.
3 MSSA Bacteraemia 2012-13
5 4 3 2 1 0 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13
Pre 48 hours Post 48 hours
3.4 E.coli Bacteraemia
The positive results for E.coli are shown as pre and post 48 hours in the chart below. Of the unavoidable 3 post 48 hour cases in July and 2 in August; 2 were urinary in source, 1 likely hepatobilary, 1 related to an intra abdominal collection post surgery and 1 source unknown. The community cases of E.coli continue to be high, see chart below, with often limited information available regarding previous interventions.
E.coli Bacteraemia 2012-13
16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13
Pre 48 hours Post 48 hours
3.5 Clostridium Difficile Infection (CDI)
During July 2012, 2 post 72 hour Trust attributed CDI positive patients have been confirmed. In August no cases were Trust attributable. This maintains the Trust at 8 post 72 hour cases to date against a trajectory of 21 for the year. Enhanced trend analysis via the South of Tyne and Wear Infection Control Practice and Performance (IC, P and P) group will give more robust information regarding patient susceptibility across the region to CDI. Routine CDI environmental checks have been introduced to assure against cleaning of the environment. This will be a joint initiative with some of the microbiology laboratory staff and will support cleanliness of necessary communal equipment and demonstrate to
4 ward teams the importance of cleaning in the eradication of CDI spores. CDI spores can remain in the ward environment and then be picked up causing infection within the vulnerable population. The Trust is currently scoping a detailed programme of work to reduce E.coli bacteraemia and a paper will be presented at the October Trust board.
Reportable C.Difficile Cases Against Trajectory
25
20
15
10
5
0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13
Totals > 72 hours Cumulative Trajectory Cumulative Actual
4.0 THE PATIENT ENVIRONMENT
4.1 Preparation for the New Pathology Build on the QEH Site
To protect staff working in pathology, the infection prevention and control team are working closely with the Estates Department and building contractors to ensure that hand hygiene and environmental safety is maintained. Minimal distruption to the external building will be required and therefore risk from dust and debris to inpatients has been assessed as insignificant.
4.2 Environmental Inspections
The first unannounced Patient Environmental Action Group (PEAG) meeting will take place in September 12. This will provide additional Trust assurance to the robust monitoring via Matrons, Ward managers and Domestic services already insitu.
4.3 Domestic Services
As outlined within the June 12 report additional training for Domestic and Nursing staff has been completed for use of isolation rooms and special personal protective equipment.
4.4 Waste Management
The Trust is required to have a pre acceptance audit to demonstate adequate segregation of waste generated at source. This audit must be provided to ensure that contractors will continue to remove waste from the Trust site. To gather evidence an intensive programme of waste audits has been untertaken by the Deputy Director of Estates/Waste responsible officer and Head of Infection Prevention and Control. A third of the Trust has been inspected and all necessary specialist areas.
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5.Surgical Site Infection
An intensive programme of work is in progress with the Matron from maternity leading to facilitate robust caesarian section surveillance. The team in maternity will also gain access to Ormis which is an electronic theatre system. By participating in the national surveillance scheme facilitated by the health protection agency the Trust will be able to measure rates of infection and risk factors against national statistics.
6. Education and Training for Infection prevention and Control (IPC)
Within the 2013 prospectus 3 new sessions will be provided by the Trust. This will consist of: i) A hand hygiene master class, ii) IPC in the patient environment and iii) How to use Trust resources and support from the IPC team to take forward surgical site surveillance.
These formal sessions are in addition to mandatory sessions and requests to attend staff group meetings to ensure current IPC issues are fully supported via informed staff.
6. CONCLUSION
An E.coli bacteraemia programme of work across the local health economy will be devised to improve trend information. A multimodal approach to Trust assurance for IPC remains of paramount importance with Matron, ward manager and clinician engagement for compliance with the ward quality measures a significant Trust assurance. Reduction in MRSA and Clostridium difficile is not replicated for E.coli and MSSA bacteraemia.
7. RECOMMENDATIONS
i) Recognise the work undertaken by ward teams and their matrons to support the IPC agenda and promote patient safety. ii) Support the continued use of environmental screening for CDI as a quality indicator. iii) Acknowledge the current gaps in trend data for community E.coli bacteraemia and the potential implications for the Trust once objectives are agreed.
Mrs Gillian MacArthur Dr David Beaumont Director of Nursing and Midwifery and Joint DIPC Medical Director and Joint DIPC
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Trust Board
Report Cover Sheet Agenda Item: 12
Date of Meeting: 25 September 2012 Report Title: Patient, Quality, Risk and Safety Committee (PQRS) – Self Assessment Review Purpose of Report: To provide assurance of compliance against the Terms of Reference of the PQRS Committee Decision: Discussion: Assurance: Yes Information:
Corporate Objectives report relates to: The report provides assurance in relation to the governance and (Including reference to any risk management arrangements for the organistion and therefore specific risk) supports the achievement of all of the corporate objectives
Recommendations: The recommendation arising from this report are in relation to the (Action required by Board reporting timetable of the PQRS Committee which will be of Directors) implemented by the PQRS Committee Secretary
Financial Implications: Nil
Risk Management The report provides the Trust Board with assurance that the high Implications: level risk committee with overarching responsibility for risk (excluding financial risk) is compliant with it’s terms of reference. Human Resource Implications: Nil
Equality and Diversity Implications: Nil
Author: S A Gair, Risk Management Facilitator
Presented by: G MacArthur, Director of Nursing, Midwifery and Quality
Gateshead Health NHS Foundation Trust
Patient, Quality, Risk and Safety Committee (PQRS)
Self Assessment Review August 2012
Report date Author
22 August 2012 S A Gair, Risk Management Facilitator
Presentation date Committee/Group presented to
26 September 2012 Trust Board
Action plan included Action plan review date
Yes January 2013
1
Section Page
1 Introduction 3 2 Monitoring & audit 4 2.1 Aims and objectives 4 2.2 Methodology 4 2.3 Results 5 2.4 Conclusions 7 3 Recommendations 8 4 Action plan 8
Appendices
Appendix 1 Risk Management Committee Structures 9 Appendix 2 Results - monitoring schedules 11 Appendix 3 PQRS report timetables for 2011 and 2012/13 19 Appendix 4 Action plan – August 2012 21
2 1. Introduction
The National Health Service carries a number of risks which if not properly managed and controlled have the potential to cause harm to patients, staff and visitors and may contribute to an adverse effect on the Trust’s assets and/or reputation.
It is accepted that given the nature of the services provided by the NHS some risks may never be totally eliminated. It is however essential that NHS trusts have in place good governance and risk management systems and practices which eliminate risk wherever possible and reduce the impact of those risks that can not be eliminated to an “acceptable level”.
The Chief Executive and Board of Directors are required to ensure that all types of risk; clinical, organisational and financial are monitored to ensure appropriate controls are in place. Whilst the Audit Committee provides independent verification on the organisations systems for risk management to make sure that structures and processes for managing key risks are in place, under a scheme of delegation of authority the Board of Directors has delegated responsibility for overseeing risk management to the Patient Quality, Risk and Safety Committee (PQRS Committee) which is ‘to act as a focal point for all risk issues’.
Appendix 1 details the structure and communication of other relevant committees relating to the PQRS Committee as outlined in the trust’s Risk Management Strategy. The Governance Structure was reviewed during the period relevant to this report and appendix 2 shows both the structures up to December 2011 and after December 2011. It should be noted that financial risk is monitored closely by the Director of Finance and financial risks are monitored directly by the Finance Committee and the Board.
The trust’s performance with regard to the management of non clinical and clinical risk is monitored and assessed by the PQRS Committee on behalf of the Board of Directors. It is essential to be able to provide assurance that the PQRS Committee is functioning effectively according to its Terms of Reference. Furthermore, an assessment of compliance with the terms of reference (ToR) is required by the National Health Service Litigation Authority (NHSLA) using the structured framework of the Risk Management Standards for Acute Trusts and to identify whether the committee is communicating appropriately in an effort to manage risk comprehensively throughout the organisation. Specific assurance is required in relation to the reporting arrangements to the Board from the PQRS Committee and reporting arrangements into the PQRS Committee from its sub-committees.
An annual self assessment review is carried out to provide such assurance to the board.
The purpose of this report is to provide assurance for the PQRS Committee and Trust Board on compliance during the period April 2011 – March 2012 on the PQRS Committee compliance against the Terms of Reference.
2. Monitoring & audit
3 2.1 Aims and objectives
To examine the ToR of the PQRS Committee and analyse the level of compliance with the communication requirements detailed in the ToR to provide assurance that the committee is communicating effectively as an essential component of the Trust’s objective to managing risk effectively, outlined in the Risk Management Strategy.
A further objective is to identify where improvements can be made and provide an action plan to ensure those actions are undertaken.
2.2 Methodology
The ToR of the PQRS Committee was updated during the period under review i.e. April 2011 – March 2012. Compliance is therefore being assessed against:-
• ToR March 2007 (updated July 2009) for the period 1 April 2011 – 31 December 2011; and
• ToR updated December 2011 for the period 1 January 2012 – 31 March 2012
Compliance was audited against the following criteria and defined requirements:
ToR to December i.e. March Defined requirement 2007 (amended July 2009) ToR updated December 2011
How often meetings take Bi-monthly Bi-monthly place Reporting arrangements All PQRS Committee minutes to The minutes of the PQRS into the board be received at the following the Committee will be approved at Board meeting the following meeting and will then be submitted to the subsequent board meeting. How often members All members to attend a Committee members or their must attend minimum of 66% of meetings. nominated deputy must attend a Where a deputy has been minimum of 5 of the 6 bi-monthly identified they are expected to meetings. attend in the absence of the committee member Reporting arrangements To receive reports from existing The reporting committees will into the PQRS feeder groups to monitor risk provide an annual overview of Committee management activity across the each committee’s performance trust to ensure their effectiveness with The feeder groups were : Health exception reporting as & Safety Committee, Corporate necessary. The feeder groups Clinical Risk, SafeCare Council are defined as the Mortality and Healthcare & Environment Steering Group, Health & Safety Committee, SafeCare Council and Infection Prevention & Control Requirements for a Minimum of 4 directors or senior There should be a minimum of 3 quorum managers, 1 non-executive directors or their nominated
4 director and 5 other attendees deputy, 1 non-executive director, and 6 others (A minimum of 10 people)
Minutes of the PQRS Committee meetings held during the 12 month period were used to identify the level of compliance.
2.3 Results
The results recorded in appendix 2 illustrate compliance with:
• Frequency of meetings and reporting arrangements to the Board
During the 12 month period there were 6 PQRS Committee meetings which were held every two months demonstrating 100% compliance with the frequency of meetings. (See appendix 2, section 1)
100% of the minutes were submitted to the Board. Whilst there were two occasions in 2011 where the PQRS Committee minutes were not submitted to the next subsequent Board meeting this was because they could not be ratified by the PQRS Committee within the timescale. The amendment to the ToR in December 2011 clarified the requirement to say that “The minutes of the PQRS Committee will be approved at the following meeting and will then be submitted to the subsequent board meeting.”
• Frequency of attendance by members
RM01 Risk Management Strategy version 4.2 identified the following directors as responsible for the specific areas of risk during the period of this compliance assessment:
• Director of Estates and Risk Management: all elements of risk (clinical and non clinical risk) • Director of Finance: financial risk • Medical Director and Director of Nursing, Infection Prevention and Control: executive responsibility for the implementation and monitoring of clinical governance.
Membership of the PQRS Committee includes the above Executive Directors together with the Chairs of the feeder groups, executive and non-executive directors, governors together with representation from the divisional directors and managers.
An analysis of attendance at PQRS Committee for April 2011 – March 2012 was carried out and identified the following results:
Member Attendance in April 2011 – March 2012 Chairperson/deputy 100% or 6/6 meetings Non executive Directors 100% or 6/6 meetings Chief Executive/deputy 66% or 4/6 meetings Medical director/deputy medical director 66% or 4/6 meetings Director of Finance/deputy 50% 3/6 meetings
5 Director of Health Development and Modernisation/deputy 83% or 5/6 meetings Director of Estates and Risk Management/deputy 100% or 6/6 meetings Divisional representation To Oct 2011 From Nov 2011 Assessment & Diagnostics (Clinical Support & Screening from Nov 2011) 100% 3/3 meetings 100% 3/3 meetings Clinical Support 66% 2/3 meetings N/A Surgical services 66% 4/6 meetings Medicine& Elderly 66% 4/6 meetings Women & Children’s 100% 6/6 meetings
The table at appendix 2 section 2 shows attendance at PQRS Committee for April 2011 – March 2012 together with the percentage attendance.
1 April – 31 December 2011 - There is significant compliance against the 66% attendance requirement with the exception of the Director of Finance.
1 January – 31 March 2012 - In terms of the ToR from December 2011 there are a number of areas which do not achieve 5/6 meetings. This will be due to the fact that there is only 3 months worth of data and compliance may be achieved when a full 12 months data is available.
The attendance of the directors (or their nominated deputy) with specific areas of risk management during 2011/12 is:
% attendance 2011/2012 Director of Estates and Risk Management/deputy: 100% Director of Finance 50% Medical Director and Director of Nursing, Infection 100% Prevention and Control:
• Reporting arrangements to the PQRS Committee
Compliance with the requirement of reporting to the Board is detailed above. Appendix 1 illustrates the governance structure and identifies that the following groups report to PQRS Committee:
To December 2011
Health & Safety Sub Committee SafeCare Council Co-ordinating Committee Corporate Clinical Risk Co-ordinating Committee Healthcare & Environments Co-ordinating Committee (disbanded prior to the timescale for the submission of reports as detailed on appendix 3)
From December 2011
Health & Safety Committee SafeCare Council
6 Mortality & Morbidity Steering Group Infection Prevention & Control
Both of the ToR say:
“These committees will provide an annual overview of each committee’s performance to ensure their effectiveness, with exception reporting as necessary”
The tables at appendix 2 illustrate the level of communication of the PQRS Committee with the committees required to report to it. The business agenda of the PQRS Committee is substantial and it deals with relevant risk issues, approval of relevant policies and risk reporting. Analysis in appendix 2 shows the submission of the annual reports of the feeder groups is compliant (also detailed in table below) and the significant range of risk issues considered by the Committee.
Feeder Group Annual report to PQRS Committee Health & Safety Committee January 2012 Corporate Clinical Risk Committee May 2011 Safecare Council Update -September 2011 Annual report March 2012 Mortality & Morbidity Steering Group Not yet required Infection Prevention & Control Not yet required Healthcare & Environments Disbanded
The report timetables for 2011 and 2012 are attached at appendix 3 and the review of the PQRS minutes has confirmed compliance with the updates since that time. The tables detailing the reporting arrangements to the high level committee(s) and the analysis of the papers considered by PQRS shows a significant number of items which relate to the feeder groups.
• Compliance with requirements for a quorum
The quorum for April 2011 - March 2012 showed 100% compliance with the ToR in place at the time.
2.4 Conclusions
Frequency of meetings – Achieved 100% compliance. The business agenda for the meetings is substantial and any reduction in the number of meetings would reduce the effectiveness of the governance arrangements, approval process and functioning of the organisations.
Reporting arrangements to the Board – Achieved 100% compliance with minutes of all meetings being submitted to the Board. Although the minutes do not reach the Board until they have been confirmed as accurate, issues which require urgent Board approval are taken as individual items prior to the submission of the minutes if necessary.
Attendance by members – The review of attendance showed that compliance with the attendance/representation is generally compliant with the exception of the Director of Finance.
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An attendance register has been introduced at the meeting for attendance to be monitored on an ongoing basis.
Reporting arrangements to the PQRS Committee - The analysis of items submitted from the feeder groups to PQRS Committee shows compliance with the reporting timetable as far as possible since the introduction of the new structure and timetable at the beginning of 2012.
There has been an omission in terms of the requirement for a standing agenda item i.e “Exception reporting from the Human Resources Committee and Business & Service Development Committee”.
There is significant shared membership between the feeder groups and PQRS Committee. This shared membership and therefore the knowledge base between the PQRS Committee and the feeder groups allows for informed decision making. The PQRS reporting timetable which was approved in March 2012 should improve the arrangements for the submission of annual reports with 6 monthly updates from the feeder groups.
Requirements for a quorum – Achieved 100% compliance.
3 Recommendations
As a result of this monitoring process it is recommended that compliance with the reporting timetable be monitored more closely and that the standing item “Exception reporting from the Human Resources Committee and Business & Service Development Committee” be included on the agenda for future meetings.
4 Action plan
The action plan developed as a result of the recommendations as detailed above is shown at appendix 4.
