The Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT) Shared Agenda Group Committees in Common (CiC) Monday, 29th April 2019 at 10:00am Humphrey Booth Lecture Theatre, Mayo Building, Salford Royal, Stott Lane, SALFORD M6 8HD AGENDA: Part 1
1. Patient Story
2. Apologies for Absence Chairman
3. Declarations of Interest All
4. Chairman’s Opening Remarks Chairman
5. Minutes of Previous Meeting (Part 1) Chairman from meeting on 25 March 2019
6. 2018/19 Year-End Scorecard: Care Organisation Chief Officers Reports from Chief Officers
7. Review of the Group CiC Scorecard for 2019/20 Chief Delivery Officer
8. Sustainable Development Management Plan Chief Delivery Officer
9. Quality Improvement Strategy Implementation: Chief Nursing Officer NCA Quality Improvement Dashboard
10. CQC Improvement Plans Chief Nursing Officer 10.1. Pennine Acute Hospitals NHS Trust 10.2. Salford Royal NHS Foundation Trust
11. Learning from Deaths Chief Medical Officer
12. Learning from Experience Chief Nursing Officer/ Chief Medical Officer
13. Patients and Service User Experience Chief Nursing Officer
14. Annual Self Certifications Group Secretary SRFT & PAT # 274090 04/27/2019 16:44:00 15. Standards of business conduct: Board level Directors Group Secretary
16. Reports from Standing Committees:
16.1. Executive Group Risk and Assurance Committee Chief Executive
1/2 1/232 - Summary from meeting held 24 April 2019
17. Any other business (Part 1)
18. Date and Time of the Next Meeting: Monday 3rd June 2019 from 10am Venue: Humphrey Booth Lecture Theatre, Level 1, Mayo Building, Salford Royal NHS Foundation Trust.
Resolution: To exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be prejudicial to public interest, by reason of the confidential nature of business. The press and public are requested to leave at this point.
SRFT & PAT # 274090 04/27/2019 16:44:00
2/2 2/232 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust and The Pennine Acute Hospitals NHS Trust
Meeting of Group Committees in Common Monday, 25th March 2019 Part 1- Held in Public - from 10am Humphrey Booth Lecture Theatre, Mayo Building, Salford Royal
DRAFT Shared Minutes
Present: Mr Jim Potter, Chairman Sir David Dalton, Chief Executive Officer Mrs Judith Adams, Chief Delivery Officer Mr Chris Brookes, Chief Medical Officer Mrs Diane Brown, Senior Independent Director Mr Kieran Charleson, Non-Executive Director Mr Damien Finn, Chief Officer North Manchester Care Organisation Mrs Nicola Firth, Interim Chief Officer, Oldham Care Organisation Mrs Elaine Inglesby-Burke CBE, Chief Nursing Officer Mr Raj Jain, Chief Strategy and Organisational Development Officer Mrs Christine Mayer CBE, Non-Executive Director Mr Ian Moston, Chief Finance Officer Professor Chris Reilly, Non-Executive Director Mr James Sumner, Chief Officer, Salford Care Organisation Dr Hamish Stedman, Non-Executive Director Mr Steve Taylor, Chief Officer, Bury & Rochdale Care Organisation Mr John Willis CBE, Vice-Chairman Mrs Jane Burns, Director of Corporate Services and Group Secretary
In Attendance: Rebecca McCarthy, Deputy Trust Secretary
Observing: Gill Collins, Public Governor Terri Evans, Public Governor Sally Griffiths, SRFT Staff Side Chair Juston Grundy, Thornbury Nursing Gemma Liveseley, Staff Governor Andrew Lynn, NCA Director of Communications Chris Mullen, Public Governor Jackie Schofield, PAHT Staff Side Tom Wright, SRFT Staff Member
Apologies for Absence: None
No. Item Action 1. Welcome SRFT & PAT # 274090 The Chairman welcomed everyone present to the meeting of the 04/27/2019Group 16:44:00 Committees in Common and confirmed this was a shared meeting of committees established by the Boards of Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute Hospitals NHS Trust (PAHT). The Chairman confirmed that the meeting would be held in two parts: a first part open to members of the public; and a second part in private session for confidential
1/12 3/232 No. Item Action matters.
2. Presentation – North East sector Obstetrics and Gynaecology Services The Group Committees in Common received a presentation from the Divisional Director of Midwifery and Gynaecology regarding improvements across North East sector Obstetrics and Gynaecology Services, specifically highlighting improvements and action taken with respect to female genital mutilation (FGM).
The Senior Independent Director referred to the outcome of the Nursing Assessment & Accreditation System (NAAS) on Ward F1, emphasising the importance of accountability and improvement prioritisation. The Divisional Director of Midwifery and Gynaecology fully acknowledged the disappointing outcome of the NAAS assessment and his accountability in this regard. He highlighted that significant attention had been paid to this matter including appointment of an Assistant Director Nursing (ADNS) for Gynaecology to provide additional leadership and support.
The Vice-Chairman referred to empirical evidence gathered as part of the visit he undertook to the Oldham Paediatric Unit, regarding children being on the unit primarily for protection, not health related, purposes, and expressed his view regarding the importance of challenge and engagement with Oldham Local Authority on this matter. The Divisional Director of Midwifery and Gynaecology fully acknowledged this comment, and highlighted the ongoing challenge to Oldham Local Authority regarding this important matter and work underway to develop a more robust pathway.
A Non-Executive Director emphasised the importance of midwives talking candidly with women to help reduce smoking in pregnancy, alongside the importance of flu vaccinations, and strongly encouraged further intervention in this regard.
The Chief Nursing Officer confirmed the exceptional work with respect to FGM, led by the Divisional Director of Midwifery and Gynaecology, alongside further improvements in maternity and gynaecology services. The Chief Nursing Officer recommended to the Group Committees in Common that metrics Chief regarding Maternity Services were included in future Performance Nursing Dashboards, thus ensuring full visibility via the Group Committees in Common. Officer
A Non-Executive Director fully acknowledged the work that had been undertaken with respect to FGM, and expressed the importance of continued improvement on this important matter.
The Group Committees in Common commended the improvements made within Obstetrics and Gynaecology Services.
Opening Matters 3. Apologies for Absence Apologies for absence were noted as above. SRFT & PAT # 274090 04/27/2019 16:44:00
2/12 4/232 No. Item Action 4. Declarations of Interest The Chairman requested that officers declared any actual or potential conflict of interest relevant to their role as a member of the Group Committees in Common and in particular to any matter being discussed at the meeting. There were no interests declared. 5. Opening Remarks
Sir David Dalton Retirement The Chairman commented that Sir David would retire from his role as Chief Executive at the end of March 2019 and that this would therefore be his final Group Committees in Common meeting. The Chairman remarked that farewell events were being held across all of Care Organisations, and on behalf of the Group Committees in Common thanked Sir David for his exceptional contribution as Chief Executive and wished him a long and happy retirement.
Mrs Diane Brown The Chairman commented that Mrs Diane Brown would also be stepping down from her role as Senior Independent Director at the end of March, and that this would therefore be her final Group Committees in Common meeting also. The Chairman commented that Diane had been an outstanding non-executive director, with her commitment to the role and determination to instil best practice bringing much benefit to the Group Committees in Common and the organisation as a whole. On behalf of the Group Committees in Common, the Chairman extended his sincere gratitude and very best wishes to Diane.
Group Committees in Common Away Day The Chairman stated that the Group Committees in Common did not meet formally in February 2019, instead holding an informal ‘away day’, at which the principal risks to delivery of the 2019/20 Annual Plan were reviewed, as articulated by each Care Organisation. The Chairman confirmed that discussions held at the away day had supported the development of the Northern care Alliance NHS Group (NCA) Business Plan for 2019/20, which would be considered further today.
6. Minutes of the Previous Meeting The Chairman confirmed that Part 1 of the previous meeting held on from meeting on 28 January 2019 had been open to members of the public. The draft minutes, recorded of that session, were reviewed by the Group Committees in Common and approved as a true record.
7. Matters Arising No matters arising.
8. Verbal CEO Report, including review of Group CiC Performance Dashboard
8.1 Performance Indicators The Chief Executive Officer provided an overview of the key performance indicators within the Group Performance Dashboard. He specificallySRFT & PAT # 274090 highlighted performance with respect to mortality and harm, confirming04/27/2019 that the 16:44:00 Hospital Standardised Mortality Ratio (HSMR) for Pennine was now statistically better than expected. The Chief Executive Officer confirmed that Salford Royal also remained statistically better than expected for both HSMR and Summary Hospital-level Mortality Indicator (SHMI) with current position of 82.27 and 91.36 respectively.
3/12 5/232 No. Item Action
The Vice-Chairman referred to the surge in diagnostic performance at the North Manchester Care Organisation and queried if this improvement was sustainable. The Chief Officer for North Manchester Care Organisation stated that the actions put in place were sustainable and anticipated continued performance for this standard.
A Non-Executive Director referred to the stubborn performance with respect to stranded patients and sought further information regarding action to address this. The Chief Delivery Officer acknowledged the challenges being faced across the Care Organisations. She confirmed that the National Improvement Team were completing a review at Salford Care Organisation to identify improvements and that the outcome of the review, alongside collective learning from across the NCA, would be utilised in 2019/10 as part of a group- wide Quality Improvement collaborative focused on reducing patients with a long length of stay, and specifically, identification of standardised ways of working.
A Non-Executive Director referred to HSMR at the Oldham Care Organisation, noting a trajectory increase and higher weekend HSMR than other Care Organisations; and queried action being taken to address this. The Chief Medical Officer fully acknowledged this comment, and further to actions highlighted in the Learning from Deaths Report provided to the Group Committees in Common in March 2019, highlighted that Dr Jawad Hussain (Medical Director, Oldham Care Organisation) was focusing much attention on this matter, to improve the maturity of ‘learning from deaths’ structures within Oldham Care Organisation. The Interim Chief Officer for Oldham Care Organisation echoed these comments and confirmed that Dr Hussain was leading this work via the Clinical Effectiveness Committee, and that an audit of weekend mortality was underway to explore this matter further, with report and action plan to be presented to the Clinical Effectiveness Committee, and onward to the Group Risk and Assurance Committee when concluded. The Chief Chief Medical Officer confirmed that the action plan would be presented to the Medical Group Committees in Common as part of the next Learning from Deaths Officer Report.
A Non-Executive Director referred to North Manchester Care Organisation’s performance against the 2 week standard for Breast Symptomatic referrals; noting that performance was some way below the 93% standard, the Non- Executive Director queried actions being put in place to address this. The Chief Officer for North Manchester Care Organisation acknowledged the underperformance for this specialty, and highlighted that a Cancer Improvement Board had been established, with huge amounts of work initiated to rectify underperformance by the end of the financial year. The Chief Delivery Officer highlighted the significant workforce issues in this area, and on no account accepting current performance against the 2 week standard, highlighted that performance for this specialty generally recovered, and performed against the 62 day cancer standard. SRFT & PAT # 274090 A Non-Executive Director sought further information regarding pressure ulcers 04/27/2019 16:44:00 at the North Manchester Care Organisation. The Chief Officer for North Manchester Care Organisation commented that there had been an increase in grade 2 pressure ulcers, citing workforce issues as a contributing factor, and stated that improvement was anticipated in March 2019.
4/12 6/232 No. Item Action 8.2 Financial Position The Chief Executive Officer provided headlines with regard to the financial position as at the end of month 11. He confirmed that the Northern Care Alliance NHS Group (NCA) had an operating deficit of £20.3m and a net deficit of £68.7m, with PAHT on plan, and SRFT £7m adverse from the plan. With respect to SRFT, the Chief Executive Officer confirmed that clinical income was £8.2m better than plan due to better than planned performance in non- elective medicine, critical care, dermatology and neurosurgery, and that positive discussion had concluded with partner organisations regarding financial support to enable achievement of the control total for 2018/19.
The Chief Executive Officer reported that discussions regarding control totals were underway and would be discussed later in the meeting.
8.3 Care Organisation Reports Group Committees in Common reviewed a Care Organisation Performance Summary with respect to the following measures: − Financial control (Bury & Rochdale) − Emergency Department 4 hour standard (Salford) − 62 day cancer standard (Oldham) − Workforce (North Manchester)
The Care Organisation Chief Officers for Salford, North Manchester, Oldham and Bury & Rochdale, each provided focus on a specific measure (as above), highlighting key issues and recovery actions. In addition, each Chief Officer provided further update on performance against the national Emergency Department 4 hour standard. Further discussion took place as follows:
8.3.1 Bury & Rochdale Care Organisation (Financial Control) The Chief Officer for Bury & Rochdale confirmed a year to date adverse variance of £3.2m, highlighting key drivers to were undelivered cost improvements of £2.2m and under-delivery of Contract Income (c£1m). With respect to Emergency Department performance, the Chief Officer for Bury & Rochdale confirmed that performance was 89.67% in February, below the improvement trajectory, highlighting pressure due to a loss of community beds. He confirmed focus on stranded and super-stranded patients, and highlighted that performance for patients that did not require admission was consistently between 97-100%.
A Non-Executive Director asked if there was a view of stranded and super stranded patients at a Greater Manchester level, emphasising the importance of understanding out of hospital capacity across the conurbation. The Chief Officer for Bury & Rochdale confirmed that different mechanisms were in place to understand capacity at a local level; however this was not uniformly available for Greater Manchester. The Chief Delivery Officer echoed these comments, and added that further work was underway to understand out of hospital capacity for the NCA, including automation of this information as part of a dashboard. She added that Greater Manchester had commenced a piece of work to better understand whole system capacity and compare this at a SRFT & PAT # 274090 national level. 04/27/2019 16:44:00 8.3.2 Salford Care Organisation The Chief Officer for Salford Care Organisation confirmed that the Salford Care Organisation was below its revised improvement trajectory of 87% with performance of 72.00% in February. He confirmed an improvement plan, at
5/12 7/232 No. Item Action the request of Greater Manchester, had been produced, with performance in March 2019 currently at 89%. The Chief Officer for Salford Care Organisation confirmed that the need to reduce stranded patients, and repatriate patients quickly, was vital to improved performance. The Senior Independent Director queried if the stranded patients were mostly from outside of Salford. The Chief Officer for Salford Care Organisation confirmed that approximately 50% of stranded patients were from Salford; however 70% of patient admissions were Salford. He added that a Greater Manchester Repatriation Team had been established to support this work, with improvement being seen slowly.
8.3.3 Oldham Care Organisation The Interim Chief Officer for Oldham Care Organisation highlighted that all specialties had seen a decline in performance against the 2WW in January due to an increase in breaches attributed to patients choosing to delay appointments till after the Christmas/New Year period, with 60% of all January breaches attributed to patient choice and 31% due to capacity. She confirmed that invalidated 2WW performance in February 2019 showed an improving position. With respect to the 62 day cancer standard, the Chief Officer for Oldham Care Organisation confirmed that performance remained on trajectory, reflecting the work being undertaken by the specialties to reduce the overall size of their PTLs and clearing the backlog of long waiting patients.
With respect to Emergency Department performance, the Chief Officer for Oldham Care Organisation confirmed focus on stranded and super-stranded patients.
8.3.4 North Manchester Care Organisation The Chief Officer for North Manchester Care Organisation highlighted actions taken to reduce agency spend, including migration of locum doctors to NHSP, with reductions in both agency spend and locum use above trajectory.
The Chief Officer for North Manchester Care Organisation commented that sickness absence continued to be a cause of concern, stating that whilst good progress had been made reducing long term sickness, short term absence had increased in recent months. He added that review processes were in place to ensure management action; best practice and policy were being actively followed.
The Chief Officer for North Manchester Care Organisation confirmed Emergency Department performance against the 4 hour standard was below trajectory, notwithstanding a 13% increase in attendances, with some improvement being seen in March 2019.
The Senior Independent Director referred to the successful introduction of the Malinko System and Trendcare, and encouraged the organisation to challenge current practices to ensure most effective and efficient staffing across 7 days. A Non-Executive Director referred to the levels of sickness absence across the North East sector Care Organisation, acknowledging the various initiatives in place to reduce this; and queried the extent to which the organisation SRFT & PAT # 274090 understood which initiatives were most effective. The Chief Strategy & 04/27/2019 16:44:00 Organisational Development Officer acknowledged that this matter was multifaceted, highlighting the Salford journey in this regard. He expressed his view that two fundamental matters to support reduction in sickness absence, were effective leadership and improved facilities for staff, noting that the latter was not wholly within the gift of the NCA. A Non-Executive Director expressed
6/12 8/232 No. Item Action his view that sickness absence at such levels was unacceptable. The Chief Executive Officer expressed his view that at the heart of the People Strategy was the aim to ensure staff wanted to work for the NCA and to provide support to middle managers and ward managers to support and engage with staff. He stated that developing this sense of belonging was fundamental to changing cultures across the organisation, including the ability to impact on sickness absence.
8.4 Strategic Matters The Chief Executive Officer provided update with respect to the following strategic matters: − GM Improving Specialised Care Programme (previously referred to as Theme 3) − GM Theme 4 Work Programme – Clinical Support Services − North East Sector (NES) − North West Sector (NWS) − Pennine Care NHS Foundation Trust Community Services − Local Care Organisations − Transaction: SRFT Acquisition of Oldham, Bury and Rochdale elements of PAHT
9. Risk Management Strategy The Chief Medical Officer presented the NCA Risk Management Strategy, confirming that this superseded the PAHT and SRFT Risk Management Strategies, and aligned all Care Organisations and Group Business Units under one Risk Management Strategy.
The Chief Medical Officer highlighted that there were on-going Mersey Internal Audit Agency (MIAA) audits being undertaken on Committee Effectiveness and Risk Maturity, and that the recommendations from these reports (expected April – May 2019) would form the basis of NCA wide improvement work to refine and further develop the Risk Management Strategy, Risk Register Management and the Assurance Framework as a whole. He added that the Risk Management Strategy had been approved at the March 2019 Group Risk and Assurance Committee (GRAC) as an interim document, and that following the aforementioned improvement work, a revised document would be presented to GRAC by September 2019.
Group Committees in Common ratified the NCA Risk Management Strategy and supported the development of the new strategy, risk register and assurance framework documents by September 2019 following MIAA recommendation reports.
10. Complaints Policies The Chief Nursing Officer and Chief Medical Officer presented the NCA ‘Complaints Handling Policy’ and the ‘Dealing with Unreasonably Demanding, Persistent or Vexatious Complainants Policy’ (Vexatious Complainants Policy). The Chief Nursing Officer specifically highlighted the strengthened process for SRFT & PAT # 274090 handling joint complaints. With respect to the Vexatious Complainants Policy, 04/27/2019 16:44:00 the Chief Medical highlighted that the policy detailed action to be taken if an individual’s behaviour in trying to resolve a concern or complaint was unreasonably demanding, persistent or vexatious.
The Senior Independent Director expressed her view that the policies were
7/12 9/232 No. Item Action well written and emphasised the importance of local resolution where possible. In addition, she highlighted the importance of the Vexatious Complainants Policy in order to safeguard staff and resources.
A Non-Executive Director referred to an incident where a complaint had been made verbally and the complainant had not received a response regarding the investigation, and sought assurance as to how verbal complaints were handled. The Chief Nursing Officer commented that she was aware of only a very small number of occasions where a verbal complaint had not been responded to, adding that this matter would be recorded as an incident on the Datix system. She added that there must be clarity of language with patients, so not to confuse with incident investigations.
In addition, the Non-Executive Director expressed her view that there may be occasion whereby the complaint should be investigated outside of the line management to ensure impartiality; and suggested a biennial report to Group Committees in Common that captured learning from the Complaints Review Panel. The Non-Executive Director suggested the appeals process for complainants/vexatious complainants should be included within the policy and highlighted the need to be mindful of vulnerable people when following such a process. The Chief Nursing Officer fully acknowledged these comments, confirming that right of appeal for complainants would be included within the policy, and added that patients identified as having a mental health condition were excluded from this policy. The Chief Nursing Officer welcomed the Chief inclusion of a summary of themes from the Complaints Review panel to be Nursing included in the six monthly Learning from Experience Report. Officer
The Group Committees in Common reviewed and confirmed the Complaints Handling Policy and Vexatious Complainants Policy.
11. People Report including 2018 National Staff Survey Outcome The Chief Strategy & Organisational Development Officer presented the first People Report, noting that metrics were not yet available for all strategic themes. The Chief Strategy & Organisational Development Officer provided update with respect to productive staffing, operational gaps, statutory and regulatory compliance (mandatory training), contribution framework mobilisation, talent development, leadership development and skills and competencies.
The Vice-Chairman referred to the identified estates risks and, in light of this, emphasised the importance of staff undertaking appropriate fire safety mandatory training. The Chief Strategy & Organisational Development Officer fully acknowledged this comment and confirmed that there had been special focus on training frontline staff at the North Manchester Care Organisation, however the systems of recording training compliance required update in this regard.
In addition, the Chief Strategy & Organisational Development provided a detailed presentation on the 2018 National Staff Survey results. He confirmed SRFT & PAT # 274090 that response rates had increased by 1% for both Salford and North East 04/27/2019 16:44:00 sector (NES) Care Organisations compared to 2017 results, however further work was needed to increase staff engagement in completing the survey, especially at NES Care Organisations where the 34% response rate was significantly lower than the national average. The Chief Strategy & Organisational Development Officer expressed his disappointment in the
8/12 10/232 No. Item Action results of the National Staff Survey 2018, and confirmed that both Salford and NES Care Organisation results were within the parameters of best and worse national results for the 10 themes, highlighting upward and downward trends. The Chief Strategy & Organisational Development Officer highlighted areas of future focus including health and well-being and quality appraisals.
The Senior Independent Director welcomed the depth and transparency of reporting. She commented on the number of staff engagement initiatives developed over recent years, and encouraged focus on a small number of initiatives that were known to have successful outcomes. The Chief Nursing Officer fully acknowledged these comments. With respect to the slower than anticipated progress in rolling out CF2, she highlighted the challenge in releasing staff and stated that new ways of delivering programmes to staff must be identified to galvanise leaders across the organisation. In addition, the Chief Nursing Officer expressed her disappointment regarding the number of Black and Minority Ethnic (BME) staff members on the talent management programme. The Group Committees in Common acknowledged that this reflected the number of BME staff in positions that would enable them to access the current talent management programme.
A Non-Executive Director emphasised the importance of early planning in order to improve the response rate for the following year and obtain a cross sectional view. In addition, she expressed her view that staff engagement at the NES Care Organisations had previously been seen as the responsibility of HR and Senior Leaders, and emphasised the importance of ownership of all staff with responsibility for appraisals and engaging with staff.
A Non-Executive Director echoed the above comments, expressing his view that such low response rates impacted the meaningfulness of the survey; with response rates in the private sector generally between 85-90%, aligned to the importance of the survey to influence change in the organisation. The Chief Strategy & Organisational Development Officer acknowledged a perception in the NES Care Organisations that the responses were not anonymous, reflecting culture across the organisation, subsequently influencing response rates. The Chief Officer for Bury & Rochdale stated that the approach taken by the Care Organisation to staff engagement in 2019/20 would be slightly different, with staff side engagement in the Care Organisation’s objectives and granularity to the objectives to ensure meaningful to all staff.
A Non-Executive Director referred to the 11 strategic themes presented, and again encouraged streamlining of focus. The Chief Strategy & Organisational Development Officer acknowledged this observation and referred to consideration of this as the Group Committees in Common reviewed the 2019/20 Annual Plan later in the meeting, and identification of a specific numbers of areas on which to focus.
The Group Committees in Common reviewed and confirmed the People Report. SRFT & PAT # 274090 12. NCA EU EXIT Preparations Report 04/27/2019 16:44:00 The Chief Delivery Officer outlined the continuing preparations that were being undertaken by the NCA EU Exit Task Group to mitigate the impact of the planned United Kingdom exit from the European Union on March 29th 2019. She confirmed that the Exit Plans for the NCA conformed to guidance from the NHS EU Exit Strategic Commander, with daily reporting to NHS England to
9/12 11/232 No. Item Action confirm NCA preparedness and report any local difficulties.
The Group Committees in Common reviewed and supported the NCA’s direction in continuing to conform to NHS England requirements on preparation for EU exit, particularly in the case of a no deal scenario.
13. NAAS / SCAPE Award(s) The Group Committees in Common reviewed the recommendation of the SCAPE Panel held on 19th March 2019.
The Group Committees in Common confirmed SCAPE status for the Salford Care Organisation Swinton District Nurses and East Central 0-19 Team.
14. Annual Review: FT Code of Governance The Group Secretary presented the annual review of SRFT’s compliance with the NHS FT Code of Governance, highlighting that although the ‘Code’ was relevant to NHS Foundation Trusts; the review has been widened to encompass compliance for the Northern Care Alliance NHS Group (NCA).
The Group Secretary confirmed a review of compliance with each provision had been undertaken by the Group Secretary and Chairman. This had determined that the Trust complied with the Code’s provisions, with the exception of:
Provision B.7.1 In exceptional circumstances, NEDs may serve longer than six years (two three-year terms following authorisation of the FT) but subject to annual reappointment.
o In March 2017, the Council of Governors extended the tenure of two Non- Executive Directors, the Vice Chairman and Senior Independent Director, both of whom had served more than three years. The original term of office for both Non-Executive Directors was one year (1.1.17 until 31.12.17). This was extended to a term of office of two years and three months, until 31.03.19. Governors acknowledged the importance of stability during Group transitional arrangements, and the outstanding performance and significant expertise of these Non-Executive Directors, also appointed as PAHT Non- Executive Directors.
o At 31st March 2019, the Vice-Chairman will have served eleven years and three months. In December 2018, the Council of Governors reappointed the Vice-Chairman for a two month period, with a term of office ending on 31st May 2019, to ensure appropriate scrutiny of the 2018/19 Annual Report and Accounts via Audit Committee, prior to submission to NHS Improvement at the end of May 2019.
o At 31st March 2019, the Senior Independent Director will have served ten years and three months, and will stand down as a Non-Executive Director. SRFT & PAT # 274090 The Group Committees in Common received a detailed report that04/27/2019 described 16:44:00 the NCA’s level of compliance across every provision within the Code.
The Group Committees in Common reviewed the information provided and confirmed compliance with the provisions of the Code as described,
10/12 12/232 No. Item Action including explanation of why the Trust had departed from B.7.1.
The Group Secretary confirmed that SRFT’s 2018/19 Annual Report and Accounts would confirm compliance with the provisions of the Code and an explanation of the reasons for departure from B.7.1 as described above.
15. Sealed Documents
The Group Committees in Common reviewed and confirmed all documents sealed between 1st October 2018 and 28th February 2019 by the Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust respectively.
16. Chairman’s Report from the Council of Governors The Chairman provided the Group Committees in Common with a summary of the key issues discussed and decisions made at the meeting of the Group, and SRFT, Council of Governors on 21st March 2019.
The Group Committees in Common reviewed and confirmed the information provided.
17. Reports from Standing Committees
17.1 Group Audit Committee – Meeting held on 1st February 2019 The Vice-Chairman provided overview of the key matters and decisions made at the meeting on 1st February 2019.
17.2 Group Executive Risk and Assurance Committee (GRAC) - Meeting held on 18th February and 18th March 2019 Group Committees in Common reviewed key matters and decisions made at the meeting held on 18th February and 18th March 2019.
In response to a Non-Executive Director querying if the 36% increase in MRO referrals at the Salford Care Organisation had been sustained, the Chief Officer for Salford Care Organisation confirmed that this was not sustained month on month, with no additional understanding of this sudden increase.
17.3 Group Charitable Funds Committee – Meeting held on 20th February 2019 The Vice-Chairman provided overview of the key matters and decisions made at the meeting on 20th February 2019.
18. Any Other Business (Part 1) No other business. 19. Date and Time of the Next Meeting The Chairman confirmed that the next meeting would take place on Monday, Monday 29th April 2019 from 10am in the Humphrey Booth Lecture Theatre, Mayo Building, Salford Royal.
Closure of Part 1 of the Group Committees in Common Meeting SRFT & PAT # 274090 20. Exclusion of the Public 04/27/2019 16:44:00 The Group Committees in Common resolved to exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be inappropriate, by reason of the sensitive and confidential nature of business.
11/12 13/232 SRFT & PAT # 274090 04/27/2019 16:44:00
12/12 14/232 Committee in Common
2018/19 Performance Review
Bury & Rochdale North Manchester Oldham Salford
Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Two Week Wait Target: 93% 62 Day Standard Target: 85%
NMCO experienced significant capacity issues OCO has been unable to deliver the cancer BRCO consistently delivered high performance throughout the year which impacted on its ability standards all year. Significant capacity issues, Salford has consistently delivered the cancer for the 2 week wait standard but has mainly failed to deliver both cancer standards. The main areas particularly in upper and lower gastro-intestinal standards throughout the year, only failing to Commentary to deliver the 62 day target. This relates to Head with capacity issues were breast surgery and services have contributed to this under meet the 62 day standard on two occasions. and Neck cancers and sarcoma. Cancer Care Cancer lung. performance
18 Week Standard Local Trajectories Waiting List Size Local Trajectories 6 Week Diagnostics Target: 99% SCO's RTT performance deteriorated in the latter Achieving the elective access standards has Capacity issues at OCO have severely impacted half of the year with increased demand Despite capacity issues at NMCO the locally been challenging for BRCO, with a stretch target its ability to deliver the RTT standard but the particularly in Dermatology. The list size has agreed RTT trajectories were largely delivered above the national standard and specific issues diagnostic standard was consistently delivered reduced by 2.7% from the September '19 over the course of the year. The NMCO and with Cardiology capacity impacted on the delivery for the majority of the year. The NMCO and OCO baseline. Radiology capacity for MR scanning Commentary OCO waiting list is taken in its entirely due to mid- Elective Care Elective of the 6wk diagnostic standard. An overall waiting list is taken in its entirely due to mid-year has adversely impacted on the achievement of year service changes and overall there has been reduction of 19% was achieved in the size of the service changes and overall there has been a 2% the diagnostic standard but there have been long a 2% increase in the size of the waiting list. waiting list. increase in the size of the waiting list. waits in other diagnostic services that have also contributed to the failure of the standard.
SRFT & PAT # 274090 04/27/2019 16:44:00
1/4 15/232 Committee in Common
2018/19 Performance Review
Bury & Rochdale North Manchester Oldham Salford
Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar
A&E Standard* Local Trajectories Delayed Transfers Target: 3.5% Stranded Local Trajectories Super-Stranded Local Trajectories
BRCO began the year achieving across a range of urgent care indicators however the position NMCO has had a challenging year in the urgent OCO has maintained good performance in terms SCO achieved it’s A&E local trajectories for the
Urgent Care Urgent deteriorated in the latter half of the year. care setting and has had difficulties delivering its of delays and stranded patients throughout the first quarter of the year but then performance has Commentary Initiatives to improve discharge flow during the local trajectories for A&E and other urgent care year but has not delivered its local trajectories for deteriorated and stranded patients continue to be final quarter of the year has reduced the number measures. the A&E 4hr standard. above the adjusted GM standard. of delayed transfers to help improve flow.
Clostridium Difficile Local Trajectories Pressure Ulcers Normal, Improving, Worse Falls Normal, Improving, Worse HSMR Better, Worse, Expected
SCO did not achieve its trajectory for C.Dif NMCO achieved their C.Dif trajectory at the end OCO saw increased levels of C.Dif at the BRCO has reduced levels of C.Dif and was under SRFT & PAT # 274090 although occurrences per 1,000 bed-days remain of the year with a reduced number of infections. beginning of the year but the end of year its trajectory at the end of the year. HSMR is as at low levels, reflecting increased activity. Improvements have been 04/27/2019seen in the trajectory16:44:00was delivered. There have been Commentary expected and both occurrences of pressure Pressure ulcers saw an increase at the beginning QualitySafety & occurrences of pressure ulcers and HSMR is reductions in pressure ulcers and falls are within ulcers and falls are within normal variation. of the year but are now within normal variation as better than expected. normal variation. HSMR is as expected. are falls. HSMR remains better than expected.
2/4 16/232 Committee in Common
2018/19 Performance Review
Bury & Rochdale North Manchester Oldham Salford
Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar
Sickness Absence Local Targets Vacancy Rates: N&M
Vacancy Rates: M&D
Agency Use: N&M Normal, Improving, Worse Agency Use: M&D Normal, Improving, Worse Nurse Staffing: Day Target: 95% Nurse Staffing: Night Target: 95% Care Staffing: Day Target: 95%
Workforce Care Staffing: Night Target: 95% Sickness absence levels have worsened during BRCO achieved its 5% sickness absence target NMCO has not achieved its sickness absence Sickness absence levels have been above the the second part of the year and SCO has not met at the beginning of the year but not in the latter target for the year and N&M vacancy rates are 5% target for the majority of the year. N&M it's 4.2% target for the most recent months. N&M part. N&M vacancy rates were slightly lower and almost 2% higher at the end of the year with M&D vacancy rates are at similar levels at the end of vacancy rates are nearly 3% lower than the start M&D were slightly higher at the end of the year. rates almost 6% higher. Agency usage has the year as they were at the start and M&D rates of the year and M&D rates are 2% higher. Use of Agency shifts have largely been within normal improved throughout the year for all staff groups are slightly higher. Agency use for N&M has both N&M and M&D agency staff has seen Commentary variation with some periods of improvement and trajectories for agency spend have been begun to improve but M&D agency use has been significant improvement in the last quarter of the across the year. Nursing staffing levels do not achieved. The Care Organisation is the only one largely deteriorating in the latter part of the year. year. Nurse staffing levels only met the 95% achieve the 95% recommended threshold but to deliver the 95% standard for some of its Nurse staffing level standards were not met for SRFT & PAT # 274090 standard on one occasion however the Care care staffing is consistently at this level nursing shift levels and consistently delivers the year however Care staffing levels were 04/27/2019 16:44:00 staffing levels are consistently achieved with only throughout the year with only three exceptions. against the standard for Care staff. delivered consistently. three months in exception.
3/4 17/232 Committee in Common
2018/19 Performance Review
Bury & Rochdale North Manchester Oldham Salford
Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Control Total Target: Control Total Bury & Rochdale Care Organisation position for NMCO has achieved its control total for 2018/19. Oldham Care Organisation has a reported The draft end of year normalised position for the end of month 12 is an adverse variance of The financial plan was achieved through position of a £48.9m surplus some £2.0m below SRFT is a surplus of £15.8m including PSF which c£1.4m, (an improvement of £1.8m since last undertaking additional activity above plan and its control total surplus of £50.9m.Below plan is £10.6m better than plan. Excluding PSF, the month). The main driver to the favourable securing additional income from commissioners, performance predominantly as a result of BCLC position is a deficit of £6.9m which is £2.4m movement in the position is related to increased good control of costs, delivery of the BCLC target stretch target not being delivered. BCLC better than control total excluding PSF. This urgent care and stroke activity (£1.2m). and reductions in the use of agency staffing. delivered standing at £3.5m against stretch target position includes SRFT services (£11.8m surplus The in-year delivery of BCLC was £3.5m against Workforce challenges, including sickness rates, of £6.7m.Majority of savings delivered via pay including PSF) and Hosted Services (£4.0m a target of £6.2m representing a £2.7m adverse remain a key financial risk. and non-pay scrape with only £0.85m recurrent surplus). variance against plan at the end of month 12. .Clinical income at year end was £5.2m above Provider Sustainability Funding (PSF) related to The BCLC stretch target of £2.7m for 2018/19 plan(HCD at £2.2m).This was offset by financial performance of £10.3m is included as was not achieved. expenditure being some £7.2m above plan with income in the reported position – this is 100% of The 3 core programmes of work; medical non-delivery of BCLC standing at £3.2m.Agency the total available for financial performance in staffing, theatre productivity and ophthalmology expenditure stood at £11.6m with premium costs 2018/19. Because both SRFT and Greater Commentary continue to submit evidence to the DMO as part adversely impacting on I&E surplus position. Manchester NHS organisations performed better
of the assurance framework process into 2019- than control total during the year, additional Finance 20 with an additional outpatient productivity focus (provisional) PSF funding has been allocated to via the 4 eyes work. SRFT of £12.6m which includes £0.88m as a Key drivers to the overall year end adverse share of the Greater Manchester PSFG incentive variance are specialities underperforming against funding. These sums are provisional as are income plans within ENT, Elective Orthopaedics subject to change if either SRFT or NHS and sub-acute rehab. These issues have been organisations in GM amend their reported reviewed and corrected as part of the 2019-20 2018/19 outturn between submission of key data contract negotiations and capacity planning work. returns on 15th April 2019 and final audited accounts on 29th May 2019.
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4/4 18/232 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT)
Title of Report Review of the Group Committees in Common Scorecard
Meeting Group Committees in Common Emma Wright, Director of Information & Business Intelligence Author (s) Judith Adams, Group Delivery Officer Presented by Judith Adams, Group Delivery Officer Date 29th April 2019
Executive The new financial year brings the opportunity for review and refresh of our Summary Group Committees in Common Scorecard. It is important that our performance reporting supports performance improvement and purely retrospective performance reporting does not effectively allow for this opportunity.
This paper proposes a number of guiding principles for our 2019/20 scorecard for consideration as well as a review of how the report is presented to ensure Care Organisation performance is seen in the round and the Committee in Common is guided to areas of risk through a number of signals.
Annual Plan Applicable to all operational objectives Objective Associated Risks The review and refresh of the Scorecard brings opportunity to mitigate risk relating to our ability to effectively monitor the delivery of the Annual Plan Recommendations The Group Committees in Common is asked to support the revision of the Scorecard as described.
Equality Does this paper relate to a matter where equality issues may arise? Y/N If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and can be Information made available to the public. x Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public.
This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
Data Sharing Under the Data Sharing Agreement, the NCA may be required to Agreement with share this paper with MFT. This is distinct from information Manchester disclosed under the FOIA. As MFT will acquire part of PAT they will University NHS FT need to understand a range of matters which may otherwise be (MFT) in relation to exempt under FOI e.g. contracts to be split and specific workforce- the Transaction related issues. SRFT & PAT # 274090 04/27/2019 16:44:00 Please consider the statements below and indicate which applies in relation to this paper:
1/2 19/232 a) This paper relates solely to PAT and can be released
b) This paper relates solely to SRFT and is therefore not eligible for release
c) This paper contains information relating to both PAHT and SRFT. All information other than that relating to PAHT will be fully redacted.
d) This paper contains reference to both PAHT and SRFT but contains no quality, finance or operational performance data x relating to PAHT which could be relevant to the transaction and is therefore not eligible for release.
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2/2 20/232 Northern Care Alliance Committees in Common Scorecard Review
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1. Introduction
The new financial year brings the opportunity for review and refresh of our Committees in Common Scorecard. It is important that our performance reporting supports performance improvement and purely retrospective performance reporting does not effectively allow for this opportunity.
This paper proposes a number of guiding principles for our 2019/20 scorecard for consideration as well as a review of how the report is presented to ensure Care Organisation performance is seen in the round and the Committee in Common is guided to areas of risk through a number of signals.
2. Guiding Principles
The following guiding principles are proposed for our Committees in Common scorecard report. These principles will also be reflected into Care Organisation performance reports.
Alignment with our Annual Plan for 2019/20
Focus on leading & balancing indicators rather the just retrospective performance
Inclusive reporting that covers all our services, including maternity and social care
Reporting performance at a Northern Care Alliance level wherever possible
Utilisation of SPC or run-charts rather than two data point comparison
Triangulation of indicators to give a fuller picture of performance
Accompanying commentary to give context
Avoiding duplication with other CiC reports and scorecards
3. Proposed Format of Scorecard
The current CiC Scorecard reviews single indicators across our four Care Organisations, limiting the opportunity to triangulate leading and balancing metrics. The development of the NCA will see closer relationships across services within our Care Organisations and the development of Group services like the Diagnostics and Pharmacy function. It is important that we can continue to review performance of our Care Organisations and Group functions side-by-side but also to ensure we have the opportunity to signal risk to performance through leading and balancing indicators.
The new performance scorecard should provide views of single domain areas so, for example, all elements of cancer performance can be reviewed across leading and balancing metrics alongside our statutory metrics with a view across all Care Organisations and Group functions to understand comparative performance and inter-dependencies.
SRFT & PAT # 274090 Emma Wright 04/27/2019 16:44:00 Director of Information & Business Intelligence April 2019
2/2 22/232 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT)
Title of Report Sustainability Strategy and Development Management Plan
Meeting Group Committees in Common Board Jude Adams – Group Chief Delivery Officer Rob Jepson – Deputy Director of Estates and Facilities Author (s) Andrew Montgomerry – Head of Estates
Presented by Jude Adams Date 29th April 2019
Executive The NCA has over recent years undertaken steps to reduce our impact on the Summary environment using a number of projects, policies and procedures. Our actions have formed the principles around the requirement to support a Sustainable Development Action Plan (SDMP) in line with guidance from the NHS Sustainable Development Unit.
The next phase of our strategy aims to identify additional approaches to enable a reduction in our carbon footprint and which takes account of the UK Climate Projections 2018 (UKCP18).
This report sets out the next steps in the development and delivery of our strategy and plans to ensure we build upon current foundations and comply with our obligations under the Climate Change Act.
A full risk assessment underpins our current position and describes action planning.
Annual Plan Annual Plan Theme 6: Develop and Implement our Service Development and Objective the Northern Care Alliance enabling strategies Associated Risks Without considering social and environmental sustainability as part of our organisational strategy we will not achieve economical sustainability. This is fundamental to the vision for the NCA and a cornerstone to providing a high quality, productive and efficient healthcare service.
Recommendations Group Committees in Common Board is asked to support the next phase of development to deliver our Sustainability Strategy and Development Management Plan
Equality Does this paper relate to a matter where equality issues may arise? Y/N If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and can be SRFT & PAT # 274090 Information made available to the public. x 04/27/2019 16:44:00
1/2 23/232 Please ‘cross’ one This document contains some confidential information that would need of the boxes to be redacted before the document was made available to the public.
This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
Data Sharing Under the Data Sharing Agreement, the NCA may be required to Agreement with share this paper with MFT. This is distinct from information disclosed Manchester under the FOIA. As MFT will acquire part of PAT they will need to University NHS FT understand a range of matters which may otherwise be exempt under (MFT) in relation to FOI e.g. contracts to be split and specific workforce-related issues. the Transaction Please consider the statements below and indicate which applies in relation to this paper: a) This paper relates solely to PAT and can be released
b) This paper relates solely to SRFT and is therefore not eligible for release
c) This paper contains information relating to both PAHT and SRFT. All information other than that relating to PAHT will be fully redacted.
d) This paper contains reference to both PAHT and SRFT but contains no quality, finance or operational performance data x relating to PAHT which could be relevant to the transaction and is therefore not eligible for release.
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2/2 24/232 Northern Care Alliance
Sustainability Strategy and Development Management Plan
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Introduction The NHS must tackle sustainability in the widest terms possible. That is, the NHS can’t just be economically sustainable without considering social and environmental sustainability at the same time. The combinations of these elements are fundamental to the vision for the NCA and are a cornerstone to providing a high quality, productive and efficient healthcare service.
The NHS Carbon Reduction Strategy seeks to ensure that all NHS organisations establish a fully integrated strategy to tackle climate change. Its principle is firstly to identify and address all of the Trust’s sources of carbon emissions, and secondly to embed the principles of sustainability throughout the organisation and its stakeholders.
Sustainability Strategy and Development Management Plan The requirement for all NHS organisations to implement a yearly sustainable development plan - or SDMP – was emphasised as a core objective in the National Sustainability Strategy for Health and Care (2014). For the NCA, to now develop further our Strategy we need to build upon previous work and deliverables to broaden our foundation and activities aligning these to national and local drivers, including; The NCA’s own business and/or operational strategy Available financial savings and payback timescales The National Sustainable Development Strategy for Health and Care and its seven delivery modules National legislation to drive environmental and social change including the Climate Change Act (2008) and the Public Services (Social Value) Act (20121) The current revision of The NCA’s Corporate Social Value Strategy Sustainability strategies of the Greater Manchester Clinical Commissioning Groups and other NCA Providers
Our next phase plan will set out additional activities to from a progressive ladder of achievement. Reaching the top will enable The NCA to realise ‘Exemplar Organisation’ for sustainability; our plan will be iterative and implementation will be phased over the next few years.
Current Foundations As an organisation we have undertook various steps to reduce our impact on the environment using a number of projects, policies and procedures. These include, but are not limited to, waste policies, travel policies, cycle to work schemes, carbon reduction plans, climate change levies, European Union Emissions Trading Scheme (EU-ETS), the introduction of combined heat and power (CHP) units as well as the developing our Corporate and Social Value commitment.
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1 Reviewed in 2014/15
2/4 26/232 These actions combined have formed the principles around the requirement to support a Sustainable Development Action Plan (SDMP) in line with guidance from the NHS Sustainable Development Unit.
In our ambition to provide high quality healthcare into the future we recognise that we must formalise these approaches through our next phase strategy development, in a way that minimises negative effects and results in a reduction in our carbon footprint.
Future Strategy Development The Objective Our ambition is to make NCA an exemplar Organisation for sustainability and a better corporate neighbour within the North East and North West Sectors. To address this objective we aim to: Evaluate our current position of the organisation and understanding the work delivered to date and improvement margins available (developing our understanding) Decide and Act upon specific further improvement initiatives that will enable the environmental, social and economic benefits of sustainability to be realised (setting out our strategy and opportunity). Progress and evidence improvements towards beacon trust status (compiling our action plan for delivery and measurement)
Next Phase Approach Our approach will set out and propose packages of work which align to and reflect the project objectives. Activity will run concurrently across this development. As a valued partner across our localities it is crucial to identify the intrinsic links between the sustainable improvement arena, and the benefit it creates to local health and wellbeing. The model below is an embellished sustainability ‘Venn diagram’ developed to help illustrate this point.
The bigger picture of Sustainable Healthcare
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3/4 27/232 Senior leaders from across the organisation as well as Executive board members will be key to driving the next phase development and delivery of our plan. Importantly we will leverage our ambition to be a valued partner, to actively engage our localities and commissioners in our plans and agree jointly new ways of working. Clear communication plans will be developed that effectively deliver the intended sustainability message through teams and champions. We will develop a baseline of sustainable performance by engaging with experts who will utilise headline performance data from across the NCA to indicate performance overall at Care Organisation and locality level. In addition to which, we will complete the Sustainable Development Unit Good Corporate Citizen Tool (GCC) - a self-assessment exercise that covers all NCA activities relating to sustainable development. This benchmarking tool examines factors such as leadership and engagement, estates and facilities, travel and procurement. Following assessments we will estimate the likely improvements that could be achieved from improvement programmes. These will help to steer whether change focuses on a particular resource theme; on a particular department, or selection of departments; or on the organisation as a whole.
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4/4 28/232 Northern Care Alliance
Quality Improvement Update Progress Report: April 2019
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1/28 29/232 Pressure Ulcer Collaborative (NES Sites)
Aims
A 20% reduction in hospital acquired Category 2 Pressure Ulcers in pilot areas by April 19 Zero tolerance of hospital acquired Category 3&4 Pressure Ulcers in pilot areas by April 19 A 20% reduction in avoidable Category 2 pressure ulcers in community areas by April 19
Project Status: On track. Special cause reduction has been observed for overall NES category 2 pressure ulcers, there have been no category 3 and 4 pressure ulcers on pilot areas and HMR community services have maintained their reduction.
Measures/Data:
NES Trust Wide Category 2/3/4 (includes hospital and community acquired, collaborative wards and all other wards)
The chart above shows the number of category 2, 3&4 pressure ulcers across the whole North East Sector, including both community and hospital acquired. The limits were reset in June 2017 as special cause variation was observed.
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2/28 30/232 NES Trust wide Acute Category 2 Overall (includes collaborative wards and all other wards)
The chart above shows the number of category 2 pressure ulcers across all North East Sector wards. From May’18 there were 8 points below the mean so control limits have been reset.
NES Pilot Areas Days between Category 3&4 (F6 was added to the collaborative in August ’18 following a category 3 pressure ulcer, so is excluded from the charts below.)
The chart above shows the number of days between category 3 and 4 pressure ulcers across North East Sector Collaborative areas. As at 31/3/19 it has been 787 days since the last category 3 or 4 pressure ulcer for collaborative areas. SRFT & PAT # 274090 04/27/2019 16:44:00
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3/28 31/232 NES Pilot Areas Category 2
The chart above shows the number of category 2 pressure ulcers across North East Sector pilot areas. This chart is displaying normal variation. At a care organisation level, special cause improvement has been displayed for Oldham collaborative wards with 8 points below the mean since April ’18. Charts for the pilot areas at other care organisations are displaying normal variation.
HMR Community Category 2
SRFT & PAT # 274090 The chart above shows the number of acquired category 2 pressure ulcers for HMR Community04/27/2019 teams. 16:44:00 This data is currently showing normal variation following a step change improvement in July 2017.
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4/28 32/232 Current activity
A learning session was held 8th October 2018 and was attended by 60+ people. A further learning session took place on 23rd January, teams presented their progress since October and designed further tests of change.
Task and Finish Groups have also been established to look at specific areas of improvement in specialist areas. These are listed below:
Clinical Photography – standardising approach across NCA Acute & Community A&E – reviewing handover documentation HCA Champions – developed resource pack for PU HCA Champions PU Investigation Document – testing revised version at Oldham CO Critical Care – testing PU process map and developed sharing forum Community – change package launched, spread plan underway
The current changes proposed for inclusion as part of the Acute Change Package are:
Bedside visual prompt “When pressure is found” process map Bedside handover tool Pressure ulcer champion tool Ward to ward transfer tool/SBAR Sticker in the patients notes
Next steps
The next steps for the collaborative are to:
Continue to spread the change ideas in the Community Change Package. Continue to develop the Acute Change Package in preparation for a launch at the Collaborative Celebration Event 13th May 2019. This will include the spread plan for post-April ’19. Continue to progress the Task and Finish groups Continue to conduct walk rounds, communicating our findings to senior staff using the update document.
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5/28 33/232 Deteriorating Patient Collaborative
NES Aim:
To reduce the cardiac arrest rate (per 1000 admissions) in care organisations (knowing that the majority of wards are collaborative wards in Phase 1, 2 or 3), by 75% by December 2019. Phase 1 wards have achieved almost a 50% reduction and so the 75% is against the original baseline. The aim has been signed off by the Steering Groups at each of the NES Care Organisations.
Project Status: On track
NES Measures/Data
The figure below shows cardiac arrests per 1000 admissions for the North East Sector Care Organisations. The chart shows that there is an average of 2.70 cardiac arrests per 1000 admissions attended by the resus team each month. There is ‘special cause’ in December 2015 with an astronomical data point and from Jan 2018 with consecutive points downwards.
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6/28 34/232 Driver Diagram
For Phase 3, to cover 2019, the driver diagram below was designed:
Current activity
The next Faculty meeting (bringing together key stakeholders from each CO) has been booked for the 1st May 2019. Spread plans are being run for each NES CO – the first formal contact has been established via Ward Managers Meetings, and is being followed by 1-to-1 meetings with lead nurses and each ward manager. Discussions around the possible tailoring of the Change Package for Women & Children’s wards (e.g. use of MEWS for maternity) are underway.
The individual change package elements are shown below:
Highlighting sick patients Timely observations and appropriate escalation Allocation of cardiac arrest roles Manual observations ‘Stop the Clock’ i.e. reacting to intuition when recognising deterioration The Weekend Plan
The collaborative wards are supported in action periods by a fortnightly Innovation Ward Visit where they discuss their tests of change, receive quality improvement teaching from an improvement advisor and can escalate any barriers or risks to senior leaders. There is also a fortnightly walkround where the collaborative is discussed.
The embedding of the change package is tracked via an audit tool to be completed by collaborative wards. Initially a weekly schedule was followed; as wards achieve four consecutiveSRFT & PAT weeks # 274090 of green classifications on all changes (excluding manual observations; discussed in more04/27/2019 detail below), 16:44:00 their status is discussed on the local steering group and, if agreed, moved to a monthly schedule. Currently
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7/28 35/232 F7 from ROH, Oasis, CAU and Wolstenholme from RI, and F6, J6, E3/1, H3, F4 and I6 from NMGH are following a monthly schedule. The figure below shows the most recent data from the audits.
Change 1 - Highlighting sick Change 2 - Timely observations and appropriate escalation Change 3 - Cardiac arrest role allocation Change 4 - Manual observations Change 5 - Stop the Chg 6 - patients clock Wkd plan Staff Visual Ward Timely Paper: Paper: EWS: 1-4 EWS: 5-6 Esc. Roles Roles Staff Role Manual obs Rollout Adeq. Process Raising Docume engagem prompt round obs EWS obs freq stamp allocatd displayd engagem handing plan equip. concerns nted Date NMGH H3-AMU ent score ent March NMGH J3-J4 28-Jan NMGH F3 08-Oct NMGH E1 March NMGH Paed Unit 11-Mar 1 FGH W8 June 18-Mar e s
a FGH W11b June 11-Mar h
P FGH AMU-W6-W7 25-Mar ROH F7 March ROH AMU 04-Mar ROH G2 18-Mar ROH T5 25-Mar RI CAU Morning shift March NMGH F6 March NMGH STU-G2 25-Feb NMGH F4 March NMGH I6 04-Mar NMGH J6 March FGH W21 By July 25-Mar 2
e
s FGH W9 1 manual obs per shift 25-Feb a
h ROH STU-T4 On triage 25-Mar P ROH F9 28-Jan ROH T7 11-Mar ROH F11 By May 25-Mar ROH T3 11-Mar RI Wolstenholme March RI Oasis March
Key: • All positive; • Majority positive; • Majority negative; • All negative; • N/A; • No answer
Manual observations are regularly performed at RI-CAU, RI-Wolstenholme, FGH-AMU and NMGH-F3. Other wards are starting their implementation process with different approaches. Training is being provided by the L&OD team; a SOP for equipment is ready, and the COs’ Divisions are working on the process of obtaining equipment. It should be noted that the roll out process has been delayed by the complexity of the purchasing process.
Salford Royal Care Organisation
Salford has not been involved in the initial North East Sector Collaborative following the Acutely Unwell Adult Collaborative that was undertaken ten years ago. A parallel project is being commenced to develop a refreshed piece of improvement work around deteriorating patients, guided by the outcome aim of achieving a 25% reduction in the number of cardiac arrests (excluding critical care) per 1000 admissions by November 2019 and the process aims of:
90% of patients will be seen by the correct grade of doctor for their NEWS as per policy 90% of patients will be seen within the correct response time to first elevated NEWS as per policy 90% of patients are seen within the correct response time to change in NEWS as per policy
A Learning Session exclusively for Salford wards took place over two days (21st November 2018 and 4th December 2018) in order to engage as many staff as possible (i.e. different staff attending different days). A Steering Group has been set up and runs monthly.
Currently the Acutely Unwell Adult Collaborative wards are starting to plan and run tests of change, supported with fortnightly ward rounds by the QI team. In order to explore in more detail the SRFT & PAT # 274090 escalation process based on the NEWS use, a monthly list of NEWS-escalated patients is sent to each 04/27/2019 16:44:00 collaborative ward for the teams to analyse and identify any themes.
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8/28 36/232 NCA Next steps:
The next steps for the NES entail the work identified via the Phase 3 driver diagram (previously presented).
The possibility of adding a QI slot to the NES clinical inductions is being explored, with the aim of raising awareness of the Change Package, as well as possibly other relevant topics from other QI projects.
The Ceilings of Care video has been shared widely via the existing communications digital tools (e.g. weekly staff newsletter, intranet homepage) and will be shared with medical teams through existing meeting and teaching sessions, with other possible sharing venues currently being considered.
A pilot panel to review cardiac arrests cases will be established at NMGH, with the aim of replicating it in the future for the other CO's. Current plans include the review of each cardiac arrest case in partnership with the parent team using a classification system; this will lead to feedback and depending on the result to a possible root cause analysis governance process.
Regarding the Acutely Unwell Adult Collaborative at SRFT, next steps entail the revision of the set of metrics developed for the original collaborative (to align them with the NES DPC metrics) and the setup of the standard process/system to produce monthly SPC charts, as well as the running of Learning Session 2 on the 19th July 2019.
Sepsis (NES)
Aim:
For a minimum of 90% of patients with red flag sepsis to be given antibiotics within 1 hour of identification by September 2019
Project Status: On track
Measures/Data:
Currently results are tracked via the existing AQ and CQUIN processes. The measures topics for AQ have changed in March 2018; hence the starting point is April 2018.
The two figures below show the percentage of patients that receive antibiotics within 1 hour measured via AQ methodology (77.05%) and CQUIN methodology (77.39% for A&E and 79.33% for Inpatients) for the NES CO's.
Please note there is a gap in AQ’s November 2018 data; the AQ team are aware and working on it. As it is, November’s data is a ‘ghost’ data point in the charts and followed with December’s data. This means that from a tracking perspective (e.g. definition of control limits) the November point does not exist.
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10/28 38/232 Driver Diagram
Current activity
We are approaching the end of Phase 1 of the project. This phase entailed the setup of the various groups that support the project as well as the development and baseline assessment of measurements. The project structure is shown below:
The Sepsis launch event took place on the 8th October 2018, the local Steering Groups are meeting bimonthly, and the first quarterly NES Committee has taken place. A regular fortnightly Microsystem at FGH has not been set up yet due to conflicting schedules, with meetings SRFToccurring & PAT as needed # 274090 in the 04/27/2019 16:44:00 meanwhile.
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11/28 39/232 Next steps
Phase 2 is concentrated on brainstorming ideas, carrying out tests of change, sharing knowledge, and acting upon the results. Additional work regarding data capture is planned as well.
Learning from the existing Microsystems groups is being fed back into the CO Steering Groups and NES Committee.
Conversations with the SRFT Clinical Effectiveness Lead are planned in order to understand where there is synergy to be built upon.
VTE Improvement Project
Aim:
To meet VTE exemplar criteria across the North East sector hospitals by September 2019
Project Status: Currently on track; this will be contingent on appointing the new VTE Leads.
Measure/Data:
VTE across the NES
Avoidable VTE c Chart
8 7,566 7 6 5 4 UCL 3,66 3 2,667 Avoidable VTE Avoidable 2 0,87 1 CL 0,00 0
jul-17 jul-18 jun-17 aug-17sep-17okt-17nov-17des-17jan-18feb-18mar-18apr-18mai-18jun-18 aug-18sep-18okt-18nov-18des-18jan-19feb-19 Jun-17 - Feb-19
Total numbers of avoidable hospital acquired VTE saw a step change in October 2018. This was triggered by observing a point above the upper control limit which resulted from a change in our process for coding incidents as avoidable.
The chart below shows the total number of hospital acquired VTE and shows no increase in the figures. This demonstrates the increase in avoidable VTE is not due to the NES causing more harms, but rather coding them more accurately. SRFT & PAT # 274090 04/27/2019 16:44:00
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12/28 40/232 Total Hospital Acquired VTEs c Chart
54,00 50,00 UCL 49,315 44,00 40,00 34,00 CL 32,273 30,00 24,00 20,00 LCL 15,230 14,00 Total Hospital Acquired VTEs Acquired Hospital Total 10,00
jul-17 jul-18 jun-17 aug-17sep-17okt-17nov-17des-17jan-18feb-18mar-18apr-18mai-18jun-18 aug-18sep-18okt-18nov-18des-18jan-19feb-19mar-19 Jun-17 - Mar-19
VTE Risk assessment compliance:
The chart above shows VTE completion rate for the North East Sector, averaging at over a 95% which meets the national standard of 95% shown by the purple line.
When reviewed at Care Organisation level, the data identifies areas for improvement. These are now being examined at ward level and additional support is being offered to these teams. Further, the introduction of the electronic risk assessment for VTE, discussed below, will be of great assistance in improving our risk assessment compliance across the board. SRFT & PAT # 274090 04/27/2019 16:44:00
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13/28 41/232 Current activity:
1. Microsystems
The microsystems were put on pause at the end of January 2019 due to staffing pressures and problems with medic engagement.
The re-establishment of the microsystem for T7 at ROH has been requested by the ward manager following a less than ideal performance on the NAAS regarding VTE risk assessments. To improve chances of engagement a consultant on the ward has been asked by the CD and MD to provide senior medical support and oversight.
2. Fast Follower project
The fast follower project is nearing the testing phase for the VTE electronic risk assessment. The form was developed with support from the Quality Improvement group and had input from the medics on ward F11 at ROH where the previous version was trialled.
The roll out plan, including the communications plan, from the Fast Follower team is due to be shared with the VTE Committee and then subsequent CECs next month.
Fast Follower have indicated the completion of an updated policy by the working group is a risk to their project. Although this is on our scope, until the VTE Leads are appointed, we cannot guarantee a timescale for completion.
3. VTE Committee
The VTE Committee is now reformed and terms of reference are set. The first meeting in January 2019 was held as a conference call due to the weather and as a result an extraordinary meeting was organised for March 2019. At this an agreement over the RCA process and the new VTE Lead structure was made.
4. Incident process
The incident process had traditionally sat outside the normal incident policy, through the working group this has been reset to ensure incidents are visible and that learning is an outcome wherever possible.
The new process was approved at the VTE Committee and is planned for circulation to the CECs for final sign off. Bury and Rochdale have been using this process for the past few months.
In addition to the process itself, there has been some work completed around the documentation used to collect information from wards. It was noted that a lot of re-work was required on the parts of the clinicians due to confusion about the information being requested. The document is currently undergoing its second iteration of a test of change to make it simpler to complete and to ensure learning is captured.
5. Alignment with SRFT
As the move to a single organisation, the Northern Care Alliance, draws closerSRFT the policies& PAT and# 274090 leaflets the working group is creating are aiming to align with those used at SRFT, where04/27/2019 available, and 16:44:00 where there are no counterparts currently in use we are involving the SRFT VTE team in their development.
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14/28 42/232 Although there are several differences, the overall processes and procedures should be comparable. We are also aiming to share learning from incidents and create more group wide awareness to share learning throughout.
Next steps:
The education package completed and available Update policies to include electronic risk assessment Continue to align work with SRFT
Productive Community Services (PCS) (Salford)
Aim: To free up staff time so that more can be spent with service users and the quality of care can be improved.
PCS is one of the many Productive initiatives and is made up of 9 modules. QI are supporting a range of work across the District Nursing Service, much of this aligns directly to the PCS modules but we are also providing support to some additional projects where we can add value.
PCS Salford – 100 Day Pressure Ulcer Challenge
Aim:
200 days free of above the knee community acquire category 3/4 pressure ulcers by 19th April 2019. 20% reduction in above knee community acquired category 2 pressure ulcers by 19th April 2019
Project Status: Stretch Targets Agreed
Measure/Data:
The graph below shows the days between above knee category 3 or 4 community acquired pressure ulcers in the District Nursing Service. Since the launch of the challenge on 1st October 2018 the service went 71* (under review for potential non-concordance) days without a category 3 or 4 pressure ulcer above the knee. The pressure ulcer on the 11th December 2018 was the first category 3 or 4 within the service for 210 days. Since the potential pressure ulcer on the 11th December 2018 the service has gone a 51 days without a above knee community acquired pressure ulcer
SRFT & PAT # 274090 04/27/2019 16:44:00
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15/28 43/232 Not a pressure ulcer – date of latest data period
The graph below shows the rate of above knee community acquired category 2 pressure ulcer per 500 patients on the District Nursing Caseload. Since the launch of the challenge on 1st October 2018 the performance each month has been below the target line, though not yet statistically significant current performance is showing a 81% reduction
Current activity:
Following the completion of the initial 100 day challenge on 9th January 2019 a 2nd collaborative event was held on the 6th February 2019.
The District Nursing teams review and celebrated their progress to date and agreed the following next steps:-
Two change ideas to be adopted city-wide:- o New starter buddy system SRFT & PAT # 274090 o Board of Brilliance (staff feedback) 04/27/2019 16:44:00
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16/28 44/232 Two other change ideas to continue testing (non-concordance process & care home engagement) Stretch aims agreed to extend challenge to 200 days Two additional projects identified:- o Pilot extending the challenge to include below knee community acquired pressure ulcers o Pilot focused work on moisture lesions within care homes
Next steps:
Two new PDSA projects will run over the next Challenge period:-
Extending the challenge to include community acquired below knee pressure ulcers & linking with podiatry Focused project on moisture lesions within care homes
Initial project meetings are booked for both during April 2019. The third collaborative event is scheduled for the 27th June 2019.
PCS Salford – Structured Safety Huddle Project
Aim:
To improve the reliability and effectiveness of the daily team safety huddle.
Project Status: On Track
Measure/Data:
Full roll out of the new huddle is underway city wide.
Baseline After Staff Survey Collecting data Awaiting data Safety Huddle Duration Collecting data Awaiting data
Current activity:
Safety Huddle SOP agreed and full city-wide rollout underway:
4 of 6 teams now using new Safety Huddle Final 2 teams starting new Huddle in April 2019 Further changes being tested by rollout teams
Next steps:
Collection of City-Wide data Review of rollout at each site – April / May 2019 Consolidation of further tests / adaptations and update of SOP SRFT & PAT # 274090 04/27/2019 16:44:00
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17/28 45/232 PCS Salford – Equipment Checks Project
Aim:
To reduce the number of Pressure Area Checks on the District Nursing Caseload
Project Status: On Track
Measure/Data:
Reviewing measures in line with shift in project focus to specific cohort of patients
Current activity:
Flow sheet developed with supported EPR recording note and initial team trail undertaken at Swinton. Feedback from the team highlighted that the flow sheet is most useful for infrequent pressure area check patients. Due to the sporadic nature of these visits the team decided a targeted approach might work better
Next steps:
Identify cohort of patients who have infrequent pressure area check visits using the Malinko system Schedule and complete equipment review for these patients
PCS Salford – FP10 Prescribing Project
The current District Nursing prescribing model for ‘Stock in Patients Homes’ is FP10 prescribing via local private chemist providers.
The FP10 is a prescription that can be issued by a GP, nurse, pharmacist prescriber, supplementary prescriber or a hospital doctor and is collected at a local chemist or delivered to a patients home. There are a number of challenges with the FP10 prescribing model for District Nursing – including: transparency of data, value for money / cost control, quality of service and delays in getting stock to patient’s homes.
Aim:
To reduce ‘stock in patient home’ expenditure To reduce the time taken for the internal FP10 prescribing process
Project status: On track
Measure/Data:
The graph below shows the FP10 Prescribing Spend. There is a statistically significant shift in February 2018 which matches the end of the direct prescribing pilot at Lanceburn & Swinton (during the period between Nov 16 and Jan 18 these sites were directly sourcing the majority of dressings outside of the FP10 process – creating an artificial reduction in overall FP10 spend). SRFT & PAT # 274090 04/27/2019 16:44:00
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18/28 46/232 Prescription turnaround time – exploring potential measures
Current activity:
A lookup excel spread sheet has now been built which bolts onto the ePACT2 data team and formulary information allowing for more detailed analysis of prescribing activity across the city and by team.
This work has successfully proven that there is no business case for switching to a direct prescribing model through NHS supplies. FP10 provides value for money for dressing products.
To support a reduction in the time taken to internally process FP10 prescriptions the following Change Ideas are being tested with Walkden DN team:
Change Idea 2 – Allocated time and rotation for Prescriber to complete prescriptions Change Idea 3 – Improve the prescription request form to capture more key information
Next steps:
The outputs from the ePACT2 analysis are being shared with the DN team leads, community prescriber and finance colleagues in April 2019. At the meeting we aim to identify ideas to provide teams with the FP10 data to support a reduction in the FP10 expenditure Continue testing of Change Ideas 2 & 3 at Walkden To work with and engage community chemists with potential tests of changes with specific district nursing sites. SRFT & PAT # 274090 04/27/2019 16:44:00
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19/28 47/232 PSC Salford – Bags to Go
Aim:
Re-establish and then maintain monthly stock spend at April 16 to April 17 levels
Project status: Complete
Measure/Data:
The graph below shows the monthly District Nursing spend on stock from NHS supplies. The graph shows:
Statistically significant reduction in April 2016 corresponding to the launch of the Bags to Go process City-wide Statistically significant increase in May 2017 corresponding to the direct prescribing pilot at Lanceburn and Swinton which significantly increased NHS Supplies expenditure Statistically significant reduction in February 2018 corresponding to the end of the direct prescribing pilot. This reduction returns performance to April 16 to 17 levels detailed in the aim
Current activity:
Finalisation of B6 pilot at Lanceburn and rollout City-Wide.
Next steps: SRFT & PAT # 274090 No further activity planned 04/27/2019 16:44:00
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20/28 48/232 End PJ Paralysis
Aim:
To ensure 100% of wards are embedding the End PJ Paralysis change package.
Measures/Data:
Since July 2017, the NCA has been auditing the “Top 5” End PJ Paralysis wards sampling the improvements realised since the change package was launched. The wards are C6 (NMGH), Wolstenholme (RI), G1 (ROH), Pendleton Suite (SRFT) and H8 (SRFT).
Falls
The comparison shows that from April 2017 there was an average of 26 falls per month on those wards which has fallen to 20.64 since the project began.
SRFT & PAT # 274090 04/27/2019 16:44:00
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21/28 49/232 Pressure Ulcers
Although the numbers are relatively small the 6 months before the project saw 7 pressure ulcers at an average of 0.83 per month. Since the project began on the top 5 wards, we have seen 10 pressure ulcers over 16 months at an average of 0.27 per month.
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22/28 50/232 Average Length of Stay
The average length of stay data is collected for the NES wards.
The data continues to show the average length of stay has reduced from 11.47 days to 9.59 days.
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23/28 51/232 Driver Diagram:
The Driver Diagram features in the Project Initiation Document; this was approved at Group Executive Quality Committee and will the shape the future work in phase 2 as outlined below.
Phase 2 – Next Steps
At the Group Executive Quality Committee on the 4th April 2019 the PID outlining phase 2 of the project was approved.
The next stage of the project will see the auditing of the change package continue; however, this will now take place quarterly via the senior nurse walkrounds. The results will then be taken to the newly established End PJ Paralysis steering group.
Phase 2 will also see the launch of a number of microsystems which will take place at all sites across the NCA. The Quality Improvement team are proposing 6 microsystems as set out below;
Salford Care Organisation North Manchester Care Organisation
Pendleton Suite Emergency Department
TBC
Oldham Care Organisation Bury and Rochdale Care Organisation
T4 Ward 20 (Fairfield General Hospital) SRFT & PAT # 274090 Rochdale Community04/27/2019 16:44:00
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24/28 52/232 Clinical Reliability Groups
Clinical Reliability Groups (CRGs), sometimes known as Clinical Practice Groups are an improvement approach used by a number of healthcare organisations which have a group structure (including Intermountain Healthcare and the Royal Free London NHS Foundation Trust).
They are an approach which utilises the hospital group structure to standardise care processes across pathways according to best practice with the purpose of improving clinical outcomes, reducing unwarranted variation and efficiently using resources.
This approach is being tested at group level with End of Life Care.
The End of Life Clinical Reliability Group has now started its monthly meetings and Dr Matt Makin has been appointed as Clinical Chair for the first two years with Dr Katie Hobson as Deputy Chair. Initial areas of focus are:
Scoping and review of operational governance arrangements across care organisations including resource, team structures and variation in the ways of working Scoping and review of current data collection across the care organisations Implementation of palliative care patient flow model developed by Salford Care Organisation Improving serious illness conversations Promotion of improvement work including patient leaflets and potentially a NCA palliative and end of life care conference
Urgent Care/Flow Improvement Work
Aim: To improve whole system flow, evidenced by a number of measures such as 4 hour target compliance, reduction in stranded patients etc.