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Appendix 1 Committee Structures
To December 2011 Gateshead Health NHS Foundation Trust Committee Structure
Internal Assurance Sub Charitable Funds Audit Committee Committee Committee
Mental Health COUNCIL OF TRUST BOARD OF DIRECTORS Committee GOVERNORS
Remuneration Finance Committee Committee
Business & Service Human Resources Development Patient, Quality, Risk & Safety Committee Committee Committee
Corporate Clinical Healthcare & Health & Safety Risk Co-ordinating SafeCare Council Environments Co- Committee Committee ordinating Committee
Health Records & Infection Prevention & Interprofessional Resuscitation Group Documentation Group Control Committee Learning Council
Achieving the Targets Transfusion Group Clinical Audit Group PEAT Group Local Negotiating Group Group
Medicines Management Joint Consultative IM&T Strategy Group Major Incident Group Group Committee
Information Governance Radiation Protection & Medical Education CLIPA Group Group MRI Group Group
Education Research & Marketing Group Trauma Group New Procedures Group Development Committee
Supplies Procurement Medical Devices & Patient Information SIFT Committee Group Ultrasound Group Group
Hospital at Night Group
From January 2012
9
Trust Board of Directors
Audit Committee Charitable Funds Mental Health Remuneration Council of Committee Committee Governors
Business & Service Human Resources Patient, Quality, Finance Development Committee Risk & Safety Committee Committee Committee
Achieving the Inter-professional Efficiency Plan Targets Group Learning Council Programme Board Mortality Steering Health & Safety SafeCare Infection IM & T Strategy Group Committee Council Prevention & Local Negotiating Control Board Committee
Health Informatics Resuscitation & Safe Working Health Records & Clinical Audit Assurance Deteriorating Group Documentation Committee Joint Consultative Group Committee Committee Patient Committee Radiation Transfusion Bids Management Medicines Patient Protection & MRI Committee Project Team Research & Management Environment Development Safety Committee Action Group Committee Capital Investment Group Major Incident Multidisciplinary CLIPA Group Decontamination Health & Trauma Working and Sterilisation Wellbeing Planning Group Group Group PCPI Committee Steering Group New Clinical Equality & Medical Gas Medical Devices & Committee Ultrasound Group Procedures Supply Procurement Diversity Steering Committee Committee Group Patient Service Training & Security Group Patient Experience & Dignity Steering Information Gateshead Advisory Group Group Review Panel Prescribing & Management VTE Committee Central Alert System Monitoring Theatre User Group Group
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Appendix 2
Results
Section 1 Compliance with frequency of meetings and reporting arrangements to the Board
PQRS Committee Month minutes Minutes at subsequent meetings (bi-monthly) reviewed by the Board/timing Board May 2011 July 2011 √ 2 months July 2011 September 2011 √ 2 months September 2011 November 2011 √ 2 months November 2011 March 2012 √ 3 months January 2012 April 2012 √ 3 months March 2012 June 2012 √ 3 months
11
Appendix 2: Section2 Attendance register – April 2011 – March 2012
20 15 16 18 20 16 Attendance Year to date Risk Position Name May July Sept Nov Jan Mar responsibi 2011 2011 2011 2011 2012 2012 lity
Director of Nursing & Member + Chair Mrs G MacArthur Midwifery (Chair) Y Y Y Y 100% or 6/6 For the meetings implementa Deputy Director of Nursing Deputy for above Mrs H Lloyd Y Y Y Y tion and monitoring Medical Director Dr D M Beaumont Y Y Y Y of clinical Assistant Medical 100% or 6/6 governance Director/Deputy Director of Deputy for above Mr K Godfrey Y Y Y Y Y meetings Nursing Mrs H Lloyd All Director of Estates & Risk Vice Chair Mr P Harding elements of Management (Vice Chair) Y Y Y Y 100% risk (clinical 6/6 and non- Health & Safety Risk & Mrs S Winn Y Y Y Y Y Y clinical) Assurance Manager Financial 50% or 3/6 Director of Finance Mrs L Hodgson to 25 Y Y Y meetings March 2011 66% or 4/6 Chief Executive Mr I Renwick Y Y meetings with deputy Director of Health & Modernisation Deputy for above Mrs Y Ormston Y Y 83% or 5/6 Head of Personnel Deputy for above Mrs K Forsyth Y Y Y Y meetings Mr RA Smith (until Not Director of Operations 23/12/11) Y applicable
Trust Chair Mr PJ Smith Y Y Y
Non-Exec Directors Mr M Brown Y Y Y Mr M Graham Y Y Y Y Mr F Major Y Y Y Y
12 20 15 16 18 20 16 Attendance Year to date Risk Position Name May July Sept Nov Jan Mar responsibi 2011 2011 2011 2011 2012 2012 lity
Mrs J Parkin Mr R Simpson Governors Mrs A Clark Y Y Y Y Mr J Ross Mrs B Wilson Y Divisional Director (Assessment & Dr P Cross Diagnostics) Divisional Manager Mrs S Pearson to Y Y Y Y 100% or 6/6 (Assessment & October 2011 meetings Diagnostics) Mrs S Richardson from November 2011 Assistant Divisional Managers Mrs J Bowes Y Y
Mr C Charlton Y Mrs K Stainsby from November 2011 Y Y Divisional Director can nom. deputy Dr F McAuley to (Clinical Support) October 2011 To October Divisional Manager can nom. deputy Division no longer in 2011 2/3 (Clinical Support) Mrs S Richardson Y Y existence meetings or Assistant Divisional Deputy for Div. Mrs K Stainsby 66% Manager Man Y attendance Divisional Director (Medicine & Elderly) Dr C Scott/ Dr R Allcock Divisional Manager (Medicine & Elderly) Mrs C Coyne 83% or 5/6 Assistant Divisional meetings Managers Ms P Naylor Mrs A Davies Safecare Matron Y Y Y Y Divisional Director can nom. deputy Mr K Godfrey to Feb (Surgical Services) 2010 then Mr D Browell 66% or 4/6 13 20 15 16 18 20 16 Attendance Year to date Risk Position Name May July Sept Nov Jan Mar responsibi 2011 2011 2011 2011 2012 2012 lity
Divisional Manager can nom. deputy meetings (Surgical Services) Mr S Atkinson Y Y Y Assistant Divisional Deputy for Div. Mrs L Turner Managers Man Y Divisional Director can nom. deputy Dr R Menzies 100% or 6/6 (Women & Children) Y Y Y Y meetings Divisional Manager can nom. deputy Mrs GM Wiggham (Women & Children) Y Y Y Y Y Y Assistant Divisional Deputy for Div. Mrs G Thompson Manager Man Y Quorate Y Y Y Y Y Y
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Reporting arrangements to the high level committee (s)
Summary PQRS Committee meetings Papers received by committee members/tabled at meeting To December 2011 Health & Safety Corporate Clinical Risk SafeCare Council Healthcare & Environment May 2011 Y (Disbanded) July 2011 September 2011 Y November 2011 From December 2011 Health & Safety Mortality Steering Group SafeCare Council Infection Prevention & Control January 2012 (due July 2012 and achieved) (due July 2012 - considered Y September 2012) March 2012 Y
The information was taken from the following detailed analysis
PQRS Committee Papers ~ 2009/10
Key CCR ~ Corporate Clinical Risk Committee SafeCare ~ SafeCare Council H&S ~ Health & Safety Committee H&E ~ Healthcare & Environment Committee MSG ~ Mortality Steering Group IPC ~ Infection Prevention & Control
Departmental ~ Departmental Meeting Risk management reports
Date of Meeting Papers received by Committee Members/Tabled at meeting Ongoing action points from previous meetings 20 May 2011 • Clinical Audit Strategy & Policy Departmental Out of hours’ interventional • End of Life Strategy Departmental radiology service Minutes went to Board • Clinical Support Risk Register meeting – • Operational Services Risk Register • Surgical Risk Register • National in-patient survey results Departmental • Safeguarding Children Inspection Departmental • Safeguarding Vulnerable Adults Report Departmental • National Cancer Patient Experience Departmental • Maternity Quarterly Incident Report Jan-Mar 11 Departmental • Self assessment compliance report – action plan update Risk management 15
Date of Meeting Papers received by Committee Members/Tabled at meeting Ongoing action points from previous meetings report • CLIPA report – Oct-Dec 2010 Risk management report • CQC Quality and Risk Profile Sept 10 – Mar 11 Risk management report • Risk Management Annual Report 10/11 Risk management report • Corporate Clinical Risk Co-ordinating Committee update CCR • Education, Research & Development minutes Feb & Mar 2011 15 July 2011 • Patient Experience Strategy 2011 Departmental Out of hours’ interventional • Physical Control and Restraint Policy Departmental radiology service Minutes went to Board • Care Programme Approach & Care Co-ordination Departmental meeting – • Mental Capacity Act 2005 Departmental • Chaperone Policy Departmental • Estates Risk Register • Medical Services Risk Register • QU Report/Action plan for the Bowel Cancer Screening North East Programme Hub Departmental • CLIPA Jan-Mar 2011 Risk management report • Quality Account 2010/11 Risk management report • Review of PQRS Committee Risk management report • NICE Guidance – UTI in Children (CG54) Departmental • Update of NHSLA Action Plans Risk management report • Policy & Procedures Audit May 2011 Departmental 16 September 2011 • Safeguarding Adults Policy Departmental Out of hours’ interventional • Risk Management Committee Presentation Risk management report radiology service Minutes went to Board • Maternity Quarterly Incident Report Apr-June 2011 Departmental meeting – • SafeCare Council Update SafeCare • Annual CLIPA report 2010/2011 Risk management report • Falls & Bone Health National Audit Feedback Departmental • CQC Report Risk management report • Audit report – NHSLA Assessment Risk management report • Lift between wards 1&2 Departmental 18 November 2011 • Policy for the Rapid Tranquilisation (RT) of Patient Displaying Acutely Disturbed Out of hours’ interventional or Violent Behaviour Departmental radiology service Minutes went to Board • RCA Report – Calprotectin Error Reporting Risk management report Lift between wards 1&2 – update meeting – • Risk associated with mislabelled blood samples Risk management report Risk Management Committees • NHSLA monitoring schedule and update Risk management report CQC report • Maternity quarterly incident report July – September 2011 Departmental • CLIPA Apr-Jun 2011 Risk management report • NHSLA 5.3 Complaints Report – action plan update Risk management report 16
Date of Meeting Papers received by Committee Members/Tabled at meeting Ongoing action points from previous meetings • Audit report GHE 132 Risk Management Risk management report • Compliance assessment – learning from experience 2010/11 Risk management report • Compliance report – RM04 Incident/near miss reporting and investigation policy – Investigation monitoring report 2011 Risk management report • Compliance report – RM04 Incident/near miss reporting and investigation policy – reporting to external organisations 2011 Risk management report • Research & Development Committee minutes – September 2011 20 January 2012 • Women & Childrens Risk Register Out of hours’ interventional • Assessment & Diagnostics Risk Register radiology service Minutes went to Board • Nursing & Midwifery Risk Register Risk associated with mislabelled meeting – • Picker Survey Feedback – outpatients Departmental blood samples • Syphilis update Risk management report NHSLA 5.3 Complaints Report – • CLIPA Jul-Sept 2011 Risk management report action plan update • Health & Safety Committee Feedback H&S Compliance report – RM04 Incident/near miss reporting and • NHSLA Compliance report on risk management training for senior management investigation policy – reporting to Risk management report external organisations 2011 • NHSLA update Risk management report
• PQRS Terms of Reference Risk management report • Audit report GHE1147: NHSLA 5.4 Claims management Risk management report • QRP summary Risk management report 16 March 2012 • RM01 Risk Management Strategy Risk management report Out of hours’ interventional • OP27 Policy on Policies Departmental radiology service Minutes went to Board • PQRS reporting timetable Risk management report meeting - • PQRS Terms of Reference Risk management report • Health Development & Modernisation Risk Register • Blood Sampling Labelling Errors Risk management report • SafeCare Council update SafeCare • Picker Surgery results – inpatients 2011 Departmental • Parents’ Experience of neonatal care unit Departmental • Syphilis update Risk management report • NHSLA update Risk management report • Research and Development Committee minutes
17
PQRS Committee – Report Timetable 2011 Appendix 3
Report for PQRS Committee Date for Presentation at Committee/Council Meeting Lead Meeting (Update Report) PQRS Committee Meeting
Health & Safety Committee Health & Safety Committee Report Sue Winn Back 21st January 2011
External Assessments NHSLA 15th July 2011 Avril Lowery Monitoring (Jan only) SafeCare Dept Corporate Clinical Risk Incorporating reports from – Co-ordinating Committee Resuscitation Group, Transfusion Group, Major Incident Group, Radiation 18th March 2011 Protection & MRI Group, Trauma Angela O’Brien (Disbanded) Group, Medical Devices& Ultrasound Group Incorporating reports from – Health Records & Documentation Group, Clinical Audit Group, Medicines 18th March 2011 SafeCare Council Avril Lowery Management Group, CLIPA Group, New 16th September 2011 Procedures Group, Patient Information Group, Hospital at Night Group Healthcare & Environments Co-ordinating Committee Incorporating reports from – Infection 20th May 2011 Prevention & Control Committee, PEAT Viv Atkinson 18th November 2011 Group (Disbanded)
18
PQRS Committee – Report Timetable 2012/13
PQRS Reporting timetable
Committee reports 2012 2013 Report Frequency Named person Jan Mar May Jul Sept Nov Jan Mar May Jul Sept. Nov
Performance Health & Safety Committee report Annual S Winn Update 6 months
Infection Prevention & Control Performance Committee report Annual V Atkinson Update 6 months
Performance D Beaumont/A Mortality Steering Group report Annual Lowery Update 6 months
Performance SafeCare Council report Annual A Lowery Update 6 months
Exception reporting ‐ standing Each Y Ormston/J agenda item HR committee Verbal report meeting Connolly and BSDC Reports and assurance
Aggregated Jul‐ Oct‐ Jan‐ Apr‐ Jul‐ Oct‐ Jan‐ Apr‐ CLIPA analysis Quarterly S Gair Sep Dec Mar Jun Sep Dec Mar Jun Annual 2010/11 2011/12
19
H Llolyd/A CQC Assurance report 4 monthly O'Brien
Each NHLSA Acute standards Update report meeting S Winn
Each NHSLA Maternity standards Update report meeting C Dunn
Jul‐ Oct‐ Jan‐ Jul‐ Oct‐ Jan‐ Maternity incidents Trend report Quarterly G Wiggham Sep Dec'10 Mar Apr‐Jun Sep Dec'10 Mar Apr‐Jun
The Risk Register All risks 12 > 4 monthly A O'Brien All new risks 12 > 4 monthly A O'Brien
Risk Management Report Update Annually A O'Brien
20 Appendix 4
1.3 Risk Management Committees Action plan – August 2012
Target Recommendation Action Lead Date Progress/Completed Monitoring of the reporting timetable to Bi-monthly review of reporting PQRS ensure compliance timetable and Secretary Ongoing Exception reporting from the Human Inclusion of standing agenda item PQRS 21 Resources Committee and Business & Secretary September Service Development Committee”. 2012 and thereafter
21
Trust Board
Report Cover Sheet Agenda Item: 13
Date of Meeting: 25 September 2012
Report Title: Audit Committee Annual Report 2011/12
Purpose of Report: To inform the Board how the Committee has met its Terms of Reference and fulfilled the role set out in relation to the financial year ended 31 March 2012.
Decision: Discussion: √ Assurance: Information:
Corporate Objectives report relates to: 2. Ensure all services delivered are compliant with CQC standards (Including reference to any 3. To deliver the Trust’s Financial Plan specific risk)
Recommendations: To receive the report on behalf of the Audit Committee (Action required by Board of Directors)
Financial Implications: None
Risk Management None Implications:
Human Resource None Implications:
Equality and Diversity None Implications:
Author: Mr J Connolly, Director of Finance and Information
Presented by: Mrs Julia Hickey, Chair of the Audit Committee
Paper for Board of Directors Meeting Agenda item: 13 Tuesday 25 September 2012
Draft Audit Committee Annual Report 2011/12
1. Introduction
Foundation Trusts establish their governance framework in line with Monitor’s Code of Governance. This Code of Governance requires that the Trust establish an independent Audit Committee as a central means by which a Board ensures effective internal control arrangements are in place.
The Committee’s primary role is to conclude upon the adequacy and effective operation of the organisation’s overall internal control system. In performing that role, the Committee’s work predominantly focuses upon the framework of risks, controls and related assurances that underpin the delivery of the organisation’s objectives.
Whilst it is clearly the job of the executive directors and the Accountable Officer to establish and maintain proper processes for governance, the Audit Committee independently monitors, reviews and reports to the Board on those processes and, where appropriate, facilitates and supports effective delivery.
Not all assurances can be monitored in detail by the Audit Committee therefore the committee relies on assurances from the Patient Quality Risk and Safety Committee, the Business and Services Development Committee and the Human Resources Committee which include representative members from the Audit Committee.
This report sets out how the Committee has met its Terms of Reference, and fulfilled the role set out above in relation to the financial year ended 31 March 2012.
2. Work undertaken through the year
2.1 Governance, Risk Management and Internal Control
In March 2011 the Committee reviewed the Corporate Objectives and Governance Framework for 2011/12, specifically discussing Objective 1: Improving Clinical Performance and Objective 8: To redevelop elements of the Trust information infrastructure where the new PAS and ICE systems were reviewed. The Governance Framework was subsequently discussed and reviewed at the December 2011 and March 2012 meetings.
The Corporate Governance Manual, incorporating the Standing Orders, Standing Financial Instructions and Scheme of Delegation, was fully revised in December 2011 with a new format to present the financial delegation limits. Additions were around the new Bribery Act and references to the new electronic tendering procedures. The final version was approved by the Board of Directors in January 2012.
The Trust is fully compliant with the registration requirements of the Care Quality Commission and maintains its current status as registered without conditions. The Care Quality Commission has not taken enforcement action the Trust during 2011 –
1 2012. There are processes within the Trust, including a CQC Steering Group, to monitor ongoing compliance, now aided by an electronic system to improve management of compliance information. Assurance is provided bi-annually to the PQRS Committee.
The Audit Committee continued to review how further developments can be made in the way in which the necessary assurances on internal control systems can be made. Changes have been made in the planning of Internal Audit work and the format of the corporate objectives that more readily enabled Internal Audit to link its assurance work to the objectives of the Trust ensuring all significant areas of risk are covered during the 3 year planning cycle. The 2011/12 plan was based around outcomes, and the reporting of assurances against the strategic objectives of the Trust to provide a more robust framework for the receipt of assurances. Reports also include details of the relative risk associated with the topic.
Internal Audit provided the committee with regular updates and formal reports on those aspects of the assurance framework included within the programme for the year
In May 2012, the Committee received the Head of Audit opinion relating to the financial year 2011/12. This opinion confirmed that significant assurance could be given that there is a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls may put the achievement of particular objectives at risk.
The Audit Committee reviewed the Annual Governance Statement taking assurance from Internal Audit Reports, the PQRS Committee, the Finance Committee and updates of the risk register, the Committee were not made aware of any particular concerns around governance or breaches of internal control during the year, and as a result of the assurances received, were able to ‘sign off’ the Annual Governance Statement for the year. All reports in which Internal Audit reported that they had gained ‘limited assurance’ from their review were considered specifically by the Audit Committee. As a result of these specific reviews, the Committee were able to satisfy themselves that none of the concerns raised were significant in the context of the Annual Governance Statement and its other responsibilities.
2.2 Internal Audit
The Committee initially approved the Internal Audit 3 Year Plan at its meeting in May 2010 and, in March 2011, approved the second year of this plan to be put in place for 2011/12. They followed this up with regular reviews of both progress against the 2011/12 audits in the plan and the outcomes of the various reviews carried out, with the Internal Auditors being regular attendees at the meetings to provide these updates.
A full programme of internal audit reviews was undertaken during the year. A total of 39 audits were planned. As at May 2012, 33 had been issued as final reports, 1 was in draft, 1 was cancelled and the days transferred to another audit, and 4 were carried forward and have been completed in 2012/13. The Commdittee received the findings for each completed review, and had the opportunity to discuss the main findings for the draft and ongoing reports with the auditors.
2
Internal Audit updated their Terms of Reference during the year and these were approved at the December 2011 meeting.
2.3 External Audit
Following notification to the Trust that the Audit Practice of the Audit Commission was to be outsourced to the private sector pending the wind-up of the Audit Commission, the Governors agreed the competitive tender process for External Audit Services and this was conducted during April & May 2012. The evaluation resulted in the award of a 3 year contract to KPMG LLP effective July 2012. The Audit Commission completed all audit work relating to the 2011/12 financial year.
Representatives of External Audit attend each Audit Committee meeting, and have regular liaison meetings with the Chair of the Committee and the Director of Finance.
At the meeting in May 2012, the Annual Accounts and Annual Report were reviewed prior to presentation to the Board. External Audit gave an unqualified opinion on the accounts and a clean opinion on the economy, efficiency and effectiveness of the Trust following the receipt of the third party assurances on the Quality Report following the meeting date.
At the end of the Committee Meeting held in September 2012, members of the Committee took the opportunity to have a discussion with the auditors without any officer of the Trust being present. The purpose of the discussion was to ensure that there were no matters of concern regarding the running of the organisation that should be raised with the Audit Committee. No such matters were reported.
There were no additional pieces of work commissioned from the external auditors during 2011/12. For 2011/12, the fee to External Audit for work undertaken under the Audit Code included the opinion on the financial statements, the review of the Annual Governance Statement, the opinion on economy, efficiency and effectiveness, work to support the Whole of Government Accounts and the review of the Quality Report. The total audit fee was £45,000 plus VAT.
The Audit Commission has managed an assurance framework for Payment by Results (PbR) at the request of the Department of Health since 2006/07. For 2011/12 the work programme included a national data assurance audit at the Trust and follow-up of all previous local work delivered by the assurance framework to ensure actions agreed have been completed and improvements secured.
2.4 Local Counter Fraud Service (LCFS)
An important function of the LCFS is to ensure that the organisation is being proactive in the prevention of fraud and that any potential frauds that do come to light are dealt with and reported appropriately.
The Committee approved the 2011/12 work plan in May 2011 at a level of 80 proactive days. This was 5 days less than 2010/11 but the extra days (10 in total) allocated in 2010/11 to provide greater resources in the prevention of fraud have proved successful. The Local Counter Fraud Specialist is a regular attendee at Committee meetings and provides regular updates on progress against the plan.
3
The main areas of work undertaken during 2011/12 were:
• To continue the work creating an anti-fraud culture by raising awareness of fraud issues to all staff. This included presentations to staff groups and meetings of the Fraud Focus Group which resulted in a much closer working relationship between the LCFS and Local Security Management Specialist (LSMS) and a cohesive approach to Protecting the Trust; • Several presentations and provision of advice and support around updating policies and Trust awareness on the Bribery Act 2010, including receipt by the Audit Committee of the Bribery Act Action Plan in December 2011; • To work on the prevention, detection and investigation of fraud, involving interfacing with Internal Auditors and other organisations.
There were 3 referrals of suspected fraud or corruption to the LCFS during the year. One of the investigations has been completed, which resulted in changes to systems and processes. The two remaining cases are ongoing. The number of planned days (80) was exceeded by 16 in 2011/12 mainly due to additional work on investigating frauds.
The Local Counter Fraud Specialist presented to the Committee that on 11th January 2012 NHS Protect released the final Qualitative Assessment report for 2010/11. As previously reported to the Audit Committee, this assessment rated the Trust’s counter fraud arrangements as a level 2 – which is summarised as “evidence of a range of outputs”. The Trust’s performance in this area has been rated at level 2 since the annual assessment process began in 2006/7.