Project Status: Behind schedule
Fairfield
SRFT & PAT # 274090 04/27/2019 16:44:00
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25/28 53/232 Oldham
North Manchester
4 Hour Target Compliance p' chart Set 6: UCL = 75.93, CTL = 70.04, LCL = 64.15 (84 - 92) (Lloyd Nelson option) Inspected Mean = 1,987.00, Counts Mean = 1,391.67
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UCL = 90.37 90 UCL = 87.78
CTL = 85.96 +2 sigma = 85.93 85 +2 sigma = 84.48
+1 sigma = 81.19 +1 sigma = 81.50 80 CTL = 77.89 -1 sigma = 77.85 CTL = 77.07 UCL = 75.93 -1 sigma = 74.59 UCL = 74.79 75 +2 sigma = 73.97 +2 sigma = 73.00 -1 sigma = 72.63 +1 sigma = 72.00 -2 sigma = 71.30 +1 sigma = 71.22 CTL = 70.04 70 CTL = 69.43 -2 sigma = 69.73 -2 sigma = 68.20 -1 sigma = 68.08 LCL = 68.00 -1 sigma = 67.65 -2 sigma = 65.86 -2 sigma = 66.11
65 LCL = 64.08 LCL = 64.15 LCL = 63.77
LCL = 61.62 60
+1 sigma = 57.31
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26/28 54/232 Salford
% of patients admitted or discharged within 4 hours 101% 100% UCL 90%
80% 78% 0,7414
% 70% LCL
60%
50%
date 08/01/201829/01/201819/02/2018 - 14/01/201812/03/2018 - 04/02/201802/04/2018 - 25/02/201823/04/2018 - 18/03/201814/05/2018 - 08/04/201804/06/2018 - 29/04/201825/06/2018 - 20/05/201816/07/2018 - 10/06/201806/08/2018 - 01/07/201827/08/2018 - 22/07/201817/09/2018 - 12/08/201808/10/2018 - 02/09/201829/10/2018 - 23/09/201819/11/2018 - 14/10/201810/12/2018 - 04/11/201831/12/2018 - 25/11/201821/01/2019 - 16/12/201811/02/2019 - 06/01/201904/03/2019 - 27/01/201925/03/2019 - 17/02/2019 - 10/03/2019 - 31/03/2019
Current Activity
All Northern Care Alliance Care Organisations have embedded and mature work streams addressing the constraints that inhibit flow within each site. The site based QI teams are using their resources to target the specific pain points within each care org which broadly focus on the following areas:
Fairfield & Rochdale
Fundamental standards – focuses on analysing and creating optimised board/ward rounds to facilitate swift decision making contributing to overall patient flow through inpatient wards, back into the community. The QI team are currently working with the stroke ward as patient and family choice is the biggest contributor to delays in medically optimised patients, it is anticipated that a more structured board round should reduce these delays. Whole System Flow – Operational Leads and the IDT hold a weekly meeting to discuss the top 25 Medically optimised patients that still occupy an acute bed in the Trust. This meeting is used to constructively challenge front line staff in order to minimise delays and free up bed days to increase flow through inpatient wards.
Oldham Care Organisation
Whole system Flow Programme - Design of a whole system patient flow improvement programme is now completed, with well-defined projects and associated leads accountable for the delivery of their respective improvements that align with the GM Urgent and Emergency Care Improvement Standards. The programme aims toSRFT address & PAT Flow # 274090 04/27/2019 16:44:00 constraints at the “Front”, ”Middle” and “Back” of the system, looking at stranded patients, work force and role purity as well as site coordination.
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27/28 55/232 Salford Care Organisation
LOS & Non admitted performance – The QI team are still supporting the 100 day frailty challenge as well as the Emergency Department and EAU flow projects. However, the organisation is refocusing on two core pieces of Flow work; LOS and non-admitted performance. Governance structures are currently being setup to ensure clarity of reporting and sufficient accountability to drive the programmes of work moving forward. Control Centre – The QI team have also been contributing to the Control Centre system mapping process. The previous 18 months of work around understanding how Salford Care Organisation manages patient flow has been used to develop a comprehensive system map that will form the basis of further work moving forward.
North Manchester Care Organisation
Urgent care – QI resource is currently focusing on identifying and reviewing the increased re-attendance numbers QI is also focused on redesigning the processes in AMU, looking at introducing SAFER board rounds in order to ease flow through the unit. Earlier Discharge & stranded patients – Stranded patient reviews focusing on MOATs and DTOCs are being supported by the IDT and the patient flow team. A test is also being undertaken in order to embed the trusted assessor model between NMCO and Wellington Lodge Patient Flow processes – Work continues to embed SAFER principles on inpatient wards including reliable board rounds.
Next Steps
There is recognition that while there is variance in the way the QI is working on Flow across the sites, there are common themes that have emerged over the timeline of the programmes. To this end, QI is attempting to pull together all of the programmes of work to create a unified NCA approach to Flow. The first event toward this aim was the stranded patient ECIST workshop held on 29th January with two further days planned in April and May. These days will inform the direction of the NCA QI Flow programme while the site teams come together to agree some fundamental standards that can be spread across each care org.
SRFT & PAT # 274090 04/27/2019 16:44:00
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28/28 56/232 Summary of the CQC BLUE Milestone successfully achieved Successful delivery of the project is on track and seems highly likely to GREEN remain so, and there are no major outstanding issues that appear to threaten delivery significantly. Successful delivery appears probable however constant attention will be AMBER/GREEN needed to ensure risks do not materialise into issues threatening delivery. Successful delivery appears feasible but significant issues already exist AMBER requiring management attention. These appear resolvable at this stage and if addressed promptly, should not cause the project to overrun. Successful delivery is in doubt with major risks or issues apparent in a AMBER/RED number of key areas. Urgent action is needed to ensure these are addressed, and to determine whether resolution is feasible. Successful delivery appears to be unachievable. There are major issues on project definition, with project delivery and its associated benefits RED appearing highly unlikely, which at this stage do not appear to be resolvable.
Version Master Copy Version 7 Date 10/04/19 SRFT & PAT # 274090 04/27/2019 16:44:00
1/27 57/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS
What and why we need to improve
During February 2016 the CQC inspected services at PAHT. On 1st March 2016 Ms. Ann Ford, Head of Hospitals Inspection CQC, wrote to confirm immediate patient safety concerns that had been discovered as a result of the inspection. The concerns that required decisive immediate actions to stabilise services and assure patient safety were across 4 main service areas Maternity, Children, Urgent Care and Critical Care (fragile services), which were subsequently rated inadequate.
The improvement plan has been overseen by a Board chaired by Jon Rouse, CEO of Greater Manchester Health and Social Care Partnership. All actions within the improvement plan have been implemented with the exception of:
1. Availability of clinical workforce with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment, and
2. That information technology infrastructures are fit for purpose.
Both of these actions are rated “red” within the current improvement plan.
These 2 actions have also been identified as “Must Do’s” in the most recent CQC report.
All other “must and should do’s” relate to reliability of systems already deployed since the last CQC inspection.
The CQC report has now been published (March 2018). The CQC identified 19 ‘Must Dos’ and 71 ‘Should Dos’ to ensure sustainable improvement to care delivered across the Pennine Trust services.
The full CQC report has established evidence that PAHT, overall, is rated Requires Improvement with no services rated inadequate.
All of the CQC ‘must dos’ and ‘should dos’ have been themed as thereSRFT were many& PAT duplicates, # 274090 due to the number of hospitals. 04/27/2019 16:44:00 2 Summary of the CQC final master copy (10.04.19)v7CiC
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Who is responsible?
The Group Chief Executive Sir David Dalton is ultimately responsible for implementing the actions in this document, the Group Executive Team will provide the leadership to ensure we identify the right actions to improve the “must do’s” across the North East Sector Care Organisations.
Our site director teams, divisional triumvirates and clinical leaders across the Care Organisations will be key to delivering the actions within the “should do’s” that will ensure service sustainability and reliability. The deliverables articulated in this plan are now part of Group and Care Organisation governance and assurance framework.
The Clinical Quality Leadership (CQL) Group brings together parts of the local health and care economies to ensure there is a shared understanding and collective commitment to the delivery and assurance of the improvement plan, including resources that need to be made available to enable further changes to happen, if necessary.
How will we measure our improvement?
Measurement of our improvement will be fundamental to ensuring sustainability and the reliability of our care. We will develop actions against our key themes that measures our progress. We need to ensure that our improvement actions and activities are translating to improvement in outcomes for patients.
We will assure our improvement plan through our Committees in Common and assurance committees within Care Organisations.
How will we communicate progress?
Internal Communication to staff within the Trust will utilise the full range of existing communication channels and our leadership arrangements to listen, update and engage staff in the further deliverySRFT of the & improvement PAT # 274090 plan. 04/27/2019 16:44:00 3 Summary of the CQC final master copy (10.04.19)v7CiC
3/27 59/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS We will utilise a weekly message circulated to all staff, site notice boards; monthly face to face Team Talk sessions led by a Care Organisation Directors, regular briefings with the staff side representatives and direct engagement sessions between the Director team and senior managers with a particular focus on meeting with the Clinical Directors.
Briefing of key issues through the line management structure; use of dedicated pages on the Trust intranet and articles on our improvement journey will feature in the monthly News magazine. Any matters which require immediate communication will be sent through an all user email.
There are multiple routes for staff to feed-back comments including the dedicated [email protected] email address; raising issues at face to face sessions with their line managers or at Team Talk sessions; contributing through the staff engagement programme; if necessary using the Speak in Confidence system to raise matters anonymously directly with senior managers.
Well Led
Our comprehensive inspections of NHS Trusts have shown a strong link between the quality of overall management of a Trust and the quality of its services. For that reason, we look at the quality of leadership at every level. We also look at how well a Trust manages the governance of its services – in other words, how well leaders continually improve the quality of services and safeguard high standards of care by creating an environment for excellence in clinical care to flourish.
This was our first review of well led at the Trust under our next phase methodology. We rated well led as good because:
The senior leadership team had the skills, knowledge, abilities and commitment to provide high-quality services. This was being embedded through the Care Organisations to the different management levels in the Trust; however, this was still being developed and required further work to ensure the new leadership structures were effective across all of the hospital sites.
The non-executive directors had a variety of skills, knowledge and experience, which was relevant to their roles. Non-executive directors were positive about the effectiveness of the Trust leadership team; they felt it was stronger than it had previously been.
The Trust had a clear vision and strategy, but the Trust was not yetSRFT in a position & PAT to# have274090 a “bottom up” approach to strategy development through the clinical teams, due to only just establishing clear clinical 04/27/2019director roles. 16:44:00 4 Summary of the CQC final master copy (10.04.19)v7CiC
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The leadership team demonstrated a level of awareness of the priorities and challenges facing the Trust. Staffing remained a significant risk, but there had been investment in staffing across professional groups and re-basing of ward establishments. Recruitment was challenging, but there were recruitment strategies in place.
Managers and staff embraced innovation and tried hard to improve the quality and sustainability of services.
Most staff we spoke with described a continued improvement in the culture since our last inspection and spoke positively about the leadership team. There were cultural challenges with some clinical groups, particularly surgeons at The Royal Oldham Hospital, but the senior team were fully aware of this.
The Trust engaged with staff and people who used services to design improvements to meet their needs. Engagement between the Trust and external stakeholders was improving.
Governance frameworks were being established, but this was work in progress. We were assured there was a “line of sight,” but there remained a variation of managing risk and performance frameworks across the Care Organisations. However, given the challenges identified from the previous inspection, this would take time.
The Trust had responded to national guidance on learning from deaths and demonstrated it was prepared to learn from the death of patients, and support families and carers through any investigation process.
There was a focus on continuous learning and improvement at all levels in the organisation, including through appropriate use of external accreditation and participation in research.
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5/27 61/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS Must Do’s
Improvement Summary of actions required Agreed Assurance and RAG Status Progress Executive Revised Theme timescale external support and deadline if BAF Operational required Leadership 1. IM&T a) The Trust must ensure that March EDHEC Amber Chief of Theme 6 information technology 2020 Group Risk & Strategy – Principal infrastructures are fit for Assurance ↔ Raj Jain risk 6.4.1 purpose. CiC
2. Workforce a) The Trust must ensure On-going Workforce Board Amber/Green Chief of Theme 4 availability of clinical Strategy – Principal workforce with the right Group Risk & ↔ Raj Jain risk qualifications, skills, training Assurance 4.1 and experience to keep CiC 4.2 people safe from avoidable 4.3 harm and abuse and to provide the right care and treatment (medicine, surgery, critical care, children and young people services).
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6/27 62/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS b) The Trust must continue to September Clinical Effectiveness Green Chief of July 2019 Theme 1 deliver care in line with and 2018 Group Risk & Strategy – Principal address the areas where Assurance ↔ Raj Jain risk they do not meet the CiC Chief 1.1.2 guidelines for the provision Medical Theme 6 of intensive care services Officer – Principal core standards Chris 6.3.1 Brookes 3. World a) The Trust must ensure that June 2018 Clinical Effectiveness Green Chief July 2019 Theme 1 Health WHO surgical safety checklist Group Risk & Medical Principal Organisation is completed accurately Assurance ↔ Officer – risk 1.1.2 Checklist including verbalising counts CiC Chris (WHO) of instruments (surgery and Brookes Theme 6 maternity. Principal risk 6.3.1 4. Risk a) The Trust must ensure that June 2018 Quality & Patient Green Chief July 2019 Theme 1 incidents are investigated Experience Medical Principal appropriately, actions are Group Risk & Officer – risk 1.1.2 managed and completed and Assurance ↔ Chris learning results in improved CiC Brookes / Theme 6 practices. Chief Nursing Principal Officer – risk Elaine 6.3.1 Inglesby- Burke b) The Trust must ensure that June 2018 Quality & Patient Green Chief July 2019 Theme 1 staff have the knowledge Experience ↔ Medical Principal and training to recognise Group RiskSRFT & & PAT # 274090 Officer – risk 1.1.2 what patient safety incidents Assurance 04/27/2019 16:44:00 Chris 7 Summary of the CQC final master copy (10.04.19)v7CiC
7/27 63/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS to report. CiC Brookes / Theme 4 Chief Nursing Principal Officer – risk 4.3 Elaine Inglesby- Theme 6 Burke Principal risk 6.3.1
c) The Trust must ensure that June 2018 Quality & Patient Green Chief July 2019 Theme 1 risk assessments are Experience Medical Principal completed appropriately and Group Risk & Officer – risk 1.1.2 risk management plans put Assurance ↔ Chris into place where risks are CiC Brookes / Theme 6 identified. Chief Nursing Principal Officer – risk 6.3.1 Elaine Inglesby- Burke 5. a) The Trust must ensure the September Quality & Patient Amber/Green Chief Nursing July 2019 Theme 1 Safeguarding principals of the MCA 2005 2018 Experience Officer – Principal are followed so that patients’ Group Risk & ↔ Elaine risk 1.1.2 rights are fully maintained Assurance Inglesby- and valid consent is Burke Theme 6 consistently obtained. Principal risk 6.3.1 6. Training a) The Trust must ensure that June 2018 Workforce Board Green Chief July 2019 Theme 4 theatre staff are trained in Group Risk & Strategy Principal appropriate levels of Assurance ↔ Officer – Raj risk 4.3 resuscitation to provide safe SRFT & PAT # 274090 Jain emergency care and 04/27/2019 16:44:00 8 Summary of the CQC final master copy (10.04.19)v7CiC
8/27 64/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS b) The Trust must ensure that June 2018 Workforce Board Amber/Green Chief July 2019 Theme 4 all levels of medical staff Group Risk & Strategy Principal have completed mandatory Assurance ↔ Officer – Raj risk 4.3 training in line with the Jain Trusts targets. 7. a) The Trust must ensure that September Quality & Patient Amber/Green Chief Nursing July 2019 Theme 1 Documentation appropriate records of 2018 Experience Officer – Principal & Standards patients’ care and treatment Clinical Effectiveness Elaine risk 1.1.2 are up to date and accurate GRAC ↔ Inglesby- to ensure that risks to Burke Theme 6 patients are consistently Chief Principal assessed or action taken to Medical risk 6.3.1 reduce those risks. Officer – Chris Brookes
b) The Trust must ensure that September Quality & Patient Amber/Green Chief Nursing July 2019 Theme 1 patient records are 2018 Experience Officer – Principal completed appropriately in Clinical Effectiveness ↔ Elaine risk 1.1.2 order to allow staff to GRAC Inglesby- effectively monitor the care Burke Theme 6 of patients. Chief Principal Medical risk 6.3.1 Officer – Chris Brookes
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9/27 65/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS c) The Trust must ensure that September Quality & Patient Amber/Green Chief Nursing July 2019 Theme 1 management of pain is 2018 Experience Officer – Principal consistently recorded, Clinical Effectiveness ↔ Elaine risk 1.1.2 monitored and actioned, GRAC Inglesby- particularly for patients with Burke Theme 6 a cognitive impairment Chief Principal where the assessment of Medical risk 6.3.1 pain is more complex. Officer – Chris Brookes d) The Trust must ensure that June 2018 Quality & Patient Green Chief Nursing July 2019 Theme 1 assessments to identify a Experience Officer – Principal deteriorating woman are Clinical Effectiveness Elaine risk 1.1.2 completed within the GRAC ↔ Inglesby- prescribed timescale and any Burke Theme 6 deterioration recorded and Chief Principal escalated according to Trust Medical risk 6.3.1 policy. Officer – Chris Brookes e) The Trust must ensure that May 2018 Quality & Patient Blue Chief Nursing Complete Theme 1 systems for checking and Experience Officer – with on- Principal monitoring emergency GRAC Elaine going risk 1.1.2 equipment are consistent Inglesby- monitoring across maternity services. Burke Theme 6 Principal risk 6.3.1 8. a) The Trust must ensure that June 2018 Medicines Green Chief Nursing July 2019 Medicines medication is prescribed, ManagementSRFT Group & PAT # 274090 ↔ Officer – Management recorded and given correctly GRAC 04/27/2019 16:44:00 Elaine 10 Summary of the CQC final master copy (10.04.19)v7CiC
10/27 66/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS to patients. Inglesby- Burke Chief Medical Officer – Chris Brookes
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11/27 67/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS Should Do’s
Improvement Summary of actions required Agreed Assurance and RAG Status Progres Director Revised Theme timescale external support s and deadline if BAF Operational required Leadership 9. a) The Trust should ensure it Sept 18 CEC Green Medical June 2019 Theme 1 Documentation continues to take action to COARC Director Principal & Standards improve performance ↔ Director of risk 1.1.2 against the Royal College of Nursing Emergency Medicine’s Theme 6 Clinical Standards Principal risk 6.3.1 b) The Trust Should continue Sept 18 CEC/QPE Amber/Green Managing June 2019 Theme 5 to ensure that it meets key COARC Director Principal national targets for caring risk 5.1 for patients in urgent and ↔ emergency care c) The Trust should ensure Oct 2018 CEC/O&P Green Managing June 2019 Theme 5 that unplanned re- COARC ↔ Director Principal attendance rates are risk 5.1 reduced. d) The Trust should consider Sept 18 QPE Blue Director of Complete N/A the demographical and COARC Nursing Information language needs of the standard service’s local population in achieved across the provision of leaflets NES within the department SRFT & PAT # 274090 04/27/2019 16:44:00 12 Summary of the CQC final master copy (10.04.19)v7CiC
12/27 68/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS e) The Trust should consider July 2018 CEC/QPE Green Medical June 2019 Theme 1 what actions could be COARC Director Principal taken to improve the use of ↔ Director of risk 1.1.2 paediatric pathways and Nursing formal guidance within the Theme 6 department. Principal risk 6.3.1 f) The Trust should consider July 2018 CEC/OPE Green Director of June 2019 Theme 1 what actions could be COARC Nursing Principal taken to improve and risk 1.1.2 monitor the quality and ↔ completion of paediatric Theme 6 assessment forms. Principal risk 6.3.1 g) The Trust should consider June 2018 O&P/ QPE Blue Managing On-going Theme 6 how it can ensure all COARC Director monitoring Principal patients are informed of ↑ Medical risk 6.3.1 the likely waiting time for Director treatment. h) The Trust should ensure June 2018 QPE Blue Director of On-going Theme 1 that complaints are COARC Nursing monitoring Principal responded to in line with risk 1.1.2 Trust policy. ↑ Theme 6 Principal risk 6.3.1 i) The Trust should consider June 2018 QPE Green Director of June 2019 Theme 6 how patient information is COARC ↔ Nursing Principal consistently displayed in all SRFT & PAT # 274090 Dir of risk 6.3.1 areas. 04/27/2019 16:44:00 Estates 13 Summary of the CQC final master copy (10.04.19)v7CiC
13/27 69/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS
j) The Trust should ensure June 2018 QPE Green- Director of June 2019 Theme 6 that safety information COARC Nursing Principal displayed publicly is Medical risk 6.3.1 accurate. ↔ Director k) The Trust should ensure Oct 2018 QPE Amber/Green Director of June 2019 Theme 1 that there is an effective COARC Nursing Principal system for records from ↔ risk 1.1.2 community midwives to be available to other health Theme 6 professionals. Principal risk 6.3.1 l) The Trust should ensure May 2018 CEC/QPE Blue Director of Complete Theme 6 that systems to record the COARC Nursing with on- going Principal temperature of water in monitoring risk 6.3.1 the birthing pools are consistent. m) The Trust should ensure Sept 2018 QPE Amber/Green Director of June 2019 Theme 1 that administration of COARC Nursing Principal intravenous fluids is ↓ risk 1.1.2 accurately recorded Theme 6 Principal risk 6.3.1 n) The Trust should ensure June 2018 CEC Blue Medical Complete Theme 1 that there are clear COARC Director 1.1.2 guidelines for the SRFT & PAT # 274090 Director of emergency admission of 04/27/2019 16:44:00 Nursing 14 Summary of the CQC final master copy (10.04.19)v7CiC
14/27 70/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS women into the maternity triage area.
o) The Trust should consider a Oct 2018 CEC/QPE Green Medical June 2019 Theme 1 review of systems to COARC ↔ Director Principal ensure that waiting times risk 1.1.2 for women to see doctors in the triage area are Theme 6 reduced. Principal risk 6.3.1 p) The Trust should ensure it August CEC/QPE Green Director of June 2019 Theme 1 continues to improve its 2018 COARC ↔ Nursing Principal compliance in the use of risk 1.1.2 the Manchester Children’s Early Warning scoring Theme 6 system. Principal risk 6.3.1 q) The Trust should ensure Sept 2018 CEC/QPE Amber/Green Director of June 2019 Theme 1 staff keep appropriate COARC Nursing Principal records of patients’ care Medical risk 1.1.2 and treatment. ↔ Director Theme 6 Principal risk 6.3.1 r) The Trust should ensure Oct 2018 CEC Amber/Green Medical June 2019 Theme 1 arrangements to review COARC Director Principal clinical guidelines are risk 1.1.2 effective. ↔ SRFT & PAT # 274090 Theme 6 04/27/2019 16:44:00 Principal 15 Summary of the CQC final master copy (10.04.19)v7CiC
15/27 71/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS risk 6.3.1
s) The Trust should ensure August CEC/QPE/O&P/ Blue Director of Complete Theme 6 that minutes of meetings 2018 Workforce/MB Nursing Principal have clear actions COARC risk 6.3.1 documented, indicating who will need to complete actions and by when. t) The Trust should make sure May 2018 CEC/QPE Blue Director of Complete with Theme 6 notes trolleys are locked COARC Nursing on-going Principal when not attended to by Medical monitoring risk 6.3.1 an authorised member of Director staff. u) The Trust should continue Sept 2018 CEC Green Medical June 2019 Theme 1 to improve standards COARC Director Principal identified in the 2016 Lung risk 1.1.2 Cancer Audit, particularly ↑ around the proportion of Theme 6 patients seen by a Cancer Principal Nurse Specialist. risk 6.3.1 v) The Trust should ensure Sept 2018 CEC/QPE Green Director of June 2019 Theme 1 that staff use interpreters COARC Nursing Principal for patients where Medical risk 1.1.2 required. ↔ Director Theme 6 Principal risk 6.3.1 SRFT & PAT # 274090 04/27/2019 16:44:00 16 Summary of the CQC final master copy (10.04.19)v7CiC
16/27 72/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS w) The Trust should ensure August QPE Green Director of June 2019 Theme 1 that intentional rounding is 2018 COARC Nursing Principal completed on time and in ↔ risk 1.1.1 an effective way. 1.1.2 x) The Trust should ensure its April 2018 CEC Blue Director of Complete with Theme 1 arrangements to keep COARC Nursing on-going Principal doors closed when patients Medical monitoring risk 1.1.1 are being barrier nursed in Director side rooms. y) The Trust should ensure Oct 2018 CEC/QPE Amber/Green Director of June 2019 Theme 6 effective arrangements to COARC Nursing Principal manage records including Medical risk 6.4.1 electronic copies to allow ↔ Director staff to effectively manage and monitor the care of patients. z) The Trust should ensure Oct 2018 CEC Amber Medical June 2019 Theme 1 action is taken to improve COARC Director Principal compliance with best Director of risk 1.1.2 practice in the taking of ↓ Nursing consent so that patients are given sufficient time to understand the information about their care and treatment. aa) The Trust should ensure August CEC Blue Medical All mandatory Theme 1 rates of surgical site 2018 COARC Director requirements Principal infections are monitored. achieved risk 1.1.1 SRFT & PAT # 274090 Business case 1.1.2 04/27/2019 16:44:00 to be 17 Summary of the CQC final master copy (10.04.19)v7CiC
17/27 73/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS developed to enhance service further bb) The Trust should ensure Sept 2018 CEC Amber/Green Medical June 2019 Theme 1 continued improvement to COARC Director Principal review Do Not Attempt risk 1.1.2 Cardiopulmonary ↔ Resuscitation decisions regularly, particularly when a patients’ condition and prospects change. cc) The Trust should ensure Oct 2018 CEC Amber Medical June 2019 Theme 1 action is taken to improve COARC Director Principal compliance with the risk recommendations of the ↔ 1.1.2 British Orthopaedic Association Standards for trauma to prevent patients waiting longer than 36 hours before surgery for a fractured neck of femur 10.Training a) The Trust should ensure Oct 2018 Workforce/CEC Amber/Green Medical June 2019 Theme 4 relevant grades of medical COARC Director Principal staff are trained to level 3 risk 4.3. adults and children’s ↔ safeguarding. b) The Trust should ensure June 2018 CEC Amber/Green Medical June 2019 Theme 1 that time is allocated for COARC Director Principal medical staff to attend SRFT & PAT # 274090 ↔ risk 1.1.1 mortality and performance 04/27/2019 16:44:00 1.1.2 18 Summary of the CQC final master copy (10.04.19)v7CiC
18/27 74/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS management meetings.
c) The Trust should ensure all Oct 2018 Workforce Green Director of June 2019 Theme 4 staff achieve mandatory COARC Nursing Principal training compliance levels ↑ Chief risk 4.3. which have been set by the Officer Trust. d) The Trust should consider July 2018 QPE Blue Director of Complete Theme 1 how it can improve COARC Nursing Principal patients’ and carers’ risk 1.1.1 knowledge of how to alert 1.1.2 staff to the deterioration of a child within the paediatric waiting area at Fairfield Hospital. e) The Trust should ensure Sept 2018 CEC/Workforce Amber/Green Director of June 2019 Theme 4 that staff have the training COARC Nursing Principal and competency to Medical risk 4.3. undertake their job roles, ↔ Director particularly staff working on cardiology wards. f) The Trust should ensure June 2018 CEC Green Medical June 2019 Theme 1 staff compliance with COARC Director Principal patient related infection ↔ risk 1.1.1 prevention and control training. Theme 4 Principal SRFT & PAT # 274090 risk 4.3. 04/27/2019 16:44:00 19 Summary of the CQC final master copy (10.04.19)v7CiC
19/27 75/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS g) The Trust should ensure Sept 2018 CEC/Workforce Amber/Green Medical March 2019 Theme 1 continued improvement for COARC ↔ Director Principal staff to complete sepsis six risk 1.1.1 training. Theme 4 Principal risk 4.3. 11.Workforce a) The Trust should ensure June 2018 O&P/CEC Amber/Green Medical June 2019 Theme 1 that there is consultant COARC Director Principal presence in urgent and Managing risk 1.1.2 emergency care which is in ↔ Director line with national guidance for consultant presence 16 of hours per day. b) The Trust should ensure June 2018 QPE/Workforce Green Director of June 2019 Theme 4 that staff movements to COARC Nursing Principal different wards are ↔ risk recorded, in order that 4.1 accurate staffing levels on 4.2 the critical care unit are 4.3 documented. c) The Trust should ensure June 2018 QPE/Workforce Green Director of June 2019 N/A that the midwifery staffing COARC Nursing rota accurately reflects the ↔ actual number of midwives working in one area at all times. d) The Trust should ensure Sept 2018 QPE Blue Director of Supervision Theme 4 that plans to introduce COARC SRFT & PAT # 274090 Nursing plan in place Principal arrangements for 04/27/2019 16:44:00 with dates risk 4.3 20 Summary of the CQC final master copy (10.04.19)v7CiC
20/27 76/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS safeguarding supervision for all midwives are expedited. e) The Trust should continue Oct 2018 CEC/QPE Amber/Green Medical June 2019 Theme 1 to review and monitor COARC Director Principal progress to ensure Director of risk 1.1.2 compliance with Facing the ↔ Nursing Future: Standards for Acute General Paediatric Services f) The Trust should ensure Oct 2018 Workforce Green Director of June 2019 Theme 1 that all staff feel safe to COARC Nursing Principal speak up if they have ↔ Chief risk 1.1.1 concerns. Officer Theme 4 Principal risk 4.3 g) The Trust should ensure Oct 2018 QPE/Workforce Amber/Green Director of June 2019 N/A staff movements to COARC ↔ Nursing different wards to fill staffing gaps are effectively monitored and evaluate the impact of this on patient care. h) The Trust should ensure Oct 2018 Workforce Amber/Green Medical June 2019 Theme 4 that staffing levels are COARC Director Principal maintained in accordance Director of risk with National Guidelines. ↔ Nursing 4.1 4.2 SRFT & PAT # 274090 4.3 04/27/2019 16:44:00 21 Summary of the CQC final master copy (10.04.19)v7CiC
21/27 77/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS
12. Facilities a) The Trust should ensure March 2018 QPE Blue Complete Theme 6 and Estates that there is an appropriate Principal viewing room for recently risk 6.1.1 deceased patients at North Manchester General Hospital and Fairfield Hospital. b) The Trust should consider Oct 2018 O&P Amber/Red Managing June 2019 Theme 6 how it can ensure there is COARC Director Principal sufficient physical capacity risk 6.1.1 within the paediatric ↔ department at Royal Oldham Hospital to meet the demands on the service. c) The Trust should consider Oct 2018 CEC/QPE/O&P Amber Managing June 2019 Theme 6 how it can ensure provision COARC Director Principal of an appropriately Medical risk 6.1.1 designated place of safety ↔ Director for children attending Royal Director of Oldham Hospital Nursing experiencing mental health symptoms. SRFT & PAT # 274090 04/27/2019 16:44:00 22 Summary of the CQC final master copy (10.04.19)v7CiC
22/27 78/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS d) The Trust should consider June 2018 QPE Blue Director of Complete Theme 6 removal of potential COARC Nursing Principal ligature points in the toilet Director of risk 6.1.1 next to the mental health Estates assessment room within the “majors” at Fairfield Hospital. e) The Trust should ensure June 2018 CEC Green Medical June 2019 N/A that all cleaning fluids are COARC ↓ Director in locked cupboards when not in use. f) The Trust should make sure June 2018 CEC Green Medical June 2019 Theme 1 that intravenous stands COARC ↔ Director Principal have “I am Clean” stickers risk 1.1.1 with dates on once they have been cleaned. g) The Trust should ensure June 2018 CEC Blue Medical Complete Theme 6 the outdoor play area near COARC Director Principal the children’s ward at Royal risk 6.1.1 Oldham Hospital is clean and update play equipment where necessary. h) The Trust should consider Blue Managing Complete Theme 6 what actions it can take to Director Principal improve the environment risk 6.1.1 within the triage room at Fairfield Hospital in order to maintain patient privacy during triage assessments. SRFT & PAT # 274090 04/27/2019 16:44:00 23 Summary of the CQC final master copy (10.04.19)v7CiC
23/27 79/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS i) The Trust should ensure Sept 2018 CEC/QPE Blue Director of Complete-Unit Theme 6 that the ambulatory unit at COARC Nursing now relocated Principal North Manchester General Managing risk 6.1.1 Hospital is suitable to meet Director the needs of patients, reduce the risk of infection and maintain patient dignity. j) The Trust should ensure Sept 2018 CEC Blue Medical Complete with Theme 6 consistent completion of Director on-going Principal cleaning checklists. Director of monitoring risk 6.1.1 Estates k) The Trust should ensure Sept 2018 O&P Blue Director of Complete with Theme 6 theatre premises are COARC Estates on-going Principal maintained and fit for Managing maintenance risk 6.1.1 purpose. Director plan l) The Trust should ensure Sept 2018 O&P/CEC Amber Managing March 2019 Theme 1 that the Paediatric COARC Director Principal Observation and Medical risk 1.1.2 Assessment Unit at Royal ↔ Director Oldham Hospital are not used as a holding area for children awaiting admission. m) The Trust should ensure Sept 2018 CEC Green Managing June 2019 Theme 1 that all equipment within COARC ↔ Director Principal theatres is in date and Director of risk 1.1.2 serviced. Estates SRFT & PAT # 274090 04/27/2019 16:44:00 24 Summary of the CQC final master copy (10.04.19)v7CiC
24/27 80/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS 13. IM&T a) The Trust should ensure Sept 2018 QPE/CEC Green Director of June 2019 N/A that staff routinely lock COARC Nursing computer stations when ↓ Medical they are not present to Director protect patient data. 14. Medicines a) The Trust should ensure Sept 2018 CEC Blue Medical Complete Theme 1 Management that patients’ medicines on COARC Director Principal the urgent and emergency Director of risk 1.1.2 observation ward at Royal Nursing Oldham Hospital are stored Director of securely and separately Estates from the Ward’s stock of controlled medicines b) The Trust should ensure Oct 2018 CEC Green Medical March 2019 Theme 1 staff communicate with COARC Director Principal women to ensure that their ↔ Director of risk 1.1.2 pain is managed effectively. Nursing c) The Trust should ensure June 2018 CEC/QPE Blue Director of Complete with Theme 1 that fridge temperatures COARC Nursing on-going Principal are checked, monitored monitoring risk 1.1.2 and recorded every day. d) The Trust should ensure Oct 2018 CEC Green Medical June 2019 Theme 1 that medicines are stored COARC Director Principal at safe temperatures, in Director of risk 1.1.2 accordance with ↔ Nursing manufacturer’s Chief recommendations. Pharmacist e) The Trust should ensure Sept 2018 CEC Green ↔ Medical June 2019 Theme 1 action is taken when COARC SRFT & PAT # 274090 Director Principal temperature readings of 04/27/2019 16:44:00 Director of risk 1.1.2 25 Summary of the CQC final master copy (10.04.19)v7CiC
25/27 81/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS medicine fridges or areas Nursing where medication is stored Chief and recorded outside of Pharmacist the recommended range. 15. a) The Trust should consider Oct 2018 QPE Amber/Green Medical June 2019 Theme 1 Safeguarding how it can ensure COARC Director Principal consistency in the Director of risk 1.1.2 completion of the ↔ Nursing paediatric assessment form, encourage a “think family” approach, and reduce the reliance on professional curiosity to identify potential safeguarding concerns. b) The Trust should consider Sept 2018 QPE Green Director of June 2019 Theme 1 how it can improve the COARC Nursing Principal quality of safeguarding risk 1.1.2 referrals to the local ↑ authority safeguarding teams. c) The Trust should ensure Sept 2018 CEC /QPE Amber/Green Medical June 2019 Theme 1 that assessments of mental COARC Director Principal capacity are completed Director of risk 1.1.2 appropriately and reviewed ↔ Nursing as capacity alters. d) The Trust should ensure Sept 2018 CEC/QPE Amber/Green Medical June 2019 Theme 1 there are processes to COARC Director Principal show women have been SRFT & PAT # 274090 ↔ Director of risk 1.1.2 asked the required 04/27/2019 16:44:00 Nursing 26 Summary of the CQC final master copy (10.04.19)v7CiC
26/27 82/232 NORTHERN CARE ALLIANCE NHS GROUP – NORTH EAST SECTOR HOSPITALS questions to identify safeguarding concerns at every interaction. e) The Trust should ensure May 2018 CEC/QPE Blue Medical Complete N/A that the office in the COARC Director Paediatric observation and Director of Assessment Unit at Royal Nursing Oldham Hospital is not Director of accessible to unauthorised Estates persons to safeguard data protection of clinical information. 16. Risk a) The Trust should consider May 2018 QPE Blue Director of Complete Theme 6 more clearly defining and COARC Nursing Principal recording the dates that risk 6.3.4 risks were first entered onto the risk register b) The Trust should improve June 2018 QPE Green Director of June 2019 Theme 6 systems for identifying COARC ↔ Nursing Principal risks, planning to eliminate risk 6.3.4 risks or reduce risks. c) The Trust should ensure Oct 2018 QPE Green Director of June 2019 Theme 6 consistent reporting of COARC ↔ Nursing Principal incidents by all staff risk 6.3.4
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27/27 83/232 The Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust & Pennine Acute Hospitals NHS Trust
Title of Report CQC Action Plan, Pennine Acute NHS Trust
Meeting Group Committees in Common
Author Jayne Downey Director of Governance and Corporate Nursing
Presented by Elaine Inglesby- Burke, Chief Nursing Officer
Date 29th April 2019
Executive To outline current progress against the Pennine Acute NHS Trust, Summary CQC action plan, ‘Must’ and ‘Should’ do actions
Annual Plan Pursuing Quality Improvement to assure safe, reliable and compassionate care Objective Principal Saving Lives, reducing harm and CQC quality improvements Associated Risks
Recommendations The Group Committees in Common is asked to note the content of the report, review and confirm the progress against the CQC, ‘Must’ and 'Should do' actions.
Public and/or Patient Involvement (including equality related impacts): N/A Communication: To be discussed through NES CO Quality Improvement Meetings and Team Brief
Freedom of Information: This document is for full publication.
1.0 Introduction 1.1 Following the publication of the CQC report for Pennine Acute Hospitals NHS Trust in March 2018, a comprehensive action plan and process for monitoring was presented to the Committees in Common (CiC) in June 2018. 1.2 This report provides an update on progress made against the ‘Must do’ and ‘Should do’ actions recommended by the CQC within the report provided. 1.3 A total of 16 ‘Must do’ actions and 71 ‘Should do’ actions were identified. 1.4 Each Care Organisation within the North East sector has developed an action plan, a process to monitor progress and provide assurance through the assurance committee framework for each action. 1.5 All of the Care Organisations have considered all of the actions even if an action related to a specific Care Organisation at the time of the inspection, with the exception of the clear actions identified for a specific Care Organisation such as; the ambulatory care unit at North Manchester.
2.0 Progress SRFT & PAT # 274090 04/27/2019 16:44:00 2.1 Since the previous report in June 2018, progress collectively has been made across a number of actions, including:
1
1/3 84/232 Consistently informing patients of waiting times for treatment Complaints response times in particular North Manchester and Oldham Mandatory training compliance Quality of safeguarding referrals to the Local Authority 2.2 All Care Organisations have made progress since the last report in progressing a number of the ‘Must’ and ‘Should’ do actions including but not limited to: North Manchester Availability of staff Intensive care standards Resuscitation training Mandatory training compliance Emergency equipment checks Oldham Intensive care standards Completion of the WHO checklist Freedom to speak up Risk recording Medical staff compliance with mandatory training BARCO Completion of the paediatric assessment forms in A/E Re-attendance rates in A/E Test of change to improve Mental capacity assessments 2.3 Each of the Care Organisations has a process of monitoring the actions in real time through regular walk rounds, mock inspections, NAAS and regular audits which have identified a number of actions across the care organisations, where consistent assurance is not always provided and which the leadership teams are addressing immediately as identified, these include:
staffing not always locking computers when they leave them storage of cleaning fluids in lock cupboards daily fridge temperature checks and escalation 2.4 Particular challenges identified in Q4 across CO include:
Consistent recording of intravenous fluid administration Obtaining Consent
2.5 A review of progress at the end of Q4 is noted below. The table sets out the percentages achieved, in all of the ‘Must do’ and ‘Should do’ actions, aggregated across all Care Organisations. It is to be noted there are no Red rated actions. The arrows identify where there has been an increase, decrease or if action progress remains the same since the last report in January 2019.
‘Must 6% 50% 38% 6% 0% do’ Completed actions actions Green actions actions Amber actions Blue Amber/Green Amber/Red ↔ ↔ ↔ ↔ ↔
‘Should 31% 37% 25% 6% 1% do’ Completed actions actions Green Actions actions Amber Actions Blue Amber/Green Amber/Red ↔ ↑ ↓ ↑ ↔
2.3 A revised date has been included in a number of the ‘Should do’ actions as although the Care Organisations have implemented a number of changes they feel that further assurance viaSRFT the monthly & PAT assurance # 274090 committees is required to ensure that systems are embedded and consistently applied across04/27/2019 their organisations 16:44:00
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2/3 85/232 3 Monitoring 3.3 Each Care Organisation is monitoring progress through regular meetings with divisions and through the assurance framework via the Quality Committees 3.4 Risks identified are discussed at COARC and included on risk registers or the BAF as required 3.5 Monthly meetings to discuss progress and review data are undertaken, between the Group Director of Governance and Corporate Nursing and the Care Organisation’s Associate Directors of Governance with a quarterly meeting to include the Directors of Nursing prior to reporting to the Chief Nurse and CiC 4 Conclusion 4.1 Progress is being made against the ‘Must’ and ‘Should' do actions identified following the publication of the CQC report in March 2018. A number of issues have been identified in Q4 in which consistent assurance is not being provided and areas of particular challenge as identified in the report. 4.2 Monitoring of the actions across all Care Organisation is undertaken with divisions and via the Quality Committees, with Group oversight undertaken monthly and with the Directors of Nursing quarterly prior to reporting to the Chief Nurse and CiC. 4.3 All risks identified are discussed through COARC and included on relevant risk registers and BAF. 5 Recommendations 5.1 The Group Committees in Common is asked to note the content of the report, review and confirm the progress against the CQC 'Must' and 'Should do' actions
SRFT & PAT # 274090 04/27/2019 16:44:00
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3/3 86/232 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT)
Title of Report CQC Action Plan, Salford Royal NHS Foundation Trust
Meeting Group Committees in Common Alex Larkin, Associate Director of Governance, Salford Care Author (s) Organisation Presented by Elaine Inglesby- Burke, Chief Nursing Officer Date 29th April 2019
Executive To outline current progress against the Salford Royal NHS Foundation Summary Trust (SRFT) CQC action plan Should do actions.
Annual Plan Pursuing Quality Improvement to assure safe, reliable and Objective compassionate care Associated Risks Saving Lives, reducing harm and CQC quality improvements
Recommendations The Group Committees in Common is asked to note the content of the report, review and confirm the progress against the CQC 'Should do' actions.
Equality Does this paper relate to a matter where equality issues may arise? No If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and Information can be made available to the public. X Please ‘cross’ one of This document contains some confidential information that the boxes would need to be redacted before the document was made available to the public. This document is entirely confidential, as the redaction of confidential information would render the document meaningless. Data Sharing Under the Data Sharing Agreement, the NCA may be required Agreement with to share this paper with MFT. This is distinct from information Manchester disclosed under the FOIA. As MFT will acquire part of PAT University NHS FT they will need to understand a range of matters which may (MFT) in relation to otherwise be exempt under FOI e.g. contracts to be split and the Transaction specific workforce-related issues. SRFT & PAT # 274090 Please consider the statements below and indicate04/27/2019 which 16:44:00 applies in relation to this paper: a) This paper relates solely to PAT and can be released
Page | 1 1/20 87/232 b) This paper relates solely to SRFT and is therefore not eligible for release X
c) This paper contains information relating to both PAT and SRFT. All information other than that relating to PAT will be fully redacted.
d) This paper contains reference to both PAT and SRFT but contains no quality, finance or operational performance data relating to PAT which could be relevant to the transaction and is therefore not eligible for release.
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Page | 2 2/20 88/232 Summary of the CQC Assessment Introduction
During April and May 2018 the CQC inspected services at Salford Royal NHS Foundation Trust. The CQC inspected urgent and emergency care, medical care, surgery and critical care as part of the continual checks on safety and quality of healthcare services. Out patients was also inspected as it was rated as ‘requires improvement’ following the 2015 inspection. Community dental services were also inspected for the first time. The CQC report has now been published (August 2018).
The overall rating for the Trust was outstanding. It was rated outstanding because: • Well led’ was rated as outstanding. • Caring and responsive’ were rated as outstanding. • Safe and effective’ were rated as good. • Use of Resources was rated as Outstanding.
Corporate Highlights • Salford Royal is the only NHS acute and community Trust to have been rated as Outstanding on two consecutive occasions which is an astonishing achievement – given the financial and clinical staffing challenges we have faced since our last inspection. • Emphasis has been placed on the way we care for patients, respect them, treat them as individuals – inspectors were reported to have been moved to tears during the inspection with examples of the compassionate care that has been provided. “Services had comprehensive systems co-designed by staff embedded into practice to keep people safe. The Nursing Assessment and Accreditation System and Community Assessment and Accreditation System provided a high level of transparency to the Group, Care Organisation and to patients in relation to clinical performance indicators and measures. This information was publicised throughout the wards and clinical areas for people to consider and scrutinise.” • “The Trust was part of the Global Digital Exemplar programme which provided technology solutions to embed safe care. The electronic patient record was assessed against an international set of quality indicators and Salford Royal was in the top 5% internationally.” • Excellent care and services for patients with dementia, for example, reminiscence pods and a dementia courtyard; and • Innovative medicines and pharmacy projects
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3/20 89/232 Divisional Highlights
Integrated Care Division • Inspectors said we are a national exemplar for integrated care, reducing delayed transfers of care and supporting the wider health and social care system • Services had comprehensive systems co-designed by staff embedded into practice to keep people safe • The pharmacy department had embraced working as an Integrated Care Organisation and staff worked across primary and secondary care boundaries. • Innovative practice noted in fracture clinic: physiotherapists providing a service that enables patients to exercise at home • Excellent examples of improving care for patients living with dementia. • Significant work has been undertaken to develop a coaching collaborative style to support senior clinical and non-clinical managers.
Surgery and Tertiary Medicine and Clinical Support Services • The overall rating for Surgery improved on this inspection and is now rated as ‘good’. Improvements were noted with regards to the application of the 5 steps to safer surgery. • Improvements in outpatients – environmental issues improved, high quality patient level feedback, Doctors, nurses and healthcare professionals from different specialities supported and worked together as a team to improve patient care. • In critical care, we saw outstanding practice that demonstrated staff consistently treated patients in a compassionate, dignified, and respectful way. • Innovative practice noted in community dental services: staff on Thursday afternoons treated homeless patients from a local drop-in centre • There were a number of innovative medicines and pharmacy projects • Excellent examples of improving care for patients living with dementia • Significant work has been undertaken to develop a coaching collaborative style to support senior clinical and non-clinical managers. • Significant work has been undertaken to develop a coaching collaborative style to support senior clinical and non-clinical managers. • The trust was working to improve outcomes for patients with acute kidney injury (AKI) and the wards involved had seen a reduction in patients developing AKI while in hospital and a reduction in patients progressing from early stage AKI to more severe AKI.
Manchester Centre for Clinical Neurosciences • The overall rating for Surgery improved on this inspection and is now rated as ‘good’. Improvements were noted with regards to the application of the 5 steps to safer surgery. • The stroke service worked with external partners to redesign and improve the service • Staff of different kinds worked together as a team to benefit patients.SRFT There &were PAT regular # 274090 multidisciplinary meetings from admission through to discharge planning. 04/27/2019 16:44:00 • Significant work has been undertaken to develop a coaching collaborative style to support senior clinical and non-clinical managers
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4/20 90/232 • Staff provided emotional support to patients to minimise their distress. • Excellent examples of improving care for patients living with dementia • The service had a tracheostomy steering group to help improve and standardise the care of tracheostomy patients with complex needs in the community. There was joint working with international colleagues, pre-discharge visits by district nurses to help understand patient needs, and the trialling of technology to help improve communication.
Well Led
The CQC overall rating of well-led stayed the same. It was rated it as good because: • The trust had an experienced leadership team with the skills, abilities, and commitment to provide high-quality services. • Managers across most services promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. • There were examples where services engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and worked with partner organisations effectively. • The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. • Managers took action to improve services by learning from when things go well and when they go wrong. • The trust collected, analysed, managed and used information well to support all of its activities, using secure electronic systems with security safeguards. Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment, though an electronic records system that they could all update. • The trust had a clear, systematic and proactive approach to seeking out and embedding new and more sustainable models of care. There was a strong record of sharing work locally, nationally and internationally.
The CQC identified 2 key actions the Trust SHOULD take Trust Wide: The trust should ensure that it improves its response times to complaints The trust should ensure that serious investigation reports are consistent in quality and gaps in root cause analysis are resolved.
The CQC also identified a further number of ‘Should Dos’ to ensure continued improvement to care delivered across Salford Care Organisation. SRFT & PAT # 274090 The full CQC report has established evidence that Salford Royal Hospital NHS Foundation04/27/2019 Trust 16:44:00 overall, is rated as Outstanding with no services newly rated as Requires Improvement.
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5/20 91/232 All of the CQC‘s should dos’ have been themed in the table below. Who is responsible?
The Group Executive Sir David Dalton is ultimately responsible for implementing the actions in this document. Supported by the Group Executive Team, the Salford Care Organisation Chief Officer, Medical Director and Nursing Director will provide the leadership to ensure we identify the right actions to address the ‘should do’s’ across the Salford Care Organisation.
Our site director teams, divisional triumvirates and clinical leaders will be key to delivering the actions within the “should do’s” that will ensure service sustainability and reliability. The deliverables articulated in this plan are now part of Group and Care Organisation governance and assurance framework.
How will we measure our improvement?
Measurement of our improvement will be fundamental to ensuring sustainability and the reliability of our care. We will develop actions against our key themes that measure our progress. We need to ensure that our improvement actions and activities are translating to improvement in outcomes for patients.
We will assure our improvement plan through our Committees in Common and assurance committees within the Salford Care Organisation Care Organisation Risk and Assurance Committee and Quality and People Committee.
How will we communicate progress?
Internal communication to staff within the Trust will utilise the full range of existing communication channels and our leadership arrangements to listen, update and engage staff in the further delivery of the action plan.
We will utilise a range of communication channels to share the CQC rating, examples of outstanding practice and update on actions taken to continually improve by delivering the ‘should do’ recommendations. This will include executive committees, divisional governance committees, service management teams and professional forums (e.g. ADNS/ ward managers’ meetings), Leaders Forum led by care organisation directors, executive and senior nurse SRFT & PAT # 274090 walkabout and SIREN. 04/27/2019 16:44:00
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6/20 92/232 There are multiple routes for staff to feed-back comments including raising issues at face to face sessions/meetings with their line managers or at Team Talk sessions; contributing through the staff engagement programme; utilising the HELP phone, Freedom to Speak Up Guardians, ‘staff question and answer hub’ intranet portal to raise matters anonymously directly with senior managers.
Action Plan – Key BLUE Milestone successfully achieved Successful delivery of the project is on track and seems highly likely to remain so, and there are no major outstanding issues that appear GREEN to threaten delivery significantly. Successful delivery appears probable however constant attention will be needed to ensure risks do not materialise into issues AMBER/GREEN threatening delivery. Successful delivery appears feasible but significant issues already exist requiring management attention. These appear resolvable at this AMBER stage and if addressed promptly, should not cause the project to overrun. Successful delivery is in doubt with major risks or issues apparent in a number of key areas. Urgent action is needed to ensure these are AMBER/RED addressed, and to determine whether resolution is feasible. Successful delivery appears to be unachievable. There are major issues on project definition, with project delivery and its associated RED benefits appearing highly unlikely, which at this stage do not appear to be resolvable.
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7/20 93/232 Should Do’s Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme Group COARC/Management scale rate Theme Operational Director Board and NCA type Lead GRAC/CiC as appropriate RAG) A member of the complaints team attends the weekly governance review meeting to triangulate complaints and incidents. Complaints performance is monitored by the DDNs The Trust should ensure that Director Complaints Divisional and reported monthly at 1 Complaints a it improves its response All of QPE Q2 1 Manager Governance QPE. The last 12 months times to complaints. Nursing have seen significant improvements made in complaints performance, with above 90% target being sustained for the last 5 months, and 100% achieved in February 2019 Robust process in place at divisional and director level. Clinical The Trust should ensure that Associate Effectiveness lead attends serious investigation reports Director Director of SI panel and is active in 2 Governance a are consistent in quality and All of SUI meeting QPE Q3 1 Governanc reviewing and gaps in root cause analysis Nursing e commenting on reports, training are resolved. SRFT & PAT # 274090 and is supporting the 04/27/2019 16:44:00 investigation teams where required.
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8/20 94/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme Group COARC/Management scale rate Theme Complete. The trust should consider Board and NCA type increasing staff awareness of NCA FTSU SCO FTSU Divisional b All GRAC/CiC as appropriateQPE Q2 RAG) 1 the Freedom to Speak Up Lead Lead Governance Guardians The Trust should ensure Each area risk assessed there is sufficient nursing daily Trendcare utilised Director staff and appropriate skill Medic Workforce Review of workforce/ a of DDNs QPE Q3 4 mix to meet the agreed al Care Meeting blended roles/ roster re- Nursing establishments for each engineering 3 Workforce ward The Trust should continue to OP Go engage project (Jill Director ensure that the culture in Governance May) underway with key b OP of ADNS OP QPE Q3 1 the out patients department Workforce milestones and objectives Nursing is improved Meeting defined The Trust should ensure it Divisional reviews the risk Associate Governance Risk registers reviewed management processes to NCA Risk Director of NCA 4 Risk a OP COARC Q3 1 and updated via divisional ensure gaps are identified, Lead Governanc Corporate governance processes monitored and included on e Department the risk register. s PANDA – Child protection The Trust should ensure that informatics system staff can access previous available to check on safeguarding information admission. All ED nursing/ Safe- NCA Salford CO Divisional including the details medical staff have access. 5 guarding a U&EC Safeguard Safeguardi governance QPE Q4 1 contained within referrals Still has some gaps with ing Lead ng Team board and multi agency risk regard to access to health assessment conference visitor records however SRFT & PAT # 274090 requests. there is a HV liaison 04/27/2019 16:44:00 service to consult with
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9/20 95/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme Group COARC/Management scale rate Theme 15/04/19: re rated as Board and NCA type amber as issues in this GRAC/CiC as appropriate RAG) area require management attention as follows: The corporate safeguarding team are The Trust should ensure all commencing a business staff are aware of the tools Re- case to recruit an LD NCA Salford CO Divisional to enable them to provide rated specialist nurse for SCO. b U&EC Safeguard Safeguardi governance QPE Q3 1 person centred care for to This post will link with ing Lead ng Team board patients with a learning amber ICO colleagues from adult disability social care LD team to ensure that acute and community staff are aware of and have access to tools to provide patient centred care for patients with LD 27/03/19 New NCA Safeguarding training strategy approved via The Trust should consider Care organisations reviewing the number of awaiting final approval at staff eligible for safeguarding Safeguarding committee. children level 3 training and NCA Salford CO Divisional 24/04/19. c to provide training CC Safeguard Safeguardi governance QPE Q3 1 Cohorts for all levels of accordingly, to assure itself ing Lead ng Team board training in line with of sufficient cover of trained intercollegiate staff when caring for older documents and children SRFT & PAT # 274090 safeguarding standards. 04/27/2019 16:44:00 ADNS safeguarding children working with L&D to ensure that 10
10/20 96/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme Group COARC/Management scale rate Theme eligible staff are Board and NCA type mandated to the correct GRAC/CiC as appropriate RAG) level of training. Actions on going but on track for full launch September 2019. The Trust should ensure that there is appropriate 15/04/19: Re rated as ED information readily available U&EC green as whilst this area d Director QPE Q3 1 for patients with mental ED is well managed it needs ate health, learning disabilities oversight to maintain and or dementia if required improve. Salford 15/04/19: see comments The trust should ensure that NCA CO on 5c. improved all levels of staff understand e Safeguardin Safeguar QPE Q3 1 assurance should follow how to escalate and follow- g Lead ding the implementation of up safeguarding concerns Team new training strategy 15/04/19: Re-rated amber green as constant attention is needed in this area. A new Mental The Trust should ensure that capacity training and processes for documenting Salford competency framework is capacity and best interest NCA CO in development by the f decisions are understood by Safeguardin Safeguar QPE Q3 1 safeguarding team. staff and are consistent and g Lead ding A range of methods to in line with the Mental Team assess competency Capacity Act 2005 include, training, supervision and ward SRFT & PAT # 274090 based audit underway. 04/27/2019 16:44:00
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11/20 97/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme The Trust should review its Group COARC/Management scale rate Theme arrangements for bank staff Board and NCA type Director of OP a working in clinics if they OP GRAC/CiC as appropriateQPE Q2 RAG) 4 Nursing Matron have never worked there before OP The Trust should ensure that Matron/ all levels of staff understand Director of Governa b what constitutes an incident OP QPE Q2 4 Nursing nce and they report these Manager accordingly 6 Training s In-house training is provided for ENT scopes, all staff compliant with The Trust should ensure it mandatory training and Divisional provides staff with Director of competencies and blood c OP ADNS OP Service QPE Q4 4 opportunities to gain further Nursing glucose monitoring. Review skills and knowledge Bespoke training provided in response to service developments eg Quanterferon training Trust Board Urgent ED performance The Trust should ensure care Assurance and continues to be below is provided in line with Framework. Emerg trajectory. A range of targets and ED Managing Urgent and ency initiatives are underway a recommendations set by the ED Senior Q4 1 Documenta Director ICD Emergency Care to improve performance. Department of Health and Manager 7 tion & Care Deliver Royal College of Emergency Delivery y Standards Medicine ED performance Board Board briefing April 2019 v2.docx SRFT & PAT # 274090 The Trust should ensure Review on safety Director of Divisions04/27/2019 16:44:00 b equipment checks are ADNS QPE Q4 1 walkabout. Timetable Nursing DDNs recorded in line with Trust developed. Use 12
12/20 98/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme policy Group COARC/Management scale rate Theme structured CQC checklist Board and NCA type GRAC/CiC as appropriate RAG) As above The Trust should ensure Director of Pharmacy staff will checks are undertaken of Nursing Divisions complete three monthly c QPE Q3 1 expired stock and action is Director of DDNs expiry date checks on taken to replace items. Pharmacy wards and departments
The trust should ensure that privacy and dignity of Director of Divisional d ED ICD DDN QPE Q2 1 patients is always Nursing Governance maintained The Trust should consider reviewing the programme of re-audit of clinical practice ED to ensure the service Manage Divisional e U&EC ICD chair QPE Q3 1 measures the impact of ment QPE changes made to systems of Team practice and has led to improvement The Trust should ensure that patient care records and Divisiona patient risk assessments are Medic l Divisional f ICD Chair QPE Q3 1 completed and reassessed al Care Governa QPE within the appropriate nce timeframes The Trust should ensure it improves its diagnostic Ops and Neurol Performance g waiting times in neurology MD MCCN Perform O&P Q4 1 ogy Board including nerve conduction ance.SRFT & PAT # 274090 studies 04/27/2019 16:44:00
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13/20 99/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme The Trust should ensure Group COARC/Management scale rate Theme senior nurses are able to Divisiona Board and NCA type attend divisional governance Medic l GRAC/CiC as appropriate RAG) h ICD DDN Divisions QPE Q3 1 meetings and staff are given al Care Governa the time to attend ward nce meetings. The trust should ensure Medical there are consistent Surger i S&TM MEMS Equipment CEC Q4 1 processes for equipment to y Committee be safety tested. The Trust should consider ways to improve the effectiveness of care, with Divisiona regard to groin hernias and l Surger S&TM O&P j hip fractures, the average S&TM Governa Q4 1 PROMS data under y Governance CEC length of stay of patients, nce & review – report supplied the number of delayed Ops to QPE. Surgical patients discharges and theatre >ASA ¾ - check push back utilisation rates in accuracy information Workforce are continuing to align reporting systems to The Trust should consider improve reporting Director of Workforce k ways to improve appraisal All Divisions QPE Q3 1 accuracy. Nursing Board rates for non medical staff CF2 being rolled out across the organisation. Training is also being provided. The Trust must continue to deliver care in line with and CC Medical SRFT & PATCC Steering # 274090 l address the areas where CC Director04/27/2019 16:44:00CEC Q4 1 Director Group they do not meet the ate guidelines for the provision 14
14/20 100/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme of intensive care services Group COARC/Management scale rate Theme core standards Board and NCA type GRAC/CiC as appropriate RAG) The Trust should ensure it reviews its mixed sex accommodation escalation policy and staff practice in CC recording accurate times of Nurse S&TM m CC Director O&P Q2 1 discharge decisions and Director Governance ate managing discharges from the unit, so these are in line with national guidance on mixed sex accommodation The Trust should ensure that single sex breaches are CC S&TM n reported internally and CC S&TM MD Director O&P Q3 1 Governance externally as required by ate national guidance The Trust should ensure that CC the time of decision to admit S&TM o CC S&TM MD Director O&P Q3 1 to the unit is clearly Governance ate recorded The Trust should ensure there are provisions in place to meet the needs of CC S&TM p patients who require CC S&TM MD Director QPE Q3 1 Governance reasonable adjustments or ate require assistance to enable communication SRFT & PAT # 274090 04/27/2019 16:44:00
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15/20 101/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme The Trust should ensure it Group COARC/Management scale rate Theme reviews the availability of Board and NCA type equipment in the practice GRAC/CiC as appropriate RAG) Comm (community dental) to Clinical Divisional q unity S&TM MD CEC Q3 1 manage medical Team governance Dental emergencies taking into account the Resuscitation Council (UK) guidelines The Trust should ensure the process for regular checking Comm of emergency oxygen is in Clinical Divisional r unity S&TM MD CEC Q3 1 line with the guidelines Team governance Dental from the Resuscitation Council (UK) To be included in DDN/ADNS walkabout Seek assistance from pharmacy. Mock The Trust should ensure assessments to be action is taken to remove Director of undertaken and replace expired Nursing Medicines Pharmacy to complete a medicines, and recording of All DDNs CEC Q3 1 Director of Safety three monthly audit of medicine refrigerator Medicines Pharmacy safe storage of medicines temperatures are in line with 8 Manageme on the wards and Trust policy nt departments and to escalate areas of non- conformance to the DDNs
The Trust should ensure that To be included in Director of drug balance charts for DDN/ADNS walkabout Nursing SRFT & PATMedicines # 274090 b controlled drugs are fully All DDNs04/27/2019 16:44:00CEC Q3 1 Seek assistance from Director of Safety completed and fridge and pharmacy. Mock Pharmacy room temperatures assessments to be 16
16/20 102/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme recorded. Intravenous fluids Group COARC/Management scale rate Theme undertaken/ should be stored Board and NCA type Pharmacy to complete appropriately. GRAC/CiC as appropriate RAG) three monthly audit of controlled drugs and controlled drugs registers on the wards and departments and to escalate areas of non- conformance to the DDNs
To be included in DDN/ADNS walkabout Seek assistance from pharmacy. Mock The Trust should ensure that assessments to be staff record ambient room Director of undertaken and fridge temperatures Nursing Medicines Pharmacy to complete c daily in line with Trust policy, All DDNs CEC Q3 1 Director of Safety three monthly audit of including recording actions Pharmacy safe storage of medicines taken when temperatures on the wards and are out of range departments and to escalate areas of non- conformance to the DDNs
To be included in The Trust should ensure all DDN/ADNS walkabout medicines are stored Seek assistance from Director of securely and staff pharmacy. Mock Nursing Medicines d understand how to monitor All DDNs CEC Q3 1 assessments to be Director of Safety and record refrigeration and undertaken Pharmacy SRFT & PAT # 274090 room temperatures and take 04/27/2019 16:44:00 Pharmacy to complete appropriate action three monthly audit of safe storage of medicines 17
17/20 103/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme Group COARC/Management scale rate Theme on the wards and Board and NCA type departments and to GRAC/CiC as appropriate RAG) escalate areas of non- conformance to the DDNs To regularly circulate the fridge and room temperature guidance. Seek assistance from pharmacy Mock audits Director of Liaise with medicines The Trust should ensure the Nursing Medicines safety group e omitting a medicine is clearly All DDNs CEC Q3 1 Director of Safety Pharmacy to undertake recorded Pharmacy the three monthly omitted doses audit and feed back the results to the DDNs. The Trust should consider reviewing the access for ED young children in and out of U&EC Manage the main waiting are (in the a PAND ICD MD ment QPE Q4 6 emergency department) A Team/Es with a view to reducing the tates Estates and risk of exiting easily through 9 Facilities automatic doors. The Trust should consider a ED review of the children’s U&EC Manage environment such as waiting b PAND ICD MD ment QPE Q4 6 areas to ensure it is A Team/Es responsive the children’s tatesSRFT & PAT # 274090 needs. 04/27/2019 16:44:00
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18/20 104/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme Group COARC/Management scale rate Theme Included in current Board and NCA type practise. Monit surveys GRAC/CiC as appropriate RAG) are completed to confirm cleaning levels remain at The Trust should ensure Medic SCO E&F Facilities a high standard and c ward cleaning checklists are QPE Q3 6 al Care Lead Team provide evidence of completed and monitored assurance via divisions / directorates with regular liaison with infection control.
E & F are undertaking a full review of fire safety risk assessments with each CO having a The Trust should ensure that designated fire safety its current system for officer. Training has been monitoring fire safety is revised and new delivery sufficiently robust to identify systems introduced. New and act on areas of concern NCA Fire SCO E&F d All QPE Q2 6 fire extinguisher including fire extinguisher Safety Lead Lead maintenance contracts maintenance and ensuring are in place and being that all fire exits and ‘fire closely managed break glass’ units are free from blockages.
The Trust should ensure SRFT & PAT # 274090 stock is stored off the floor 04/27/2019 16:44:00 e CC DDN ADNS CC QPE Q3 6 and stored sample trays are CQC checklist and ADNS/ clean DDN walkabout 19
19/20 105/232 Assurance/External Progres Executive and Operational support s CQC Leadership All progress will be Agreed (To Annual Improvement Summary of actions required Service reported to Salford Time- RAG Plan Comments Theme The Trust should consider Group COARC/Management scale rate Theme CQC checklist with periodically reviewing Board and NCA type security CQC checklist security arrangements for GRAC/CiC as appropriate RAG) with security. f coded access to secure All DDN ADNS QPE Q3 6 This is undertaken by the rooms on the unit to prevent Group Security Lead and poor practice by staff liaison with the PFI compromising security provided security teams The Trust should consider that areas in main out A review will be carried SCO E&F Facilities g patients are reviewed to OP QPE Q3 6 out to confirm correct Lead Team ensure there are sufficient numbers of bells are in emergency call bells place The Trust should consider what actions could be taken Childrens to improve the use of PANDA Board PANDA action plan in h U&EC ICD Chair CEC Q3 6 paediatric pathways and Team Divisional place. MD is senior formal guidance within the governance responsible department. officer for this
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Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & the Pennine Acute Hospitals NHS Trust (PAT)
Title of Report Group Learning from Deaths Report
Meeting Group Committees in Common
Roger Prudham, Clinical Director of Professional Standards, Northern Care Alliance NHS Group Alison Talbot, Head of Legal Services, Northern Care Alliance NHS Authors Group Rheanne Laybourn, Interim Mortality Improvement Project Lead, Northern Care Alliance NHS Group
Presented by Chris Brookes, Chief Medical Officer Date 29th April 2019
Executive Summary This paper represents the Northern Care Alliance (NCA) scheduled Group ‘Learning from Deaths’ report in compliance with National Guidance requirements. This report provides:
The Q2 and Q3 report for 2018/19;
Provides a dashboard report for awareness and scrutiny in line with National Guidance and the required National Reporting Criteria; and
Sets out how Salford Care Organisation and the North East Sector (NES) Care Organisations systematically review and learns from deaths.
Key point:
In Q2 and Q3 the number of Structured Judgement Reviews (SJR’s) completed has continued to increase.
HSMR across the NES Care Organisations remains within the as expected range on the HSMR andSRFT in the & belowPAT # expected 274090 range for the SMR on the rolling 12 month04/27/2019 period December 16:44:00 2017 – November 2018.
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Salford Care Organisaiton is in the below expected range on the HSMR and SMR rolling 12 month period January 2018 – December 2018.
HSMR at the Oldham Care Organisation has increased since the last quarterly report. The HSMR/SMI is above the peer group average, 104:98. Whilst the HSMR confidence interval remains in the as expected range, incident data has been reviewed to ensure the patient harm ratio has not increased alongside the crude mortality rate. The number of incidents reported continues to increase whilst the harm ratio follows a downward trajectory in comparison to previous reporting periods. A focus group has convened and an action plan around HSMR/SMR improvement has been incorporated into the Learning from Deaths programme at the Oldham Care Organisation. [Appendix 1].
The NCA continues to increase the uptake of trained SJR reviewers across the multi-disciplinary team by offering training sessions across all sites. The number of Consultants, Nurses and Allied Health Professional trained in SJR case records review methodology has increased at the NCA from 41 to 117.
The Datix system has gone live and all SJRs will now be completed electronically.
A bereavement leaflet has been developed by the Bereavement Team which incorporates the National Learning from Deaths Guidance on information and support to provide to bereaved families and carers.
The March 2019 CQC Report ‘Learning from Deaths: A Review of the First Year of NHS Trusts implementing the National Guidance’ has been reviewed by the mortality team and key points incorporated into improvement work.
Annual Plan Objective Corporate Priorities supported by this paper: 1. To pursue quality improvements, to assure safe, reliable and compassionate care. 3. To support our staff to deliver high performanceSRFT and & PATimprovement. # 274090 4. To improve care and services through integration04/27/2019 and collaboration. 16:44:00 5. To demonstrate compliance with mandatory standards.
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Associated Risks Lack of embedded learning from patient safety incidents, inquests and mortality will increase risk to patient safety and impact negatively on the reputation of the Northern Care Alliance NHS Group. Non-compliance in reporting and learning from deaths as per the National Guidance may result in additional performance monitoring being implemented, and the organisations ability to identify and address themes to improve patient safety.
Recommendations The Group Committees in Common is asked to review and approve the content of the report for subsequent dissemination throughout the Northern Care Alliance NHS Group, commissioning organisations and the general public.
The committee is asked to note the action plan devised by Oldham Care Organisation to support with HMSR.
Public and/or Patient Involvement (including equality related impact) None
Communication: The report should be shared internally with the Care Organisations, and following approval at Group Executive Assurance and Risk Committee, submitted to Committees in Common, and subsequently shared with external partners and the public.
Freedom of Information Please ‘cross’ one of the boxes below:
a) This document does not contain confidential information and x Can be made available to the public.
b) This document contains some confidential information that would Need to be redacted before the document was made available to the public.
c) This document is entirely confidential, as the redaction of confidential Information would render the document meaningless.
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Learning from Deaths
1. Introduction
The NCA is committed to learning from both positive and negative aspects of patient’s care, with a clear process for completing mortality reviews and providing a clinical judgement on areas of preventability. Learning identified during mortality reviews allows specialities to review and improve their processes, with collated learning providing corporate themes for larger quality improvement projects. The NCA is committed to systematically investigating, reporting and learning from deaths and delivering a clinical quality improvement agenda.
All review data is collated for shared learning and improvement and is presented to the Group Executive Risk and Assurance Committee for review and approval, prior to review by the Group Committees in Common (Board). The paper is subsequently disseminated throughout the NCA, commissioning organisations and the general public.
2. Scope
The purpose of this report is to inform the Board and the general public of the progress of, and findings from, mortality reviews for Q2 and Q3 2018/19 data and learning.
3. Mortality Review Process
Each reported death is reviewed in line with three levels the NCA has adopted in line with the National Quality Board guidance:
1. Death certification. 2. Case record review, through SJR methodology or other nationally indicated reviews LeDer, MBRRACE or Child Death Review. 3. Investigation – service level, serious incident (SI) reported on StEIS or safeguarding.
The three levels of review are not systematic and any deaths identified at Stage 1 or 2 will be immediately escalated to Stage 3 investigations if they are identified as meeting the StEIS or safeguarding criteria.
The Care Organisations report quarterly on the number of deaths that are considered to have been “preventable”. At the time of the mortality review a reviewer will make a judgement about the preventability of death and allocate a Hogan score of 1 to 6. A Hogan score of 4 will trigger a more detailed review by the clinical division to determine if the declaration to an SI is required. A Hogan score of 5 or above will be declared as an SI and recorded on StEIS.
If a cause for concern is identified about the care provided this must be escalated for discussion at the Mortality & Morbidity Meetings (M&M) and/or reported as a clinical incident where the StEIS criteria is not met (Hogan score of 3).
SRFT & PAT # 274090 04/27/2019 16:44:00
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3.2 Developments in the Mortality Review Process
The NES Care Organisations are working towards implementing a revised mortality process that aligns with Salford Care Organisation. Each death will be reviewed using a four step process:
1. Death Certification, GP Summary and Clinical Coding. 2. Care Quality Review. 3. Case record review, through SJR methodology by an independent Consultant or other nationally indicated reviews LeDer, MBRRACE or Child Death Review. 4. Investigation – service level, serious incident (SI) reported on StEIS or safeguarding.