The Trust’s Fraud Risk Register was updated with advice from LCFS to reflect the changes in likelihood and potential consequence of the fraud risks identified. This did not change significantly the level of risk to the trust.
Other Assurance functions
A particular function of the Committee is to review the Losses and Special Payments Register of the Trust on a regular basis, ensuring that payments made under this heading are reasonable, and identifying any particular risks/trends that may become apparent through this particular process.
3. Future Plans
The Committee is constantly looking to develop the way that it works and improve the efficiency of the internal control systems across the organisation. In 2012/13 the committee will take particular cognisance of the level of efficiency programme required by the Trust due to the change in the economic environment taking assurance from Internal Audit and Finance Committee. A specially commissioned report from Internal Audit towards the end of 2011/12 on the Cost Efficiency Programme will be received and discussed by the Audit Committee in September 2012, the results of which will continue to help shape the ongoing development of the Trust Efficiency Programme.
The Committee will continue to review their Terms of Reference, ensuring compliance with the Code of Governance, and will constantly seek the assurances
4 required of the organisation that the systems of internal control are documented, fit for purpose and complied with consistently.
Since the appointment of Non-Executive Director and Audit Committee Chair, Julia Hickey, to Chairman of the Board of Directors from 1st July 2012, a recruitment process has been undertaken to appoint another Non-Executive Director with a finance specialty to the Board who will then take the Chair of the Audit Committee role. A recommendation on the new appointment will be taken to the Council of Governors in September 2012 for approval.
The Committee will support the new external auditors, KMPG LLP, in their new contract with the Trust and a series of meetings with the audit team, Executive Directors, Non-Executive Directors and Governors is in place for the autumn.
The Committee will continue to invite the Trust Board leads to the meeting on a regular basis to update the committee on progress toward meeting the Trust wide Corporate Objectives.
The Committee will continue to report to the Board of Directors on a regular basis, and the governors through the annual report.
4. Recommendation
The Board of Directors and Council of Governors are asked to receive the report on behalf of the Audit Committee.
5 Appendix 1
GATESHEAD HEALTH NHS FOUNDATION TRUST AUDIT COMMITTEE
TERMS OF REFERENCE
1. Constitution and Purpose
The Board hereby resolves to establish a Committee of the Board to be known as the Audit Committee (the Committee). The Committee is a non-executive committee of the Board and has no executive powers, other than those specifically delegated in these Terms of Reference.
The purpose of the Committee is to conclude upon the adequacy and effective operation of the Trust’s overall internal control system including an effective system of integrated governance and risk management. It provides a form of independent check upon the executive arm of the Board.
2. Authority and Relationship with other Committees
The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.
The Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control.
The Committee may also request specific reports from individual functions within the Trust (e.g. clinical audit) as they may be appropriate to the overall arrangements.
In addition, the Committee will review the work of other committees within the Trust, whose work can provide relevant assurance to the Audit Committee’s own scope of work.
The Committee will wish to satisfy themselves on the assurance that can be gained from the Patient Quality Risk and Safety (PQRS), Business and Service Development (BSD) and Human Resources Committees (HR. The Committee will receive regular updates from the Director of Estates and Risk Management on delivery against the governance framework, and an annual report on Risk Management.
Members of the committee also attend PQRS, BSD and HR committees.
3. Duties
The Committee is responsible to the Board of Directors for the following main functions:
6 3.1 Governance, Risk Management and Internal Control
The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the Trust’s activities (both clinical and non-clinical), that supports the achievement of the Trust’s objectives.
In particular, the Committee will review the adequacy of:
• All risk and control related disclosure statements (in particular the Statement on Internal Control), together with any accompanying Head of Internal Audit statement, External Audit opinion or other appropriate independent assurances, prior to endorsement by the Board. • The underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements as set out in the Trust’s Governance Framework and risk register. • The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements. • The policies and procedures for all work related to fraud and corruption as set out in Clause 47 and Schedule 14 of the Terms and Conditions for the Provision of Health Services as required by the Counter Fraud and Security Management Service.
In carrying out this work the Committee will primarily utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these audit functions. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.
This will be evidenced through the Committee’s use of an effective Governance Framework to guide its work and that of the audit and assurance functions that report to it.
3.2 Internal Audit
The Committee shall ensure that there is an effective Internal Audit function established by management, which meets mandatory Government Internal Audit Standards and provides appropriate independent assurance to the Committee, Chief Executive and Board. This will be achieved by:
• Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal of the Internal audit Service. • Review and approval of the Internal Audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the Trust as identified in the Governance Framework • Consideration of the major findings of Internal Audit work (and management’s response), and ensuring co-ordination between the Internal and External Auditors to optimise audit resources
7 • Ensuring that the Internal Audit function is adequately resourced, subject to the processes outlined in the Audit Consortium Constitution, and has appropriate standing within the Trust • Annual review of the effectiveness of Internal Audit.
3.3 External Audit
The Committee shall review the work and findings of the External Auditor appointed by the Governors and consider the implications and management’s responses to their work. This will be achieved by:
• The committee will agree with the Council of Governors the criteria for appointing, reappointing and removing auditors. The audit committee should make recommendations to the Council of Governors in relation to the appointment, re-appointment and removal of the external auditor and approve the remuneration and terms of engagement of the external auditor. • Consideration of the performance of the External Auditor and reporting at least annually to the Council of Governors on the continued adequacy or otherwise of the appointed auditors, including recommendations for the tendering of External Audit services. • Discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan, and ensuring co-ordination, as appropriate, with other External Auditors in the local health economy • Discussion with the External Auditors of their evaluation of audit risks and assessment of the Foundation Trust in line with the tendered audit fee and agreement of any additional work and fees • Reviewing all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work carried outside the annual audit plan, together with the appropriateness of the management responses • Develop and implement policy on the engagement of the external auditor to supply non-audit services, taking into account relevant ethical guidance regarding the provision of non-audit services by the external audit firm
3.4 Local Counter Fraud Service
The Committee shall ensure that there is an effective LCFS function established by management, which meets Secretary of States Directions. This will be achieved by:
• Consideration of the provision of the LCFS function, the cost of the service and any questions of resignation and dismissal of the service, subject to the processes outlined in the Audit Consortium Constitution • Review and approval of the LCFS Strategic and Annual Plan • Consideration of the major findings of LCFS work and fraud investigations (and management’s response) • Ensuring that the LCFS function is adequately resourced • Annual review of the effectiveness of the LCFS function
8 3.5 Other Assurance Functions
• The Committee shall review the findings of other significant assurance functions, both internal and external to the Trust, and consider the implications to the governance of Trust. • The Committee shall review arrangements by which staff of the NHS foundation trust may raise, in confidence, concerns about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters.
3.6 Financial Reporting
The Committee shall review the Annual Report and Financial Statements before submission to the Board, focusing particularly on:
• The wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the Committee • Changes in, and compliance with, the accounting policies and practices • Unadjusted mis-statements in the financial statements • Major judgemental areas • Significant adjustments resulting from the audit
The Committee shall also ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the Board.
3.7 Other Functions
The Committee shall review proposed changes to the Standing Orders and Standing Financial Instructions.
The Committee shall receive and review the schedules of losses and special payments and authorise the Chief Executive and Director of Finance to sign off the approval to write off these items
4. Reporting and Accountability Arrangements
The minutes of Committee meetings shall be formally recorded and submitted to the Board. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board, or require executive action.
The Committee will report to the Board annually on its work in support of the Annual Governance Statement, specifically commenting on the fitness for purpose of the Governance Framework, the completeness and embeddedness of risk management in the Trust, the integration of governance arrangements and the appropriateness of the self-assessment against the Standards for Better Health.
The Committee will carry out annual self assessment reviews of its effectiveness and functioning.
9 5. Other Matters
The committee shall be supported administratively by the Deputy Director of Finance, as audit liaison officer, whose duties in this respect will include:
• Arranging the taking of the minutes and keeping a record of matters arising and issues to be carried forward through appropriate secretarial support
• Advising the Committee on pertinent areas
The Director of Finance will agree the agenda with the Chair and attendees and collation of papers.
6. Membership and Responsibilities
Chair & Members
Membership will comprise the Non-Executive Director Chair of the Audit Committee and three other Non-Executive Directors.
Attendees Director of Finance and Information Director of Nursing, Midwifery & Quality A representative of External Audit A representative of Internal Audit A representative of the Local Counter Fraud Service Other Executive Directors and officers will be invited to attend as required to discuss matters of internal control
Officers Deputy Director of Finance PA to Director of Finance (to service the committee)
Quorum The committee shall be quorate when at least two members are present.
Frequency of Meetings Meetings shall be held not less than 4 times a year, including at least one meeting a year with both internal and external auditors without Executive Director presence. Internal auditors, External Auditors, or Local Counter Fraud Specialist may request a meeting in exceptional circumstances.
Reporting Line The Committee will report to the Board of Directors, and report to the Council of Governors, where there any matters in respect of which it considers that action or improvement is needed, making recommendations as to the steps to be taken.
Minutes Minutes are held by the PA to the Director of Finance and Information and are circulated to members and attendees with the agenda for the following meeting.
10 Appendix 2 Audit Committee Members Attendance April 2011 – March 2012
Member 23.05.11 15.09.11 08.12.11 08.03.12
Mitch Brown √ √ √
Andrew Fairbairn √ √ (appointed to Committee 1st July 2011)
Peter Harding √ √ √
Julia Hickey (Chair) √ √ √ √
Lynne Hodgson √ √ √
Frank Major √ √ √ √
Jacqueline A Parkin √ (retired 30th June 2011)
11
Trust Board
Report Cover Sheet Agenda Item: 14
Date of Meeting: Tuesday 25 September 2012
Report Title: Energy Conservation and Carbon Reduction
Purpose of Report: To provide the Board with an update on the Trust’s progress towards NHS targets to reduce carbon emissions.
Decision: Discussion: √ Assurance: Information:
Corporate Objectives 3. To deliver the Trust’s Financial Plan report relates to: (Including reference to any specific risk)
Recommendations: To note the progress made to date. (Action required by Board of Directors)
Financial Implications: Yes
Risk Management Yes Implications:
Human Resource No Implications:
Equality and Diversity No Implications:
Author: Peter Harding and Kevin Smeaton
Presented by: Peter Harding
Paper for Board of Directors’ Meeting Agenda Item No: 14
Tuesday 25 September 2012
ENERGY CONSERVATION AND CARBON REDUCTION
1. Introduction This paper provides the Board with a brief update on the Trust’s progress towards the NHS targets to reduce carbon emissions and also outlines the Trust’s actions to respond to ever increasing energy costs.
2. Background The NHS carbon footprint has been calculated at 21M tonnes per year. This is larger than some medium sized countries and has increased by 3M tonnes since the previous footprint was calculated 4 years earlier.
The NHS Carbon Reduction Strategy requires every NHS organisation to reduce its carbon emissions by 10% by 2015 (based on the 2007 baseline energy data). There are further targets to reduce emissions by 34% by 2020 and 80% by 2050. In addition, over the last 6 years there have been record energy price increases and a higher demand for energy from all parts of the world. The government has introduced a number of initiatives to focus organisations on energy/carbon reduction including:
• European Union Emission Trading Scheme (EU/ETS) • Carbon Reduction Commitment (CRC) • Introduction of Display Energy Certificates (DEC)
3. Progress to Date The Trust has had a very effective and successful Energy Reduction Strategy for a number of years. Considerable credit must be given to Kevin Smeaton the Trust’s Senior Engineer and to his predecessor Stuart Bell, who have identified and successfully delivered a wide range of energy conservation schemes, some of the recent schemes implemented are highlighted below:
• Boiler economisers (achieving a 6% saving in gas consumption £65,000) • Scheme III Lifts (replaced existing hydraulic lifts with traction control lifts achieving a £17,500 saving in electrical consumption) • Installation of lighting controls (600 presence detection controllers installed in various locations around the Trust reducing electrical consumption) • Scheme III Server Room (installation of evaporative cooling generating savings of £6,500. per annum) • Bensham Hospital (installation of point of use water heaters generating savings of £15,000 pa) • Lighting (installation of high efficiency and LED lighting throughout the Trust saving £12,000) • Insulation Programme (exposed valves and pipes at various locations around the Trust have been insulated) • Variable Speed Drives (installation of variable speed drives to reduce energy consumption on both pumps and fans throughout the Trust) • Boiler Sequence Controller (to determine the correct amount of boilers required to provide steam for the hospital, which has generated savings of £5,000) • Health Records Store (installation of lighting controls which has generated savings of £4,000) • Street Lighting (replacement of existing hospital street lights with energy efficient fittings £5,000)
As a result, the Trust has already achieved the first target of a 10% reduction in omissions by 2015. This is a creditable achievement given that during this period the Trust has seen the development of the Peter Smith Surgery Centre, Jubilee Wing and Beacon Centre all of which significantly increase energy consumption. Very few Trusts have achieved this target.
The reduction on energy consumption for the Trust from 2004 to 2011 is set out in Appendix 1. This shows a reduction in electricity usage of 6.4% and a reduction in gas usage of 44.7% during this period.
Under the EU/ETS Scheme, this reduction in energy consumption has allowed the Trust to sell 10,000 tonnes of carbon onto the carbon trading markets which has generated an income for the Trust of £140,000. We are the only Trust in the country to do so.
4. Energy Procurement The Trust currently uses the Government Energy Service for the procurement of utilities. Over numerous years this has proven to be the best value for the Trust and gives security of supply. We are currently on an uninterruptable variably tariff, historically this gives on average a 10% saving against a fixed price option.
The contract term (currently 3 years) is due to expire in April 2015. A review of the energy markets will commence approximately 6-9 months prior to the expiry of this contract in order to compare alternatives, for both price and security of supply.
5. The Future The introduction of the CRC Scheme has resulted in an additional cost to the Trust of £85K last financial year and £97K this year. This is effectively based on a percentage of energy used and is forecast to rise significantly over the new few years.
The Trust continues to put a greater focus on energy efficiency and sustainability and is committed to continuous investment to improve energy efficiency and sustainable developments. With two new developments commencing in 2012, the Emergency Care Centre and Pathology Centre of Excellence the Trust is committed to building in a sustainable and energy efficient way and aims to achieve a BREEAM ‘Excellent’ and BREEAM ‘Very good ’ rating respectively.
We are also currently carrying out a range of feasibility studies in the following areas:
• Installation of an alternative fuel CHP with potential savings of £160,000 per annum • On-site incineration of medical waste to generate heat/power • Installation of further energy efficient LED lighting • Expansion of evaporative cooling to all server rooms • Installation PV Cells (photovoltaic/solar panels) • Continued expansion of Heating/Cooling from general waste
With continued investment in new technologies together with improved use of existing plant, constant monitoring of energy inefficiencies, further significant reductions in consumption can be anticipated.
Finally, a new Sustainability Strategy is being developed for the trust, which will also encompass carbon reduction in relation to travel and procurement. This will be brought back to a future board meeting.
The Board is asked to note the progress made to date.
Peter Harding Director of Estates and Facilities
Trust Board
Report Cover Sheet Agenda Item: 15
Date of Meeting: Tuesday 25 September 2012
Report Title: Trust Branding update
Purpose of Report: To update Board members with regard to the final designs and implementation of the new Trust branding and website
Decision: Discussion: Assurance: Information:D
Corporate Objectives Commercial development strategy report relates to: (Including reference to any specific risk)
Recommendations: None (Action required by Board of Directors)
Financial Implications: Budget of circa £5k has been given to the project (final sum will be known once the work is completed) Risk Management None Implications:
Human Resource None Implications:
Equality and Diversity Seeking final comments from sight services representatives Implications: concerning the font on the strapline
Author: Lucia Hiden Head of Communications Presented by: Lucia Hiden Head of Communications
Trust branding
Introduction
This report introduces the Trust’s new branding and website to the Board and is accompanied by a presentation of the visuals. The presentation demonstrates how the new branding can be used in practice and some of the features on the website. It follows on from the papers received by the Board in the June meeting concerning the commercial development strategy and promotional marketing.
Background - branding
The Trust has recognised a need to update its branding and corporate identity to ensure that it is fit for purpose in the new NHS with increased competition and marketing from both the private sector and other NHS organisations. The corporate identity needs to be positive and distinctive and reflect our values.
The decision has already been taken to re-brand ourselves QE Gateshead to reflect the colloquial name by which we are affectionately known. The strapline of Quality and Excellence has also been agreed.
Work has been progressing over the last few weeks with a professional designer to turn this strategy into a reality and it is these visuals which are being presented today. The branding and website have already been shared with heads of service, senior management team, governors and the Patient Carer and Public Involvement Group. All have been extremely positively received. There are some outstanding queries from the sight services representatives regarding the font of the strapline but an alternative plain black and white version of the logo will also be available which is considered to be an acceptable alternative to the colours used.
Background – website
The decision to re-do the Trust’s website stems back to 2010. It is very much viewed as being the front window for the organisation. For a variety of reasons, the website is only now in a position to be launched. External support has been used to ensure the website looks professional but more importantly is easy for patients and visitors to navigate to find the information they are looking for quickly and easily.
The website has been written in an easy format using sub menus and links to ensure consistent ease of access to information.
Visuals
The visuals have been shared with the groups mentioned in the introduction and from the feedback received are being worked up into templates and documents. Some of the materials which will include the new corporate identity include: • Headed paper and appointment letters • Powerpoint presentations • Reports, committee papers and agendas • Patient information leaflets • Signage and hoardings • Email signatures.
Part of the feedback received to date has been to include a recognised font for the Trust to use. There are some NHS guidelines nationally on which can be used but this guidance predates the introduction of new Microsoft software which allows for improved fonts. With this in mind, the Trust intends to use Calibri (this font) as its font.
Copies of the visuals will be shared in hard copy at the Board meeting when they will be accompanied by explanations.
Ensuring consistency – a policy
A policy is being introduced to ensure consistent compliance with the new corporate identity. This is important in projecting the image of the Trust.
A policy is also being introduced to ensure the successful management of the new website.
Implementation
The new identity will be formally launched when the new website is launched, expected to be Wednesday 24 September. It will be introduced gradually to ensure the support of services and to ensure that existing collateral (such as headed paper) is run down first for financial and environmental reasons. A section will be established on the intranet to help staff with its successful implementation and assistance on both the web presence and the corporate identity will be available to services from the communications department.
Conclusion
The Board is asked for its feedback, approval and support for the new Trust branding and website.
Lucia Hiden
Head of Communications
17 September 2012
Trust Board
Report Cover Sheet Agenda Item: 16
Date of Meeting: 25th September 2012
Report Title: South of Tyne and Wear Serious Incident Reporting and Management Policy Purpose of Report: Decision: Discussion: Assurance: Information: 9 9 Corporate Objectives Objective 3 – To reduce harm and improve the quality of services for all report relates to: Trust patients ensuring that all services delivered are compliant with CQC (Including reference to any standards for quality and safety specific risk)
Recommendations: The Board are asked to receive this paper for Information (Action required by Board of Directors)
Financial Implications: None
Risk Management Yes Implications:
Human Resource None Implications:
Equality and Diversity None Implications:
Author: Gillian MacArthur, Director of Nursing, Midwifery and Quality Hilary Lloyd, Deputy Director of Nursing and Midwifery Presented by: Gillian MacArthur, Director of Nursing, Midwifery and Quality
G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T
South of Tyne and Wear Serious Incident Reporting and Management Policy
1. Purpose
This paper is intended to provide the Board with information regarding the NHS South of Tyne and Wear policy for the management of external reporting of Serious Incidents.
2. South Of Tyne and Wear Serious Incident Reporting and Management Policy
The purpose of this policy is to assist with identifying what a Serious Incident (SI) is and to describe the process for the reporting and management of those identified by providers of NHS services commissioned by NHS South of Tyne and Wear.
This is an updated policy issued in March 2012, which provides a concise definition of those incidents requiring reporting externally and therefore provides the Trust with a robust, systematic approach to its reporting and assists the Serious Incident Review Group in its decision making. This policy has become a working tool within Gateshead Health NHS Foundation Trust Serious Incident Review Panel which is held monthly.
It also sets out defined timescales for providing anonymised copies of Gateshead Health NHS Foundation Trusts investigation reports regarding these incidents to the commissioners. This in turn assures our Commissioners that incidents are properly investigated, action taken to improve clinical quality, and lessons have been learnt to ensure the risk of similar incidents occurring are minimised.
The policy also provides details of those agencies with which we would be required to report incidents to externally.
3. Recommendations
The Board is asked to:
• Note for information • Note the definitions of Serious Incidents • Note the process for reporting externally to our commissioners and to other external agencies. • Note the timescales involved in reporting investigatory reports
NHS SOTW Serious Untoward Incident Policy for Commissioners: Version V4.2
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South of Tyne and Wear Serious Incident Reporting and Management Policy
Scope Commissioning
Ratified Quality and Patient Safety, Clinical Governance Committee
Status Final Version
Issued March 2012 Approved by Quality and Patient Safety, Clinical Governance Committee
Consultation Quality Review Group members, Patient Safety and Clinical Governance Committee members, SOTW commissioning leads, FT representatives Equality Impact Assessment Completed
Implementation Plan Completed
Distribution All relevant commissioning staff and external partners
Date Amended following initial February 2012 ratification (if relevant) Implementation Date 22 March 2012 Planned Review Date April 2013 Version V4.2 Author C Donaldson, Associate Director of Quality and Patient Safety D Cornell Risk and Patient Safety Lead Reference No N – GD – 01 - 1007
Location Keylink/Policies/Corporate Policies
Previous policy: NESHA Guidance for Reporting and Management of Serious incidents
Previous policy reference number: as above
Issue date of previous policy: October 2008
Location of previous policy: SHA Policy archive
NHS SOTW Serious Incident Policy for Commissioners: Version V4.2
Contents Page Section 1: Introduction 1.1 Introduction 4 1.2 Policy Statement 5 1.3 Purpose 5 1.4 Duties & Accountability 5 1.5 Definitions 9 1.6 Related Documents 9 1.7 Equality and Diversity 9
Section 2: Criteria for Reporting a Serious Incident 10
Section 3: Guidance for South of Tyne Commissioned Service 13 Providers including Independent Contractors
Section 4: Additional Guidance 15 4.1 Mental Health and Learning Disabilities 15 4.2 Children 15 4.3 Safeguarding Vulnerable Groups 17 4.4 MAPPA 17 4.5 Prison Healthcare 18 4.6 Domestic Homicide review 18 4.7 Maternity Services 18 4.8 Screening Programmes 19 4.9 Breach of Confidentiality 21
Section 5: Information for Training Organisations 23
Section 6: Document Consultation, Approval & Ratification 6.1 Consultation 23 6.2 Document Approval & Ratification 24 6.3 Document Development 24 6.4 Version Control 24
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Section 7: Training, Distribution & Implementation 25
Section 8: Monitoring Compliance 8.1 Standards and Key Performance Indicators 26 8.2 Monitoring Compliance 26
Glossary 27
References 27
Useful Contacts 27
Appendices 1 Appendix 1 – Extract from NPSA guidance: National Framework for 28 Reporting and Learning from Serious Incidents Requiring Investigation (i.e. SIs) 2 Appendix 2 – Example of Standard Contract Information in relation 29 to Serious Incidents 3 Appendix 3 – List of „Never Events‟ 30 4 Appendix 4 - Management of Pressure Ulceration - definitions 31 5 Appendix 5 – Flowchart for Reporting Serious Incidents (NHS 35 Providers Organisations and Foundation Trusts) 6 Appendix 6 – Flowchart for Reporting Serious Incidents 36 (Independent Contractors) 7 Appendix 7 – SI Reporting Form for Independent Contractors 37 8 Appendix 8 – Initial SI Report and Action Plan Template 39 9 Appendix 9 – Allegations Management 41 10 Appendix 10 – Additional Advice and Regional Contact Details for 42 SIs in Screening or immunisation Programmes 11 Appendix 11 – Additional Guidance on Reporting SIs relating to 43 Information Governance breaches (actual and potential)
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Section 1
1.1. Introduction
1.1.1. The NHS treats over one million patients every single day. The vast majority of patients receive high standards of care, however incidents do occur and it is important they are reported and managed effectively.
1.1.2. As a commissioner of health care services, NHS South of Tyne and Wear is committed to promoting patient safety and making an effective contribution to the North East Strategic Health Authority‟s (NESHA) vision of no avoidable deaths, injury or illness and no avoidable suffering or pain.
1.1.3. NHS South of Tyne and Wear seeks to assure that all services which are commissioned meet nationally identified standards. This is managed through the local contracting and performance review process. Compliance with serious incident (SI) reporting is a standard clause in all contracts and service level agreements and reviewed as part of the quality schedules.
1.1.4. The role of NHS South of Tyne and Wear is to gain assurance that incidents are properly investigated, action is taken to improve clinical quality, and lessons are learnt in order to minimise the risk of similar incidents occurring in the future. It is intended that intelligence gained from SIs will be used to influence quality and patient safety standards for care pathway development, service specifications and contract monitoring.
1.1.5. This policy is intended to support and interface with the National Patient Safety Agency guidance on the reporting and Learning from Serious Incidents Requiring Investigation and the Information Resource to Support the Reporting of Serious Incidents.
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1.2. Policy Statement
1.2.1. It is the duty of each NHS body to establish, and keep in place, arrangements for monitoring and improving the quality of healthcare provided by and for that body. NHS South of Tyne and Wear is committed to this policy, and its implementation, to ensure a consistent approach to the implementation of robust arrangements for the management of SIs.
1.3. Purpose
1.3.1. The purpose of this policy is to identify what a SI is and to describe the process for the reporting and management of those identified by providers of NHS services commissioned by NHS South of Tyne and Wear. This will include community services providers, foundation trusts, independent contractors and independent providers of NHS services. The policy aims to ensure that NHS South of Tyne and Wear, as a commissioner, complies with current legislation as well as national guidance, NESHA guidance and National Patient Safety Agency (NPSA) requirements with regard to accident/incident reporting generally, but in particular identifying, reporting and investigating SIs.
1.3.2. This policy applies to all employees of NHS South of Tyne and Wear and the services they commission.
1.4. Duties & Accountability
Lead Individual duties and accountabilities:
1.4.1. The Chief Executive as Accountable Officer has responsibility for ensuring that the three primary care organisations have the necessary management systems in place to enable the effective management of implementation of all risk management and governance policies and delegates the responsibility for the management of serious incidents to the Director of Governance and
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Quality.
1.4.2. The Director of Governance and Quality has executive responsibility for ensuring the necessary management systems are in place for the effective implementation of serious incident reporting for commissioned services and independent contractors and delegates‟ management of serious incident reporting to the Associate Director for Quality and Patient Safety.
1.4.3. The Associate Director of Quality and Patient Safety has responsibility for the management of serious incident reporting and ensures an appropriate case manage is allocated following assessment of the reported incident. They have responsibility for ensuring lessons learned from serious incidents influence quality and safety standards for care pathway development and service re- design. They are a member of the Joint Risk and Governance and Quality, Patient Safety and Clinical Governance Committees.
1.4.4. The Chief Operating Officer is responsible for ensuring that the serious incident reporting and monitoring is incorporated into all contracts for services commissioned by the NHS South of Tyne and Wear.
1.4.5. The Director of Finance has executive responsibility for ensuring that lessons learned from serious incidents influence quality and safety standards for finance and estates.
1.4.6. The Risk and Patient Safety Lead has responsibility for ensuring that all areas identified from serious incidents as high risk are included, if appropriate, in the Corporate Risk Register and Assurance Framework in accordance with the Risk Management Strategy. The Risk and Patient Safety Lead is supported by the Risk and Patient Safety Team.
1.4.7. The Associate Director for Information Technology has responsibility for ensuring lessons learnt from serious incident reporting influence quality and safety standards for information technology.
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1.4.8. The Accountable Officer for Controlled Drugs has overall responsibility for ensuring that all serious incidents related to controlled drugs are investigated appropriately. They are directly accountable to the Medical Director and a member of the Local Intelligence Network for controlled drugs.
1.4.9. Named SI Case manager(s) are responsible for ensuring investigations are managed and monitored appropriately in accordance with current guidance and this policy, the apporpirate grading of incidents (see Appendix 1 for the NPSA) and for identifying lessons to be learnt as a result. SI case managers are responsible for providing reports within the appropriate timescales as follows:
24 hour initial report for all SIs, plus, 45 day final report for all grade 1 SIs, or, 30 day interim and 60 final reports for all grade 2 SIs. N.B If a grade 2 SI is likely to exceed the 60 day deadline, monthly update reports are required until a final report can be submitted.
1.4.10. NHS South of Tyne and Wear commissioning leads and specialist commissioning leads need to make explicit reference to serious incident reporting in contracts with all providers and, in particular, the expectations regarding serious incident reporting and management and the indicators and process for performance management of such incidents (see Appendix 2 for an example of the standard contract information for Foundation Trusts).
1.4.11. The North East Strategic Health Authority will continue to be responsible for the management of serious incidents originating from the NHS South of Tyne and Wear commissioning function and all SIs reported prior to 1 April 2011. Responsibility for the management of SIs reported after this date transferred to NHS South of Tyne and Wear as from 1 April 2011. Responsibility for the management of SIs reported by Northumberland, Tyne and Wear Mental Health Trust (those relevant to the South of Tyne and Wear area) also transferred to NHS South of Tyne and Wear as from 1st February 2012. However any SIs prior to this date will also continue to be managed by NESHA.
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1.4.12. NESHA will continue to monitor performance in relation to the incidents outlined in 1.4.11 and continue to undertake this function until such times further guidance is received nationally.
Lead committee duties and accountabilities:
1.4.13. Joint Risk and Governance Committee is directly accountable to the Joint PCT Board and will be responsible for the ensuring the monitoring of serious incident quarterly reports.
1.4.14. Quality, Patient Safety and Clinical Governance Committee has responsibility for overseeing the detailed case management and receives regular updates at its 6 weekly meetings. The Committee reports to the Joint Risk and Governance Committee and Clinical Commissioning Group Boards.
1.4.15. Serious Incident Panel has been established and has responsibility to review and monitor each individual incident until closure can be recommended to ensure the completion of all required actions and identification of appropriate lessons learnt. The Panel is chaired by the PCT Medical Director.
1.4.16. Quality Review meetings currently take place monthly to discuss quality issues and strengthen links with providers. Serious incidents are a standing item on the agenda and issues discussed directly with the provider concerned.
General duties and accountabilities:
1.4.17. NHS Community Health Services, Foundation Trusts and Independent Contractors will need to ensure that they have robust mechanisms in place for the reporting and management of all incidents meeting the criteria for serious incident. This should include informing NHS South of Tyne and Wear as commissioners.
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N.B. Organisations have a duty to report any serious incident via the appropriate process in the interests of patient safety regardless of whether the reporting organisation were the provider of healthcare at the time. A discussion should take place with the appropriate SOTW lead officer to establish which organisation takes responsibility for the investigation.
1.5. Definitions
Serious incident (SI)
1.5.1. An incident or near miss occurring on health service premises or in relation to health services provided, resulting in death, serious injury or harm to patients, staff or the public, significant loss or damage to property or the environment, or otherwise likely to be significant public concern. This shall include „near misses‟ or low impact incidents which have the potential to contribute to serious harm. The definition also applies to any incident involving the actual or potential loss of personal information that could lead to identify fraud or have significant impact on individuals should be considered as a serious.
1.6. Related Documents
NHS South of Tyne “Policy for Handling Concerns about the Performance of Independent Healthcare Professionals”. SI Section of commissioned service contracts and service level agreements. NHS South of Tyne and Wear and Wear Risk Management Strategy NPSA National Framework for the Reporting and Learning from Serious Incidents Requiring Investigation.
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1.7. Equality and Diversity
1.7.1. Equality Impact Assessments: All public bodies have statutory duties under the Race Relations (Amendment) Act (2000), the Disability Discrimination Act (2005) and the Equality Act (2006) to set out arrangements to assess and consult on how their policies and functions impact on race, gender and disability equality, in effect to undertake equality impact assessments on all policies/guidelines and practices. Best practice also suggests that Equality Impact Assessments should be extended to include equality and human rights with regard to age, religion, and sexual orientation and the three NHS South of Tyne and Wear and Wear PCT‟s have adopted this best practice approach within its EIA as from the date of the adoption of this policy.
1.7.2. The three PCTs of NHS South of Tyne and Wear and Wear are committed to providing services that meet the equality and diversity needs of staff and service users within the framework of current legislation. Current equality and diversity legislation includes disability, gender, age, race, sexual orientation, and religion. It is the responsibility of managers and staff to ensure that they act on this policy in a manner that meets the needs of people from these groups. It is always best to check with individual staff/service users what their needs are, but needs may include providing information in an accessible format, considering mobility and communication issues, being aware of sensitive and cultural issues.
1.7.3. This policy has been Equality Impact assessed; recommendations from the assessment have been incorporated into the document and have been considered by the approving committee.
Section 2
2.1. Criteria for Reporting Serious incidents (SIs) Page 10 of 52
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The definition of a SI can be quite broad so the following criteria has been adopted, based on current guidance from the NPSA Information Resource to Support the Reporting of Serious Incidents, which outlines the type of incidents that are likely to be included as follows:
2.1.1. Never Events: Any incident identified as being on the core set of “Never Events” (see Appendix 3 for a definitive list).
2.1.2. Unexpected death, serious harm or injury: Patients, individuals, or groups of individuals suffering serious harm or catastrophic harm or unexpected death whilst in receipt of health services, including screening and immunisation, radiation errors and equipment failures. Examples could include: false negative screening test results blood testing issues inappropriate vaccination of patients in a care home. Serious injury or unexpected death of any individual to whom the organisation owes a duty of care including staff, visitor, contractor, or another person. Examples could include: An elderly patient has a fall and suffers death or serious injury as a result. Patient receives incorrect dosage of medication/wrong medication, suffers an adverse reaction, has a cardiac arrest and suffers brain damage as a result or dies. Chest drain bottle found to have fluid level below the prime line and the patient dies. Female catheter being used on a male patient and causing damage to the uretha Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting. Death or injury where foul play is suspected.
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2.1.3. Mortality/Morbidity/Care Incidents: Category 3 and above pressure ulcers should be reported following initial rapid root cause analysis and appropriate investigations undertaken (see Appendices 4a and 4b for agreed definitions and pressure ulcer reporting flowchart). Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient (within 48 hours). Clusters of unexpected or unexplained deaths Where the death results in adverse comments from a coroner Suicide of any person currently in receipt of NHS services on or off NHS premises, or who has been discharged within the last 12 months. Where there is obvious evidence or strong suspicion of self-harm Abuse that has perpetrated within the remit of the organisation. This may be by a member of staff, visitor or member of the public.
2.1.4. Children (please refer to section 4.2 and Appendix 9 for further information) Significant harm to a child where reported under the local child protection procedures. Examples could include: A child death where abuse or neglect is suspected to be a factor in the death When a child has suffered significant injuries suspected to be as a result of child abuse Where a child has suffered further harm as a result of health care worker failing to follow procedures Unexplained child death in a health care setting Unexplained death or more than one sibling Where a serious case review is to be undertaken Children and adults with complex health needs failing to obtain their assessed and agreed packages of health care, thus putting their health at serious risk
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Multiple attendances at A&E for a single child or more than one sibling Death of a child on the child protection register The admission of a child of under the age of 16 to an adult psychiatric ward. Where a child is over 16 and not yet 18 years of age there are specific criteria which must be met with regard to their accommodation, namely: The beds must be specifically set aside for this use and are single sex Staff are Criminal Record Bureau checked and have support and training available to them from child mental health professionals Local Safeguarding Children Board is satisfied with the measures in place Adult mental health staff and CAMHS work closely together to plan the care, discharge and after care utilising the Care Programme approach Education, recreational facilities, and advocacy services are available to children and young people. Advocates, trained in mental health legislation, work with children and young people Local Authority and voluntary social care, vocational and housing services are part of the network supporting the young people In the event of any of these criteria not being met the incident with regard to the child aged 16/17, this should be reported as a serious incident.
2.1.5. Screening Programmes (please refer to section 4.8 and Appendix 10 for further information) An actual or possible failure of the screening service that has consequences for the clinical management of patients. Examples could include: Loss of test results
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Failure to detect cancers Incorrect notification of results to a patient or groups of patients.
National and regional guidelines exist in relation to screening programmes which should be adhered to in conjunction with this policy (see section 4 for further information).
2.1.6. Abuse of Adults (please refer to section 4.3 and 4.4 for further information) The abuse of an adult described in „No Secrets‟. Examples of this could include: Death or injury to a vulnerable adult where abuse or neglect is suspected to be a factor Where a vulnerable adult has suffered harm as a result of staff failing to follow agreed procedures or acceptable practice When a vulnerable adult has suffered significant injuries suspected to be a result of abuse.
2.1.7. Health Protection A confirmed death of a patient due to hospital acquired infection including MRSA and C.difficle. Outbreaks of infection that involve presumed transmission within healthcare settings (acute, community). Examples could include: norovirus C.difficle Panton-valentine leukociden (PVL) positive MRSA Cases/outbreaks of infection with an NHS-attributable food, water or environmental source. Examples could include: nosocomial legionnaires disease salmonella failed vaccination cold chain failed sterilisation of instruments
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an outbreak, such as viral gastroenteritis, necessitating ward closures to new patients and resulting in significant restrictions of hospital activity. Exposure to checmical agents or radiation caused by failures in healthcare settings An outbreak/health protection incident that is poorly managed, resulting in harm.
2.1.8. Medical devices: Any serious harm to staff or patients involving medical equipment whether due to human error or due to equipment found to be suspected of being faulty or to have failed. Examples could include: hoist collapsing defibrillator failing Any serious injury or death associated with the use/function of a device in which the device is used/functions other than as intended. Any medical device-related incident that causes, or has the potential to cause, unexpected or unwanted side effects involving the safety of device users (including patients) or other persons.
2.1.9. Information Technology Any IT systems failure occurring which impacts on clinical care of patients and service users, including all systems used or required to deliver patient and/or service user care, such as PAS, GP systems, results reporting systems . Examples could include: High number of pathology results, including smear and INR results, being sent to GP practices due to software problem Loss of network connectivity for a large number of staff
2.1.10. Information Governance (please refer to Appendix 11 for further information) Major breaches of confidentiality such as the loss or theft of personal identifiable records or information (including missing notes).
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Actual or potential loss of personal information that could lead to identity fraud or have other significant impact on individuals (see section 4 and Appendix 11 for further information on what should be considered as a serious incident).
2.1.11. Staff-Related Incidents: Allegations/ criminal proceedings instigated regarding serious professional misconduct Serious complaints about a member of staff or independent contractor or any incident relating to a staff member where adverse media interest could occur. Where a member of staff is suspected of committing serious fraud. Where a member of staff is suspected of harming patients. Suspicion of a serious error(s) by a member of staff, independent contractor or other healthcare contractor. Where a member of staff shows a gross disrespect for the dignity of a patient/deceased patient. Serious verbal or physical aggression
2.1.12. Emergency Plan Invoked: Adverse incident which would invoke an emergency plan (affecting business continuity including multiple ward or practice closure, due to infection, serious damage to occupied NHS property through fire, flood or criminal damage, IT failure). Wilful damage to property, destruction and vandalism. Terrorist threats/incidents which include incendiary devices or the use of other weapons including chemical, biological, radiological or nuclear agents (CBRN).
2.1.13. Media Issues: Matters likely to attract interest from local, regional or national newspapers, TV or radio.
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All incidents reported to or involving the police that are considered serious or may have an adverse media effect. Cancellation of surgery by a Trust for a patient on more than 3 occasions. Serious fraud or security-related media matters.
2.1.14. Mental Health, Substance Misuse and Learning Disabilities: (please refer to section 4.1 for further information) A serious offence including homicide committed by an individual in receipt of mental health and/or learning disability services Patients detained under the Mental Health Act (1983) who abscond from health services and who present a serious risk to themselves and/or others. Specific national guidance governs incidents such as homicides and other serious incidents involving mentally ill people (Health Service Guidance 94,27) Arrangements for dealing with major incidents (Health Service Circular 98,197). A serious offence that involves an assault of staff by patients.