The NES Care Organisations face unique structural challenges in comparison to Salford Care Organisation who benefits from an electronic patient system (EPR) and health information system (HIS) with systems interoperability. However, Oldham Care Organisation has been piloting the revised mortality process on wards F7 (Respiratory), F9 (Medical) and AMU with plans to expand into the other NES Care Organisations in Q4 2018/19.
The NCA is committed to increasing the proportion of deaths reviewed to 100% by March 2020. The revised mortality process will assist the NES Care Organisations with achieving this aim and transforming organisational culture towards desired values; ownership, reflection and learning from death.
4. SJR Methodology
The NCA will continue to review all deaths using case record review methodology that are triggered in line with the National Guidance on Learning from Deaths:
Learning Disability (SJR & LeDer); Serious Mental Illness (SJR); Perinatal and maternal deaths (MBRRACE); Child Deaths ( Child Death Overview Process); Unexpected deaths; elective admissions and certain cardiac arrests (SJR); Care concern and/or complaint and/or ‘alarm’ (SJR); Planned improvement work (SJR); Regulation 28 Report on Action to Prevent Future Deaths (SJR); and Random selections of deaths.
4.2 Developments in the SJR Methodology
The criteria for SJR methodology for Q2 and Q3 2018/19, included additional triggers:
All care organisations within the NCA reviewed deaths where an SI was being undertaken SRFT & PAT # 274090 to triangulate all elements of learning from deaths; 04/27/2019 16:44:00
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In Q2 2018/19 Bury and Rochdale Care Organisation and North Manchester Care Organisation reviewed a random selection of deaths within 24 hours of admission to the Emergency Department to understand trauma mortality;
In Q2 and Q3 2018/19 Salford Care Organisation, North Manchester Care Organisation and Oldham Care Organisation reviewed deaths from re-admissions within 30 days of discharge to understand trends in post discharge mortality and re-admission.
Each Care Organisation within the NCA will continue to develop bespoke triggers that are individual to the patient population and services to understand prime mortality factors and help plan improvement work. This will be in addition to the minimum requirements of the National Guidance on Learning from Deaths and will be led by the Clinical Mortality Lead and overseen by the Care Organisation Mortality Oversight Group/Committee.
4.3 Challenges to completing SJR’s and Learning from Deaths
It has been recognised across the NCA that SJR reviewers have faced difficulty when completing the reviews. This has impacted on the number of reviews historically undertaken.
In order to overcome this barrier the patient safety team introduced a support system in December 2018. Improvement work and support has continued and a key focus for Q2 and Q3 2018/19 was to increase the number of SJRs completed to enhance opportunities for learning across the NCA. The NES has seen a significant increase in the number of reviews undertaken and the focus is now on translating learning into SMART (specific, measurable, achievable, realistic, and timed) actions. A Mortality Improvement Lead will be permanently recruited in Q4 2018/19 and will continue to support with the Learning from Deaths programme across the NCA.
5. Mortality Review Data Q2 2018/19
The data below (Figure 1) show the total number of deaths with number and percentage of mortality reviews completed for each Care Organisation and preventability scoring allocated.
Key points:
In Q2 2018/19 918 deaths were recorded, of which 5 patients were known to have Learning Disabilities and 12 were investigated as Serious Incidents (SIs).
In Q2 2018/19 this increased to 86 of 89 (96%), of deaths triggering SJR methodology were completed across the NCA, inclusive of all cases indicated within the minimum requirements of the National Guidance on Learning from Deaths.
In Q2 2018/19 the total number of deaths reviewed using SJR methodology was 9%, (5.4% in Q1) with the aim to increase the number to approx. 10-15%SRFT & of PAT all deaths# 274090 by Q3, 2018/19. 04/27/2019 16:44:00
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Preventability scoring:
Mortality reviews were undertaken for 547 cases with 540 confirmed as non-preventable deaths. There was 2 possibly preventable deaths due to problems in healthcare identified during Q2 2018/19 (0.3% of all deaths reviewed, n= 547 for the quarter). This is expanded on within the individual Care Organisations learning section in this report.
Fig. 1 Q2 2018/19 Mortality Review Data for the Northern Care Alliance NHS Group
Total Total Total Deaths Total Preventability CO LD Deaths SJRs Number of SJR Reviews Reviewed including Deaths scoring Deaths SI those reviewed by SJR 66 Non- North preventable Manchester Q1 17 Q2 14 151 1 2 14 deaths Care (89.4%) (100%) Organisation 1 Possibly Q1 77 Q2 59 preventable (41.3%) (39%) death
84 Non- Q2 20 preventable Oldham Care Q1 6 deaths Organisation 253 1 5 20 (100%) (26%) 0 Possibly Q1 111 Q2 84 preventable (43.1%) (33.2%) death
130 Non- preventable deaths Q2 11 Q2 133 208 2 - 11 Q1 19 Q1 68 Bury & (100%) (63.9%) 0 Possibly Rochdale Care (100%) (31.7%) Organisation preventable death
*3 in review 271 Non- preventable deaths
306 1 5 44 Q1 13 Q2 41 (93%) Q1 258 Q2 271 1 Possibly Salford Care Organisation (100%) (75%) (75%) preventable *100% of deaths national min. in review requirement *2 in review 543 Non- preventable deaths Q2 86 Q1 514 Q2 547 918 5 12 89 Q1 55 2 Possibly NCA (96%) (51%) (59%) (74%) preventable death
*5 in review SRFT & PAT # 274090 04/27/2019 16:44:00
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Phase of care scoring:
Fig. 1a North Manchester Care Organisation Of the 14 independent SJR reviews performed (100% of cases flagged) during Q2, care was rated as:
Phase of care * Very Poor Adequate Good Excellent poor First 24hours/ - 2 5 1 6 admission Ongoing care 1 1 3 3 2 Care during - - 3 3 1 procedure Peri-operative - 2 1 1 - care End of life Care 1 - 3 2 2 Overall care 1 1 3 3 6
1 out of 2 cases where overall care was judged to be very poor or poor, death was judged to be possibly preventable due to problems in healthcare. However, the Coroner determined the death was due to natural causes due to the identified risk with the procedure. 1 case where the end of life care was judged to be very poor, death was judged to be non-preventable. 1 case where the admission phase of care was judged to be poor for a patient with Learning Disabilities, a clinical incident and an investigation was completed. 5 cases where poor or very poor care was identified were referred to the speciality team for further review and feedback. 2 cases were referred to clinical governance for divisional review and investigation where necessary.
Fig. 1b Oldham Care Organisation Of the 20 independent SJR reviews performed (100% of cases flagged) during Q2, care was rated as:
Phase of care Very Poor Adequate Good Excellent * poor First 24hours/ - 5 5 8 1 admission Ongoing care - 5 6 2 1 Care during - 1 2 3 - procedure Peri-operative - - - 2 - care End of life Care 1 1 5 SRFT3 & PAT #3 274090 04/27/2019 16:44:00 Overall care - 7 6 6 1
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All cases where poor or very poor care was identified were referred to the speciality team for further review and feedback. 2 cases were referred to clinical governance for divisional review and investigation where necessary.
Fig. 1c Bury and Rochdale Care Organisations Of the 11 independent SJR reviews performed (100% of cases flagged) during Q2, care was rated as:
Phase of care Very Poor Adequate Good Excellent poor First 24hours/ - - 3 5 3 admission Ongoing care - - - 5 - Care during - 1 - - 3 procedure Peri-operative - - - - - care End of life Care - - 2 2 - Overall care - - - 8 3
1 case where care during a procedure was judged to be poor, death was judged to be non-preventable. Care was judged to be poor due to missing/ incomplete documentation at the time of the case record review.
Fig. 1d Salford Care Organisation Of the 40 independent SJR reviews performed (93% of cases flagged) during Q2, care was rated as:
Phase of care Very poor Poor Adequate Good Excellent First 24hours/ - 1 4 10 25 admission Ongoing care - 4 6 1 8 Care during - 1 2 1 4 procedure Peri-operative - - 1 2 7 care End of life Care - - 7 9 24 Overall care - 3 6 8 23
2 cases where overall care was judged to be poor were referred to the governance manager for divisional review and investigation where necessary, the other 2 cases were subject to ongoing investigation. SRFT & PAT # 274090 3 cases were referred to specialty team for further 04/27/2019 review and 16:44:00 feedback
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6. Mortality Review Data Q3 2018/19
The below data (Figure 2) shows the total number of deaths with number and percentage of mortality reviews completed for each Care Organisation and preventability scoring allocated.
Key points:
In Q3 2018/19 1133 deaths were recorded of which 16 patients were known to have Learning Disabilities and 10 were investigated as Serious Incidents (SIs).
In Q3 2018/19 78 of 93 (83%) of deaths triggering an SJR mortality review methodology were completed across the NCA.
Salford Care Organisation continues to review 100% of all cases that are indicated within the National Guidance minimum requirements. The outstanding cases at the NES Care Organisations that are within the minimum requirements of the National Guidance on Learning from Deaths will be completed and reported in Q4 2018/19.
Preventability scoring:
Mortality reviews were undertaken for 455 cases with 445 confirmed as non-preventable deaths. There was 1 possibly preventable death identified during Q3 2018/19 (0.3% of all deaths reviewed, n= 547 for the quarter). This is expanded on within the individual Care Organisations learning section in this report.
The current total number of potentially preventable deaths due to problems in care identified across the NCA to date for 2018/19 is 5 (0.3% of all reviewed deaths n=1516).
Fig. 2 Q3 2018/19 Mortality Review Data for the Northern Care Alliance NHS Group
Total Total Total Deaths Total Preventability CO LD Deaths SJR’s Number of SJR Reviews Reviewed including Deaths scoring Deaths SI those reviewed by SJR
62 Non- North preventable Manchester 206 4 3 18 Q1 17 Q3 18 (100%) deaths Care (89.4%) Organisation 0 Possibly Q1 77 preventable (41.3%) Q3 62 (30%) death
59 Non- preventable deaths Oldham Care Q3 18 (81%) Organisation 308 3 1 22 Q1 6 (26%) 0 Possibly Q1SRFT 111 & PAT # 274090 Q3 59 preventable (43.1%)04/27/2019 16:44:00 (19%) death
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130 Non- preventable deaths
Bury & Rochdale Care 257 5 1 10 0 Possibly Organisation preventable Q1 19 Q3 7 Q1 68 Q3 61 death (100%) (70%) (31.7%) (23.7%) *7 in review
271 Non- preventable deaths Q3 35 362 4 5 43 Q1 13 Q1 258 Q3 273 1 Possibly Salford Care (81%) Organisation (100%) (75%) (75%) preventable death *100% of in review national min. requirement *2 in review
445 Non- preventable deaths 1133 16 10 93 Q1 55 Q3 78 NCA (74%) (83%) 1 Possibly preventable death Q1 514 Q3 455 (51%) (40%) *9 in review
Phase of care scoring:
Fig. 2a North Manchester Care Organisation Of the 18 independent SJR reviews performed (100% of cases flagged) during Q3, care was rated as:
Phase of care * Very Poor Adequate Good Excellent poor First 24hours/ 5 5 3 5 admission Ongoing care 1 3 4 7 2 Care during 3 1 procedure Peri-operative 1 1 care End of life Care 2 5 4 5 Overall care 3 5 7 3
1 case where ongoing care was judged to be very poor, death was judged to be non- preventable. 3 cases where overall care was judged to be poor, deathSRFT was & judged PAT # to274090 be non- 04/27/2019 16:44:00 preventable.
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9 cases where poor or very poor care was identified were referred to the speciality team for further review and feedback. 1 case where poor care was identified is associated with a clinical governance investigation and 1 case where poor care was identified had an associated incident reported.
Fig. 2b Oldham Care Organisation Of the 18 independent SJR reviews performed (81% of cases flagged) during Q3, care was rated as:
Phase of care Very Poor Adequate Good Excellent * poor First 24hours/ - 3 4 6 3 admission Ongoing care 1 3 2 6 3 Care during - - 5 1 5 procedure Peri-operative - - 2 2 1 care End of life Care 1 1 5 5 5 Overall care - 2 5 8 2
2 cases where overall care was judged to be poor, death was judged to be non- preventable. 2 cases where very poor care was identified, death was judged to be non-preventable. 7 cases where poor or very poor care was identified were referred to the speciality team for further review and feedback.
Fig. 2c Bury and Rochdale Care Organisations Of the 7 independent SJR reviews performed (70% of cases flagged) during Q3, care was rated as:
Phase of care Very Poor Adequate Good Excellent poor First 24hours/ 3 3 1 admission Ongoing care 1 2 4 Care during 1 1 procedure Peri-operative care End of life Care 3 4 Overall care 1 SRFT5 & PAT #1 274090 04/27/2019 16:44:00 1 case where the on-going phase of care was judged to be poor for a patient with Learning Disabilities, death was judged to be non-preventable. Page 12
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Fig. 2d Salford Care Organisation Of the 43 independent SJR reviews performed (81% of cases flagged) during Q2, care was rated as:
Phase of care Very poor Poor Adequate Good Excellent First 24hours/ - 4 4 12 15 admission Ongoing care - 5 3 6 9 Care during - - - 1 4 procedure Peri-operative - - - - 3 care End of life Care - 1 4 11 19 Overall care - 5 4 12 14
4 of the 5 cases where overall care was judged to be poor are associated with a clinical governance investigation. 1 case was judged to be poor due to recognised limitations in the current arrangements for provision of clot retrieval in stroke in the context of otherwise excellent clinical care. This case has been used to illustrate the importance of this intervention in ongoing discussion with commissioners.
7. Mortality and Morbidity (M&M) Meetings
A baseline audit demonstrated variable quality in the output of the M&M meetings; standards have been defined in terms of agendas, attendance, actions around learning and availability of minutes. Whilst it is recognised that there are challenges to introducing standardised M&M meetings across the NCA the quality output will continue to be monitored, with planned improvement work around SMART (specific, measurable, achievable, realistic, and timed) actions.
The Medicine M&M meetings at the Oldham Care Organisation have been piloting themed meetings. A Learning Disability and Severe Mental Illness M&M meeting took place with a guest speaker presenting on care quality and improvement methods. A specialist Learning Disability Nurse, member of Safeguarding and Consultant Psychiatrist delivered presentations and the Clinical Mortality and Morbidity Lead presented themes and learning from the SJR’s.
The M&M minutes for each speciality will be forwarded for review by the Clinical Mortality Lead and/or Care Organisation Mortality Oversight Group/Committee. Greater organisational assurance of the value of M&M meetings will come from evidence that actions escalate up through the organisation and may be visible at divisional, organisational or NCA level if appropriate. This will continue to be audited in Q4 2018/19. SRFT & PAT # 274090 04/27/2019 16:44:00
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8. Engagement with Bereaved Families and Carers
The March 2019 CQC Report ‘Learning from Deaths: A Review of the First Year of NHS Trusts implementing the National Guidance’ highlighted that more needs to be done to engage with bereaved families and carers.
Embedded processes are in place for engaging with bereaved families and carers where there is a care concern, complaint or investigation. However, it is recognised more can be done to incorporate the Learning from Deaths guiding principles that sets out what bereaved families and carers can expect. These include:
1. Being treated as equal partners. 2. Receiving clear, honest, compassionate and sensitive response in a sympathetic environment. 3. Receiving a high standard of bereavement care including being offered appropriate support. 4. Being informed of their rights to raise concerns. 5. Receiving help to inform decisions about whether a review or investigation is needed. 6. Receiving timely, responsive contact and support in all aspects of an investigation process, with a single point of contact and liaison. 7. Being partners in an investigation as they offer a unique and equally valid source of information and evidence. 8. Being supported to work in partnership with trusts in delivering training for staff in supporting family and carer involvement where they want to.
8.2 Bereavement Service
The NCA is committed to compassionate, supportive and person-centred engagement with families, carers and/or friends following the death of a loved one.
Positive engagement is facilitated by the availability of specialist resources and training from the Bereavement Team and commitment to the SWAN end of life care model. There is a clear pathway of contact which is facilitated by our specialist trained Bereavement Nurses. Families, carers and/or friends have the opportunity to discuss any concerns or questions they may have when they attend at the Bereavement Office. If clinical issues are raised then a specialist trained Bereavement Nurse may arrange for a joint meeting with clinical staff and/or signpost the complaints service and/or investigation process. Information is available to bereaved families, carers and friends in an accessible format that they may choose to read at home and later contact the services should they wish to discuss any grievances.
The NCA is committed to creating an open, honest and responsive learning culture, where we listen to experiences of bereaved families and carers and use what we hear to drive improvements. SRFT & PAT # 274090 The Bereavement Team collate feedback from families prior, during & 04/27/2019following the 16:44:00death of a loved one to create ‘You Said, We Did’ boards which are displayed in the Bereavement Office. Patient stories are also shared at the End of Life Committee meetings for reflection and learning Page 14
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and bereaved families and carers are invited to attend the monthly study day to share their experience with the Beareavement Team.
As part of participation in the National Individual Care and Support for the Dying Patient audit a feedback questionnaire is sent out to families and carers. The results of this are reviewed to inform service delivery improvement work.
8.3 Service Developments
All Bereavement Nurses are trained in SJR methodology and will be undertaking regular reviews, with plans to introduce LeDer training.
In Q4 2018/19 an audit will be conducted from a random selection of deaths to help identify and map existing good practice and methods for service development. This will be led by the Mortality Improvement Lead and Associate Director of Nursing.
The recommended ‘Information for families following a bereavement’ from the Learning from Deaths National Guidance is being incorporated into NCA bereavement resources that are offered to bereaved families, carers and friends.
The Inquest Team will be piloting writing to bereaved families and carers where there is no SI to advise of the inquest and provide opportunity for any care concerns to be raised. The Oldham Care Organisation will be the pilot site and support will be provided from the Bereavement and Inquest Team. The learning will be summarised in the next quarterly report.
9. Engagement with Partner Care Organisations
Salford Care Organisation has reviewed a cohort of deaths in Q3 2018/19 that provided an insight into the standard of end of life care being provided outside the acute hospital.
There were a total of 31 deaths. 78% of deaths occurred in a care home setting and of these, 90% had an Advanced Care Plan.
There were 7 hospital deaths, of these 57% had an Advanced Care Plan. Of the 7 patients, 3 patients did not achieve their Preferred Place of Death. 1 patient had the Preferred Place of Death as the hospital and for 3 patients; the Preferred Place of Death was unknown.
The review identified the following themes:
Out-of-hours discharge from Salford Care Organisation in this complex patient group was more likely to lead to subsequent readmission; Hospital admission was more likely to occur outside office hours; Poor co-ordination and communication between services was SRFT a key & factorPAT # resulting 274090 in patient admission; and 04/27/2019 16:44:00 Face-to-face patient review could potentially have reduced the likelihood of patient admission. Page 15
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It should be noted that besides this analysis, there was evidence of excellent emotional support provided by the care team combined with good symptom management to result in a patients being treated with dignity and respect at the end of their life.
10. Learning from Deaths
North Manchester Care Organisation
Trauma Mortality No care issues were identified.
Ownership of patient care In response to incident 27360 and M3734, a review is being undertaken of the Surgical Pathway into the North Manchester Care Organisation to provide clearer guidance on ownership of patient care when multidisciplinary speciality involvement is indicated.
Triaging patients In response to investigation 30336 and M3210, a newsletter highlighting the learning from this death was shared with clinical staff. A review of current training packages has been undertaken to ensure staff are fully trained and are aware of what is expected when triaging patient.
Deteriorating patient In response to investigation 32887 and M3501, Sepsis Six flowcharts are to be clearly displayed and individual pocket size laminated flowcharts re deteriorating patient and Sepsis Six to be provided to all clinical staff. Refresher training will be provided to clinical staff on SBAR, NEWS observations and escalation. The interim Divisional Director of Nursing and Surgery will be leading on the implementation of a delirium pathway on surgical wards by circa. June 2019.
The Medical Director will leading on the implementation of an Acute Kidney Injury Protocol to address issues related to fluid balance, deteriorating patient and early management of sepsis by circa. June 2019.
Escalation of care In response to investigation 33364 and M3734, the referral policy from the Emergency Department has been reviewed and all ICU referrals are to be seen by the Emergency Physician In Charge (EPIC) with a documented plan of care. An increased awareness campaign of aortic dissection in the Emergency Department has been completed with an RCEM safety alert placed in the resuscitation room and majors area.
M4063 identified a delay in obtaining a blood culture in the Emergency Department. This was discussed with the Clinical Mortality and Morbidity Lead for Emergency Medicine and fed back to the Care Oversight Mortality Group. The learning has been shared with the SRFT & PAT # 274090 Sepsis Improvement Group who has been driving delivery service improvement04/27/2019 work 16:44:00via. Sepsis CQUIN.
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phase. A patient who presented with a very poor clinical prognosis was treated actively up to death. It was noted that this was in contradiction to recurrent plans for fast track discharge so to achieve the patient’s preferred place of death. There was a lack of clinical leadership around end of life care. This has been communicated with the speciality team for presentation at the Mortality and Morbidity Meeting.
The North Manchester Care Organisation is leading on:
Deteriorating Patient Collaborative A video has been developed to act as a teaching aid around difficult conversations with patients with uncertain chances of recovery at acute presentation. This is aimed at improving early discussion with patients, families and/or carers around the ceiling of care and possible end of life planning.
End of Life Care A Statement of Intent form is being piloted in order to further improve the care for families of patients being discharged home who are expected to die. This is aimed to improve the care we provide, but also to reduce the demand on General Practitioners for ‘same day’ visits on the day of patient discharge in order to complete the form.
M2343 identified poor care in the peri-operative and overall care. The death was investigated by the Coroner and an inquest was opened. The Coroner determined the death resulted from recognised complication following surgery.
Good practice themes identified from SJR The following good practice has been identified from SJR during Q2 and Q3:
Clear plans and ceiling of care; Good multidisciplinary care approach; Clear communication with patients and carers; Timely treatment and appropriate escalation of care; Regular and timely reviews; Appropriate decision to cease treatment and planned investigations.
Oldham Care Organisation
Re-admissions within 30 days of discharge It was identified that the majority of re-admissions were to the Haematology Ward and involved patients at high risk of deterioration and mortality. Targeted improvement work is planned around recognising the deteriorating patient with uncertain chances of recovery. The mortality team will present a precis of all the SJRs done toSRFT date & at PAT the # next274090 haematology M&M meeting and support the team in identifying 04/27/2019 opportunities 16:44:00 for improvement. One recommendable action is to put in place AMBER care bundles (validated methodology for clinical teams to proactively manage the care of hospital
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patients to support the Haematology Ward teams and/or a pathway to promote earlier decision making and better communication when it is uncertain whether a patient may recover.
Management of inpatient acute cognitive/behavioural disturbance It was identified during review of patients with severe mental illnesses that a Trust policy on agitated patients would assist clinical staff. Planned cross-organisational work with Salford Care Organisation to address this is part of a planned improvement project.
Clinical Records Keeping Policy In response to investigation 26383 and M2363 staff have been reminded fluid balance scoring and appropriately documenting patient choice.
Safeguarding champions In response to investigation 29723 and M2380 there will be increased safeguarding / mental capacity training for medical and nursing staff on Ward F9 and a Mental Health Act Awareness Campaign. As part of improvement work, there are plans to develop a Safeguarding Champion for each medical ward.
M2065 identified an omission to carry out a repeat ECG on a patient who presented to the Emergency Department, although it was noted the patient did not present with any chest pain. There was a further omission to action low haemoglobin. A lesson learned newsletter was shared on the staff Notice Board. The Mortality and Morbidity Lead for Emergency Medicine is devising a tool on what to do regarding “Any Significant Abnormal” blood gases, to be shared on the Registrar Notice Board.
M2958 identified an omission to document comment on blood gases. Clinical staff was reminded of the stamp system in place for blood gas results.
M2021 identified learning around fluid management and appropriate clinical records keeping.
M2495 was escalated for SJR methodology by staff following discussion of the case at the speciality Mortality and Morbidity meeting. It was identified that there was a delay in attending to a deteriorating patient. A clinical incident was completed, 37396. No harm was identified and an SI was not declared. However, learning around timely communication was shared with staff involved.
M3254 identified learning around the Major Haemorrhage Protocol and discussion with other speciality teams as to whether this may need updating.
M2479 identified learning around enhancing better co-ordination of patient care where there is multi-disciplinary input between specialities.
M3839 and M2373 identified poor end of life care and missed opportunity to enhance community care package as the patient was approaching end of life.
Good practice themes SRFT & PAT # 274090 identified from SJR The following good practice has been identified04/27/2019 from SJR 16:44:00 during Q2 and Q3:
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Clear plans and ceiling of care; Good multidisciplinary care approach; Clear communication with patients and carers; Timely treatment and appropriate escalation of care Regular and timely reviews; Appropriate decision to cease treatment and planned investigations.
Bury and Rochdale Care Organisations
Trauma mortality No care issues were identified.
Recognising a deteriorating patient In response to incident 30753 the following issues were identified:
Lack of awareness that this rare disease increases risk of PJP; Medical staff did not make it clear that they required an ITU review in addition to central venous access; ITU staff were task focused on central venous access and missed an opportunity to recognise a deteriorating patient; Delay in prescribing laxatives on admission to ITU.
The learning identified for the development of a bowel management protocol across NCA Critical Care Network, which will be completed by circa. April 2019.
Good practice themes identified from SJR he following good practice has been identified from SJR during Q2 and Q3:
Clear plans and ceiling of care; Good multidisciplinary care approach; Clear communication with patients and carers; Timely treatment and appropriate escalation of care; Regular and timely reviews; Appropriate decision to cease treatment and planned investigations; Prompt recognition of EOL and use of DNACPR.
SRFT & PAT # 274090 04/27/2019 16:44:00
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Salford Care Organisation
Management of inpatient acute cognitive/behavioural disturbance Investigation R123282 has recognised the need to highlight the availability of the following Trust guidance to supplement the information within this document: Diagnosis and Management of Delirium Guideline (trust-wide guidance excluding CCU and alcohol withdrawal) Delirium in Critical Care Patients. Management guidelines (CCU use only) Mental Capacity (2005) Policy and its Application for SRFT Patients (includes QRG for decision-making and details around best interest decision meetings/IMCA/LPA/DOLS etc.)
Management of electrolyte deficiency In response to R123282, pharmacy is currently in the process of finalising a series of QRGs to support safe electrolyte replacement (specifically potassium, magnesium, calcium and phosphate). Once published we will notify all prescribers within the organisation. This is the first stage of promoting safer practice and will act as a platform to start work on a potential EPR solution in due course.
Management of Major Haemorrhage (excluding Code Red ED pathway) In response to R121648, the major haemorrhage protocol QRG has been updated and posted in key areas throughout the theatre complex. There is close working between our specialist transfusion practitioner and theatre nursing and anaesthetic teams to support learning through simulation and themed learning at departmental governance meetings. This supplements existing simulation training in the ED and for junior doctors within the Foundation Programme. There is further scope for rollout into other clinical areas in the coming year.
Optimising use of acute non-invasive ventilation (NIV) In response to R120913, the CO NIV guidance is currently under review and the learning encompassed within this paper aims to build on activity within the clinical areas immediately responsible for this patient group (ED, EAU, MHCU, and H2). There is currently work being undertaken to understand our baseline and there is scope for further improvement work based on these findings.
Code Red for Acute Confusion Beyond the actions implemented following investigation R121415 and R123282, the Acutely Unwell Adult QI Collaborative project is now underway across the NCA and the following areas are involved across SCO: B2, B3, B5, B6, B7, B8, H1, H3, H4, L4, M2, EAU, Heart Care Unit, Surgical Triage Unit alongside input from the Hospital at Night and Palliative Care Teams.
Recognition and prioritising time-critical inpatient investigation In response to incident R125782, contact numbers for key Neurosurgical staff have been updated to minimise any delay in ward staff contacting them. The wardSRFT area & PAT is actively# 274090 engaged in the Acutely Unwell Adult project to improve the standard of04/27/2019 care provided 16:44:00 to their patients. The escalation for time critical portering support to the site co-ordinator has been clearly highlighted to the clinical areas and shared. Current arrangements for
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scheduling porters are undergoing further review.
Management of patients at risk of falls H2 for shared their local sign used to remind patients to use the call buzzer in response to investigation R124063.
L5 responded to investigation R124644 with weekly documentation audits during Jan/Feb 2019 demonstrating: 100% completion of falls risk assessments; 92-100% completion of patient safety prescriptions. This has been supported through ongoing safety huddle discussions of all falls that occur on the ward within the last 72hours.
At present, SCO is undertaking a trial of a new Falls prevention and care plan which stratifies the falls risk into simpler low and high classification, as well as providing more direction for necessary intervention where a falls risk factor maybe identified. This provides greater alignment with current evidence and other care organisations within the NCA.
This new care package is currently in paper form but will move to the EPR in due course. In the meantime a new EPR Escalation document is being launched at the end of March which is a multi-purpose document for use by medical staff and will have a specific sub- section covering post-falls documentation with guidance on head injury assessment post- falls and create an additional flag within the patient record for the medical team when a fall occurs.
These organisation-wide changes will accompany the new falls policy and act as a catalyst for the organisation to deliver beyond the minimum national target of 80% of patients >65 years receiving the core triad of high impact actions including: At least one recorded lying and standing blood pressure; No prescribed hypnotics/anxiolytics or antipsychotics unless absolutely necessary and rationale clearly documented; Early mobility assessment ideally within the first 24hours of admission with an indication of the need for any walking aids identified at this stage.
Learning from Structured Judgment Review
M1823 recognised a need to discuss and clarify the process for clinical admissions from clinic to ensure that there is an optimal balance of timely senior specialty review that works within the overall acute medical patient flow.
M1888 identified excellent consultant-led care across 7days with good family discussions and consideration of care ceilings by the ACM consultants. The junior doctors demonstrated a real attention to patient-centred care and the wider care team were very attentive to the patient’s needs in obtaining extra support for her husband at home for which she was the main carer. There were 2 learning points identified from this case: Care should be taken to be vigilant for patient’s using transcutaneous patch medication, particularly if a patient is being discharged from the hospital; Pathology samples collected from SCO PIU should be labelled as location: CPIU SRFT & PAT # 274090 M1818 identified the need to document all lines and devices on insertion.04/27/2019 This is critical 16:44:00 to for the organisation to provide ongoing observation and minimise the risk of unnecessary device related infection. Page 21
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M2399 highlighted the problem of a lack of provision of 24/7 clot retrieval service in stroke and this was used to support further discussions with the CCG as part of the response to incident R126586. It was recognised that there was excellent care provided by SRFT within the current agreed service template.
M2563 identified that: Antibiotics must be administered within the hour following a septic screen (including blood culture) using the STAT prescription (the antibiotic order bundles in EPR will do this automatically- search “antibiotic”) The need to challenge the necessity of invasive lines (e.g. temporary central line) on a daily basis to minimise potential harm.
M2572 identified that poor documentation around decision-making on NBM status meant that there was a lack of clarity in the administration of key medications (e.g. anti- consultants) which could have been converted to an alternative route. It was also recognised that if a patient’s frailty had led to implementation of an in-patient end of life care plan, even if the patient were to improve, the clinical team should give strong consideration to communicating with the patient/family/GP etc. where possible that advanced care planning may be useful following hospital discharge if the patient is considered to be entering the final months of their life.
M2204 identified insufficient detail in capturing capacity assessments and subsequent best interest decision making in a patient with known Learning Disability. Though an observation of “may lack capacity” provides a little context, the level of detail required to help guide clinical care in this vulnerable group should be very explicit using the tools provided within the EPR and wider CO safeguarding guidance available on the intranet.
M2449 identified pre-hospital limitations in GP assessment of a patient with a UDNACPR and advanced care plan in place at a Salford Care Homes Practice residence. This case has been fed-back to colleagues. There were 2 key issues identified within this SJR: the need for care homes to keep up-to-date contact details for next of kin where possible; The challenges in having detailed and explicit discussions in the context of advanced care planning within the community. Good practice themes The following good practice has been identified from SJR identified from SJR during Q3:
1st 24hr of care Evidence of a high standard of resuscitative care/CPR in the ED using focussed ultrasound to guide decision-making; Isolated omission of VTE prophylaxis on admission was rapidly identified by safety huddle; Timely clerking and assessment of acutely ill patients on arrival by Stroke and Neurosurgical teams; High quality major trauma care withSRFT detailed & PAT primary # 274090 and secondary treatment; 04/27/2019 16:44:00 Excellent care provision by Homesafe team supporting community care with regular visits Page 22
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documented well. Key issues (e.g. meds safety) were identified and addressed in timely fashion through safety huddles and follow-up documentation. Excellent preparation and team-work in delivery of high quality resuscitation following a paediatric out-of- hospital cardiac arrest. There was excellent family support demonstrated and consideration of wider issues such as SUDC process and safeguarding. Good recognition of the MHA status of a patient admitted from a mental health facility for ongoing medical care.
Ongoing care: Evidence of timely multi-specialty team-working to deliver good patient care (ENT, endocrinology, general surgery and interventional radiology); Frequent senior clinical decision-making with excellent attention to detail supporting good care; Timely escalation and de-escalation of patients to NHDU; Excellent support of parent/carer of patient with LD by ward nursing staff; Evidence of excellent care, decision-making and candour with family around current lack of funded 24/7 interventional clot retrieval service in relevant acute stroke cases; Excellent Consultant –led collaborative care provided by medical and psychiatric teams for patient with complex mental and physical health needs.
Procedural care Excellent documentation of lines insertion by ICU by junior medical staff; There were good examples of safe central line insertion demonstrated including use of real-time LoCSIPPS checklist.
Peri-operative care Good operative practice from detailed pre-operative assessment, through completion of surgical bundles/checklists and detailed operation notes demonstrated good communication and situational responsiveness as well as clear post-operative instructions; Evidence of detailed pre-operative work-up of patient for elective surgery with detailed patient-specific discussions during consent process; Excellent peri-operative recordSRFT & PAT keeping # 274090 04/27/2019 16:44:00 demonstrated by theatre team including use of all relevant WHO and patient-safety checklists; Evidence of excellent Consultant-led decision Page 23
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making with regard to timing of emergency laparotomy and good discussions around continuation of surgery in critically ill patient; Detailed anaesthetic and surgical peri-operative record keeping.
End of life care: Timely prescribing of palliative care medications during end of life care; Timely discussions with family on ICU when moving to end of life care phase including discussions around organ donation; Senior collaborative decision-making to assist best interests decision regarding end of life care and respect patient and family wishes in a time-critical and sensitive fashion; Regular senior review of patient on EoLC plan meant that: o when condition improved slightly active care was reinstituted; o Medications were adjusted in a timely fashion to provide excellent symptom control; o Supported regular family discussions and exploration of issues such as the patients preferred place of death.
11. Mortality Indicators – Dr Foster Data Source
The HSMR is calculated each month for each hospital in England. It includes deaths of patients with the most common conditions in hospital which account for around of 80% of deaths in hospital. HSMR is the ratio of observed to expected deaths, multiplied by a 100, from 56 baskets of the 80% most common diagnoses. If the HSMR is above 100 then there are more observed deaths than expected deaths. Upper and lower confidence intervals are applied to HSMR. HSMRs with values between the confidence intervals are consistent with random or chance variation. To have a red flag means the HSMR is above 100 and the lower confidence interval is above 100 which signifies the variation is unlikely to be due to random or chance variation and other issues may be causing the variation.
It is important to note that while the mortality indices from the Dr Foster data source are important, the frequency of risk groups (both in the treatments and operations that each hospital offers and the make-up of its local population) vary widely between Trusts. Whilst the HSMR scoring system works by taking a hospital’s crude mortality rate and adjusting it for a variety of factors such as frequency of risk groups; local weightings suchSRFT as &lack PAT of #community- 274090 based hospice services and clinical coding errors may have an impact on04/27/2019 HSMR as well 16:44:00 as the quality of clinical services.
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11.2 The NES Care Organisations
The confidence interval is in the as expected range on the HSMR and in the below expected range for the SMR on the rolling 12 month period December 2017 – November 2018. HSMR data remains lower than the peer group average, RR 97:98.
11.2.1 North Manchester Care Organisation
The confidence interval is in the below expected range on the HSMR and SMR rolling 12 month period January 2018 – December 2018. HSMR data remains lower than the peer group average, RR 91:98.
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11.2.2 Bury and Rochdale Care Organisation
The confidence interval for Fairfield General Hospital and Rochdale Infirmary is in the as expected range on the HSMR and SMR rolling 12 month period January 2018 – December 2018. HSMR data remains lower than the peer group average, RR 95:98 and RR 80:98.
The HSMR has slightly increased at both the Fairfield General Hospital and Rochdale Infirmary. The crude mortality rate for Fairfield General Hospital has increased whilst Rochdale Infirmary has continued to decrease.
In the Q1 2018/19 it was determined a sample size of records from the following disease groups which potentially appeared as outliers should be completed to determine whether there were any significant issues for these groups of patients; Conduction disorders; Gastrointestinal haemorrhages, and; Gastrointestinal blockage. A review has been completed by the clinical coding department. The report highlighted several cases where coding had an effect on the reporting of these patient groups. It was determined no further action was required.
11.2.2.1 Fairfield General Hospital
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11.2.2.2 Rochdale Infirmary
11.2.3 Oldham Care Organisation
The confidence interval is in the as expected range on the HSMR and the SMR on the rolling 12 month period January 2018 – December 2018. HSMR data remains above the peer group average, RR104:98.
There has been a slight decline in upward trajectory, whilst this is welcome, as HSMR remains above the expected level it remains imperative to keep a disciplined focus on mortality in the Oldham Care Organisation. Both the HSMR and SMR have increased with an increase in the crude mortality rate observed. A clinical coding review has been completed from diagnosis groups which potentially appeared as outliers. There were 3 diagnostic mortality alerts with satisfactory coding that require further clinical review; ‘aspiration pneumonitis food/vomitus’, ‘peri- endo- and myocarditis cardiomyopathy’ and ‘deficiency and other anaemia’. These will be reviewed and the results published in the Q4 2018/19 report.
A data assurance exercise will be carried out in reference to the diagnosis group sepsis to check whether this is a clinical outlier and a cohort of these deaths will be reviewed using SJR methodology.
A cohort of patients who have died following admission on a Sunday, deaths in low risk diagnosis groups and deaths after surgery will be reviewed by the ClinicalSRFT Mortality & PAT #Lead 274090 for the NCA to assess any patient safety indicators, mortality trends and 04/27/2019 possible clinical 16:44:00 care improvement areas.
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The palliative coding HSMR influence is significantly below the national average for both non- elective spells and non-elective deaths with specialist palliative care involvement (SPC). Oldham Care Organisation is performing at 1.84% for non-elective spells and 13.5%; the national average is 4.07% and 30.97%. An improvement project will be led by the Clinical Coding team and Lead Palliative Care Consultant for the NES Care Organisations to improve specialist care coding and service delivery. The aim will be to standardise the documentation and coding of SPC. The degree to which HSMR is influenced by under coding of SPC is not clear and will be clarified.
Coding feedback has indicated that there is a potential weakness in clinical documentation in respect of frailty. Clinicians may use this term to aggregate a number of complex conditions to give an overall impression of increased physical vulnerability and mortality. Coding does not recognise this in the same way and relies upon explicit documentation of each individual condition that informs the Charlson index. It may be the case that the Charlson index is underscored if the comorbidities are not listed. This would reduce the likelihood of expected death and therefore increase mortality for the site if it is occurring.
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11.2.4 Salford Care Organisation
The confidence interval is in the below expected range on the HSMR and SMR rolling 12 month period January 2018 – December 2018. HSMR data remains significantly lower than the national average, RR 82: 98.
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Appendix A
Actions Owner Due by
Review of harm allocated to incidents reported at Medical Director, COMPLETED Oldham CO. Exercise to be undertaken to provide Head of Legal assurance regarding ratios of harm reported within Services, Datix. Associate Director (Increases in harm levels would provide an initial of Governance indication of concerns regarding practices).
To quality assure the diagnosed outliers in the Clinical Coding COMPLETED HSMR basket to determine if there are any coding errors. To measure staff mix on acute medical wards to Diabetes and 30 April 2019 determine mix between substantive and locum endocrinology medical staff and triangulate against mortality – consultant/ disparities to be escalated by medical division. Directorate Manager A sample audit of the diagnosis group (*within the Clinical Mortality 30 June 2019 HSMR basket) ‘septicaemia (except in labour)’ to be leads for medicine reviewed using SJR case record review methodology to determine quality improvement areas and opportunities for learning. A sample audit of the diagnosis group (*within the Consultant 30 June 2019 HSMR basket) ‘aspiration pneumonitis/food/vomitus’ Physician to be reviewed using SJR case record review methodology to determine quality improvement areas and opportunities for learning. A sample audit of the diagnosis group (*within the Consultant 30 June 2019 HSMR basket) ‘peri- endo- and myocarditis Cardiology cardiomyopathy’ to be reviewed using SJR case record review methodology to determine quality improvement areas and opportunities for learning. Patient Safety Indicators on Dr Foster Dashboard to Clinical Mortality 30 June 2019 be data assured and reviewed using SJR case Lead for the record review methodology to determine quality Northern Care improvement areas and opportunities for learning. Alliance Coding process will be reviewed with input from the Clinical Palliative 30 June 2019 North East Sector Clinical Palliative Lead to improve Lead and Coding the current under coding of specialist palliative care patients. Develop guidance for coding on specialist palliative Clinical Palliative 30 June 19 care. Lead and Coding To develop a business case to enable 7 day TBC 30 September 2019 services for specialist palliative care patients. Scope changing the ward clerking proforma to Clinical Mortality 30 September 2019 include the Charlson index; explicitly discourage Lead SRFT & PAT # 274090 recording of ‘complex frailty’ as a diagnostic term. 04/27/2019 16:44:00
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To develop a business case to enable 7 day service CD 30 September 2019 on Gastroenterology. Gastroenterology Medical Director/Associate Director of Governance Right patient right ward walk round to be included in SJR reviewers 30 September 2019 the SJR reviews to determine if there is learning around patient transfers. To review volume and acuity trends for Oldham Care Associate Director 30 June 2019 Organisation admissions. of Governance Coding ward walk rounds to educate Consultants on Clinical Coding On- going FCE1 and FCE2 and the importance of correct documentation.
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31/31 137/232 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & The Pennine Acute Hospitals NHS Trust (PAT)
Title of Report Group Learning From Experience Report
Meeting Group Committees in Common
Beverley Cook, Head of Patient Safety, Northern Care Alliance NHS Group (NCA) Josh Hennighan, Risk Manager, (NCA) Stuart Logan, Associate Director of Governance, North Manchester Care Organisation (NMCO) Natalie Davies, Associate Director of Governance, Oldham Care Organisation (OCO) Authors Eve Scott, Associate Director of Governance, Bury & Rochdale Care Organisation (BRCO) Alex Larkin, Associate Director of Governance, Salford Care Organisation (SCO) Mandy Barnes, Deputy Complaints and PALS Manager, North East Sector Alison Talbot, Head of Legal Services, (NCA)
Chris Brookes, Chief Medical Officer Presented by Elaine Inglesby, Chief Nursing Officer Date 29th April 2019
Executive This paper provides the scheduled Learning from Experience Report for Summary complaints, Patient Advice Liaison Service (PALs) and incident management for the Northern Care Alliance. (NCA). Each Care Organisation (CO) prepares a local Learning from Experience (LFE) report and submits to its Care Organisation Assurance and Risk Committees.
This report covers the period Q2 and Q3 2018/19 combining the Learning from Experience reports of each of the four Care Organisations.
Key points to note are;
Never Events are indicative of an organisations inability to learn and provide relatively basic but essential safety barriers. There were zero Never Events reported in Q2 & Q3 2018/19. NMCO and OCO continue to experience challenges managing and eliminating Concise Investigations (CIs). Using methodology proven successful in Q2/Q3 2018/19 from SCO and B&RCO the NCA Patient Safety team will support OCO and NMCO in Q1 2019/20 to expedite investigations. Duty of Candour for concise investigations was >=97% for Q2/Q3 2018/19. Duty of Candour for Serious Incident investigations remained at 100% for all Care Organisations within Q2/Q3. SRFT & PAT # 274090 04/27/2019 16:44:00 In response to identified themes or individual incidents learning examples, newsletters, patient care alerts and the request for Take 5
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1/23 138/232 learning presentations increased in Q2/Q3 with examples detailed within the paper. Since its launch in June 2018 Take 5 learning presentations have been viewed by over 3500 staff, monitoring views provides intelligence for provision of further subject matter learning.
Annual Plan Corporate Priorities supported by this paper: Objective 1. To pursue quality improvements, to assure safe, reliable and compassionate care 3. To support our staff to deliver high performance and improvement. 4. To improve care and services through integration and collaboration. 5. To demonstrate compliance with mandatory standards. Associated Risks The absence of embedded learning from patient safety incidents and patient responsiveness will increase risk to patient safety.
Recommendations The Group Committees in Common (Board) is asked to review and approve the report prior to subsequent dissemination throughout the Northern Care Alliance (NCA/Group), commissioning organisations and the general public.
The committee is asked to note the progress with the management of incidents, complaints and learning.
Equality Does this paper relate to a matter where equality issues may arise? Y/N If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and can be Information made available to the public. x Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public.
This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
Data Sharing Under the Data Sharing Agreement, the NCA may be required to Agreement with share this paper with MFT. This is distinct from information Manchester disclosed under the FOIA. As MFT will acquire part of PAT they will University NHS FT need to understand a range of matters which may otherwise be (MFT) in relation to exempt under FOI e.g. contracts to be split and specific workforce- the Transaction related issues.
Please consider the statements below and indicate which applies in relation to this paper: a) This paper relates solely to PAT and can be released
b) This paper relates solely to SRFT and is thereforeSRFT & notPAT eligible # 274090 for release 04/27/2019 16:44:00
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2/23 139/232 c) This paper contains information relating to both PAHT and SRFT. All information other than that relating to PAHT will be x fully redacted. d) This paper contains reference to both PAHT and SRFT but contains no quality, finance or operational performance data relating to PAHT which could be relevant to the transaction and is therefore not eligible for release.
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3/23 140/232 Learning from Experience (LFE)
1. Introduction/background
Learning from experience is Governance led, with learning from adverse events and the management of risk informing each care organisations annual business plan and the wider NCA quality improvement strategy.
Successful learning organisations learn continuously from everything they do, from failures and successes; encouraging innovation and the sharing of good practice which is valued, driven and modelled by senior leadership.
Learning from incidents, complaints and mortality reviews is being embedded within each of the Care Organisations with good evidence of improvement and shared learning within newsletters. There is still room for improvement in the consistency in which the care organisations share learning both internally and group wide along with enhancing current methods of learning to meet staff needs.
In addition a learning audit will be developed as the proposed Learning Framework is progressed to provide assurance that learning is reaching its intended audience.
2. Learning from Investigation
2.1 Falls management - Following a Falls panel review at North Manchester the team identified several themes within the ‘no and low harm’ reported incidents to provide areas for improvement. (see below) Aligning with this review the Falls team have piloted a best interest booklet across several wards on all NES sites as a test of change to address concerns previously identified by coroners. Following several pilots, new documentation for Enhanced Patient Observation documentation is currently being rolled out at Bury & Rochdale across all ward areas. A sample can be seen at appendix 1. Early indication would suggest that there has been a reduction in the number of falls for patients with cognitive impairment, but figures are yet to be finalised.
Issue/Theme identified: Actions proposed: 1 Falls Risk assessment not completed on 1. Ward team to check that risk assessments are admission, therefore appropriate plan of care fully completed on admission. not in place for patient with a cognitive 2. If there are concerns that Evolve is not saving impairment. Patient not assessed as requiring risk assessment then this should be reported to Enhanced Patient Observation (EPO)is not the Evolve Team observed in bay. 2 Mental Capacity Assessment (MCA ) not 1. Look at MCA + Best Interest booklet being completed on patient with questionable trialed on H3. capacity for specific decision i.e. can patient 2. EPO process currently being reviewed to maintain their own safety? e.g. can they use include specific MCA assessment. call bell, understand instructions, advice, etc. 3. Contact Safeguarding Team for further advice around assessing capacity. 3 The use of chemical sedation dramatically 1. MCA and Best InterestSRFT process & PAT should # 274090 be 04/27/2019 16:44:00 increases the risk of patients falling. followed to ensure these medications are used in the patient’s best interest.
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4/23 141/232 4 Cohort bays – are patients in the bay 1. Ward team to assess cohort bay daily, to appropriate, when higher risk patients may be ensure patients are appropriate in other parts of the ward
2.2 Central venous catheters (CVC) – An organisation wise task and finish group was established to review all aspects of CVC insertion, management, removal, training and policy guidance. This was in response to a Prevention of Future Deaths (PFD), following an inquest where the patient was found to have exsanguinated following the removal of a central venus catheter inserted to facilitate dialysis. Two other low level harms relating to central venous catheters (CVC) at Salford, also supported appropriate development/ implementation of LocSIPS to share across the NCA. The multi-professional task and finish group is chaired by Salford’s Associate Medical Director and has representation from surgery, heart care, medical high care, critical care, renal, infection control and the IV team.
Initial discussions have taken place with the Associate Medical Director to work collaboratively with the quality and safety faculty. The specific QI projects that will be undertaken by medical trainees will be informed by the incidents and harms reported.
2.3 Fat Embolisms – In Q2/Q3 an index patient within critical care at Salford Care Organisation triggered a review of the pathway for polytrauma patients with traumatic brain injuries. A task and finish group to review suspected fat embolus in polytrauma patients was established in response to concerns raised by clinicians working in ED, Critical Care, Orthopaedics and Theatres. The purpose of the group is to review a small cluster of potential incidents relating often to young polytrauma patients with traumatic brain injury (TBI) who develop fat embolus. Learning and protocols developed will be shared across the NCA.
2.4 Inconsistent application of the WHO surgical checklist – In early 2017 work began on the redesign of safety briefing boards and swab boards to ensure that all theatres across NE Sector sites had a standardised robust system of capturing information. All members of the MDT across all sites were engaged in the design of the boards and indeed some specialties have tweaked the swab board design to suit their need. The boards have evolved and now capture more information than previously. In November 2017 there was a major re-launch of WHO Steps of Safer Surgery that was accompanied by drop in sessions for all theatre staff and a social media campaign via Twitter. The name of the process was changed to 5 Steps of Safer Surgery, in line with national standards and to embed that the process must systematically contain 5 steps. Feedback sheets were given out to staff and regular meetings have taken place to discuss progress. Since the relaunch, 5 Steps of Safer Surgery is regularly discussed within the team as part of the safety huddles and any areas of non-compliance are addressed to encourage challenge. The following further work was undertaken in 18/19 to address concerns that emerged through the reporting and learning from wrong site surgery NEVER events in previously reported periods: ‘Theme of the month’ initiative which has improved engagement in the 5 Steps. A video was produced and shared with all staff which includes the 5 Safer Steps. Quantative audits to demonstrate compliance with the 5 SaferSRFT Steps & were PAT commenced # 274090 in 04/27/2019 16:44:00 January 2019 which have demonstrated consistently high compliance.
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5/23 142/232 Recorded Sessions Recorded Full with WHO Recorded Sessions with Sessions Briefings Briefing Debriefings WHO Debriefing Jan 2019 201 196 97.5% 201 100% Feb 2019 193 192 99.5% 193 100% Mar 2019 203 200 98.5% 203 100% Apr 2019 99 99 100.0% 99 100% Total 696 687 98.7% 696 100% Data for compliance of the Safer Surgery check lists – North Manchester Care Organisation
Qualitative audits have been undertaken to ensure that the 5 Safer Steps have been completed in the spirit in which they are intended. Compliance has been consistent in most areas; further targeted work is planned within Trauma and Orthopaedics. Qualitative audit data is gathered by observation, asking staff, and review/checking IM&T systems and documentation against departmental and Trust policies and standards, and National and professional standards. E.g. Small sample from qualitative audit
Quality Element Link to Trust Source Areas of good practice and areas for standard/policy improvement There is clear evidence of a Theatre Policy Observed The sisters in theatre wore a pink hat. This designated coordinator on led to good team work in this theatre during each shift pattern the 2 procedures observed. Check WHO individual Correct Site Observe and Time out theatre - 2nd patient patient checklist is Surgery check Occurred in theatre before surgery undertaken prior to any Policy/clinical documentation commenced. All staff were not engaged in intervention in the Professional this with a silent pause. Some staff were appropriate areas Standards placing absorbent pads under the patients head, some were checking equipment. Felt like this occurred too soon, as the team were not fully ready for team brief.
2.5 Blood Glucose Best Practice Monitoring & Transfer - The following learning was identified as part of an investigation into the death of an elderly patient who was transferred from NMCO to Wolstenholme Intermediate Care Unit. The investigation found the patient had raised blood glucose indicators prior to transfer.
All registered nurses to follow the Blood Glucose Monitoring Best Practise Document and escalate blood ketones of greater than 0.6mmol on 2 consecutive occasions to the medical staff for review. For all patient transfers the SBAR communication document needs to be completed and should contain the clinical details of the patient’s condition. A clinical change in a patient’s condition prior to transfer to an Intermediate Care Unit must be escalated to the medical staff.
Following the investigation a detailed learning from incidents newsletter was cascaded across the Division of Integrated Medicine at NM Care Organisation.
A high priority Patient Care Alert has also been disseminated to communicate the importance of blood glucose monitoring.
To support best practice for blood glucose monitoring best practice a Take 5 learning presentation is in draft to support staff learning and will be shared across the NCA. A slide from SRFT & PAT # 274090 the draft presentation can be seen in appendix 4. 04/27/2019 16:44:00
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6/23 143/232 2.6 Diagnostics and Pharmacy Group Learning - The highest category of incident relating to Diagnostics & Pharmacy Group is ‘Sample error not involving a blood transfusion’ which accounts for 28% of incidents, there are 9 subcategories within this which relate to Pathology tests not being carried out, or being delayed. A further category of ‘blood and blood product related’ relates to broadly similar issues involving blood transfusion tests and accounts for a further 5% of incidents. A sample of emerging themes are below with actions taken:
Issue/Theme Actions taken: Q2 data Q3 data identified: 1 Incidents of error in A risk assessment has been carried out in 8 4 collection of blood conjunction with the Head of Workforce bank samples show a Resourcing – Nursing and Midwifery and this has strong association with been shared with the Care Organisations to highlight the risk of agency staff taking part in the agency staff who do blood transfusion process. not receive training on Blood Transfusion Practitioners have a Datix NCA policy and dashboard set up for agency/bank staff involved in protocols for blood transfusion incidents which allows them to transfusion. monitor trends at a glance and make timely interventions.
Blood Transfusion Practitioners Dashboard for monitoring agency/bank incidents
2 There were 8 ‘Wrong Transfusion Practitioners have obtained and will Q2 - 7 Q3 - 1 Blood in Tube’ Blood circulate ‘Wrong Blood in Tube’ circular from the incidents incident Transfusion incidents Serious Hazards of Transfusion (SHOT) reported reported reported during Q2 & haemovigilance scheme, [SHOT is the agency to which serious blood transfusion incidents are (9 Q3, in the majority of reported to externally and works closely with incidents cases these had been MHRA]. have labelled away from the Blood Transfusion Practitioners have a Datix been patient’s bedside. dashboard set up for ‘Wrong Blood in Tube’ reported incidents which allows them to monitor trends and in Q4) make timely interventions. 3 A significant number of the incidents reported as A Datix category hasSRFT been &added PAT to # facilitate 274090 ‘Sample error not involving a blood transfusion’ are better monitoring and 04/27/2019intervention in areas 16:44:00 samples collected from the wrong patient or labelled with where these occur. the wrong name but which are not for compatibility
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7/23 144/232 testing. There has been no Datix category to identify these specific incidents. 4 The transfusion Practitioners carried out an audit in Transfusion Service is collaborating with the September 2018 which has identified poor compliance Quality Improvement Team to address and with documentation of observations during transfusion improve practice and will develop an action and consent. plan. 5 A complaint from HM Coroner lead to an investigation of As a result of the investigation a protocol has the process in place for maintaining the ‘chain of been developed to process Coroner’s evidence’ for samples collected at post mortem. As the samples and storage facilities have been put samples are not processed within NCA there was no in place to preserve samples securely when protocol in place for these samples. left in our refrigeration units/freezers. 6 A theme in Radiology NES missed diagnosis incidents Review of this theme at Radiology Quality has been abnormalities found in retrospect which were Governance (NES) has indicted that: not indicated as an area for examination in the request Previous images must be examined and or by the clinical details provided. alternative diagnosis must be considered despite presenting conditions. Progress to be monitored quarterly and will be Images must be reviewed beyond the reported within the next LFE report. expected diagnosis. A Radiology crib sheet has been developed to assist the vetting process. Escalation of case to subspecialty peers must take place where in doubt of diagnosis. Communication has been requested through the Medical Directors Team for requestors to include all relevant clinical history in requests.
3. Learning from Governance
3.1 Human Factors Training –Communication and Human factors play an element in a large number of incidents that have occurred. In line with this, the Oldham CO has gained support from AQuA to undertake Human Factor Training on site for the Care Organisation. Success will be evaluated and further events across other sites can be organised. In addition Bury & Rochdale CO have highlighted learning following an incident which suggests that Human Factors training would be of benefit to understand the need to maintain situational awareness of needs such as anti-coagulation when managing a patient with multi-organ failure.
3.2 Learning Newsletters - There are multiple learning newsletters being generated throughout the NCA, from Divisions and within Care Organisations. The newsletters provide learning around incidents and patient safety issues and are distributed to all relevant staff via governance processes. As an example the Associate Director of Governance and the Medical Director at Oldham CO have developed an SIs newsletter which is shared widely, and focuses upon developing understanding of issues relating to incidents, and also providing a spotlight on lessons learnt. An example newsletter is attached at Appendix 2.
3.3 Learning from other Organisations – Following the recent case of a patient with learning disabilities receiving poor care at another organisation this has prompted a review of deaths of patients with learning disabilities at the NCA to confirm learning. In Q2/Q3 there were a total of 21 deaths identified as patients with learning difficulties. (5 in Q2 and 16 in Q3) A total of 17 of these cases had a mortality review, withSRFT learning & PAT identified. # 274090 In addition there were 160 incidents reported at NES Care Organisations,04/27/2019 (information will 16:44:00 be
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8/23 145/232 available for Salford following Datix merger Feb 2019) with 1 Severe harm 3 moderate and 155 low or no harm incidents. The learning from mortality reviews and incident investigations will be incorporated into a Take 5 learning presentation being developed to help staff understand issues and communicate support processes for caring for patients with learning disabilities.
3.4 Horizon Scanning - Specific search criteria has been agreed with communications to enable horizon scanning of patient safety adverse events at other organisations to provide focus for deep dives into incident and mortality data, and as an early warning of potential incidents to trigger preventative learning.
3.5 Take 5 – End of Life Care/SWAN – To support learning identified via mortality reviews and incidents regarding the quality of end of life care a Take 5 learning presentation has been created to promote the SWAN dignity, compassion and respect message. It provides staff with contacts and how to access resources to help them provide compassionate end of life care for patients and their families, including bereavement care. This will be live at the end of April 2019. Draft slide at Appendix 4.
3.6 Take 5 – Learning Environment - The below table shows the number of views and downloads of the live Take 5 learning presentations generated from incidents, mortality and improvement work. Take 5 Learning statistics;
Length of time Take 5 Title Total views available Clinical Coding NES 133 3 months Advance Care Planning NES 117 3 months Coroner reporting NES 104 3 months Disability Confident NES 169 4 months The Accessible Information Standard NES 102 3 months Supporting people at risk of Malnutrition SRFT 263 4 months Fire Safety & Evacuation NES 276 4 months FTSU Guardian NCA 242 4 months Macmillan Recovery Package NCA 208 5 months How we improve Mortality NCA 277 7 months Minimising the risk of falls NES 329 7 months Research Opportunities NCA (in revision) 462 6 months VTE & PE's NCA 714 10 months Overseas Visitor NES 76 2 months Supporting patients with Dementia NCA 92 2 months Total Views for all Take 5 presentations 3564 *unfortunately our system does now allow for us to confirm staff groups accessing each
The profile of the Take 5 learning environment will be ramped up in the coming months, with the launch of Take 5 lightening talks and several new Take 5 learning presentations currently in draft. SRFT & PAT # 274090 3.7 Patient Care Alerts – To improve the effectiveness of sharing incident04/27/2019 Root Cause Analysis’ 16:44:00 (RCAs) within a Situation Background Assessment Recommendation (SBAR) patient care alert
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9/23 146/232 (PCA) the format has been revised to streamline the process for easier distribution. This is to ensure that when Serious Incidents are approved at each Care Organisations sign off panel, the SBAR Patient Care Alert is quickly reviewed and distributed across the organisation. A total of 7 high priority Red patient care alerts have been distributed since June 2018 to highlight patient safety risk from incidents.
3.8 Patient Care Alerts (non-incident related) - Patient care alerts are also used to share urgent patient safety information throughout the NCA. A recent alert example distributed in April 2019 can be found at Appendix 3. This alert was due to a rebranding of a product for the treatment of Hypoglycaemia which needed to be shared across the NES care organisations for all staff awareness. (Salford did not use the product)
4. Incidents
Incident reporting is the frontline of intelligence gathering when it comes to risk management across all areas of the organisation. When the organisation has good systems and processes in place to recognise, manage and learn from incidents then it is indicative of a positive safety culture. Therefore it is important the organisation can demonstrate continuous attempts to increase incident reporting as a source of intelligence gathering. As per the below SPC chart; incident reporting has seen a significant increase in the last 3 years.
NCA patient safety incident reporting per month SPC
2200
2000 1930.27
1802.89 1800
1675.51 1605.69 1600
1489.89
UCL 1363.19 1400 1374.09
CL 1256.83
1150.48 1200 LCL
1000 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 ------6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 8 8 8 8 8 8 8 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
Each Care Organisation (CO) has a robust governance arrangement to review incidents at all levels including harm validation methodology, use of Root Cause Analysis (RCA) and thematic reviews.
A primary purpose of the Serous Incident process is to investigate root causes and then develop an action plan to address the risk and work to manage, mitigate or eliminate it. SRFTEvery Serious& PAT #Incident 274090 (SI) and Concise Investigation (CI) has a formal action plan created with one or more04/27/2019 actions to improve 16:44:00 patient and staff safety. Each one of these actions is the embodiment of a learning opportunity to drive
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10/23 147/232 change to improve process, system, practice or share the details with wider sets of colleagues. In Q2Q3 2018/19 there were 1589 individual actions completed.
4.1 Concise Investigations – Overdue
A Concise Investigation (CI) is where an incident requires a Root Cause Analysis (RCA) but it is not a Serious Incident (SI). Typically this is when the incident is validated as moderate harm.
Concise Investigations – Overdue per month CO/GPU SPC Chart Commentary NCA total 140 The improved position shown in the NCA total UCL 120 in the SPC chart for 2018 relate mainly to an improvement in Salford’s position. All other 100 CL COs have sustained their count within 80 LCL standard deviation. 60
40
20
0
Bury and Bury and Rochdale operates a zero tolerance Rochdale policy on anything overdue in relation to Care incidents, including CIs. This has continued Organisation into Q2Q3 2018/19 with no more than 6 overdue per month. North NMCO’s variation of overdue CIs is between Manchester 12 – 17 per month within Q2Q3 2018/19. The Care position is consistent with previous quarters Organisation however NMCO cannot evidence improvement. Oldham Oldham has the highest number of overdue Care CIs from any CO, with a variation of 33 – 54 Organisation per month within Q2Q3 2018/19. The Oldham surgical division has majority of these CIs. Salford Care Salford CO completed a large piece of Organisation improvement work in Q4 2017/18 and Q1 2018/19, driven by a re-designed the Serious Incident Action Review Committee (SIARC) focusing on assurance. This improved position was sustained in Q2Q3 2018/19. Compliance reports for incidents have been rebuilt in line with the NES methodology to allow the divisional teams to be aware of what is required of them on a live basis. Previously CIs and other items were “lost in the long grass”. Diagnostics D&P’s variation of overdue CIs is between 8 – and 10 per month within Q2Q3 2018/19. The Pharmacy position is consistent with previous quarters however D&P cannot evidence improvement. Corporate Corporate Services had 2 CIs open since Services 2017, both of which have been closed since December 2018.
Both SCO and B&RCO can evidence good positions on CIs, which has continued into Q4 2018/19. NMCO and Oldham CO cannot evidence improving positions. SCO and B&RCOs have a high quality weekly review meetings chaired by the CO Associate Director of GovernanceSRFT to seek & PAT assurance # 274090 from the divisions that all aspects of incidents, including CIs, are being progressed and04/27/2019 an opportunity 16:44:00 to
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11/23 148/232 escalate problems. The NCA Patient Safety team will be supporting NMCO and OCO further progress CIs by working to standardise approach learning from SCO and B&RCO.
4.2 Who reports incidents?
Sample of the last 8000 incidents submitted in February and March 2019
Staff Group Total Percentage of total Nursing 5824 73% Non-clinical 842 10.5% Medical 506 6.3% Consultants* 329 (872 Consultants across NCA) 4.1% Junior Doctors* 177 (256 Junior Doctors across NCA) 2.2% Allied Health 828 10.3% *Datix extract has not provided all staff groups, therefore, only Consultants and Junior Doctor staff numbers have been provided.
Note: Whilst this report focuses on Q2Q3 2018/19 the above data is from February and March 2019 to be indicative of the test of change in removing anonymous reporters rolled out in October 2018. (Anonymous test of change)
4.3 Improving Incident Reporting in Junior Doctors
In the previous NCA LFE report it was determined that, out of 20,000 incidents, only 6% (3.1% Consultant, 2.9% junior) of incidents were reported by medical staff. There is nationally published evidence based BMJ research which indicates all junior doctors will state involvement in incidents however this is not reflected in the reported figures on Datix. https://bmjopenquality.bmj.com/content/3/1/u203658.w2114
As a direct response to this the NCA Associate Directors of Governance provided representation at the latest influx of junior doctors to highlight the importance of incident reporting. There has been a slight increase in number of medics reporting incidents (6.3 % from 6.0%) however, this could be normal variation. Additional work is required at all COs to address this required change in culture. Each CO has an incident improvement plan which includes targeting underreporting staff groups.
The BMJ article and library search on various databases (CINAHL, MEDLINE, EMBASE and PUBMED) has not provided any statistics for the number of incidents Junior Doctors report at any Trusts. This suggests that individual Trusts need to be approached to understand if the NCA is an outlier. The research has however provided details of successful improvement programmes which the NCA can adapt to improve Junior Doctor incident reporting. Our Junior Doctor reporting rates will be monitored going forward for the NCA, to enable initiative successes to be measured.
4.4 Anonymous reporting (test of change)
Anonymously reported incidents made up 7% of the 20000 incidents. When sampled, all of the incidents reported anonymously did not contain any sensitive information and at the time the decision was taken by the NCA Serious Incident Assurance Group to discontinue the anonymous reporting option as a test of change. Instead directing any reporters with serious practice concerns to SRFTFreedom & PATto Speak # 274090 Up or Safecall. Whilst there have been multiple operational benefits to ensuring a reporters04/27/2019 name is 16:44:00 attached
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12/23 149/232 to every incident, feedback from the Medical Education department indicates it may disengage medical staff from the incident process. This is a group known to under report as described above.
As a result, in Q1 2019/20 anonymous reporting will be turned back on in Datix but will be re-designed to capture the reason why a reporter did not feel comfortable having their name attached. These reasons will then be themed to address any cultural concerns that may be emerging. E.G. if a certain division or directorate is unwilling to complete a named report due to potential repercussions of seniors, then this can be escalated a risk to CO leaders.
4.5 Never Events
Never Events are indicative of an organisations inability to learn and provide relatively basic but essential safety barriers. There were zero Never Events reported in Q2&Q3 2018/19.
4.6 Risk Management The management of risk, including the NCA Board Assurance Framework (BAF), the CO BAFs, and Divisional Assurance Frameworks (DAFs) were noted to have variation in approaches at different levels with varying levels of effectiveness and maturity across the organisation. In risk mature organisations learning from adverse and historic events should be transcribed into proactive risk management driven by learning from experience. Mersey Internal Audit Agency (MIAA) has been commissioned to conduct audits into Risk Maturity and Committee Effectiveness to provide recommendations to strengthen risk processes. The results of these audits are expected by April 2019 and will drive improvement work in Q1 2019/20. A NCA risk management strategy has been written to supersede the previous Pennine and Salford versions to promote standardisation and harmonise risk management across group.
4.7 Datix – Risk Management System
Datix is the Risk Management Database used across the NCA. In August 2017 Datix was launched at NES which, due to technical barriers, was a separate instance to the Salford solution. As discussed in previous Learning from Experience reports, NES’s instance helped contribute to an increase of incident reporting and better monitoring tools for incidents, complaints, PALS, inquests, claims and risk. Salford and NES had separate instances of Datix with different forms, coding and user flow. Therefore it was difficult to collectively analyse Salford and NES to identify opportunities with holistic learning, using 2 systems was operationally challenging for managers who worked across services and this contributed towards a cultural divide between NES and Salford. To address this, the Salford system was retired in February 2019 and now the whole NCA is using a single Datix system. This also promotes unity via standardisation across all COs within governance.
4.8 Duty of Candour
Duty of Candour (DoC) is the method for the NCA to apologise to patients/ families, involve them with incident investigations and to ensure concerns are addressed throughout the investigation process. It is essential to engage DoC as early as possible to help manage patient/ families concerns following an incident for the benefit of both the patient/ family and the CO. DoC remains a high priority for the NCA. SRFT & PAT # 274090 04/27/2019 16:44:00 Stage 1 DoC
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13/23 150/232 DoC is set in 2 stages, the first stage is the initial contact, which should always be verbally in person wherever possible. DoC was at 100% for Serious Incidents for Q2Q3 2018/19. DoC was at 97% for Concise Investigations for Q2&3 2018/19. This reflects the importance of establishing contact and building the relationship with the patient/ family.
Stage 2 DoC The second stage is the final sharing of the completed report with the patient/ family. Stage 2 DoC for SIs is 98% and 98% for CIs for Q2Q3 2018/19.
DoC areas for improvement The NCA operates a 45 working day deadline for investigations. Due to a myriad of reasons SIs and CIs can overrun their target dates; a noted area of failing in Q2Q3 2018/19 was the lack of contact with patients/ families that the report will be later than originally stated. As a result, all NCA divisions now will proactively contact patients/ families to tell them the investigations are behind schedule and keep them apprised of progress. The overdue concise investigations situation directly affects DoC compliance. The above figures for stage 2 DoC are representative of investigations closed within Q2Q3 2018/19, but does not include those investigations which should have been completed in Q2Q3 2018/19. Therefore for these investigations stage 2 DoC has not been discharged as there is no report to share. This is being addressed via the CI improvement work addressed above.
5. Complaints
5.1 Across Group, the number of complaints received in Q2 2018/19 and Q3 2018/19 was 704. There were 7 Parliamentary Health Service Ombudsman (PHSO) referrals and 3654 Patient Advice Liaison Service (PALS) within this period. Overall we have received more complaint and PALS concerns compared to the previous two quarters.
5.2 Group has consistent top categories for complaints at each Care Organisation, with Clinical Treatment the highest category in 3 out of the 4 CO’s in Q2 and Q3, 2018/19. Categories which feature regularly in the top 5 are, attitude and behaviour, communication and issues around appointments and admission. Patient care and competence were also in the top 5 for Q2 and Q3.