2.1.15. Maternity incidents: (please refer to section 4.7 for further information) Maternal deaths – unexpected death of a mother and/or baby, including a cot death in hospital neonatal deaths unexpected stillbirths. Baby abduction
2.1.16. Premises/Equipment incidents Failure of equipment so serious as to endanger life, whether or not injury results Suspicion of malicious activity, such as tampering with equipment Serious damage that occurs on the premises of NHS, primary care or independent sector providing NHS work Serious damage to property belonging to the NHS
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Any serious service failure occurring which impacts on clinical care of patients and service users. Examples could include: Mains power failure Closure of ward due to flooding
2.1.17. Blood Transfusion Serious adverse reaction – any unintended response in a donor or patient that is associated with the collection or transfusion of blood or blood components that is fatal, life-threatening, disabling or incapacitating or results in prolonged hospitalisation or morbidity Serious adverse events – any untoward occurrence associated with the collection, testing, processing, storage and distribution of blood or blood components that might lead to death or life-threatening, disabling or incapacitating conditions for patients or which results in or prolongs hospitalisation or morbidity Incorrect blood component transfused leading to serious incident or death
2.1.18. This list is not exhaustive and if there are any doubts about whether an incident should be reported as a SI, please contact the Risk and Patient Safety Lead for NHS South of Tyne and Wear to discuss the incident.
Section 3
3.1 Guidance for South of Tyne and Wear Commissioned Service Providers, including Independent Contractors
3.1.1 Each provider is responsible for identifying serious incidents and taking effective action in each instance. It is expected that clear procedures are in place for identifying, reporting and investigating such incidents.
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3.1.2 Each provider must nominate a single point of contact or lead officer for the management of all SIs.
3.1.3 The reporting arrangements for SIs will be different depending on the provider. NHS Providers, Community Services and Foundation Trusts report SIs via the STEIS system (see Appendix 5).
Independent contractors who do not have access to STEIS are required to report a SI via a dedicated NHS mail account [email protected] using the flowchart (Appendix 6) and report form (Appendix 7).
3.1.4 Internal investigations should commence immediately on notification of the SI in line with individual organisations incident management policies . Any such policies should incorporate the principles of Being Open and the Memorandum of Understanding. Where no request for a same day report has been made, the service provider should forward their routine internal investigation report to NHS South of Tyne and Wear as advised and as soon as it has been completed but not exceeding the appropriate timescale. This will be either 45 or 60 working days from the reported date depending on the level of grading for the incident (see Appendix 8 for an example of the required report contents and action plan).
3.1.5 Under the Data Protection Act (1988) organisations need to be open and transparent with regards to investigation processes, unless there are specific exceptions. Arrangements may need to be put in place to support patients and family members through the investigation process and sharing of the outcomes of investigations. The appointment of a Family Liaison Officer may be appropriate.
3.1.6 If a SI spans organisational boundaries, it is the responsibility of the Trust/provider where the incident took place to formally report it through STEIS. All other organisations/providers involved must contribute and fully co- operate with the process in line with agreed timescales. If an incident involves
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more than one NHS organisation, a decision will need to be made (mutually agreed) regarding who will be the lead investigating organisation.
3.1.7 The information within this document must not interfere with existing lines of accountability and does not replace the duty to inform the police and/or other organisations or agencies where appropriate. NHS South of Tyne and Wear expects providers to utilise guidance from the Department of Health‟s Publication Memorandum of Understanding: Investigating Patient Safety Incidents (June 2004) and accompanying NHS guidance of December 2006. The need to involve outside agencies should not impede the retrieval of immediate learning.
3.1.8 If there is evidence to indicate that a SI could be part of a cluster or trend, or where the circumstances or consequences of the incident are of particular concern, NHS South of Tyne and Wear may instigate a wider case review depending upon the nature of the incident. This may involve the provider undertaking further enquiries or suggest a particular course of action.
3.1.9 SIs which have impacted or have had potential to impact on children and/or vulnerable adults must be investigated in conjunction with the identified safeguarding lead and in accordance with related guidance. Where a SI is subject to the involvement of a coroner, an independent inquiry, serious case review, or any safeguarding issues, this should be highlighted clearly within the STEIS report as this may affect closure date.
3.1.10 The NHS South of Tyne and Wear Quality and Patient Safety Team will support the development of processes to allow sharing of information between organisations and other sectors to ensure lessons are learned. Information on lessons learnt will be collated and shared via the Joint Quality Review meetings.
Section 4: Additional Guidance
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4.1. Mental Health or Learning Disability Services
4.1.1 Any SI involving a former patient who has been discharged from mental health services within the previous 6 month period must be reported by the appropriate Mental Health Trust through STEIS. (Note: child protection arrangements may apply).
4.1.2 If the SI involves a former patient who has been discharged from the service in excess of 6 months, the Mental Health Trust should contact a member of the Quality and Patient Safety Team to seek advice about whether or not to report the incident through STEIS.
4.1.3 If an individual is referred to secondary care services by their general practitioner and is involved in a SI before being assessed and accepted by secondary care services, it is the responsibility of the relevant primary care organisation to report the incident through STEIS and to lead the investigation process. Once the assessment of the individual is complete and the individual is accepted by secondary care services, this responsibility transfers to secondary care.
4.2 Children
4.2.1 PCTs are the lead health agency within their area and provide the health lead in inter-agency co-ordination and planning for Safeguarding Children. PCTs ensure health agencies from which they commission services contribute effectively to safeguarding arrangements.
4.2.2 In addition to the SI categories set out in section 2, PCTs must also inform the SHA (via the SI process) and the Care Quality Commission when a Local Safeguarding Children Board (LSCB) serious case review sub-group has decided that a serious case review under Chapter 8 of „Working Together to Safeguard Children‟ (2010) is to be undertaken or if a single agency (health)
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management review involving the PCT or any of its provider health agencies is requested by the LSBC.
4.2.3 Providers must ensure that a copy of the single agency health report and action plan is sent in a timely manner to the Associate Director for Quality and Patient Safety. The report and action plan must include the SI reference number. The person responsible for undertaking this role, e.g. Designated Nurse, should be confirmed in the PCT Child Protection Procedures (see protocol for undertaking individual management reviews as part of the Serious Case Review Process for Adults and Children).
4.2.4 Due to the possibility of public interest or potential to share lessons in some individual cases, a copy of the overview report, action plan and executive report should be sent to the Designated Nurse for the relevant area or the NHS SOTW Quality and Patient Safety Team.
4.2.5 Providers should inform NHS South of Tyne and Wear (via the SI process) if they refer a member of staff to the Protection of Children Act (1999) list. The process for the management of information sharing when concerns are identified about health professionals through the Child Protection system will be refined and clarified by the Designated Nurse for that area (see Appendix 8 for further information).
(N.B. The relevant Designated Nurse for Safeguarding within South of Tyne and Wear should always be contacted for further guidance).
4.3 Safeguarding Vulnerable Groups
4.3.1 Provision for the protection of vulnerable groups is made in Part 7 of the Care Standards Act (2000). Providers of services are required to fully participate in interagency working to ensure the protection of vulnerable adults using health care services (No Secrets: Guidance on developing and implementing multi- agency policies and procedures to protect vulnerable adults from abuse ,
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Department of Health (2000), Protection of Vulnerable Adults Scheme: A Practice Guide Department of Health 2006). This guidance provides the bedrock for local multi-agency polices and procedures necessary to protect vulnerable adults. Providers of services should also fully participate in Multi Agency Public Protection Arrangements (MAPPA) in all relevant cases. They should also be mindful of the Safeguarding Vulnerable Groups Act 2006, as its provisions are phased in, and ensure that they have appropriate arrangements in place to meet these requirements.
(N.B. The relevant Designated Nurse for Safeguarding within South of Tyne and Wear should always be contacted for further guidance).
4.4 The Multi-Agency Public Protection Arrangements (MAPPA)
4.4.1 NHS bodies must fulfil their „Duty to Co-operate‟ with the Multi-Agency Public Protection Arrangements (MAPPA) as defined in the Criminal Justice and Court Services Act (2000). The purpose of MAPPA is to minimise the risk to the public by those who may re-offend either violently or sexually. NHS organisations are expected to: Attend case conferences; Provide advice about the assessment and management of particular cases; Share information about particular offenders to enable the responsible Authority (police and probation) to work together effectively.
4.4.2 Participation in POVA and MAPPA arrangements are in addition to, not instead of, the SI arrangements. NHS SoTW expect providers to inform them of such incidents using the SI process when a serious case review has been requested and/or a staff member, including agency staff, has been referred to the POVA list.
(N.B. The relevant Designated Nurse for Safeguarding within South of Tyne and Wear should always be contacted for further guidance).
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4.5 Prisons Health Care
4.5.1 The Prisons and Probation Ombudsman (PPO) is responsible for investigating all deaths in prisons, probation hostels and immigration detention accommodation. It will be vital that the local NHS works closely with the PPO to ensure appropriate investigation of clinical aspects of death in custody and of residents in approved premises. There is also a need to avoid any unnecessary duplication with the NHS system for investigating adverse clinical events, and maintain clear lines of accountability for services. The Ombudsman is responsible for investigating clinical issues relevant to the death where the healthcare services are commissioned from the Prison Service, by a contractually managed prison or by the Immigration and Nationality Directorate. The Ombudsman will obtain clinical advice as necessary, and will make efforts to involve the local PCO in the investigation. Where the healthcare services are commissioned by the NHS, the PCO Chief Executive will have the lead responsibility for investigating clinical issues under its existing procedures.
4.6 Domestic Homicide Reviews
4.6.1 In the event of a homicide involving a patient in receipt of health services, the relevant NHS organisation may be asked to participate in a Domestic Homicide Review.
4.7 Maternity Services
4.7.1 Under the current legislation, governing midwifery practice rule 15 of the Midwives Rules and Standards (NMC 2004) it states: „ensure that incidents that cause serious concern in its area relating to maternity care or midwifery practice are to be notified to the local supervising authority midwifery officer‟. Therefore the existing arrangements in place to report incidents to the LSA midwifery officer remain in place („trigger list‟). SIs in maternity care need to be reported through STEIS and the aforesaid categories are not exhaustive. If in
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doubt, the local supervising authority midwifery officer should be contacted for advice.
4.7.2 SIs in maternity care are reported to Confidential Enquiry for Maternal and Child Health (CEMACH). However the following should be reported to NHS South of Tyne and Wear via STEIS: Unexpected intrapartum still birth Unexpected death of a mother and/or baby including a cot death in hospital Baby abduction
4.8 Additional guidance for SIs linked with national screening programmes
4.8.1 The screening programmes which are covered are: Breast cancer Cervical screening Bowel cancer Diabetic retinopathy Abdominal aortic aneurysm
4.8.2 There are a number of immunisation or screening programmes which require a broader approach to handling SIs. Important points to remember with regard to these incidents are: Screening or immunisation pathways cross several organisations; Incidents affect the whole pathway and not just the local department or organisation in which the incident occurred; Local incidents can affect the national reputation and alter public participation in the programme nationally; “Potential “incidents are relevant to the rest of a national programme for which it may highlight real incidents elsewhere; Lessons need to be learned in the rest of the National Programme;
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The volumes involved in screening can give individually minor incidents a major population impact; There are established regional/national networks of experts who can help with the identification and handling of incidents; Local Trusts are responsible for highlighting their local incidents to others in the health system that may be impacted by their local incident. These experts can help the local Trust make contact with the relevant people/networks outside the organisation in which the incident took place; Some national programmes already have defined protocols and tools for handling incidents which will be of value in investigations and the experts can help to guide the local Trust through these e.g. breast and cervical.
4.8.2 The Quality Assurance Reference Centre (QARC) is accountable to the Regional Director of Public Health/SHA Medical Director for the quality of the breast and cervical screening programmes. The QARC also has advisory roles for developing national programmes such as the bowel cancer screening programme.
4.8.3 SIs linked to the breast and cervical screening programmes should, in addition to normal reporting, also be reported to the QARC within 5 working days, the PCT Commissioning Lead and the SHA Screening Lead. For serious incidents, the QARC should be informed immediately, and a member of the QARC team should be involved in the Incident Co-ordination Group. The QARC will inform the national Cancer Screening Programmes office as appropriate.
4.8.4 For further details for the management of screening incidents, please refer to the UK National Screening Committee Guidance „Managing Serious Incidents in National Screening Programmes.
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4.8.5 For further details on the management of incidents within the breast screening programme, please refer to the “Guidelines for Managing Incidents in the Breast Screening Programme”
4.8.6 For further details on the management of incidents within the cervical screening programme, please refer to the “Guidelines for Managing Incidents in the Cervical Screening Programme” 4.8.7 For further details on the management of incidents within the Diabetic retinal screening programme, please refer to the NHS Screening Programmes guidance „Management of Incidents within Diabetic Retinal Screening‟.
4.8.7 For SIs linked to other national screening programmes (e.g. ante natal and child health screening) the SHA Screening Lead and SOTW Screening Lead will provide advice to local organisations and will inform the national co- ordinating bodies as appropriate (see Appendix 10 for further advice and regional contacts).
4.9 Additional guidance for breach of confidentiality SIs
4.9.1 The Department of Health have provided additional guidance for how SIs relating to breaches of confidentiality should be dealt with.
4.9.2 Any incident involving the actual or potential loss of personal information that could lead to identity fraud or have other significant impact on individuals should be considered as serious.
4.9.3 NHS South of Tyne and Wear and providers of NHS services should assess the severity of the SI on a scale of 0-5 with incidents being dealt with in accordance with their severity level (see Appendix 11 for further guidance on severity levels). If the level of incident is not clear, further guidance can be sought from the Information Governance Team within NHS South of Tyne and Wear
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4.9.4 SIs rated 1-5 should be reported to NHS South of Tyne and Wear via the STEIS system within 24 hours of the incident being discovered. These must be categorised in STEIS using the “confidential Information Leak” category.
4.9.5 Individual organisations are responsible for informing the Information Commissioner of any SI with a severity level 3-5.
4.9.6 The SHA is currently responsible for notifying the Department of Health of any SI categorised with a severity level of 3-5 and will do so as soon as possible after they have been made aware of any such incident.
4.9.7 Consideration should always be given to informing patients/service users when person identifiable information about them has been lost or inappropriately placed in the public domain.
4.9.8 When reporting an information governance breach, organisations should provide the following information: short description of incident and associated actions; how the information was held (paper, memory stick etc.); any safeguards to mitigate risk e.g. encryption; number of individuals whose information is at risk; types of information e.g. demographic, clinical; whether individuals concerned have been informed, or whether a decision has/is being made whether to inform; whether the Information Commissioner has been informed or whether a decision has/is being made whether to inform; whether the SI is in the public domain and extent of media interest or publication; category of incident (1-5).
4.9.10 When an information governance SI occurs, the Quality and Patient Safety Team will pass information on to key individuals within the organisation,
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namely the Communications and Information Governance teams and the Caldicott Guardian as appropriate.
4.9.11 Loss of encrypted media should not be reported as a SI unless the data controller has reason to believe that the encryption did not meet the Department of Health Standards, that the protections have been broken, or were improperly applied.
4.9.12 Details of SIs relating to data breaches should be included in organisations annual reports and reference to managing information risks should be made in annual Statements of Internal Control.
Section 5:
5.1. Information for Training Organisations
5.1.1. In the event an incident involves a student or trainee the relevant academic institution will be notified by the Trust/PCT as appropriate.
5.1.2. Where a SI concerns the commissioning or provision of medical or dental education or training, or a medical or dental trainee or trainees, there will be appropriate communication between NHS South of Tyne and Wear and the Northern Deanery in the investigation of the incident and subsequent action planning.
Section 6: Document Consultation, Approval & Ratification
6.1 Consultation
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6.1.1 This document has been produced by the Risk and Patient Safety Lead on behalf of the Associate Director of Quality and Patient Safety. In preparing the document for formal ratification the stakeholders listed on the front sheet were consulted upon and their comments added to the document as appropriate.
6.2 Document Approval & Ratification
6.2.1 The Quality, Patient Safety and Clinical Governance Committee has delegated authority from the Joint Risk and Governance Committee (on behalf of the Board) for the approval and ratification of this document. The Committee has ensured that a full and proper consultation has been carried out and that the content of the document has been considered in terms of current best practice, guidelines, legislation and mandatory and statutory requirements before formally approving and ratifying it on behalf of the Commissioning Board. In considering the document for approval the committee also took into account the results and recommendations of the Equality Impact Assessment.
6.2.2 This policy was formally approved by the Quality, Patient Safety and Clinical Governance Committee in July 2011 (on behalf of the Joint Risk and Governance Committee).
6.3 Document Development
6.3.1 The Quality, Patient Safety and Clinical Governance Committee and nominated author is responsible for the development, review, implementation, performance management and distribution of this policy in accordance with the procedures set out in this document and the „Policy on Policies‟.
6.4 Version Control & Review
6.4.1 Version control of this document is the responsibility of the author in conjunction with the Governance Team. The author must ensure that timely
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reviews are completed and informed to the Governance Team who will in turn maintain a register of approved documents and issue index numbers.
6.4.2 This policy will be reviewed yearly by the Quality, Patient Safety and Clinical Governance Committee or as and when significant changes make earlier review necessary.
Section 7: Training, Distribution & Implementation
7.1. Training
7.1.1 There are no specific training requirements for the implementation of this policy although it is important that both staff and independent contractors are aware of their responsibilities regarding reporting, investigation and management of SIs. All commissioning staff will receive information regarding their involvement in SIs.
7.2 Distribution
7.2.1 This policy is available for all staff to access via the keylink. Staff without computer network access should contact their line managers for information on how to access policies.
7.2.2 All staff will be notified of a new or revised document via the Chief Executive‟s Bulletin.
7.2.3 The Policy will shared directly with all relevant providers to ensure its implementation across NHS South of Tyne and Wear. It will also be made available to independent contractors via the appropriate local internet portals.
7.2.3 This document will be included in the Publication Schemes for Gateshead and South Tyneside PCTs and Sunderland Teaching PCT in compliance with the
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Freedom of Information Act (2000).
7.3 Implementation
7.3.1 It is the responsibility of all directors and commissioning leads to ensure that this policy is implemented throughout their areas of responsibility.
Section 8: Monitoring Compliance
8.1. Standards and Key Performance Indicators
8.1.1 Key Performance Indicators for this policy are:
All contracts for services commissioned or provided by the NHS South of Tyne and Wear will identify SI reporting requirements; All SIs will be managed within identified timescales; Documented evidence that lessons learnt from SIs are disseminated e.g. patient safety newsletter, educational events.
8.1.2 Performance against these indicators will be monitored via the Quality, Patient Safety and Clinical Governance Committee and quality review process. Performance against the above indicators will also be shared with the appropriate contract manager(s) for further escalation as appropriate.
8.2 Monitoring of Compliance
8.2.1 The Key Performance Indicators set out above will be monitored for compliance via an annual audit. The audit will be carried out by the Quality and Patient Safety team with the results shared with the nominated committees.
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Glossary
Strategic Executive Information System (STEIS) – national database for the reporting of all SIs to the Department of Health.
References DH (2004) Memorandum of Understanding: investigating Patient Safety Incidents
DH (2000) No Secrets: Guidance on developing and implementing multi agency policies and procedures to protect vulnerable adults from abuse.