5.3 Complaints at each Care Organisation – Complaints received, PHSO and Patient Advice Liaison Service concerns – 2018/19 Q2 & Q3 comparison
Care Patient Advice Liaison Service Complaints received Organisation (PALS Q2 2018/19 Q3 2018/19 Q2 2018/19 Q3 2018/19 Northern Care Alliance – 353 351 1925 1729 Group Total Bury and 71 58 252 203 Rochdale North 95 85 262 243 Manchester SRFT & PAT # 274090 Salford 102 98 974 96504/27/2019 16:44:00 Oldham 85 110 437 318
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14/23 151/232 5.4 Parliamentary and Health Service Ombudsman Received/Closed/Upheld
Care Received Closed Upheld Organisation Q2 Q3 Q2 Q3 Q2 Q3 2018/19 2018/19 2018/19 2018/19 2018/19 2018/19 Northern Care Alliance 10 11 9 4 1 0 – Group Total Bury and 2 2 0 1 0 0 Rochdale North 4 2 3 1 1 0 Manchester Salford 2 5 3 0 0 0 Oldham 2 2 3 2 0 0
5.5 The Trust’s KPI for responding to complaints is that 90% of complaints are responded to within timescale, below are the compliance figures for each Care Organisation
Care Q2 Q3 Organisation July August September October November December Bury and 93% 92% 72% 89% 88% 80% Rochdale North 63% 66% 72% 62% 41% 70% Manchester Salford 90% 72% 83% 95% 94% 93% Oldham 73% 81% 62% 70% 80% 79%
5.6 Complaints at each Care Organisation - Top 5 categories Q2 and Q3 2018/19
Care 1st highest 2nd 3rd 4th 5th Organisation category Bury and Clinical Attitude and Date for Communication Out-patient Rochdale Treatment Behaviour Appointment Clinics North Clinical Attitude and Communication Date for Admission/ Manchester Treatment Behaviour Appointment Transfer and Discharge Salford Communication Clinical Values and Patient Care Admissions and Treatment behavior (staff) discharges Oldham Clinical Attitude and Admission/ Date for Communication Treatment Behaviour Transfer and Appointment Discharge
In order to reduce the amount of complaints and PALS, specific Complaints/customer care training (CARE Training) is going to be rolled out to ward areas within Care Organisations in an attempt to reduce the number of complaints noting attitude and behaviour.( second largest category)
Going forward as the category, clinical treatment makes up the majority of the complaint subject; it has been identified that this is too generic and from April 2019, the subject list willSRFT be more & PAT refined # 274090 to accurately reflect the reason for the complaint within the category Clinical Treatment04/27/2019 . 16:44:00
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15/23 152/232 5.7 Learning/changes from Group Complaints in Q2 and Q3 2018/19
5.7.1 CARE Training
The CARE training package is now being rolled out across all NCA Care Organisations. The training covers:
Communication: I was not told things; not being told things in a manner I could understand; lack of communication between Departments; lack of communication with relatives; being given information that was inaccurate. Attitude: the staff were rude towards me; staff were unwilling to help; staff made me feel a nuisance; staff were rude towards their colleagues. Responsiveness: staff failed to act on concerns in a timely manner; I had to ask repeatedly for assistance; staff did not escalate concerns soon enough. Evidence: staff did not write their actions in the records; staff did not provide enough detail in records; staff did not fill out forms for referral etc. appropriately.
The training aims to raise awareness around the subjects noted above and how complaints can be avoided around these issues. A complaint which has been anonymised against the particular ward/department is used as a reference and to instigate discussion around how things can be improved. For example, a patient may be unhappy with a staff member’s behaviour or attitude; if this resolved at ward level, then the patient will leave satisfied and positive about their experience in hospital.
5.7.2 Complaints Review Panel (Aligned across Group)
As part of the Group’s quality development in Complaints Management, the Complaints Review Panel, chaired by a Non-Executive Director, meets on a monthly basis to review a randomly selected complaint (a complaint that has been completed), in order to provide assurance to the Committees in Common that the Complaints service provided by the Care Organisation is appropriate and meets the requirements of the Local Authority and National Health Service Complaints (England) Regulations 2009 and Parliamentary and Health Service Ombudsman’s Principles of Good Complaint Handling:
1. Getting it right 2. Being customer focused 3. Being open and accountable 4. Acting fairly and proportionately 5. Putting things right 6. Seeking continuous improvement
There have been some action points arising from recent review panels including:
Redesign of bathrooms as they are poorly positioned to make them safer for patients. Further investigation into delays in in-patient imaging, such as x-rays when NG tubes are dislodged. The Director of Nursing for Oldham Care Organisation will ensure any delays are reported and monitored. Review of Mortality & Morbidity provision in a particular Care OrganisationSRFT & PAT # 274090 04/27/2019 16:44:00 5.7.3 Discharge Transport
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16/23 153/232 An issue was raised in a complaint regarding a patient’s discharge home via ambulance and the delay experienced whilst this transport was being booked. To ensure transport is booked as soon as the discharge plans have been confirmed, the Ward Clerk/Patient Flow Facilitator now books transport via the North West Ambulance Service (NWAS) web page. This change in process is highlighted on the discharge planning board within the ward to inform all staff of improved system. The status of booking transport for patients is noted on this board so all staff are aware where the discharge process is up to for each patient.
5.8 Compliments
Compliments and positive feedback are also collected and formally logged onto Datix to highlight examples of good practice and positive outcomes were staff have gone above and beyond for their patients. Staff are often complimented for their professionalism, care, compassion, understanding, friendliness, attention to detail and prompt action.
Compliments, positive feedback and good practice may be communicated to the PALS and Complaints teams, handed to staff in person or emailed into the designated email addresses. These are captured on Datix and can be logged by all departments/staff. The table below shows the number logged in Q2 and Q3 for all Care Organisations.
Care Organisation 2018/19 Q2 2018/19 Q3 Total Northern Care Alliance – Group Total 399 383 782 Bury and Rochdale 112 112 224 North Manchester 113 93 206 Salford 99 113 212 Oldham 75 65 140
As part of the launch of unified NCA Datix at Salford Care Organisation (SCO); the fully fledged compliments/ good practice feedback module (which has been in use within the North East Sector since August 2017) has been rolled out across SCO. This allows any member of staff to log a good practice/ compliment event directly onto Datix. Upon submission the positive feedback is emailed directly to the departmental manager for dissemination amongst the team and/or individual(s) named. As well as promoting a localisation of good feedback, this also alleviates some demand on the Salford PALS team who previously had all positive feedback bottlenecking through their service to manually distribute across SCO.
Examples of compliments are included in monthly Responsiveness Reports delivered to each of the Care Organisations Quality and People Experience Meeting.
6. Learning Improvements
Good learning practice is demonstrated across the NCA, which we capture and share across Group but there is room for improvement in both internal Group shared learning and learning from other organisations. Innovation and good practice is equally important to share across Group, whether initiated from robust governance and risk management or individuals or teamsSRFT improving & PAT patient # 274090 safety locally. 04/27/2019 16:44:00
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17/23 154/232 The next LFE report will provide additional insights into our evolving learning framework within the following areas.
Staff engagement and communication to understand where we are regarding our patient safety culture, how staff learn and how we enhance our learning culture. Patient Experience – You said we did, Friends and Family, Meet and Greet, NCA plan to deliver person – centred care, support and treatment, ‘I’ statements and ‘we will’ statements. Freedom to Speak Up Guardian – How we are learning from issues raised by staff with the FTSU teams - sharing newsletters to feedback outcomes. How we can provide support to ‘second victims’ of incidents and adverse events, to help staff who have been involved in a patient safety incident move forward. External Organisational learning – learning from others networking to share innovation, good practice and learning methodologies. The development of Patient Safety events to capture and showcase innovation and good practice, learn from experience and share across specialities and care organisations. (promoting a learning culture) How we can encourage Junior Doctors to increase their reporting of patient safety incidents.
SRFT & PAT # 274090 04/27/2019 16:44:00
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18/23 155/232 Appendix 1 – Enhanced Patient Observation Staff Guidance Cards – supporting the Falls team improve Mental Capacity Assessment for patients with cognitive impairment to prevent falls in these vulnerable patients
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19/23 156/232 Appendix 2. Salford Care Organisation Example Learning from Incidents Newsletter
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21/23 158/232 Appendix 3. Patient Care Alert – North East Sector only as Salford do not use the product.
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22/23 159/232 Appendix 4. – Sample slides from the draft Diabetes Management & SWAN End of Life and Bereavement Care Take 5
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23/23 160/232 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT)
Title of Report Patient & Service User Experience progress report (6 monthly update) Meeting Group Committees in Common
Author (s) Tammy Pike, Assistant Director of Service User Experience
Presented by Elaine Inglesby, Chief Nursing Officer Date 29th April 2019
Executive The purpose of this paper is to provide this committee with an update on the Summary delivery and progress of patient/service users experience across the 4 Care Organisations and corporate led programmes of work. Headline Updates;
National Surveys Adult Inpatients - initial Picker reports have been received (currently embargoed) and planning sessions arranged. Pennine ranked #8th as positive score change from last year’s survey (77 Trusts) Urgent & Emergency Care due to be published at the end of the month Friends & Family National review undertaken, awaiting outcomes of the final report Local Developed Feedback NES at present do not have standardised approach to local surveys, experience team developing toolkit to ensure good practice approach Pilot at Oldham has been significantly delayed due to issues with Hospedia collection of the data & reporting. Salford CO identified a significant shift in performance (negative) in their local inpatient data, resulting in a deep dive analysis. During this investigation major discrepancies were identified in the previous data provided by Picker which resulted in a suspension of current reporting. A full investigation by Picker has been requested. The PFCE still continues to provide assurance of you said/we did across the Care Organisation. Care Organisation Experience Steering/Meetings All now have established local experience meetings to identity development and delivery of local actions plan & implementation. Assurance is given that we have progress in development at all sites. (At a glance summary reports Appendix 1) Volunteers SRFT volunteers service were successful in a national project bid to deliver dining companions project and launched in April 2019 Restructure to commence by May 2019 Plan to deliver great care, support & treatment Currently being presented through NCA assurance process, with view to launch in June 2019 SRFT & PAT # 274090 04/27/2019 16:44:00 Annual Plan Pursuing quality improvement to assure safe, reliable and compassionate care Objective
1 1/6 161/232 Associated Risks Inefficacy in obtaining and utilising the patient/service user experience as an additional indicator for patient safety could potentially compromise the quality and safety of patient care.
Recommendations The Group Committees in Common is asked to review and note the content of the report and provide any further recommendations to the proposed actions to be taken.
Equality Does this paper relate to a matter where equality issues may arise? Y Yes the document has person-centred approach at its core, which moves us to establish systems which will enable us to identify and support individuals based on their individual needs. Freedom of This document does not contain confidential information and can be Information made available to the public. Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public. x
This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
Data Sharing Under the Data Sharing Agreement, the NCA may be required to Agreement with share this paper with MFT. This is distinct from information disclosed Manchester under the FOIA. As MFT will acquire part of PAT they will need to University NHS FT understand a range of matters which may otherwise be exempt under (MFT) in relation to FOI e.g. contracts to be split and specific workforce-related issues. the Transaction Please consider the statements below and indicate which applies in relation to this paper: a) This paper relates solely to PAT and can be released
b) This paper relates solely to SRFT and is therefore not eligible for release
c) This paper contains information relating to both PAT and SRFT. All information other than that relating to PAT will be x fully redacted.
d) This paper contains reference to both PAT and SRFT but contains no quality, finance or operational performance data relating to PAT which could be relevant to the transaction and is therefore not eligible for release.
SRFT & PAT # 274090 04/27/2019 16:44:00
2 2/6 162/232 1.0 Introduction 1.1 The purpose of this paper is to provide this committee with an update on the delivery and progress of patient/service users experience across the 4 Care Organisations and corporate led programmes of work.
1.2 In order for us to demonstrate that we are a learning and listening organisation, we should have clear evidence to a) capture views and experiences b) demonstrate that they review this feedback and c) use this feedback to identify areas of good practice and to use this drive improvement.
1.3 This paper focuses on key areas of work, which have been aligned to CQC key lines of enquiry; Are we a caring organisation (how do we capture & what does the feedback tell us)? - National Surveys & Friends & Family Test - Near Real time Feedback Are we responsive (how do we review and use feedback)? - Using feedback to drive improvements - Wider engagement with patients & service users
2.0 Are our services caring (what does feedback tell us about service user experience)? 2.1 National Survey Results 2.1.1 Action Plans & Progress Each care organisation has existing action plans in progress which are reviewed and developed in light of the latest survey results and key strategic priorities. These action plans have also been used to develop key programmes of work within their emerging local Patient/Service User Experience committees
2.1.2 National Inpatient Survey 2018 (currently under embargo by the CQC) Initial Picker reports have been received for Pennine & Salford, headlines results are outlined below, 77 organisations opted for Picker to run their surveys. Pennine Acute 34% response rate (29% last year) 96% overall treated with dignity & respect 80% overall rated experience as 7/10 and 89% involved as much as wanted in decisions. Overall positive score change from last year #8th from all picker trusts with average positive score ranking #58th.
Historical comparison; 60 no difference 1 significantly better 1 significantly worse Comparison with average: 15 no difference 17 significantly worse
Salford 33% response (34% last year) 97% overall treated with dignity & respect, 86% rated experience as 7/10 or more and 97% for Doctors; had confidence & trust. Overall positive score change from last year ranked #47th from all Picker Trusts with average positive score ranking #30th
Historical comparison; 56 no difference 0 significantly better 5 significantly worse Comparison with average: 53 no difference 6 significantly better 3 significantly worse
All Care Organisations have received a copy of the full report and supportedSRFT & by PAT the # experience 274090 04/27/2019 16:44:00 team will be arranging feedback/action planning sessions with Picker.
3 3/6 163/232 2.1.3 The National Urgent and Emergency Care 2018 (currently under embargo) The draft Picker results are due to land by the end of the month and will be shared with relevant care organisations, as with the adult inpatient survey the experience team will work with Picker to co-ordinate feedback/action planning sessions.
2.1.4 Maternity 2018 Both North & Oldham divisions attended the relevant Picker feedback sessions in January 2019, the event was well attended and a significant amount of work was agreed in relation to celebrating good practice and areas for improvement. Assurance has been given that good progress has been made in relation to the action plan developed at both sites.
2.1.5 Children’s and Young People 2017 North has an established action plan which shows progress being made and they have plans to establish a C&YP experience group by then end of May. Oldham are currently working through reviewing their assurance and reporting on C&YP and updates will be provided to the CO’s experience committee by the end of May 2019.
2.3 Near/Real Time Feedback 2.3.1 Friends & Family Test The experience team has commenced significant programme of work to improve FFT data reporting and has identified a number of data reporting issues across the north east sector which are linked to the inability of current IT systems to effectively transfer required data. On- going discussions and actions are being implemented led by the experience team and supported by corporate information lead & business information teams.
All Care Organisation’s now receive their comments as separate files which can be cascaded across the organisation to drive improvements, this data can now be used to demonstrate they are reviewing this feedback and developing ‘you said/we did’ in response.
2.3.2 National Review & Update Over the last 12 months, NHS England & NHS Improvement have led a national review of the FFT, an options paper has been submitted to Chief Executive and we are waiting for the revised guidance to be released which is anticipated to be May 2019.
Action The experience team will lead a review once we have sight of the new standards.
2.3.3 Local Surveys Salford Care Organisation At November’s QPE it was highlighted that a number of indicators on performance report for experience showed a deteriorating position (still within normal variation). The organisation were aware there have been on going issues with accessing the PickerSRFT site for& PAT front-line # 274090 staff. 04/27/2019 16:44:00 However, assurance had been given that a number of temporary work-arounds were in place/development to resolve this matter. Divisions were asked to review their performance against these overall performance indicators and report back on any actions taken.
4 4/6 164/232 At December’s QPE it was reported that the data indicated a significant shift (negative). The Information team, supported by the experience team, were asked to undertake a deep of this data. Initial investigations indicated a number of influencing factors, however, it later transpired there were major discrepancies in the data reported over the last 18 months by Picker.
Action The Director of Nursing requested an immediate meeting to discuss the impact of this on this on the reporting of this data through QPE. It was agreed that; an urgent investigation of this issue would be requested to Picker, a temporary hold on the reporting of the KPI’s to QPE, plus a comprehensive review of the current reporting/assurance system on experience across the CO to understand what challenges this situation brings but also opportunities.
2.3.4 The Patient, Family, Carer collaborative is still running which provides on-going evidence of assurance of using feedback to drive improvements with a QI and you said/we did approach along with a number of other initiatives (e.g. outpatient RIE, dining companions project, partnership working with Salford Carers).
2.3.5 Hospedia pilot at Oldham The patient experience team have looked at progressing with Hospedia the hosting of local surveys via the bedside units across all Care Organisations which has been in place at SRFT for some time. There have been some challenges due to capability of the current systems. A trial phase was launched last year by the previous Head of Experience however, there have been major issues with engaging with Hosepdia and we do not have assurance that the data is accurate.
Action This has been escalated to the Associate Director of Patient Responsiveness.
2.3.6 Supporting teams across the NCA to develop local data collection In the absence of a standardised approach to local surveys across the NE sector, the experience team are in the process of developing a more robust system to support areas in the development of local surveys using tried & tested questions.
3 Are we responsive (how do we review and use feedback)? 3.3 Using Feedback to drive improvements 3.3.1 SRFT has a well-established improvement model through its Patient, Family and Carer Experience collaborative, where each ward/departments has to demonstrate that it uses feedback to drive improvements and implement ‘test of change’. The interim Director of Nursing has instigated a full review of how experience is developed and reported across the care organisation which will commence at the end of April. SRFT & PAT # 274090 04/27/2019 16:44:00 3.3.2 Fairfield & Rochdale has developed an Experience Steering group, which has 5 key work streams including developing local surveys and Always Events, and work has progressed well over the last 12 months. With the development of the draft NCA Plan on experience, the Care
5 5/6 165/232 Organisation has decided to review of its current work streams in light of this emerging work. The experience & QI team are supporting this review.
3.3.3 Royal Oldham has made significant progress with the development of its local priorities which focus on 7 key work streams that also align to key pieces of improvement work.
3.3.4 North Manchester has recently established its local experience committee and identified key priorities which also align to its improvement programmes of work.
3.3.5 Assurance has been provided by all Care Organisations, through their local committees, that they are making progress at a local level to establish more robust and focused programmes of work to improve the experience of the people that access their services.
3.4 Other Corporate Led programmes of work 3.4.1 The NCA Plan to deliver great care, support and treatment. The experience team has led a significant piece of work to truly understand ‘what matters most’ to the people with lived experience that access our services taking a joint-working approach. The approach focuses on the key elements of great care, support and treatment, is clear concise, speaks to all parts of the NCA including social care, considers inclusion and is in the words of the people that use these services. The plan is currently going through the NCA assurance process and will be launched in June
3.4.2 Observe & Act (real time feedback pilot) Trials have worked extremely well across the sites and the experience team have now attended train the trainer training. Over the next few months we will be working with volunteers to develop the role and recruit suitable volunteers.
3.4.3 Elective Access Improvement Programme – a co-design approach The experience team are supporting this NCA programme of work in partnership with AQUA, to develop a co-design approach with lived experiences experts. Engagement plans are currently being finalised with service users & staff. As part of this work a Rapid Improvement Event has been held at SRFT with volunteers Meet & Greet service across main outpatients.
3.4.4 Volunteers The volunteer team has identified a series of improvement work streams to streamline the recruitment/induction process, improve the tracking and monitoring of induction/mandatory training and develop an NCA strategy & policy. There have been a number of barriers due to varying access to both IMT systems and support provided by corporate services. However, these are currently being worked through.
SRFT volunteer team were successful in their bid for £75,000, through Helpforce, to develop dining companions project across Salford, then across the NCA and atSRFT scale & nationally. PAT # 274090 04/27/2019 16:44:00
6 6/6 166/232 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute NHS Hospitals NHS Trust (PAT)
Annual Self Certifications: − General Condition: G6 Systems for compliance with licence conditions and related obligations Title of Report − NHS Foundation Trust Condition FT4: Governance arrangements including Training of Governors − Foundation Trusts only: Continuity of Services Condition CoS7: Availability of Resources
Meeting Group Committees in Committee Rebecca McCarthy, Deputy Trust Secretary Author Jane Burns, Group Secretary Presented by Jane Burns, Group Secretary Date 29th April 2019
Executive NHS foundation trusts are required to self-certify whether or not they have Summary complied with the conditions of the NHS provider licence; whether or not they have complied with governance requirements; and that they have the required resources available if providing commissioner requested services.
Although NHS trusts are not issued with a provider licence, they are also required to self-certify whether or not they have complied with conditions equivalent to the licence that NHS Improvement has deemed appropriate, as described below.
The following declarations are required:
Condition G6 (3): Providers must certify that they have taken all precautions necessary to comply with the licence, NHS Act and NHS Constitution (Condition G6 (3))
Condition FT4 (8): Providers must certify compliance with required governance arrangements (including Training of Governors)
Foundation Trusts only - Condition CoS7 (3): Providers providing commissioner requested services (CRS) must certify that they have a reasonable expectation that required resources will be available to deliver the designated service.
Although there is no submission requirement; provider Boards must confirm that they understand clearly and can confirm compliance with the above conditions.
Boards must sign off on self-certifications no later than: a. Condition G6/Condition CoS7 – 31 May 2019 b. Condition FT4 – 30 June 2019 c. Condition CoS7 (3) – 31 May 2019
Following the above dates, NHS Improvement (NHSI) may audit select providers with respect to the self-certification. SRFT & PAT # 274090 04/27/2019 16:44:00 This year’s annual self-certification review has been completed to encompass compliance for the Northern Care Alliance NHS Group (NCA) including its statutory bodies, Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute Hospitals NHS Trust (PAHT). 1
1/29 167/232 Annual Plan N/A Objective Principal N/A Associated Risks Recommendations The Group Committees in Common is asked to approve this year’s annual self- certifications as described within this paper, subject to review by the Audit Committee on the 24th May 2019.
Equality Does this paper relate to a matter where equality issues may arise? N If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and can be Information made available to the public. X
Please ‘cross’ one This document contains some confidential information that would need to of the boxes be redacted before the document was made available to the public.
This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
Data Sharing Under the Data Sharing Agreement, the NCA may be required to share Agreement with this paper with MFT. This is distinct from information disclosed under the Manchester FOIA. As MFT will acquire part of PAT they will need to understand a University NHS FT range of matters which may otherwise be exempt under FOI e.g. (MFT) in relation to contracts to be split and specific workforce-related issues. the Transaction
Please consider the statements below and indicate which applies in relation to this paper:
a) This paper relates solely to PAT and can be released
b) This paper relates solely to SRFT and is therefore not eligible for release
c) This paper contains information relating to both PAHT and SRFT. All information other than that relating to PAHT will be fully redacted.
d) This paper contains reference to both PAHT and SRFT but contains no quality, finance or operational performance data X relating to PAHT which could be relevant to the transaction and is therefore not eligible for release.
SRFT & PAT # 274090 04/27/2019 16:44:00
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2/29 168/232 1. General Condition G6
1.1 General Condition 6 within the Licence requires providers to have in place effective systems and processes to ensure compliance with licence conditions and related obligations.
1.2 A management review has been undertaken confirming compliance with General Condition 6 of the NHS Provider Licence (Appendix 1). This supports the review that has also taken place of all Licence Conditions for SRFT (Appendix 2).
1.3 SRFT and PAHT are required to publish a G6 self-certification (Appendix 3) within a month following Board sign off.
2. Condition FT4 including Training for Governors
2.1 Condition FT4 within the Licence sets out provisions relating to principles, systems and standards of good corporate governance. The Corporate Governance Statement includes the provisions set out in Condition FT4. A description of the principal risks to compliance with Condition FT4, and actions identified to mitigate those risks, are included within the SRFT and PAHT Annual Governance Statements (which will form part of the respective Annual Reports to be submitted on 29th May 2019).
2.2 A management review of the Corporate Governance Statement and Training of Governors has been undertaken. Please see attached Appendix 4 and 5 respectively.
3. Foundation Trusts only: Condition CoS7
3.1 Foundation Trust providers, providing commissioner requested services (CRS), must certify that they have a reasonable expectation that required resources will be available to continue to provide those services.
3.2 A management review of the availability of resources has been undertaken (Appendix 6).
SRFT & PAT # 274090 04/27/2019 16:44:00
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3/29 169/232 Appendix 1: General Condition 6 - Management Review
General Condition 6 Current Arrangements/Evidence The Licensee shall take all reasonable precautions against Comprehensive business planning process in place including: the risk of failure to comply with: − First submission to NHSI - 14th January including activity plans and G&A bed numbers (a) the Conditions of this Licence, − Executives finalise governing strategic objectives and share with Care Organisations (End January) (b) any requirements imposed on it under the NHS Acts, − Care Organisations review of 2018/19 plans, identifying successes and matters for carry over, align and transformation/strategic objectives to Group governing objectives, outline Business As Usual objectives and (c) the requirement to have regard to the NHS determine objectives relating to specific Care Organisation service improvements (January – End February) Constitution in providing health care services for the − Care Organisation review of delivery plans with divisions - focussing on capacity planning, efficiency plans (End purposes of the NHS. January – February) − Session with CCGs to review activity with baseline plans and assumptions in locality plans (January – February) − Care Organisation present draft plans to Group Executives, agree commitment to budgets and BCLC plans − Annual Plan sharing session with all Corporate Teams to ensure alignment (March) − Second draft operational submission to NHSi (Early March) − Group CiC approval of Annual Plan (End March) − Final organisational submission to NHSi (April) − Quarterly review of progress against Care Organisation priorities
The SRFT/PAHT Operational and Financial Plans 2018/19, submitted to NHSI at the beginning of April 2019, comprise a series of Assurance Statements, templates and declarations, including the Finance, Activity and Workforce returns. The Operational and Financial Plans 2019/20 are based on understanding of demand and capacity, alignment between commissioners and providers and development of local/integrated Care Organisations.
Group and Care Organisation priorities, objectives and success measures reflect the aims described in the Operational Plans and ensure objectives are specific and measurable with clearly defined deliverables. The Group Assurance Framework, including Care Organisation Assurance Frameworks mirror the Operational Plans and assess risk to delivery.
The Group CiC has established and operates an oversight framework for each of its Care Organisations, called the Group Single Oversight Framework (Group SOF). The Group SOF provides assurance on delivery of the Care Organisation Annual Plan objectives and supports quality and performance improvement. The five themes of the Group SOF reflect those of the NHS Single Oversight Framework (which bases its oversight on the NHS provider licence): Quality of care Finance and use of resources Operational performanceSRFT & PAT # 274090 Strategic change 04/27/2019 16:44:00 Leadership and improvement capability (well-led) A sixth cross cutting theme of Leadership, Behaviours and Culture will be added in 2019/20. Approved Group Governance Framework Manual - Sets out the control framework within which the Group’s and Care 4
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General Condition 6 Current Arrangements/Evidence Organisations objectives are delivered. The Manual complements the Trust’s Constitution and Licence and takes full account of the NHS Foundation Trust Code of Governance. The Manual highlights processes and systems in place to oversee constitutional, regulatory and legal compliance. The Manual incorporates Reservation of Powers and Delegation of Powers, Detailed Scheme of Delegation and Standing Financial Instructions. Group Governance Framework Manual is refreshed on an annual basis and will next be reviewed by Group Risk and Assurance Committee (GRAC) and Audit Committee (May 2019).
In March 2018, the Group Committees in Common approved an NCA Risk Management Strategies. The NCA Risk Management Strategy provides a framework for managing risks across the Group and Care Organisations, which is consistent with best practice and Department of Health guidance. The Strategy provides a clear, systematic approach to the management of risks to ensure that risk assessment is an integral part of clinical, managerial and financial processes across the organisation for the benefit of patients, staff, visitors and other stakeholders.
SRFT and PAHT are registered with the Care Quality Commission and systems exist to ensure compliance with the registration requirements, detailed in the respective Annual Governance Statements. SRFT: CQC Inspection – ‘Outstanding’ August 2018. PAHT: CQC Inspection – ‘Requires Improvement’ March 2018.
2018/19 Corporate Governance Statements – Reviewed by Group Committees in Common (April 2019) and Audit Committee (May 2019). Recommendation: No material risks identified.
NHS Foundation Trust – Code of Governance Annual Review 2018/19. Although the Code is relevant to NHS Foundation Trusts, the review undertaken in April 2019 encompassed compliance for the Northern Care Alliance NHS Group (NCA). Review of compliance with each provision undertaken by the Group Committees in Common in April 2019. The SRFT Annual Report 2018/19 will confirm compliance with the provisions of the Code and an explanation of why the Trust has departed from B.7.1.
Audit Committee considered and approved the SRFT/PAHT Internal Audit Plan for 2018/19 (April 18). The Internal Audit Plans were risk based, with an ongoing programme of internal audits in finance, operations and governance. During the course of the year, Audit Committee monitored progress against the Internal Audit Plans and reviewed the work and findings of the Internal Auditor. The NCA Internal Audit Assurance Framework Review 2018/19 confirmed that ‘the organisation’s Assurance Framework is structured to meet the NHS requirements, is visibly used by the Board and clearly reflects the risks discussed by the Board.’ SRFT & PAT # 274090 Audit Committee reviewed the work04/27/2019 and findings of 16:44:00the External Auditor during 2018/19, including valuable insight and benchmarking information.
SRFT/PAHT Annual Report and Annual Accounts 2018/19 – Prepared in accordance with Annual Reporting Manual for 5
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General Condition 6 Current Arrangements/Evidence NHS Foundation Trusts and the Department of Health Group Annual Reporting Manual 2018-19.
SRFT/PAHT Quality Reports 2018/19 – Prepared in line with detailed requirements for Quality Reports 2018/19.
Submission of compliance reports to NHS Improvement as required.
SRFT: Review of all Licence conditions including General, Pricing, Choice and Competition, Integrated Care, Continuity of Service and NHS Foundation Trust Conditions (Appendix 2). Without prejudice to the generality of paragraph 1, the The NCA’s Group Assurance Framework, is based on six key elements: steps that the Licensee must take pursuant to that Clearly defined principal objectives agreed with stakeholders together with clear lines of responsibility and paragraph shall include: accountability; (a) the establishment and implementation of processes Clearly defined principal risks to the achievement of these objectives together with assessment of their potential and systems to identify risks and guard against their impact and likelihood; occurrence; and Key controls by which these risks can be managed, this includes involvement of stakeholders in agreeing controls (b) regular review of whether those processes and where risks impact on them; systems have been implemented and of their Management and independent assurances that risks are being managed effectively; effectiveness. Board level reports identifying that risks are being reasonably managed and objectives being met together with gaps in assurances and gaps in risk control; Board level action plans which ensure the delivery of objectives, control of risk and improvements in assurances.
The workplan of committees within the NCA’s Assurance Framework is linked so that the Group CiC is assured that there is an aligned independent and executive focus on strategic risk and assurance. Routine referral of issues exists between committees ensuring a respective understanding of risk and assurance concerns.
The Group CiC oversees the management of all major risks, which are actively addressed by the Group Risk and Assurance Committee. The NCA Corporate Risk Register is integrated with the Board Assurance Framework thereby ensuring that risks are not only managed and communicated efficiently, but that the management of them is embedded in the NCA’s practice. The NCA Board Assurance Framework/Corporate Risk Registers is reviewed on a quarterly basis, alongside the Care Organisation Board Assurance Framework/Corporate Risk Registers. Key controls and assurances, and any identified gaps are continually reviewed and action plans developed and progressed accordingly. All significant risks are detailed within the monthly Group Performance Dashboard presented to the Group CiC by the Chief Executive Officer. SRFT & PAT # 274090 Audit Committee reviews the Board04/27/2019 Assurance Framework/Corporate 16:44:00 Risk Register and commissions additional reviews where appropriate in order to provide necessary assurance to the Group CiC.
In the latter part of 2018/19, the NCA completed a Self-Assessment against the Well-Led Framework for Governance.
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General Condition 6 Current Arrangements/Evidence Mersey Internal Audit (MIAA) conducted an independent review of the self-assessment, considering comprehensiveness and sources of evidence, in order to provide further assurance with respect to compliance with the Key Lines of Enquiry (KLOEs). The outcome of the independent review, in summary, concluded that the position statements were comprehensive and presented a compelling and positive picture of the NCA. It added that the thoroughness and quality of the self-assessment placed the NCA in a strong and informed position in terms of selecting an external review approach that adds most value (if and when appropriate).
Annual Governance Statements – To be reviewed by Audit Committee, April 2019 confirming “The Board had extensive and effective governance assurance systems in operation enabling the identification and control of risks reported through the Board Assurance Framework and Corporate Risk Register. Internal and external reviews, audits and inspections had provided sufficient evidence to state that no significant internal control issues have been identified during 2018/19, and that these control systems are fit for purpose.”
The SRFT/PAHT financial plan is approved by the Group CiC and the SRFT/PAHT Board of Directors. It is subsequently submitted to NHS Improvement. The plan, including forward projections, is monitored on a monthly basis by the Care Organisation Finance Governance Committees. The Care Organisation provide a monthly Statement of Assurance to the GRAC which confirms the sufficiency of plans for the effective use of resources. Key performance indicators and financial sustainability metrics are also reviewed monthly by the Group CiC.
SRFT: A process of self-assessment of CQC Fundamental Standards of Quality and Safety (previously Essential Standards) is in place and undertaken annually by each service. All of the CQC Fundamental Standards of Quality and Safety have an identified lead within the organisation and provide compliance evidence and evaluation to relevant Corporate Governance Committee on an annual basis. NCA: An internal CQC mock assessment programme is in operation whereby unannounced visits take place across each of the departments that do not take part in the NAAS/CAAS process. Assurance is provided by Audit Committee, which monitors the outcome of the mock assessment programme in-year and commissions specific reviews by the Trust’s internal auditors.
Group Audit Committee review of: − Register of Interests for Senior Staff and Gifts and Hospitality Registers to ensure compliance with the Trust’s Standards of Business (Annual) − The arrangements by which staff can raise issues in confidence about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters to ensure arrangements are in place for the proportionate and independent investigation of such matters and appropriate follow-up action (Annual) SRFT & PAT # 274090 − Group Governance Framework04/27/2019 Manual (Annual) 16:44:00 − Counter Fraud Plans and Reports − Internal Audit Annual Programme, progress reports and audit outcomes e.g. recent audit of risk register
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General Condition 6 Current Arrangements/Evidence processes undertaken − Clinical Audit Annual Programme and Developments − All risk and control related disclosure statements in particular the Annual Governance Statement, Corporate Governance Statement, together with the accompanying Head of Internal Audit statement and External Audit Opinion.
SRFT & PAT # 274090 04/27/2019 16:44:00
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8/29 174/232 Appendix 2: SRFT ONLY – Full Conditions of Licence Review
NB. Monitor is now part of NHS Improvement.