DH (2006) Protection of Vulnerable Adults Scheme; A Practice Guide
National Patient Safety Agency (2010) National Framework for the reporting and Learning from Serious Incidents requiring Investigation
National Patient Safety Agency (2010) – Information Resource to Support the Reporting of Serious Incidents
National Patient Safety Agency (2009) Being Open – communicating patient safety incidents with patients, their families and carers
Useful Contacts
Risk and Patient Safety Lead, NHS SOTW Tel: 0191 502 6655
Patient Safety team, NESHA Tel: 0191 210 6506
Designated Nurse for Safeguarding Tel: 0191 497 1571 (Gateshead PCT)
Designated Nurse for Safeguarding Tel: 0191 283 1379 (South Tyneside PCT)
Designated Nurse for Safeguarding Tel: 0191 529 7229 (Sunderland Teaching PCT)
NHS SoTW Screening and Immunisation Lead Tel: 0191 529 7000
NHS SoTW Information Governance Lead Tel: 0191 5297252
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Appendix 1
Extract form NPSA Guidance: National Framework for Reporting and Learning from Serious Incidents Requiring Investigation
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Appendix 2
1. Serious incident and Patient Safety Incident Reporting
1.1 The Provider shall, in accordance with the timescales set out in Schedule 12 (Serious incidents and Patient Safety Incidents), send the Co-ordinating Commissioner a copy of any notification it gives to a Regulator or Monitor where that notification directly or indirectly concerns any Patient.
1.2 The Parties shall comply with: 1.2.1 the arrangements for notification and investigation of Serious incidents; and 1.2.2 the procedures for implementing and sharing Lessons Learned in relation to Serious incidents
that there are agreed between the Provider and the Co-ordinating Commissioner and set out in Schedule 12 (Serious incidents and Patient Safety Incidents).
1.3 The Commissioners shall have complete discretion to use the information provided by the Provider under this clause 15 (Serious incident and Patient Safety Incident Reporting) and Schedule 12 (Serious incidents and Patient Safety Incidents) in any report which they make to Monitor, to any Regulator, any NHS Body, any Strategic Health Authority, any office or agency of the Crown, or any other appropriate regulatory or official body in connection with such Serious incident or in relation to the prevention of Serious incidents, provided that they shall in each case notify the Provider of the information disclosed, and the body to which they have disclosed it.
1.4 The Provider shall comply in all respects with: 1.4.1 the procedures relating to Patient Safety Incidents; and 1.4.2 the procedures for implementing and sharing Lessons Learned in relation to Patient Safety Incidents
that are agreed between the Provider and the Co-ordinating Commissioner and set out in Schedule 12 (Serious incidents and Patient Safety Incidents).
1.5 The provisions of this clause 15 (Serious incident and Patient Safety Incident Reporting) shall in respect of any Services performed under this Agreement survive its expiry or its termination for any reason.
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Appendix 3
Never Events
The following list of “Never Events” which are to be reported to commissioners through the Serious incident reporting process.
Wrong site surgery Wrong implant/prosthesis Retained foreign object post-operation Wrongly prepared high-risk injectable medicine Maladministration of potassium-containing solutions Wrong administration of chemotherapy Wrong administration of oral/enteral treatment Intravenous administration of epidural medication Maladministration of Insulin Overdose of midazolam during conscious sedation Opioid overdose of opioid-naïve Patient Inappropriate administration of daily oral methotrexate SIcide using non-collapsible rails Escape of a transferred prisoner Falls from an unrestricted window Entrapment in bedrails Transfusion of ABO blood components Transplantation of ABO or HLA-incompatible organs Misplaced naso- or oro-gastric tubes Wrong gas administered Failure to monitor and respond to oxygen saturation Air embolism Misidentification of patients Severe scalding of patients Maternal death due to post partum haemorrhage after elective caesarean section.
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Appendix 4
MANAGEMENT OF PRESSURE ULCERATION – AGREED DEFINITIONS
These definitions have been devised and agreed across the North East Region by specialists working in the field of tissue viability (see list of represented trusts) and wider consultation with management representatives from the named trusts using best evidence from the literature which has been referenced where possible. In areas where little or no evidence was available the group has made statements based on consensus / best practice recommendations.
Definition of a Pressure Ulcer
"A pressure ulcer is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors has yet to be elucidated." 1
Definition of a Non-Healthcare Attributed (Acquired) Pressure Ulcer/s
“Patients who are transferred into a care setting with obvious signs or symptoms of pressure related skin damage that were documented as absent on the previous admission / assessment within that care setting”.
Please note the development of a pressure ulcer within 72 hours2 of the start of the episode of care that goes onto be a category 3 or 4 ulcer within 2 weeks is likely to be related to pre existing damage incurred prior to admission or during the transfer of care and should be reported as an Non-Healthcare Attributed ulcer. However any pressure damage arising thereafter, the most likely cause will be related to care within the healthcare setting the patient is in; as such this must be regarded as a new event and reported as Healthcare Attributed (developed) ulceration. 2
Definition of a Healthcare Attributed (Developed) Pressure Ulcer/s
“Patients who are transferred into a healthcare setting without any obvious signs or symptoms of documented pressure related skin damage that go onto develop a pressure ulcer during their episode of care in that setting”.
Please note the development of a pressure ulcer within 72 hours2 of the start of the episode of care that goes onto be a category 3 or 4 ulcer within 2 weeks is likely to be related to pre existing damage incurred prior to admission or during the transfer of care and should be reported as an Non-Healthcare Attributed ulcer. However any pressure damage arising thereafter, the most likely cause will be related to care within the healthcare setting the patient is in; as such this must be regarded as a new event and reported as Healthcare Attributed (developed) ulceration. 2
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Additional Considerations
To accurately determine whether the ulcer is developed within the organisation or acquired from another healthcare setting or the patient‟s home it is important to go back to the first episode of care and define a timeline of events. Documented evidence of skin integrity should be established from the patients records, using the date of this assessment and the sequence of events it should become clear where the pressure ulcer occurred.
Please note that patients with pre-existing pressure ulceration can develop new areas of ulceration during an episode of care. In addition any deterioration of an existing ulcer should be documented, for example if a category 2 ulcer deteriorates to become a category 3 or 4 ulcer this should be reported alongside any new areas of ulceration and reported as either an acquired or developed dependant upon the definitions above. As such some patients may have a combination of both acquired and developed ulceration as a result of multiple episodes of care and differing providers.
Definition of preventable pressure ulcer
“The provider of care has evaluated the individual‟s clinical condition and pressure ulcer risk factors: but has failed to define and or implement interventions that are consistent with individual needs, goals and recognised standards of practice. Or has completed the risk assessment and implemented interventions but has failed to monitor and evaluate the impact of the interventions; and revise the approaches as appropriate.”
Exclusions to this definition:
Unavoidable pressure ulcers;
Kennedy Terminal Ulcer: A pressure ulcer that individuals develop with a terminal illness at end of life. It is usually shaped like a pear, butterfly, or horseshoe, usually on the coccyx or sacrum (but it has been reported on other anatomical sites), has colours of red, yellow or black, is sudden in onset, and usually is associated with imminent death4.
Chronic health conditions e.g. Multiple Sclerosis/Spinal Injury etc, healing or prevention may not be the patient‟s goal or choice. Although the individual should be assessed and offered all preventative therapies as appropriate and education as per NICE guidelines 2005. The individual‟s choices will be respected and recorded.
It is important to note that every effort will be made to prevent pressure ulceration in patients with the aforementioned conditions. They will also have access to essential services, pressure relieving equipment and will have a plan of care instigated that will be subject to regular review.
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Pressure Ulcer Categorisation
Previously pressure ulcers have been graded or staged it was a recommendation of EPAUP and NPUAP that pressure ulcers are now categorised and referred to as Category 1,2,3,or 4 as described in the table below. 3
Category Short Description Definition Category 1 Non-Blanchable Non-blanchable erythema of intact skin. erythema of intact skin Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin Category 2 Partial thickness skin Partial thickness skin loss involving loss (including blisters) epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion or blister Category 3 Full thickness skin loss Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia Category 4 Full thickness tissue loss Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full thickness skin loss
Please note that Pressure Ulcers should not be reverse categorised when they heal
A Category 1 ulcer becomes a healed category 1 ulcer – if it breaks down again it can be classified as any category of ulcer and categorisation should be based on the level of damage
A Category 2 ulcer becomes a healed Category 2 ulcer – if it breaks down again it should be Categorised as at least a Category 2 ulcer or a Category 3 or 4 Ulcer if it deteriorates further depending on the level of damage
A Category 3 ulcer becomes a healed Category 3 ulcer – if it breaks down again it should be Categorised as at least a Category 3 or a Category 4 Ulcer if it deteriorates further depending on the level of damage
A Category 4 ulcer becomes a healed Category 4 ulcer – if it breaks down again it should always be Categorised as a Category 4 Ulcer
References
1. International review (2010) Pressure ulcer prevention: pressure, shear friction and microclimate in context. A consensus document. London: Wounds International
2. Department of Health (2010) NHS Institute for Innovation and improvement Your Skin Matters - High impact Actions page 29
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3. National Pressure Ulcer Advisory Panel NPUAP (2010) Pressure Ulcer Prevention Quick Reference Guide http://www.npuap.org/Final_Quick_Prevention_for_web_2010.pdf Accessed 11/01/2011
4. Beldon P (2009) Skin Changes At Life‟s End, SCALE, Final Consensus Statement Wounds uk, 2010, Vol 6, No 1
Organisations involved
County Durham and Darlington Community Health Services Middlesbrough Redcar and Cleveland community Health Services Newcastle Primary Care Trust Newcastle upon Tyne NHS Foundation Trust South Tyneside Foundation Trust Community Health Services North Tees and Hartlepool NHS Foundation Trust North Tyneside Primary Care Trust Northumberland Care Trust Northumbria Healthcare NHS Foundation Trust South Tees Hospitals NHS Foundation Trust South Tyneside NHS Foundation Trust
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Pressure Ulcer Reporting Flowchart Appendix 4b
Category 3/and or 4 pressure ulcer identified on admission or deteriorates during episode of care
No Yes Is it hospital acquired?
Hospital to Hospital to inform PCT. report as serious incident.
Is the patient Has the patient Is the patient resident in a been admitted resident in a nursing home? from their own care/residential home? home?
Yes Yes Yes
Is patient in PCT to report receipt of care as No from community commissioner services within South Tyneside Foundation Trust
Yes
South Tyneside Foundation Trust to report
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NHS Confidential Appendix 5
Flow Chart for Reporting SIs: NHS Provider Organisations and Foundation Trusts
Serious Incident occurs
In all cases OUT OF HOURS Complete STEIS Report Form IF IMMEDIATE INVOLVEMENT IS NECESSARY CALL the NHS SoTW Director on duty on 0191 5265276
Notify commissioner via Quality and Patient Safety Team within 24 hours using initial reporting template via email sun- [email protected] Tel: 0191 5297089
Assessment by Quality and Assessment by SoTW Patient Safety Team Communications Team if appropriate
Quality and Patient Safety Team Liaise with DH Media will liaise with organisation for Centre if considered further information if required necessary
Acknowledgement letter sent to CE / Associate Director and reporting officer
Reporting Officer in the organisation forwards a copy of the SI report and action plan to [email protected] within appropriate timescale
Report received and reviewed by SI Panel
Report Satisfactory, Case closed. Letter sent to Reporting Officer Report incomplete,Agree confirming this. any further level of investigation and agree timescales for submission
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Appendix 6
Flow chart for reporting SIs: Independent Contractors
Serious Incident occurs in Practice
Lead Officer in Practice to contact OUT OF HOURS NHS South of Tyne and Wear via IF IMMEDIATE INVOLVEMENT email sun-pct.patient- IS NECESSARY [email protected] CALL the NHS SoTW Director and begin internal investigation on duty on 0191 5265276 Tel: 0191 2172846
Notify commissioner via Quality and Patient Safety team within 24 hours and supply 24 hour report on immediate actions. Tel: 0191 529 7089
Quality and Patient Safety Team Assessment by SoTW log SI and unique identifier Communications Team if applied. appropriate
Quality and Patient Safety Team Liaise with DH Media will liaise with practice for further Centre if considered information if required necessary
Acknowledgement letter sent to practices identifying the date the reports are due
Lead Officer in practice forwards a copy of the SI report and action plan to NHS SoTW sun- [email protected] Inbox within appropriate
Report received and reviewed by Risk and Patient Safety Team
Report incomplete, or learning and Report Satisfactory, Case actions not completed. Agree any closed. further level of investigation and Letter sent to Lead Officer agree timescale for submission confirming this.
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Appendix 7
SERIOUS INCIDENT (SI) REPORTING FORM FOR INDEPENDENT CONTRACTORS Please email the completed form to [email protected]
Reporting Practice:
Reporter name:
Reporter job role:
Telephone number:
Practice address:
Telephone number:
Email address:
Date of incident:
Time of incident:
Site of incident:
Date Incident Reported to NHS South of Tyne and Wear:
Gender: Male Female (delete as applicable)
Date of birth:
Media interest: Yes No (delete as applicable)
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Description of event – to include the location of the incident, job title of person /people involved in the incident, any equipment involved.
NB: Facts not opinions
What immediate action has been taken?
Has incident been reported anywhere else?
YES / NO (Please delete as appropriate)
IF “YES” please state where (i.e. National Patient Safety Agency, Coroners Office, Local Safeguarding Children’s Board)
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Appendix 8
Initial Report and Action Plan Template for Serious incidents Reported to NHS South of Tyne and Wear Quality and Patient Safety Team
SI Incident Number: SI Case Manager:
Introduction / Background
Chronology of Events
Membership of Investigation Team
Investigative Procedure / Methodology
Findings
Conclusions
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Recommendations
Action Plan Remember to Clearly set out the actions needed to complete the recommendations Identify who is responsible for the action Specify Timescales please do not enter “Ongoing” – except if t is to be incorporated in to the practices every day business for example the practice annual programme of audit.
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Appendix 9
Allegations Management
Management of Information Sharing when Concerns are identified about Health Professionals whose Children are the Subject of Child Protection Procedures.
In the event of a member of staff having allegations against them involving children or as a parent/carer the following guidance sets out good practice on how to manage the sharing of information when child protection concerns have been highlighted.
1. Employment issues should be discussed at the Strategy meeting i.e. it should be agreed whether the concerns are such that there are concerns the health professional may be a risk professionally.
2. The Strategy Meeting should agree what information needs to be shared, with whom and who will be tasked with this.
3. Where employment concerns are identified, it is expected that the Chair of the Strategy Meeting will speak to the Local Authority Designated Officer (LADO) who will contact the Nominated Officer in the health professional‟s organisation who will inform the designated nurse of the action to be taken.
4. It is the role of the Named/Designated Professional attending the Strategy Meeting to ensure employment issues and sharing of information is discussed at the Strategy Meeting and will inform the designated nurse of the concerns.
5. In the event that the Named/Designated Professional is concerned about the outcome of the Strategy Meeting with regard to employment issues, they should discuss these concerns with the Chair and contact the LADO.
6. If the Named/Designated Professional remains concerned, they should contact the LADO‟s Line Manager (this will differ within each area) and ultimately speak to the Director of Children‟s Services if the issues are not resolved.
7. If concerns are raised at any point following a Strategy Meeting, advice will need to be sought from the local Designated Professionals for Safeguarding as to the best way to facilitate the appropriate discussion at a multi-disciplinary meeting.
8. For further information please refer to Working Together to Safeguard Children
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Appendix 10
Additional Advice and Regional Contact Details for SIs in Screening or Immunisation Programmes
Clinical Governance leads in trusts are advised to:
Be aware of the wider needs of screening or immunisation programmes; Inform the staff involved in screening or immunisation that they should communicate with their regional lead contacts if there is a potential incident ; Inform the regional contacts at an early stage when investigating potential incidents. They will advise on investigating and handling the incident and of the other people to inform(e.g. others in the pathway); Ensure a relevant regional representative(s) of the programme is a key member of the incident investigation team; Make sure that local organisations‟ policies on incident handling reflect the North East SHA policy in respect of screening and immunisation; Continue to formally report SIs via the STEIS system and in accordance with this policy and the SHA “Guidance for reporting and management of Serious incidents.
In the event of an incident or potential incident in screening or immunisation, Trusts should make sure the following are informed in addition to their required reporting through STEIS
Primary Contact for all Screening Fergus Neilson, SHA Screening and immunisations Lead, or immunisation incidents in Public Health South East, Government Office for the South East, 7th Floor South East Citygate,Gallowgate, Newcastle upon Tyne NE1 4W Email: [email protected]
Tel: 0191 202 3718 mob:07880500641 Cancer Screening Dr Keith Faulkner, Regional QA Director, Quality Assurance Reference Centre, 9 Kingfisher Way, Silverlink business Park,Newcastle upon Tyne, NE28 Email: [email protected]
Tel: 0191219 7014 Mob: 07747795629 Ante-natal and Newborn Kim Moonlight, Public Health South East, Government Office for the South East, 7th Floor Citygate,Gallowgate, Newcastle upon Tyne NE1 4WH Email: [email protected]
Tel: 0191 202 3644 Mob: 07980729726 Immunisations Julia Waller Regional immunisation Advisor, Health Protection Agency, Appleton House, Lanchester Rd., Durham DH1 5XZ Email: [email protected] and [email protected]
Tel: 0191 3333372 Mob: 07990 526549
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Appendix 11
Reporting serious incidents (SIs) relating to actual or potential breaches of confidentiality involving person identifiable data (pid), including data loss
It is essential that all serious incidents that occur in the Trust are reported appropriately and handled effectively. This document covers the reporting arrangements and describes the actions that need to be taken in terms of communication and follow up when a serious incident occurs. Trusts should ensure that any existing policies for dealing with Serious incidents are updated to reflect these arrangements.
Definition of a serious incident in relation to Personal Identifiable Data
There is no simple definition of a serious incident. What may at first appear to be of minor importance may, on further investigation, be found to be serious and vice versa. As a guide, any incident involving the actual or potential loss of personal information that could lead to identity fraud or have other significant impact on individuals should be considered as serious. This includes the loss of sexual health records and any safeguarding information, even when affecting one person.
Immediate response to serious incident
The Trust should have robust policies in place to ensure that appropriate senior staff are notified immediately of all incidents involving data loss or breaches of confidentiality.
Where incidents occur out of hours, the Trust should have arrangements in place to ensure on-call Directors or other nominated individuals are informed of the incident and take action to inform the appropriate contacts
Assessing the severity of the Incident
The immediate response to the incident and the escalation process for reporting and investigating this will vary according to the severity of the incident. Risk assessment methods commonly categorise incidents according to the likely consequences, with the most serious being categorised as a 5, e.g. an incident should be categorised at the highest level that applies when considering the characteristics and risks of the incident.
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0 1 2 3 4 5 No significant Damage to an Damage to a Damage to a Damage to an Damage to reflection on individual‟s team‟s services organisation‟s NHS any individual reputation. reputation. reputation/ reputation/ reputation/ or body Possible media Some local Low key local Local media National Media interest interest, e.g. media interest media coverage. media very unlikely celebrity that may not go coverage. coverage. involved public Minor breach of Potentially Serious Serious breach Serious breach Serious confidentiality. serious breach. potential breach of confidentiality with either breach with Only a single Less than 5 & risk assessed e.g. up to 100 particular potential for individual people affected high e.g. people affected sensitivity e.g. ID theft or affected. or risk unencrypted sexual health over 1000 assessed as clinical records details, or up to people low, e.g. files lost. Up to 20 1000 people affected were encrypted people affected affected
Reporting to NHS South of Tyne and Wear
The Provider should report the SI, i.e. all incidents rated as 1 – 5, to the commissioning organisation through the usual SI process. The following information should be provided in each case:
. A short description of what happened, including the actions taken and whether the incident has been resolved . Details of how the information was held: paper, memory stick, disc, laptop etc . Details of any safeguards such as encryption that would mitigate risk . Details of the number of individuals whose information is at risk . Details of the type of information: demographic, clinical, bank details etc . Whether a) the individuals concerned have been informed, b) a decision has been taken not to inform or c) this has not yet been decided . Whether a) the Information Commissioner has been informed, b) a decision has been taken not to inform or c) this has not yet been decided . Whether the SI is in the public domain and the extent of any media interest and/or publication
Reporting to the commissioning organisation should be undertaken as soon as practically possible (and no later than 24 hours of the incident during the working week).
If there is any doubt as to whether or not an incident meets the SI reporting criteria, the Trusts‟ Risk Manager or the commissioning organisation should be contacted by telephone for advice. Early information, no matter how brief, is better than full information that is too late.
Providers should keep the commissioning organisation informed of any significant developments in internal/external investigations, as appropriate. NHS South of Tyne
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The Providers communications team should contact the Communications Team at NHS South of Tyne and Wear immediately if there is the possibility of adverse media coverage in order to agree a media handling strategy. Where necessary, NHS SOTW Communications team will brief the Department of Health Media Centre.
Reporting to the Department of Health
NHS South of Tyne and Wear will be responsible for notifying the DH of any category 3-5 incident reported by forwarding details to the appropriate dedicated mailbox established within the DH. Incidents should be notified to DH comms only if only the lighter shaded risk areas in the top two rows in the table apply and to both DH Comms and the Ministerial Briefing Unit if the significant risks in the darker shaded area at the bottom right of the table apply. This latter, most serious category is the one that should be referenced as a nationally reported SI. Those reported to DH Comms alone should be referred to as a comms alert derived from a local SI. Once an incident has been reported to DH any subsequent details that emerge relating to the investigation and resolution of the incident should also be supplied.
The DH will review the incident and determine the need to brief Ministers and/or take other action at a national level.
Reporting to the Information Commissioner or other Bodies.
The Information Commissioner should be informed of all Category 3-5 incidents. The decision to inform any other bodies will also be taken, dependent upon the circumstances of the incident, e.g. where this involves risks to the personal safety of patients, the National Patient Safety Agency (NPSA) may also need to be informed.
Informing Patients
Consideration should always be given to informing patients when person identifiable information about them has been lost or inappropriately placed in the public domain. Where there is any risk of identity theft it is strongly recommended that this done.
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Trust Board
Report Cover Sheet Agenda Item: 17
Date of Meeting: Tuesday 25 September 2012
Report Title: Minutes of Meetings
Purpose of Report: To receive the minutes of the following meetings:
• Audit Committee held on 21 May 2012 • Charitable funds Committee held on 14 June 2012 • Human Resources Committee held on 11 June 2012 • Patient, Quality, Risk and Safety Committee held on 20 July 2012 • Mental Health Committee held on 27 April 2012
Decision: Discussion: Assurance: Information: √
Corporate Objectives report relates to: (Including reference to any specific risk)
Recommendations: For the Board to receive the minutes for information. (Action required by Board of Directors)
Financial Implications:
Risk Management Implications:
Human Resource Implications:
Equality and Diversity Implications:
Author:
Presented by:
Audit
Minutes of a meeting of the Audit Committee held at 3.00 p.m. on Monday 21 May 2012, in Room 3, Education Centre, Queen Elizabeth Hospital
Present: Mrs J E A Hickey (Chair) Non-Executive Director Mr M Brown Non-Executive Director Mr F Major Non-Executive Director In Attendance: Mrs V Blenkey Internal Audit Mrs A Coulson Internal Audit Mr J Connolly Director of Finance and Information Miss K Drummond Personal Assistant Mrs G MacArthur Director of Nursing, Midwifery and Quality Mrs L McEvoy Internal Audit Mrs T Preece Deputy Director of Finance Mrs R Tribe External Audit Mr C Waddell External Audit Apologies: Mr P Harding Director of Estates and Facilities Mr A Fairbairn Non-Executive Director Mr I Bradshaw Counter Fraud
Agenda Discussion and Action Points Action Item by 12/17 Chairman’s Business:
Mrs J E A Hickey, Chair, welcomed Mr Jon Connolly, Mrs Gillian MacArthur and Mrs April Coulson to the Audit Committee.
Mrs Hickey informed the Committee that this was Mrs V Blenkey’s last meeting as a member of Internal Audit. Mrs Hickey thanked Mrs Blenkey for all her hard work.
Mrs Hickey informed the Committee that this was Mr C Waddell’s and Mrs R Tribe’s last meeting as members of External Audit. Mrs Hickey thanked them for their guidance and support to the Committee and this was echoed by Mr F Major.
12/18 Minutes of the Previous Meeting:
The minutes of the last meeting held on 8 March 2012 were approved as a correct record.
12/19 Matters arising from the Minutes:
The Committee discussed and updated the Actions Table as attached.
1 Agenda Discussion and Action Points Action Item by 11/54 Internal Audit Progress Report – Third Party Healthcare
Mr F Major informed the Committee that he had now met with Mr P Harding and Dr D Beaumont and discussed how the system is going to work with TSS. Mr Major was given re-assurance and there should be an improvement.
12/20 Internal Audit Progress Report
Mrs V Blenkey tabled a document summarising reports issued since the last meeting and those in draft, with an indication of expected levels of assurance from the draft reports. She informed the Committee that Business Data Quality had now been included in the Progress Report.
The discussion focused on those reports with limited assurance or gaps in assurance and the following issues:
Clinical Audit/Clinical Governance – a number of issues had been noted where there were gaps in assurance. An action plan was in place to address these and GMac Mrs G MacArthur will be following this up.
Sustainability – limited assurance was given re forward planning which Mrs Blenkey noted was a common issue for trusts. Again, an action plan will be drawn up.
12/21 Revised Internal Audit Plan 2012/13
Mrs V Blenkey presented the above which determines priorities to establish the most efficient and effective means of providing assurance to Gateshead Health NHS Foundation Trust. The annual plan details the major systems and key areas of activity which will be audited. The plan may be subject to updating in year. Mrs Blenkey noted that, where practical, audit work had been planned for the earlier part of the year to allow reports to be completed before the May meeting. It was agreed, however, that the review of the Datix system would be put back to allow the recommendations of the external consultant to be bedded in first.
Mrs J E A Hickey queried Page 7 relating to Stores/Stock Control and asked if Theatres and Catering should both be listed as Governance Framework.
The Committee approved the Internal Audit Plan with the above minor amendments.
12/22 Head of Internal Audit Opinion
Mrs L McEvoy presented the above and informed the Committee that this document had previously been discussed by the Audit Committee.
The Committee noted the contents and the paper was received.
2 Agenda Discussion and Action Points Action Item by 12/23 Annual Governance Statement 2011/12
Mrs G MacArthur presented the above and informed the Committee that this has been prepared in accordance with the FT ARM and it supports the achievement of the NHS Foundation Trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets.
Mrs MacArthur had received minor amendments from the Trust Board. There were no comments from Internal/External Audit.
The Committee approved this statement for inclusion in the Annual Report.
12/24 Annual Accounts 2011/12
Mrs T Preece presented the above and informed the Committee that these accounts for the year ended 31 March 2012 have been prepared on a going concern basis, by Gateshead Health NHS Foundation Trust under Schedule 7 (paragraphs 24 and 25) National Health Service Act 2006 in a form which Monitor has, with the approval of the Treasury, directed.
Mrs Preece outlined to the Committee the main reasons for the variance from plan, which were £4.1m which has been allocated from the PCT for the development of the new Emergency Care Scheme, a movement on planned impairments and a partial release of the equal pay provision.
An updated version of the Annual Accounts will be submitted to the Trust Board scheduled for the 23 May 2012.
Mrs J E A Hickey thanked Mrs Preece and her team for a very well-presented set of accounts.
Mr F Major expressed acceptance of the accounts and for delivering these in difficult circumstances. Mr Major also thanked the finance staff for their hard work.
The Committee agreed to recommend approval of the Annual Accounts for 2011/12 to the Trust Board.
12/25 Letter of Representation
Mr C Waddell presented the above and informed the Committee that this is a standard letter. It was agreed that Mrs T Preece would be changed to Mr J Connolly as a signatory (Page 3).
Mrs J E A Hickey suggested minor amendments to some of the wording and these were agreed.
12/26 External Audit Annual Governance Report
Mr C Waddell, External Audit presented the above Report and informed the 3 Agenda Discussion and Action Points Action Item by Committee that External Audit is expecting to issue an unqualified report on the Trust accounts. Some third party commentary is awaited on the Quality Report but this is expected to be received by 31 May 2012 which will enable the accounts to be signed off with no caveat relating to the Quality Report.
The Audit Commission verbally reported that they have now received PwC’s report resulting from its review of pension entitlements of senior managers for inclusion in Remuneration Reports of NHS organisations. In this report, PwC highlighted that NHS Pensions had used the most recent set of actuarial factors produced by the Government Actuary’s Department (GAD) with effect from 8 December 2011. Therefore, the GAD factors used as at 31 March 2012 are different from those used as at 31 March 2011. As a consequence, NHS bodies using this information will not be complying with the requirement for NHS bodies that the real increase in the CETV use common market valuation factors for the start and end of the period. The Trust has not made additional disclosures in respect of the change in the GAD actuarial factors and is not proposing to given it is not material.
The Committee received the report for information.
12/27 Losses and Special Payments Register
Mrs T Preece presented the above and informed the Committee that guidance issued by Monitor advises that the Foundation Trust Board has the responsibility for approving the writing off of losses and the noting of special payments made by the Foundation Trust. This responsibility has been delegated to the Audit Committee.
A query was raised regarding migrant maternity cases and whether they resulted in claims. Mrs G MacArthur informed the Committee that this would be discussed at a future meeting of the Patient Quality Risk and Safety Committee. GMac
The Committee approved the Register and agreed that this would be signed off IDR/JC by Mr J Connolly, Director of Finance and Mr I Renwick, Chief Executive.
12/28 Minutes of Meetings:
The minutes of the following meetings were attached for information:
• Patient, Quality, Risk and Safety Committee held on 20 January and 16 March 2012
• Human Resources Committee held on 7 February 2012.
12/29 Date & Time of Next Meeting
The next meeting of the Audit Committee will be held on Thursday 20 September 2012 at 10.30 a.m. in Room 3, QE Education Centre.
4
Charitable Funds Minutes of a meeting of the Charitable Funds Committee held at 9.00am on Thursday 14 June 2012 in Room 3, Education Centre, Queen Elizabeth Hospital
Present: Mr R Simpson (Chair) Non-Executive Director Mr F Major Non-Executive Director In Attendance: Mr J Connolly Director of Finance and Information Miss K Drummond PA to Director of Finance & Information Miss A Green Financial Accounting Officer Mrs L Hiden Head of Communications Mrs H Lloyd Deputy Director of Nursing, Midwifery & Quality Mrs T Preece Deputy Director of Finance and Information Apologies: Mr M Brown Non Executive Director
Agenda Discussion and Action Points Action Item by 12/12 Chair’s Business
Mr R Simpson, Chair, welcomed Mr Jon Connolly, Director of Finance, as this was Mr Connolly’s first meeting of the Charitable Funds Committee.
12/13 Minutes of the Previous Meeting:
The minutes of the previous meeting held on 8 March 2012 were agreed as a true record.
12/14 Matters arising from the Minutes:
12/05 Charity Football Match
Mrs L Hiden informed the Committee that she has had contact with Mr Uddin KD regarding the above, and it was agreed to invite Mr Uddin to the next meeting of the Charitable Funds.
This item will also be included on the agenda for the next meeting of the KD Charitable Funds.
12/15 Draft Annual Report and Accounts
Miss A Green presented the above draft documents and informed the Committee that these have been submitted to the Auditors. A more detailed version will be available for the next meeting of the Charitable Funds prior to these being discussed at the Trust Board.
Mr R Simpson suggested that photographs are taken of equipment that has been
1
Agenda Discussion and Action Points Action Item by bought from Charitable Funds which is being used in the Trust, and that these are circulated to staff to inform them of what the Charitable Funds has achieved for the Trust.
Mrs T Preece thanked Miss A Green for her work on these accounts in the absence of Mrs P Oliver.
12/16 Financial Information:
Review receipts and payments over £1,000 December 2011 to February 2012
The receipts and payments were reviewed for the period 1 March 2012 to 31 May 2012.
Miss A Green updated the Committee on some of the receipts received during this period and stated that the main expenditure was within the Chemo Day Unit.
Fund balances:
The fund balances for the above period were also reviewed and received for information. Miss A Green informed the Committee that there was nothing unusual to report.
12/17 Investments:
Current Investments:
Miss A Green informed the Committee that the total of investments has increased from April to £1,427,799.
Mr R Simpson is satisfied with the investments due to the low interest rate.
COIF Quarterly Investment Report – December 2011
The Committee received the report for information.
COIF Deposit Fund Changes
A letter had been received from CCLA informing the Trust of the increase in the Annual Management charge to the COIF Charities Ethical Investment Fund from 0.45% to 0.60%.
The response is what the Committee expected and no further action is required.
2
Agenda Discussion and Action Points Action Item by 12/18 Fundraising:
Fundraising and Marketing Strategy:
Mrs L Hiden informed the Committee that she would be meeting with LH representatives from Indigo on the 28 June 2012 to agree proposals and branding for the Strategy. Lucia will prepare a briefing prior to this meeting which she agreed to circulate to the Committee after the meeting with Indigo. Indigo have put forward a proposal to have their own website or to use a section of the Trust’s website which would be specifically allocated to Indigo.
Mrs L Hiden asked if the Committee would like to discuss the proposals at the September meeting of the Charitable Funds, or would the Committee prefer to meet prior to the September date.
Mr R Simpson stated that he would like the Committee to meet prior to the September meeting of the Charitable Funds in order to get this issue moving.
It was agreed that Mrs L Hiden and Mrs T Preece would meet to prepare a LH/TP proposal for marketing issues, and this would then be discussed by the Committee for approval.
Mrs L Hiden requested that support would be needed for the Communications Team to undertake this extra marketing work due to current staffing problems.
A query was raised regarding the membership of Nicola Downs and if she is still LH a Governor. Mrs L Hiden agreed to check this with Joanne Williamson and then report back to members. A decision will then be made if she is to remain a member of the Charitable Funds Committee.
Great North Run:
Mrs L Hiden informed the Committee that the Trust had been allocated 5 places for the Great North Run. These have now been allocated to members of staff, with 2 members of staff on the reserve list.
Mrs L Hiden informed the Committee that she has met with the staff who will be participating in the Great North Run, and she has suggested that they get together and choose one charity that they would donate to rather than each of them choosing an individual charity. Each member of staff will need to have a minimum of £200 sponsorship. The Just Giving Website will be available for people to sponsor individuals.
Mr J Connolly informed the Committee that he is also participating in the Great North Run. Mr Connolly offered to donate his sponsorship to the chosen charity for Gateshead Health NHS Foundation Trust.
12/19 Charity Commission News:
The Committee received the Charity Commission News – Spring 2012 edition for information.
3
Agenda Discussion and Action Points Action Item by 12/20 Date and Time of Next Meeting
The next meeting will take place on Thursday 20 September 2012 at 9.00am in Room 3, Education Centre, Queen Elizabeth Hospital.
4 Human Resources Minutes of a meeting of the Human Resources Committee held on Monday 11 June 2012 at 10.00 a.m. in Room 3, Education Centre, Queen Elizabeth Hospital
Present: Mrs Y Ormston (Chair) Director of Transformation & Compliance Mr J Holmes Governor Mr F Major Non Executive Director Mrs E McDonald Head of Modernisation Mrs S Richardson Divisional Manager Mrs G Forsyth Deputy Head of Personnel Mr M Graham Non Executive Director Mrs H Lloyd Deputy Director of Nursing, Midwifery & Quality Mrs C Coyne Divisional Manager Faye Butler Governor
In Attendance: Miss K Drummond PA – Director of Finance & Information Ms J Wallbank Senior Personal Manager Ms D Southworth Clinical Ergonomics Advisor (Team Leader) Mrs C Knox Equality and Diversity Co-ordinator Mr J Crawford Clinical Educator Mrs M Darroch OD & Staff Development Manager Mr S Stevens E-Learning & OLM Lead Mrs S Gair Risk Facilitator Ms J Stemp Trust Librarian
Apologies: Gillian MacArthur Julia Hickey Jon Connolly Karen Forsyth
Agenda Discussion and Action Points Actioned Item by 12/28 Minutes of the Previous Meeting
The minutes of the meeting held on 2 April 2012 were confirmed as a correct record.
12/29 Matters arising from the Minutes
i) Re-validation Update
Gillian Forsyth provided a verbal update and informed the Committee that the annual ORSA had been submitted and that the Trust’s action Plan is currently being updated. She advised that the Medical Director had written to all senior medical staff regarding details of their prescribed body, from which a database will be created for validation against GMC information. A demonstration of electronic toolkits available will be presented at the SHA Reference Group and investigation training is to be provided for responsible officers. Agenda Discussion and Action Points Actioned Item by
ii) Equality & Diversity Update
Coleen Knox provided a verbal update and informed the Committee that the E&D steering group will consider an annual audit and review the EDHR training and equality analysis at its next meeting. The group will be developing an action plan to achieve the four equality objectives published in April.
Coleen also informed members that the Equality & Steering Group did not meet therefore there were no notes for information.
Action: Coleen Knox to provide a progress report at the next meeting of the Human Resources Committee.
iii) Voluntary Severance Scheme
Yvonne Ormston informed the committee that following a good level of interest expressed in the VSS, 26 applications had been approved y the panel and those staff were intending to leave the Trust over the next 3-4 weeks. Given that the scheme had been well received, the Trust Board had indicated support for a relaunch later in 2012.
Items for Decision
12/30 HR Policies and Procedures
i) Education Audio Visual Policy
Jason Crawford presented the above and informed the Committee members that Gateshead Health NHS Foundation Trust requires those involved in taking images, or making video recordings, to ensure that the activity complies with relevant legislation, such as the Data Protection Act and the Children Act and considers the sensitivities and the rights of individuals.
Action: The above Policy was approved.
ii) Supporting Staff Involved in an Incident, Complaint or Claim Policy
Stephanie Gair presented the above and informed the Committee that this policy is due to expire in July 2012, and that it had been circulated widely for comments.
Action: The above Policy RM67 was approved.
iii) Equal Opportunities in Employment Policy
Coleen Knox presented the above and informed Committee members that this Policy has undergone a comprehensive review to take into account and comply with the requirements of the new public sector equality duty, and the NHS Equality Delivery System. As a result it has been agreed that the Trust’s Equality and Diversity Policy PP21 2
Agenda Discussion and Action Points Actioned Item by will be deleted from the HR suite of policies as much of the latter is duplication of PP14.
Action: The above Policy PP14 was approved.
iv) Hospitality, Gifts, Inducements, Social Networking and Standards of Business Conduct for NHS Staff Policy
Jennifer Wallbank presented the above and informed the Committee that this policy amalgamates several existing Trust documents, and incorporates the guidance issued recently regarding social networking and the requirements of the Bribery Act. This policy has also been endorsed by the JCC.
Action: The above Policy PP20 was approved.
v) Working Time Regulations Policy
Jennifer Wallbank presented the above and informed the Committee that this policy was reviewed last year and it is proposed to make no changes and to re-issue these policies with new review date.
Action: The above Policy PP34 was approved.
vi) Grievance Procedure
Jennifer Wallbank presented the above and informed the Committee that there are no changes to this policy, and it will roll forward with the dates being refreshed.
Action: The above Policy PP2 was approved.
vii) Non Medical Contract
Jennifer Wallbank presented the above and informed the Committee that this is a standard letter that is issued to all new staff and the only change is the reference to policies.
Action: The above was approved.
Items for Discussion:
12/31 Revised TNA for 2012/13 NHSLA Standards
Sam Stevens presented the above and informed the Committee that following the issue of the standards for this year changes have been made to all NHSLA training needs, largely due to changes in the NHSLA standard numbering system.
No other changes have been made to the majority of the training needs, apart 3
Agenda Discussion and Action Points Actioned Item by from Resuscitation Training and Violence and Aggression.
Action: The Human Resources Committee approved the above.
12/32 Changes in Education and Training
Elaine McDonald gave a presentation to the Committee. Elaine informed members of changes to Education and Training, which will be monitored through the IPLC.
12/33 IIP Update
Mary Darroch tabled a paper on the above and informed members that the Trust will be undergoing an assessment in September of this year against the gold standard. The assessment will commence on 24 September and will finish on the 3 October 2012.
During this time 3 assessors will be on site conducting short interviews, beginning with the Chief Executive, and they will select a sample of staff from a range of services areas.
Mary Darroch requested that the Assessors be invited to attend the Human Resources Committee meeting scheduled for 1 October to observe the meeting’s proceedings. Yvonne Ormston approved this and offered her full support.
12/34 Library Annual Report – Quality Assurance Framework
Joanne Stemp presented the above and informed the Committee that the Library Has currently been refurbished and updated.
Between April 2011 and March 2012 the Library has:
• Provided a total of 8,914 articles and loans to Trust staff and students; • In March 2012 the Library had 2.156 active borrowers (an 18% increase on the previous year, and one of the highest in the Northumberland, Tyne & Wear area) • There were 19,441 visits to the library (an increase of 9% on the previous year) • A total of 4,654 searches were carried out by Trust staff on Athens knowledge resources (an 11% decrease on last year) • A further 10,185 searches were carried out on the Trust-wide up to date clinical reference service (a 23% increase on last year)
Action: Yvonne Ormston thanked Joanne Stemp on behalf of the Human Resources Committee. -
12/35 Manual Handling Training Report April 2011 – March 2012
Deborah Southworth presented the above and informed the Committee that the 4
Agenda Discussion and Action Points Actioned Item by purpose of this report is to provide the Trust with an annual update on the manual handling training activities for the period April 2011 -31 March 2012.
The following main points were noted:
• 254 new staff have completed their full training in manual handling • 78 have completed non-patient manual handling course • 26 have completed one day introduction patient moving and handling • 150 have completed practical skills • It is proposed to issue a Manual Handling Passport to staff which will indicate all training that staff have undertaken.
Action: Yvonne Ormston thanked Deborah Southworth for her work on this report.
12/36 Health and Wellbeing Strategy Update
Mary Darroch presented the above and informed members that this paper updates on progress in implementing the Trust’s Health and Well-being Strategy in the past 12 months. The Strategy aims to:
• Create a safe and healthy environment and working conditions for staff; • Improve the physical and emotional well-being of staff; • Encourage and support employees to develop and maintain a healthy lifestyle; • Support people with manageable health conditions or disabilities to maintain access to or regain work; • Improve the quality of working life for staff; and • Create a healthier, more engaged workforce, thus optimising patient care.
The Trust’s further achievements are as follows:
• NE Better Health at Work Award • NHS Sport and Physical Activity Challenge
Yvonne Ormston thanked Mary Darroch for her involvement with the Health and Well-being Strategy.
12/37 Harassment & Bullying Update
Coleen Knox tabled a paper on the above and informed the Committee that the recommendations from the December 2011 Audit and Review are listed below:
• The number of formal complaints and informal contacts with Harassment Advisors will be reported to the Human Resources Committee to assess whether members of staff continue to access the policies on harassment and bullying • Feedback from the revised monitoring form will be collated and used to provide further evidence of this to the Human Resources Committee • To support an effective audit and review, which will take place at the end of each investigation, before any administration not relevant to the final investigation report is disposed of confidentiality.
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Agenda Discussion and Action Points Actioned Item by Action: The Human Resources Committee agreed the above recommendations.
12/38 Personal Development Plans & Mandatory Training
Elaine McDonald presented the above, highlighting to the Committee that there are concerns relating to non receipt/non completion of individual Personal Development Plans and poor attendance levels at Mandatory Training, both of which may have an adverse impact on the Trust’s ability to meet the standards set by the NHSLA.
It is recommended that the Trust’s Mandatory Training Policy is strengthened to remind staff of their responsibility to attend Mandatory Training before their current training expires and to advise them they have only two opportunities to attend before further action is taken.
Items for Assurance:
12/39 Monitoring Report for Supporting Staff Involved in an Incident
Stephanie Gair presented the above and informed members that the above policy (RM67) supports staff involved in an incident, complaint or claim and ensures that adequate support systems are in place for staff who have been directly involved.
It is recommended that:
• Use of the staff support checklist and “helping agencies” documents continue to be promoted through appropriate training sessions, for example complaints and PALs training, risk management training • Reference be made to the support staff documentations in the revised RCA documentation attached to RM04 Incident Reporting Policy • Consideration be given to a means of capturing data (anonymous) by the Occupational Health Department on the extent of the valuable support they provide to staff.
Action: The Human Resources Committee supports the recommendations.
12/40 Minutes for Information
The following minutes circulated were received for information:
Inter Professional Learning Council held on 28 March, 25 April and 16 May 2012 Joint Consultative Committee held on 7 March 2012.
12/41 Any Other Business
Gillian Forsyth informed the Committee of the BMA planned Industrial action, ie “action short of a strike” scheduled for 21 June 2012. All medical staff have been notified that they should attend work and to perform any urgent and emergency care. Also unless medical staff have already booked annual leave prior to the industrial action, no further request for absence would be authorised. Management representatives have had several meetings with representatives from the LNC and BMA and information has been provided regarding impact on 6
Agenda Discussion and Action Points Actioned Item by service delivery which will be discussed with members of the Central Team.
Gillian also informed that medical staffhave been advised that pay may be affected where there is partial performance of duties. Gillian advised that the Trust is working closely with LNC representatives and Divisional Managers to manage the situation.
12/42 Date and Time of Next Meeting
The next meeting will be held on Monday 6 August 2012 at 10.00 a.m. in Room 3, QE Education Centre.
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Patients, Quality
Risk & Safety Minutes of a meeting of the Patients, Quality, Risk and Safety Committee held at 12.30pm on 23rd July 2012, in Room 3 Education Centre, Queen Elizabeth Hospital
Present: Mrs G MacArthur (Chair) Director of Nursing, Midwifery & Quality Mr K Godfrey Deputy Medical Director Mrs Y Ormston Deputy Chief Executive Mrs A Clark Governor Mr M Brown Non Executive Director Mr M Graham Non Executive Director Mr F Major Non Executive Director Mrs D Atkinson Trust Secretary Mrs S Richardson Divisional Manager, Clinical Support and Screening Services Mrs G Wiggham Divisional Manager, Women and Children’s Services Mr S Atkinson Divisional Manager, Surgical Services Mrs A Lowery Head of SafeCare Mrs G Appleby Matron, Surgical Services Mr C Traill Health & Safety Manager Mrs P Knowles Risk Manager, Surgical Services Mrs S Gair Risk Facilitator Dr S Razvi Consultant – Diabetes Mrs S Hazeldine PALS Manager Mr R Webber Risk Management
In Attendance: Mrs J Charlton Bereavement Co-ordinator Mrs J Bowes Assistant Divisional Manager, Breast Screening
Apologies: Mrs J Hickey Trust Chairwoman Mr I D Renwick Chief Executive Mrs H Lloyd Deputy Director Nursing, Midwifery & Quality Mr P Harding Estates Director Mr J Connolly Director of Finance Dr D M Beaumont Medical Director Mrs S Pearson Associate Director of Strategic Transformation Mrs T Preece Deputy Director of Finance Dr P Cross Divisional Director, Clinical Support and Screening Division Mrs C Coyne Divisional Manager, Medical and Elderly Services Mrs L Turner Assistant Divisional Manager, Surgical Services Mr P Robinson Assistant Divisional Manager, Clinical Support and Screening Mrs C Dunn Assistant Divisional Manager, Women and Children’s Services Mrs K Forsyth Head of Personnel Mrs S Winn Head of Compliance Dr Narayanan Consultant - Diabetics Mr S Dae Health & Safety
Agenda Discussion and Action Points Actioned Item by 3/ Chairman’s Business:
1 Agenda Discussion and Action Points Actioned Item by
Mrs G MacArthur announced she and Mr J Connolly attended an event that morning in respect of the second Francis Report due to be published on 15th October. The report will be circulated thereafter.
4/ Minutes of the previous meeting:
The notes were accepted as a true record.
5/ Matters arising from the Minutes:
NHSLA Maternity Assessment: Mrs MacArthur informed the group the assessment had gone well with encouraging results. The main area of concern was the misfiling of maternity GW/GMac results. GA/GMac will meet to discuss and progress.
6/ Items for Decision
OP42 External Assessments Policy:
Mrs A Lowery informed the group the policy had been changed according to previously received recommendations with the key area of improvement being around action plans. The policy now states all action plans will go to the sub committees prior to going to Board.
Mrs Lowery explained the need to maintain the action plans with quarterly reporting arrangements to the appropriate group. Any risks are to be registered on the risk register.
Mr F Major asked whether unannounced visits i.e. CQC should be considered within the policy. He went on to enquire whether there was a procedure in place for such visits such as a ‘meet and greet’ group. Mrs Lowery responded saying there is a process in place. Mr K Godfrey said he thought it may be a good idea to have a paragraph in the policy explaining the procedure followed for unannounced visits. The group were reminded the NHSLA will monitor the policy and therefore the Trust must be explicit in its execution of the policy contents – unannounced visits, by their very nature, preclude ‘planning’ for such an event. The Trust does follow a recognised procedure when unannounced visits occur.
Approved: The Committee agreed to the proposed changes.
7/ OP56 – Care of the Dying and Deceased Patient Policy:
Mrs J Charlton informed the group the reviewed document contained only minor changes, mostly typographic and grammatical for easier flow and better reading. The name of the document has been changed to ‘A Guidance Document for the Non-Medical Care of the Dying and Deceased Patient (Adults and Children).
Mr Major noted the policy contains mention of the Chaplaincy and asked whether they had input into the document. Mrs Charlton confirmed there had been collaboration with the Chaplaincy.
Approved: The Committee agreed to the proposed changes.
2 Agenda Discussion and Action Points Actioned Item by 8/ OP32 - Interpreting Policy:
Mrs S Hazeldine briefly described the changes to the document including points 6.3.4, 6.7, 6.8 and 6.9.
Approved: The Committee agreed to the proposed changes.
9/ RM23 – Claims Management Policy:
Mrs C Harvey had tendered her apologies and in her absence, Mrs S Gair informed the group the only change to the document was contained in 6.8.4.
Mrs MacArthur asked that point 4 be altered to reflect the change in Directors’ roles and responsibilities.
Mr S Atkinson mentioned that he did not receive feedback on claims and therefore the department had no conclusion to the matter. Mrs G Wiggham agreed and said she had asked Mrs Harvey to forward the results of any claim and this was now being done regularly. Mrs Gair said she would relay this SG request to Mrs Harvey.
Approved: The Committee agreed to the proposed changes.
10/ RM04 – Incident Reporting and Investigation Policy:
Mrs Gair described the changes contained in pages 13 and 14 of the document which now reflect the levels of investigation. She went on to say more detailed information is now contained in the Datix system. Mrs Gair then apologised she had not concluded Appendix 6 in time to be sent out with the papers and tabled the appendix relating to the notification of external agencies for information.
Mr Major asked whether there was an audit trail ensuring comprehensive coverage of the policy and Mrs Gair confirmed action plans were developed from the audits and RCAs ensure compliance.
Mrs S Richardson requested the RCA document be added to the internet. Mrs Gair responded all second level investigators had access to the documents via the Datix library.
Mrs Y Ormston queried how incident reporting dealt with outside agencies being the main cause of an incident, for instance a late ambulance being to the detriment of a patient. Mrs Gair responded all such incidents were discussed with the Commissioners, datixed and a learning event arranged.
11/ RM49 - Being Open Policy:
Item deferred.
12/ Items for Discussion:
Policy Audit Report:
Mrs D Atkinson reported the policy changes and mentioned in particular Appendices 2 and 3. It will now be the standard to send automatic reminders 6
3 Agenda Discussion and Action Points Actioned Item by months before the review date of a policy. Although the department have been trialling this for some time, it does not appear to have any significant impact on the delay in reviewing Trust policies. It was noted many policies were out of date. Mrs Atkinson said an action plan is in place and the department continue to contact policy reviewers/authors in order to ensure NHSLA compliance.
Mrs Ormston queried whether policies were necessary in all cases and whether some could be reclassified as protocols and guidance. Mrs Atkinson said she would ask the authors to check the potential for this. DA
13/ Medical Services Risk Register:
Mr R Webber reported on the risk register.
In respect of the lift going to Wards 1 and 2, a long term plan is in place to replace.
The February Falls audit mentions a post fall protocol which is now 70% completed.
A patient footwear (slippage) audit has been completed and it has shown 89% appropriate footwear.
The movement and handling of mental health records is ongoing. Mr Webber mentioned the storage area at Bensham is in need of improvement and some staff have been injured in the process of their duties. Tamber units have been ordered and an action plan added to the risk register to counter this situation.
New A&E trolleys have been purchased and more are on order.
Mr Webber mentioned the results of a tourniquet incident audit. Comparison between 2010/11 and 2011/12 audits show improvement with only 1 incident in the last year.
A tool has been developed in respect of bed rails to ensure compliance. This is to be added to the new Falls Booklet.
Mrs MacArthur requested the risk register be updated and Mrs G Appleby will GA action.
14/ NHSLA Maternity Standards:
IMT and Finance Risk Register:
Mr J Connolly had sent his apologies and Mrs MacArthur reported on his behalf that the delivery of the efficiency plan was ongoing with controls in place and regular meetings with commissioners.
Mr Major commented on what he considers to be an emerging risk, the role of the CCG and the impact on the level of income to the Trust. The group acknowledged this was indeed something to be considered.
15/ Risk Register Report:
Mrs Gair specified risks 859; 84; 810; 124. Risks 802 and 805 have been de- 4 Agenda Discussion and Action Points Actioned Item by escalated.
Governance arrangements include quarterly risk registers for each department as part of the NHSLA compliance.
Mrs MacArthur informed the group an Away Day was held on 13th July in respect of CQC Assurance which had been well attended. Mrs Appleby is holding meetings with all Divisions and plans to do some detailed work in the next 3 months.
Mrs Richardson mentioned her department review more often than every quarter depending on need.
16/ Items for Assurance:
National Diabetes Results 2011:
Dr Narayanan had tendered his apologies and his report was given by Dr Razvi.
Dr Razvi reported the results of the In Patient National Diabetes Audit collected and disseminated by the National Audit Office. He reported the Trust having a lower nursing and consultant ratio than the rest of the country. One difference accounting for higher numbers in the planned/non planned numbers has been identified. The Trust’s MAU department receive patients from all areas as ‘unplanned’ whilst the rest of the country record these patients as ‘planned’.
Dr Razvi commented on insulin management errors, an area which is being closely monitored by the department and SafeCare with interdepartmental working and action plan in place.
Mr K Godfrey queried the Trust being an outlier in respect of diabetic nursing and consultant staff. Dr Razvi explained the Trust covered 2 sites with only 3 full time diabetes’ nurses. Their work included covering inpatients; outpatients; education; antenatal; drop in centre and emergency services. This meant stretching resources to the limit. The need for input into community care is also being discussed which will mean stretching those limits still further.
Mrs MacArthur mentioned the action plan does not reflect dietetic input into the service and it would be helpful to have an update. It was noted that the SafeCare and Diabetes Departments should meet to discuss targeted audits. AL/SN
The need for the careful monitoring of the model of care was mentioned.
Mr Major added he felt medication and prescribing incidents (page 6) are a cause of concern. Dr Razvi assured Mr Major this was in hand with changes having been made to Insulin Prescribing Charts and more detail given to SafeCare in relation to such incidents.
17/ Quality Account:
Mrs A Lowery informed the group the account is published on the intranet should they wish to read it fully. The identified targets have shown improvement.
18/ Update from the Mortality and Morbidity Steering Group:
Mrs G MacArthur tabled the minutes and asked for any comments. The minutes
were agreed. 5 Agenda Discussion and Action Points Actioned Item by
19/ Action Plan for Bowel Cancer Screening Centre QA Visit:
Mrs J Bowes informed the group the action plans were in place and information from the previous visit added. The department should be able to sign off the action plan after the next visit.
20/ Breast Screening QA Action Plan:
As point 19 above.
21/ CLIPA Report – January – March 2012:
Mrs G Appleby reported on the 4th quarter. The executive summary contains
reductions in complaints but increases in litigation and incident levels.
Organisational learning includes department themes and trends as well as
litigations, PALS and Datix reports.
Mr M Brown commented on the pie chart on page 5. 54.3% of the chart is
shown as ‘other’ causes. He requested an alternative appellation be given as he
feels ‘other’ gives the impression the Trust is not seeking assurance in these GA cases.
Mr Major commented on page 6 and the large column attributed to
‘information/advice’ – does this need to be probed more. He was assured that
this column included figures from the PALS desks which are not always
complaints and can include such queries as directions. Mrs Appleby will ask Mrs
Hazeldine to check the division of figures.
Mr Major also commented on the last page of the document which holds
compliments the Trust has received. He queried whether this should be on the
first page of the document and the group agreed this section needed to be more GA prominent.
22/ Minutes of the Research and Development Committee:
Mrs MacArthur asked the group to receive the minutes of the April, May and June meetings of the R&D Committee for information.
23/ Date and Time of Next Meeting:
RESOLVED: Next meeting of the Patients, Quality, Risk and Safety Committee be held at 12.30pm on Friday, 21st September 2012 in Room 3 Education Centre, Queen Elizabeth Hospital.
6 Mental Health Minutes of a meeting of the Mental Health Committee held at 9.30 a.m. on Friday 27 April 2012, in Room 3, Education Centre, Queen Elizabeth Hospital
Present: Malcolm Graham Non Executive Director Mrs C Coyne Divisional Manager Mr Ashley Thompson CQC Dr A Fairbairn Non Executive Director Mrs C Downes Medical Directorate
In Attendance: Kirsty Forster
Apologies: Mr David Gowland Mrs Y Ormston Mrs J Gibson Mr J Holmes
Agenda Discussion and Action Points Actioned Item by 12/42 Minutes of the Previous Meeting:
The minutes of the previous meeting of the Mental Health Committee held on 27 January 2012 were approved as a correct record.
12/43 Matters arising from the Minutes:
DH Reprovision Cragside Unit will be moving towards the end of May 2012. All inpatient services will then have gone from DHH
MH PBR Working with the Commissioning Team and Finance and Information Department – this is an ongoing piece of work around the MH Payments by Results.
FTN Benchmarking Update Nothing further to update on this.
Delayed Discharge Continually monitoring this. There are still some issues in terms of ESME care. Local Authority still assessing patients currently in Mental Health homes.
135/136 Guidelines Ambulance and Policy are happy to agree these guidelines and a letter of support will be sent from Mrs Yvonne Ormston, Deputy Chief Executive around this. 1 Agenda Discussion and Action Points Actioned Item by 12/44 Delayed Discharge Update: Mrs Claire Coyne confirmed that they continue to meet with the Social Work Teams to monitor this.
12/45 Community Mental Health Profile
The meeting discussed the above document. It showed a high percentage of patients with dementia. It also provided some interesting data for some of the younger services ie: self hard and alcohol. Mrs Claire Coyne explained that she had recently obtained some funding to further develop an alcohol nurse to work in A & E department.
12/46 Dementia Care Strategy Group
The internal Dementia Care Strategy Group had held its first meeting with a wide range of representatives from across the whole organisation as well as external representatives. Mrs Coyne asked the Committee if these would like to receive the minutes from this group for information. She also explained that an action plan would be produced and this will be cross-referenced at this committee.
This item will be a standing item on future agendas of the Mental Health Committee with the minutes and action plan from the Dementia Care Strategy Group being received by the committee for robustness.
12/47 Mental Health Act Activity
Mrs Claire Downes reported back to the Committee the following MH Act Activity
• Up to end of March this year seen a signification increase in Sections – specifically section 3 • 1 community order ongoing • Slight increase in consent to treatment • DOLs – last year Trust ended with 17 and remains consistent each month
Claire has produced a 5 year comparison chart to show the various increases in activity.
Ashley Thompson explained to the Committee that there was still some variance around the Region in terms of MH patients having a MH advocate and they were currently looking at whether there should be an “opt out” in stead of an “opt in” around having an Advocate. He talked about cases of nearest relatives lacking capacity to act and the legal ramifications around this.
12/48 Training
• 75% of all staff have now had training in Mental Capacity Act and DOLs Training • CPA – 86% of all qualified staff have received this training. 2 Agenda Discussion and Action Points Actioned Item by • Dementia Training due to start this year • Claire Downes confirmed she had attended Wards 1 & 25 Away Days to training clinical leads on dementia • Safeguarding Adult Training – a joint session with the Local Authority had been ran and an internal session is rang month. 70% of staff have been trained on this. A slot is also on the Mandatory Training Day around this.
12/49 Date and Time of Next Meeting :
The next meeting of the Mental Health Committee will be held on Friday 27 July 2012 at 9.30am – 11.00am in Room 4, Education Centre
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