Condition G1: Provision of information 1. Subject to paragraph 3, and in addition to obligations under other Conditions of this Licence, the Licensee shall furnish to Monitor such information and Confirmed documents, and shall prepare or procure and furnish to Monitor such reports, as Monitor may require for any of the purposes set out in section 96(2) of the 2012 Act. 2. Information, documents and reports required to be furnished under this Condition shall be furnished in such manner, in such form, at such place and at such Confirmed times as Monitor may require 3. In furnishing information documents and reports pursuant to paragraphs 1 and 2 the Licensee shall take all reasonable steps to ensure that: Confirmed (a) in the case of information or a report, it is accurate, complete and not misleading; (b) in the case of a document, it is a true copy of the document requested; and 4. This Condition shall not require the Licensee to furnish any information, documents or reports which it could not be compelled to produce or give in evidence Confirmed in civil proceedings before a court because of legal professional privilege. Condition G2: Publication of information 1. The Licensee shall comply with any direction from Monitor for any of the purposes set out in section 96(2) of the 2012 Act to publish information about health Confirmed care services provided for the purposes of the NHS and as to the manner in which such information should be published. 2. For the purposes of this condition “publish” includes making available to the public, to any section of the public or to individuals. Confirmed Condition G3: Payment of fees to Monitor 1. The Licensee shall pay fees to Monitor in each financial year of such amount as Monitor may determine for each such year or part thereof in respect of the Confirmed exercise by Monitor of its functions for the purposes set out in section 96(2) of the 2012 Act 2. The Licensee shall pay the fees required to be paid by a determination by Monitor for the purpose of paragraph 1 no later than the 28th day after they Confirmed become payable in accordance with that determination. Condition G4: Fit and proper persons as Governors and Directors 1. The Licensee shall ensure that no person who is an unfit person may become or continue as a Governor, except with the approval in writing of Monitor Confirmed 2. The Licensee shall not appoint as a Director any person who is an unfit person, except with the approval in writing of Monitor. Confirmed 3. The Licensee shall ensure that its contracts of service with its Directors contain a provision permitting summary termination in the event of a Director being or Confirmed becoming an unfit person. The Licensee shall ensure that it enforces that provision promptly upon discovering any Director to be an unfit person, except with the approval in writing of Monitor. 4. If Monitor has given approval in relation to any person in accordance with paragraph 1, 2, or 3 of this condition the Licensee shall notify Monitor promptly in Confirmed writing of any material change in the role required of or performed by that person. Condition G5 – Monitor guidance 1. Without prejudice to any obligations in other Conditions of this Licence, the Licensee shall at all times have regard to guidance issued by Monitor for any of the Confirmed purposes set out in section 96(2) of the 2012 Act. 2. In any case where the Licensee decides not to follow the guidance referred to in paragraphSRFT 1 &or guidancePAT # issued274090 under any other Conditions of this licence, it Confirmed 04/27/2019 16:44:00 shall inform Monitor of the reasons for that decision. Condition G6 – Systems for compliance with licence conditions and related obligations 1. The Licensee shall take all reasonable precautions against the risk of failure to comply with: Confirmed
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(a) the Conditions of this Licence, (b) any requirements imposed on it under the NHS Acts, and (c) the requirement to have regard to the NHS Constitution in providing health care services for the purposes of the NHS. 2. Without prejudice to the generality of paragraph 1, the steps that the Licensee must take pursuant to that paragraph shall include: Confirmed (a) the establishment and implementation of processes and systems to identify risks and guard against their occurrence; and (b) regular review of whether those processes and systems have been implemented and of their effectiveness. 3. Not later than two months from the end of each Financial Year, the Licensee shall prepare and submit to Monitor a certificate to the effect that, following a Confirmed review for the purpose of paragraph 2(b) the Directors of the Licensee are or are not satisfied, as the case may be that, in the Financial Year most recently (No requirement to ended, the Licensee took all such precautions as were necessary in order to comply with this Condition. submit a certificate to NHSI for 2018/19 – self certification) 4. The Licensee shall publish each certificate submitted for the purpose of this Condition within one month of its submission to Monitor in such manner as is Confirmed likely to bring it to the attention of such persons who reasonably can be expected to have an interest in it. Condition G7 – Registration with the Care Quality Commission 1. The Licensee shall at all times be registered with the Care Quality Commission in so far as is necessary in order to be able lawfully to provide the services Confirmed authorised to be provided by this Licence. 2. The Licensee shall notify Monitor promptly of: Confirmed (a) any application it may make to the Care Quality Commission for the cancellation of its registration by that Commission, or (b) the cancellation by the Care Quality Commission for any reason of its registration by that Commission. 3. A notification given by the Licensee for the purposes of paragraph 2 shall: Confirmed (a) be made within 7 days of: (i) the making of an application in the case of paragraph (a), or (ii) becoming aware of the cancellation in the case of paragraph (b), and (b) contain an explanation of the reasons (in so far as they are known to the Licensee) for: (i) the making of an application in the case of paragraph (a), or (ii) the cancellation in the case of paragraph (b). Condition G8 – Patient eligibility and selection criteria 1. The Licensee shall: Confirmed (a) set transparent eligibility and selection criteria, (b) apply those criteria in a transparent way to persons who, having a choice of persons from whom to receive health care services for the purposes of the NHS, choose to receive them from the Licensee, and (c) publish those criteria in such a manner as will make them readily accessible by any persons who could reasonably be regarded as likely to have an interest in them. Condition G9 – Application of Section 5 (Continuity of Services) SRFT & PAT # 274090 1. The Conditions in Section 5 shall apply: 04/27/2019 16:44:00 Confirmed (a) whenever the Licensee is subject to a contractual or other legally enforceable obligation to provide a service which is a Commissioner Requested Service, and (b) from the commencement of this Licence until the Licensee becomes subject to an obligation of the type described in sub-paragraph (a), if the Licensee is an 10
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NHS foundation trust which: (i) was not subject to such an obligation on commencement of this Licence, and (ii) was required to provide services, or was party to an NHS contract to provide services, as described in paragraph 2(a) or 2(b); for the avoidance of doubt, where Section 5 applies by virtue of this subparagraph, the words “Commissioner Requested Service” shall be read to include any service of a description falling within paragraph 2(a) or 2(b). 2. A service is a Commissioner Requested Service if, and to the extent that, it is: Confirmed (a) any service of a description which the Licensee, being an NHS foundation trust with an authorisation date on or before 31 March 2013, was required to provide in accordance with condition 7(1) and Schedule 2 in the terms of its authorisation by Monitor immediately prior to the commencement of this Licence, or (b) any service of a description which the Licensee, being an NHS foundation trust with an authorisation date on or after 1 April 2013, was required to provide pursuant to an NHS contract immediately before its authorisation date, or (c) any other service which the Licensee has contracted with a Commissioner to provide as a Commissioner Requested Service 3. A service is also a Commissioner Requested Service if, and to the extent that, not being Confirmed a service within paragraph 2:Section 1 – General Conditions 12 (a) it is a service which the Licensee may be required to provide to a Commissioner under the terms of a contract which has been entered into between them, and (b) the Commissioner has made a written request to the Licensee to provide that service as a Commissioner Requested Service, and either (c) the Licensee has failed to respond in writing to that request by the expiry of the 28th day after it was made to the Licensee by the Commissioner, or (d) the Commissioner, not earlier than the expiry of the [28th] day after making that request to the Licensee, has given to Monitor and to the Licensee a notice in accordance with paragraph 4, and Monitor, after giving the Licensee the opportunity to make representations, has issued a direction in writing in accordance with paragraph 5. 4. A notice in accordance with this paragraph is a notice: Confirmed (a) in writing, (b) stating that the Licensee has refused to agree to a request to provide a service as a Commissioner Requested Service, and (c) setting out the Commissioner’s reasons for concluding that the Licensee is acting unreasonably in refusing to agree to that request to provide a service as a Commissioner Requested Service 5. A direction in accordance with this paragraph is a direction that the Licensee’s refusal to provide a service as a Commissioner Requested Service in response to Confirmed a request made under paragraph 3(b) is unreasonable 6. The Licensee shall give Monitor not less than [28] days’ notice of the expiry of any contractual obligation pursuant to which it is required to provide a Confirmed Commissioner Requested Service to a Commissioner for which no extension or renewal has been agreed. 7. If any contractual obligation of a Licensee to provide a Commissioner Requested Service expires without extension or renewal having been agreed between Confirmed the Licensee and the Commissioner who is a party to the contract, the Licensee shall continue to provide that service on the terms of the contract (save as agreed with that Commissioner), and the service shall continue to be a Commissioner Requested Section 1 – General Conditions13 Service, for the period from the expiry of the contractual obligation until Monitor issues either: SRFT & PAT # 274090 (a) a direction of the sort referred to in paragraph 8, or 04/27/2019 16:44:00 (b) a notice in writing to the Licensee stating that it has decided not to issue such a direction. 8. If, during the period of a contractual or other legally enforceable obligation to provide a Commissioner Requested Service, Monitor issues to the Licensee a Confirmed direction in writing to continue providing that service for a period specified in the direction, then for that period the service shall continue to be a 11
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Commissioner Requested Service. 9. No service which the Licensee is subject to a contractual or other legally enforceable obligation to provide shall be regarded as a Commissioner Requested Confirmed Service and, as a consequence, no Condition in Section 5 shall be of any application, during any period for which there is in force a direction in writing by Monitor given for the purposes of this condition and of any equivalent condition in any other current licence issued under the 2012 Act stating that no health care service provided for the purposes of the NHS is to be regarded as a Commissioner Requested Service. 10. A service shall cease to be a Commissioner Requested Service if: Confirmed (a) all current Commissioners of that service as a Commissioner Requested Service agree in writing that there is no longer any need for the service to be a Commissioner Requested Service, and Monitor has issued a determination in writing that the service is no longer a Commissioner Requested Service, or (b) Monitor has issued a determination in writing that the service is no longer a Commissioner Requested Service; or (c) it is a Commissioner Requested Service by virtue only of paragraph 2(a) above and 3 years have elapsed since the commencement of this Licence; or (d) it is a Commissioner Requested Service by virtue only of paragraph 2(b) above and either 3 years have elapsed since 1 April 2013 or 1 year has elapsed since the commencement of this Licence, whichever is the later; or (e) the contractual obligation pursuant to which the service is provided has expired and Monitor has issued a notice pursuant to paragraph 7(b) in relation to the service; or Section 1 – General Conditions 14 (f) the period specified in a direction by Monitor of the sort referred to in paragraph 8 in relation to the service has expired. 11. The Licensee shall make available free of charge to any person who requests it a statement in writing setting out the description and quantity of services which Confirmed it is under a contractual or other legally enforceable obligation to provide as Commissioner Requested Services. 12. Within [28] days of every occasion on which there is a change in the description or quantity of the services which the Licensee is under a contractual or other Confirmed legally enforceable obligation to provide as Commissioner Requested Services, the Licensee shall provide to Monitor in writing a notice setting out the description and quantity of all the services it is obliged to provide as Commissioner Requested Services. 13. Unless it is proposes to cease providing the service, the Licensee shall not make any application to Monitor for a determination in accordance with paragraph Confirmed 10(b): (a) in the case of a service which is a Commissioner Requested Service by virtue only of paragraph 2(a) above, in the period of 3 years since the commencement of this Licence or (b) in the case of a service which is a Commissioner Requested Service by virtue only of paragraph 2(b), in the period until the later of 1 April 2016 or 1 year from the commencement of this Licence. Condition P1 – Recording of information 1. If required in writing by Monitor, and only in relation to periods from the date of that requirement, the Licensee shall: Confirmed (a) obtain, record and maintain sufficient information about the costs which it expends in the course of providing services for the purposes of the NHS and other relevant information, and (b) establish, maintain and apply such systems and methods for the obtaining, recording and maintaining of such information about those costs and other relevant information, as are necessary to enable it to comply with the following paragraphs of this Condition. 2. From the time of publication by Monitor of Approved Reporting Currencies the LicenseeSRFT shall & maintain PAT # records 274090 of its costs and of other relevant information Confirmed broken down in accordance with those Currencies by allocating to a record for each such04/27/2019 Currency all costs 16:44:00 expended by the Licensee in providing health care services for the purposes of the NHS within that Currency and by similarly treating other relevant information. 3. In the allocation of costs and other relevant information to Approved Reporting Currencies in accordance with paragraph 2 the Licensee shall use the cost Confirmed allocation methodology and procedures relating to other relevant information set out in the Approved Guidance. 12
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4. If the Licensee uses sub-contractors in the provision of health care services for the purposes of the NHS, to the extent that it is required to do so in writing by Confirmed Monitor the Licensee shall procure that each of those sub-contractors: (a) obtains, records and maintains information about the costs which it expends in the course of providing services as sub-contractor to the Licensee, and establishes, maintains and applies systems and methods for the obtaining, recording and maintaining of that information, in a manner that complies with paragraphs 2 and 3 of this Condition, and (b) provides that information to Monitor in a timely manner. 5. Records required to be maintained by this Condition shall be kept for not less than six years. Confirmed
Condition P2 – Provision of information 1. Subject to paragraph 3, and without prejudice to the generality of Condition G1, the Licensee shall furnish to Monitor such information and documents, and Confirmed shall prepare or procure and furnish to Monitor such reports, as Monitor may require for the purpose of performing its functions under Chapter 4 in Part 3 of the 2012 Act. 2. Information, documents and reports required to be furnished under this Condition shall be furnished in such manner, in such form, at such place and at such Confirmed times as Monitor may require. 3. In furnishing information documents and reports pursuant to paragraphs 1 and 2 the Licensee shall take all reasonable steps to ensure that: Confirmed (a) in the case of information or a report, it is accurate, complete and not misleading; (b) in the case of a document, it is a true copy of the document requested 4. This Condition shall not require the Licensee to furnish any information, documents or reports which it could not be compelled to produce or give in evidence Confirmed in civil proceedings before a court because of legal professional privilege. Condition P3 – Assurance report on submissions to Monitor 1. If required in writing by Monitor the Licensee shall, as soon as reasonably practicable, obtain and submit to Monitor an assurance report in relation to a Confirmed submission of the sort described in para 2 and para 3 of P3. 2. The descriptions of submissions in relation to which a report may be required under Confirmed paragraph 1 are: (a) submissions of information furnished to Monitor pursuant to Condition P2, and (b) submissions of information to third parties designated by Monitor as persons from or through whom cost information may be obtained for the purposes of setting or verifying the National Tariff or of developing non-tariff pricing guidance. 3. An assurance report shall meet the requirements of this paragraph if all of the following Confirmed conditions are met: (a) it is prepared by a person approved in writing by Monitor or qualified to act as auditor of an NHS foundation trust in accordance with paragraph 23(4) in Schedule 7 to the 2006 Act; (b) it expresses a view on whether the submission to which it relates: (i) is based on cost records which have been maintained in a manner which complies with paragraph 2 in Condition P1; (ii) is based on costs which have been analysed in a manner which complies with paragraphSRFT 3 &in ConditionPAT # 274090 P1, and (iii) provides a true and fair assessment of the information it contains. 04/27/2019 16:44:00 Condition P4 – Compliance with the National Tariff 1. Except as approved in writing by Monitor, the Licensee shall only provide health care services for the purpose of the NHS at prices which comply with, or are Confirmed determined in accordance with, the national tariff published by Monitor, in accordance with section 116 of the 2012 Act. 13
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2. Without prejudice to the generality of paragraph 1, except as approved in writing by Monitor, the Licensee shall comply with the rules, and apply the methods, Confirmed concerning charging for the provision of health care services for the purposes of the NHS contained in the national tariff published by Monitor in accordance with, section 116 of the 2012 Act, wherever applicable Condition P5 – Constructive engagement concerning local tariff modifications 1. The Licensee shall engage constructively with Commissioners, with a view to reaching agreement as provided in section 124 of the 2012 Act, in any case in Confirmed which it is of the view that the price payable for the provision of a service for the purposes of the NHS in certain circumstances or areas should be the price determined in accordance with the national tariff for that service subject to modifications. Condition C1- The right of patients to make choices 1. Subsequent to a person becoming a patient of the Licensee and for as long as he or she remains such a patient, the Licensee shall ensure that at every point Confirmed where that person has a choice of provider under the NHS Constitution or a choice of provider conferred locally by Commissioners, he or she is notified of that choice and told where information about that choice can be found. 2. Information and advice about patient choice of provider made available by the Licensee shall not be misleading. Confirmed
3. Without prejudice to paragraph 2, information and advice about patient choice of provider made available by the Licensee shall not unfairly favour one Confirmed provider over another and shall be presented in a manner that, as far as reasonably practicable, assists patients in making well informed choices between providers of treatments or other health care services. 4. In the conduct of any activities, and in the provision of any material, for the purpose of promoting itself as a provider of health care services for the purposes Confirmed of the NHS the Licensee shall not offer or give gifts, benefits in kind, or pecuniary or other advantages to clinicians, other health professionals, Commissioners or their administrative or other staff as inducements to refer patients or commission services Condition C2 – Competition oversight 1. The Licensee shall not: Confirmed (a) enter into or maintain any agreement or other arrangement which has the object or which has (or would be likely to have) the effect of preventing, restricting or distorting competition in the provision of health care services for the purposes of the NHS, or (b) engage in any other conduct which has (or would be likely to have) the effect of preventing, restricting or distorting competition in the provision of health care services for the purposes of the NHS, to the extent that it is against the interests of people who use health care services. Condition IC1 – Provision of integrated care 1. The Licensee shall not do anything that reasonably would be regarded as against the interests of people who use health care services by being detrimental to Confirmed enabling its provision of health care services for the purposes of the NHS to be integrated with the provision of such services by others with a view to achieving one or more of the objectives referred to in paragraph 4. 2. The Licensee shall not do anything that reasonably would be regarded as against the interests of people who use health care services by being detrimental to Confirmed enabling its provision of health care services for the purposes of the NHS to be integrated with the provision of health-related services or social care services by others with a view to achieving one or more of the objectives referred to in paragraph 4. 3. The Licensee shall not do anything that reasonably would be regarded as against the interests of people who use health care services by being detrimental to Confirmed enabling it to co-operate with other providers of health care services for the purposesSRFT of the NHS& PAT with #a view 274090 to achieving one or more of the objectives referred to in paragraph 4. 04/27/2019 16:44:00 4. The objectives referred to in paragraphs 1, 2 and 3 are: Confirmed (a) improving the quality of health care services provided for the purposes of the NHS (including the outcomes that are achieved from their provision) or the
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efficiency of their provision, (b) reducing inequalities between persons with respect to their ability to access those services, and (c) reducing inequalities between persons with respect to the outcomes achieved for them by the provision of those services. 5. The Licensee shall have regard to such guidance as may have been issued by Monitor from time to time concerning actions or behaviours that might Confirmed reasonably be regarded as against the interests of people who use health care services for the purposes of paragraphs 1, 2 or 3 of this Condition. Condition CoS1 – Continuing provision of Commissioner Requested Services 1. The Licensee shall not cease to provide, or materially alter the specification or means of provision of, any Commissioner Requested Service otherwise than in Confirmed accordance with the following paragraphs of this Condition. 2. If, during the period of a contractual or other legally enforceable obligation to provide a Commissioner Requested Service, or during any period when this Confirmed condition applies by virtue of Condition G9(1)(b), Monitor issues to the Licensee a direction in writing to continue providing that service for a period specified in the direction, then the Licensee shall provide the service for that period in accordance with the direction. 3. The Licensee shall not materially alter the specification or means of provision of any Commissioner Requested Service except: Confirmed (a) with the agreement in writing of all Commissioners to which the Licensee is required by a contractual or other legally enforceable obligation to provide the service as a Commissioner Requested Service; or (b) at any time when this condition applies by virtue of Condition G9(1)(b), with the agreement in writing of all Commissioners to which the Licensee provides, or may be requested to provide, the service as a Commissioner Requested Service; or (c) if required to do so by, or in accordance with the terms of its authorisation by, any body having responsibility pursuant to statute for regulating one or more aspects of the provision of health care services in England and which has been designated by Monitor for the purposes of this condition and of equivalent conditions in other licences granted under the 2012 Act. 4. If the specification or means of provision of a Commissioner Requested Service is altered as provided in paragraph 3 the Licensee, within [28] days of the Confirmed alteration, shall give to Monitor notice in writing of the occurrence of the alteration with a summary of its nature. Condition CoS2 – Restriction on the disposal of assets 1. The Licensee shall establish, maintain and keep up to date, an asset register which complies with paragraphs 2 and 3 of this Condition (“the Asset Register”) Confirmed
2. The Asset Register shall list every relevant asset used by the Licensee for the provision of Commissioner Requested Services. Confirmed
3. The Asset Register shall be established, maintained and kept up to date in a manner that reasonably would be regarded as both adequate and professional. Confirmed
4. The obligations in paragraphs 5 to 8 shall apply to the Licensee if Monitor has given notice in writing to the Licensee that it is concerned about the ability of Confirmed the Licensee to carry on as a going concern. 5. The Licensee shall not dispose of, or relinquish control over, any relevant asset except: Confirmed (a) with the consent in writing of Monitor, and (b) in accordance with the paragraphs 6 to 8 of this Condition. 6. The Licensee shall furnish Monitor with such information as Monitor may request relatingSRFT to any& PAT proposal # 274090 by the Licensee to dispose of, or relinquish control Confirmed over, any relevant asset. 04/27/2019 16:44:00 7. Where consent by Monitor for the purpose of paragraph 5(a) is subject to conditions, the Licensee shall comply with those conditions. Confirmed
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8. Paragraph 5(a) of this Condition shall not prevent the Licensee from disposing of, or Confirmed relinquishing control over, any relevant asset where: (a) Monitor has issued a general consent for the purposes of this Condition (whether or not subject to conditions) in relation to: (i) transactions of a specified description; or (ii) the disposal of or relinquishment of control over relevant assets of a specified description, and the transaction or the relevant assets are of a description to which the consent applies and the disposal, or relinquishment of control, is in accordance with any conditions to which the consent is subject; or Section 5 – Continuity of Services 27 (b) the Licensee is required by the Care Quality Commission to dispose of a relevant asset. 9. The Licensee shall have regard to such guidance as may be issued from time to time by Confirmed Monitor regarding: (a) the manner in which asset registers should be established, maintained and updated, and (b) property, including buildings, interests in land, intellectual property rights and equipment, without which a licence holder’s ability to provide Commissioner Requested Services should be regarded as materially prejudiced. Condition CoS3 – Standards of corporate governance and financial management 1. The Licensee shall at all times adopt and apply systems and standards of corporate governance and of financial management which reasonably would be Confirmed regarded as: (a) suitable for a provider of the Commissioner Requested Services provided by the Licensee, and (b) providing reasonable safeguards against the risk of the Licensee being unable to carry on as a going concern. 2. In its determination of the systems and standards to adopt for the purpose of paragraph 1, and in the application of those systems and standards, the Licensee Confirmed shall have regard to: (a) such guidance as Monitor may issue from time to time concerning systems and standards of corporate governance and financial management; (b) the Licensee’s rating using the risk rating methodology published by Monitor from time to time, and (c) the desirability of that rating being not less than the level regarded by Monitor as acceptable under the provisions of that methodology. Condition CoS4 – Undertaking from the ultimate controller 1. The Licensee shall procure from each company or other person which the Licensee knows or reasonably ought to know is at any time its ultimate controller, a Confirmed legally enforceable undertaking in favour of the Licensee, in the form specified by Monitor, that the ultimate controller (“the Covenantor”): (a) will refrain for any action, and will procure that any person which is a subsidiary of, or which is controlled by, the Covenantor (other than the Licensee and its subsidiaries) will refrain from any action, which would be likely to cause the Licensee to be in contravention of any of its obligations under the 2012 Act or this Licence, and (b) will give to the Licensee, and will procure that any person which is a subsidiary of, or which is controlled by, the Covenantor (other than the Licensee and its subsidiaries) will give to the Licensee, all such information in its possession or control as may be necessary to enable the Licensee to comply fully with its obligations under this Licence to provide information to Monitor. 2. The Licensee shall obtain any undertaking required to be procured for the purpose of paragraph 1 within 7 days of a company or other person becoming an Confirmed ultimate controller of the Licensee and shall ensure that any such undertaking remainsSRFT in force & forPAT as long# 274090 as the Covenantor remains the ultimate controller of the Licensee. 04/27/2019 16:44:00 3. The Licensee shall: Confirmed (a) deliver to Monitor a copy of each such undertaking within seven days of obtaining it; (b) inform Monitor immediately in writing if any Director, secretary or other officer of the Licensee becomes aware that any such undertaking has ceased to be 16
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legally enforceable or that its terms have been breached, and (c) comply with any request which may be made by Monitor to enforce any such undertaking. 4. For the purpose of this Condition, subject to paragraph 5, a person (whether an individual or a body corporate) is an ultimate controller of the Licensee if: Confirmed (a) directly, or indirectly, the Licensee can be required to act in accordance with the instructions of that person acting alone or in concert with others, and (b) that person cannot be required to act in accordance with the instructions of another person acting alone or in concert with others. 5. A person is not an ultimate controller if they are: Confirmed (a) a health service body, within the meaning of section 9 of the 2006 Act; (b) a Governor or Director of the Licensee and the Licensee is an NHS foundation trust; (c) any Director of the Licensee who does not, alone or in association with others, have a controlling interest in the ownership of the Licensee and the Licensee is a body corporate; or (d) a trustee of the Licensee and the Licensee is a charity. Condition CoS5 – Risk pool levy 1. The Licensee shall pay to Monitor any sums required to be paid in consequence of any requirement imposed on providers under section 135(2) of the 2012 Confirmed Act, including sums payable by way of levy imposed under section 139(1) and any interest payable under section 143(10), by the dates by which they are required to be paid. 2. In the event that no date has been clearly determined by which a sum referred to in paragraph 1 is required to be paid, that sum shall be paid within 28 days Confirmed of being demanded in writing by Monitor. Condition CoS6 – Co-operation in the event of financial stress 1. The obligations in paragraph 2 shall apply if Monitor has given notice in writing to the Licensee that it is concerned about the ability of the Licensee to carry on Confirmed as a going concern. 2. When this paragraph applies the Licensee shall: Confirmed (a) provide such information as Monitor may direct to Commissioners and to such other persons as Monitor may direct; (b) allow such persons as Monitor may appoint to enter premises owned or controlled by the Licensee and to inspect the premises and anything on them, and (c) co-operate with such persons as Monitor may appoint to assist in the management of the Licensee’s affairs, business and property. Condition CoS7 – Availability of resources 1. The Licensee shall at all times act in a manner calculated to secure that it has, or has access to, the Required Resources. Confirmed
2. The Licensee shall not enter into any agreement or undertake any activity which creates a material risk that the Required Resources will not be available to the Confirmed Licensee. 3. The Licensee, not later than two months from the end of each Financial Year, shall submit to Monitor a certificate as to the availability of the Required Confirmed Resources for the period of 12 months commencing on the date of the certificate, in one of the following forms: (a) “After making enquiries the Directors of the Licensee have a reasonable expectation that the Licensee will have the Required Resources available to it after (No requirement to taking account distributions which might reasonably be expected to be declared or paid for the period of 12 months referred to in this certificate.” submit a certificate (b) “After making enquiries the Directors of the Licensee have a reasonable expectation,SRFT subject & PATto what # is274090 explained below, that the Licensee will have the to NHSI for Required Resources available to it after taking into account in particular (but without limitation)04/27/2019 any distribution 16:44:00 which might reasonably be expected to be 2017/18) declared or paid for the period of 12 months referred to in this certificate. However, they would like to draw attention to the following factors which may cast doubt on the ability of the Licensee to provide Commissioner Requested Services”. (c) “In the opinion of the Directors of the Licensee, the Licensee will not have the Required Resources available to it for the period of 12 months referred to in 17
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this certificate”. 4. The Licensee shall submit to Monitor with that certificate a statement of the main factors which the Directors of the Licensee have taken into account in Confirmed issuing that certificate. 5. The statement submitted to Monitor in accordance with paragraph 4 shall be approved by a resolution of the Board of Directors of the Licensee and signed by Confirmed a Director of the Licensee pursuant to that resolution. 6. The Licensee shall inform Monitor immediately if the Directors of the Licensee become aware of any circumstance that causes them to no longer have the Confirmed reasonable expectation referred to in the most recent certificate given under paragraph 3. 7. The Licensee shall publish each certificate provided for in paragraph 3 in such a manner as will enable any person having an interest in it to have ready access Confirmed to it. Condition FT1 – Information to update the register of NHS foundation trusts 1. The obligations in the following paragraphs of this Condition apply if the Licensee is an NHS foundation trust, without prejudice to the generality of the other Confirmed conditions in this Licence. 2. The Licensee shall ensure that Monitor has available to it written and electronic copies of the following documents: Confirmed (a) the current version of Licensee’s constitution; (b) the Licensee’s most recently published annual accounts and any report of the auditor on them, and (c) the Licensee’s most recently published annual report, and for that purpose shall provide to Monitor written and electronic copies of any document establishing or amending its constitution within 28 days of being adopted and of the documents referred to in sub-paragraphs (b) and (c) within 28 days of being published. 3. Subject to paragraph 4, the Licensee shall provide to Monitor written and electronic copies of any document that is required by Monitor for the purpose of Confirmed Section 39 of the 2006 Act within 28 days of the receipt of the original document by the Licensee. 4. The obligation in paragraph 3 shall not apply to: Confirmed (a) any document provided pursuant to paragraph 2; (b) any document originating from Monitor; or (c) any document required by law to be provided to Monitor by another person 5. The Licensee shall comply with any direction issued by Monitor concerning the format in which electronic copies of documents are to be made available or Confirmed provided. 6. When submitting a document to Monitor for the purposes of this Condition, the Licensee shall provide to Monitor a short written statement describing the Confirmed document and specifying its electronic format and advising Monitor that the document is being sent for the purpose of updating the register of NHS foundation trusts maintained in accordance with section 39 of the 2006 Act. Condition FT2 – Payment to Monitor in respect of registration and related costs 1. The obligations in the following paragraph of this Condition apply if the Licensee is an NHS foundation trust, without prejudice to the generality of the other Confirmed conditions in this Licence. 2. Whenever Monitor determines in accordance with section 50 of the 2006 Act that the Licensee must pay to Monitor a fee in respect of Monitor’s exercise of Confirmed its functions under sections 39 and 39A of that Act the Licensee shall pay that fee to MonitorSRFT &within PAT 28 # days 274090 of the fee being notified to the Licensee by Monitor in writing. 04/27/2019 16:44:00 Condition FT3 – Provision of information to advisory panel
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1. The obligation in the following paragraph of this Condition applies if the Licensee is an NHS foundation trust, without prejudice to the generality of the other Confirmed conditions in this Licence. 2. The Licensee shall comply with any request for information or advice made of it under Section 39A(5) of the 2006 Act. Confirmed Condition FT4 – NHS foundation trust governance arrangements 1. The Licensee shall apply those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a Confirmed supplier of health care services to the NHS. 2. Without prejudice to the generality of paragraph 2 and to the generality of General Condition 5, the Licensee shall: Confirmed (a) have regard to such guidance on good corporate governance as may be issued by Monitor from time to time; and (b) comply with the following paragraphs of this Condition. 3. The Licensee shall establish and implement: Confirmed (a) effective board and committee structures; (b) clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees; and (c) clear reporting lines and accountabilities throughout its organisation. 4. The Licensee shall establish and effectively implement systems and/or processes: Confirmed (a) to ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively; (b) for timely and effective scrutiny and oversight by the Board of the Licensee’s operations; (c) to ensure compliance with health care standards binding on the Licensee including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions; for effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licensee’s ability to continue as a going concern); (e) to obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making; (f) to identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence; (g) to generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and (h) to ensure compliance with all applicable legal requirements. 5. The systems and/or processes referred to in paragraph 5 should include but not be restricted to systems and/or processes to ensure: Confirmed (a) that there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided; (b) that the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations; (c) the collection of accurate, comprehensive, timely and up to date information on quality of care; (d) that the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care; (e) that the Licensee including its Board actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and (f) that there is clear accountability for quality of care throughout the Licensee’s organisation including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate.SRFT & PAT # 274090 6. The Licensee shall ensure the existence and effective operation of systems to ensure that04/27/2019 it has in place personnel 16:44:00 on the Board, reporting to the Board and Confirmed within the rest of the Licensee’s organisation who are sufficient in number and appropriately qualified to ensure compliance with the Conditions of this Licence.
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7. The Licensee shall submit to Monitor within three months of the end of each financial year: Confirmed (a) a corporate governance statement by and on behalf of its Board confirming compliance with this Condition as at the date of the statement and anticipated compliance with this Condition for the next financial year, specifying any risks to compliance with this Condition in the next financial year and any actions it (No requirement to proposes to take to manage such risks; and submit to NHSI for (b) if required in writing by Monitor, a statement from its auditors either: 2018/19) (i) confirming that, in their view, after making reasonable enquiries, the Licensee has taken all the actions set out in its corporate governance statement applicable to the past financial year, or (ii) setting out the areas where, in their view, after making reasonable enquiries, the Licensee has failed to take the actions set out in its corporate governance statement applicable to the past financial year.
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Declarations required by General condition 6 of the NHS provider licence
1 & 2 General condition 6 - Systems for compliance with license conditions 1 Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the SRFT: Confirmed Licensee are satisfied, as the case may be that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the PAHT: Confirmed licence, any requirements imposed on it under the NHS Acts and have had regard to the NHS Constitution.
Further explanatory information should be provided below where the Board has been unable to confirm declarations under G6.
A
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Response Risks and Corporate Governance Statement Current Arrangements/Evidence Mitigating actions The Board is satisfied that Salford Royal NHS Foundation Trust/Pennine SRFT/PAHT: Confirmed Acute Hospitals NHS Trust applies those principles, systems and − April 2019 - Annual review of Monitor's (part of NHSI) NHS FT Code of No material risk identified standards of good corporate governance which reasonably would be Governance. Review widened to encompass NCA compliance. regarded as appropriate for a supplier of health care services to the NHS − Established Group Assurance Framework – With Group and Care Organisation governance committee structures in place. − NCA Internal Audit Assurance Framework Review 2017/18 confirmed that ‘the organisation’s Assurance Framework is structured to meet the NHS requirements, is visibly used by the Board and clearly reflects the risks discussed by the Board.’ − Comprehensive review of the Group Assurance Framework overseen by and reported to Group CiC. − Group Governance Framework Manual in place. Annual review via the Group Risk and Assurance Committee, Audit Committee and Group CiC meeting. The Board has regard to such guidance on good corporate governance as SRT/PAHT: Confirmed may be issued by NHS Improvement from time to time −All corporate governance guidance and direction issued by NHSI rigorously No material risk identified reviewed and implemented appropriately. −Regular updates to the Group CiC and Care Organisation Leadership Teams on new guidance and / or consultations from NHSI on corporate governance. The Board is satisfied that Salford Royal NHS Foundation Trust/Pennine SRFT/PAHT: Confirmed Acute Hospital NHS Trust implements: − Board and committee structures reviewed and revised for 2018/19 – 2019/20. No material risk identified Set out within the Group Governance Framework Manual (incorporating a) Effective Board and Committee structures; Standing Orders and Schemes of Reservation/Delegation of Powers). − Group CiC approved terms of reference in place for all standing committees b) Clear responsibilities for its Board, for Committees reporting to clearly stating responsibilities, reporting arrangements, membership. the Board and for staff reporting to the Board and those − Care Organisation corporate governance committees established. Committees; and − NCA: Positive outcome of independent review of NCA Well Led Governance Self-Assessment. c) Clear reporting lines and accountabilities throughout its − 2018/19: Annual review of Group CiC standing committees. The Group CiC organisation routinely receives the summary minutes of all Standing Committees. − Group Assurance Framework based on clearly defined principal objectives agreed with stakeholders together with clear lines of responsibility and accountability,SRFT interpreted & PAT at # all 274090levels within the NCA. − NCA established04/27/2019 Group Single Oversight 16:44:00 Framework (Group SOF) for each of its constituent Care Organisations. The Board is satisfied that Salford Royal NHS Foundation Trust/Pennine SRFT/PAHT: Confirmed Acute Hospitals NHS Trust effectively implements systems and/or a) Strong systems of financial and quality governance in place. All statutory No material risk identified 22
22/29 188/232 Appendix 4: Self Certification Template Condition FT4: Corporate Governance Statement
Response Risks and Corporate Governance Statement Current Arrangements/Evidence Mitigating actions processes audits and reporting requirements fulfilled. b) The Group SOF provides assurance on delivery of the Care Organisation a) To ensure compliance with the Licence holder’s duty to operate Annual Plan objectives and supports quality and performance improvement. efficiently , economically and effectively The five themes of the Group SOF reflect those of the NHS Improvement Framework: b) For timely and effective scrutiny and oversight by the Board of the − Quality of care Licence holder’s operations − Finance and use of resources − Operational performance − Strategic change − Leadership and improvement capability (well-led) c) To ensure compliance with health care standards binding on the Sixth, cross-cutting theme of Leadership, Behaviours and Culture will be added Licence holder including but not restricted to standards specified in 2019/20. Performance dashboards at all levels within the NCA with by the Secretary of State, the Care Quality Commission, the NHS divisional and corporate systems for appropriate escalation and review to Commissioning Board and statutory regulators of health care ensure timely and effective scrutiny and oversight of all operations. professions; c) Effective systems and processes in place to ensure compliance with national and local healthcare standards - internal and external assurance systems in d) For effective financial decision-making, management and control place. SRFT – CQC ‘Outstanding’, August 2018. PAHT – CQC ‘Requires (including but not restricted to appropriate systems and/or Improvement’, March 2018. processes to ensure the Licence holder’s ability to continue as a d) Detailed financial plans in place and approved by the Group CiC and Board of going concern) Directors. Cost Improvement programme agreed with Care Organisations and Group-wide Corporate functions. e) To obtain and disseminate accurate, comprehensive, timely and Internal Audit Plan includes review of combined financial systems (SRFT/PAHT) up to date information for Board and Committee decision-making Contracts, service level agreements and leases under constant review. Biannual and rigorous review of the Trust as a Going Concern overseen by f) To identify and manage (including but not restricted to manage Audit Committee and reported to Board/Group CiC. Care Organisation through forward plans) material risks to compliance with the financial performance scrutinised via respective Care Organisation Finance Conditions of its Licence; Governance Committee, with detailed reports to Group CiC. e) Group CiC and committee structures fully serviced. Accurate, comprehensive, g) To generate and monitor delivery of business plans (including any up-to-date information available for Group CiC and committees. changes to such plans) and to receive internal and where f) NCA Board Assurance Framework/Corporate Risk Register in place that appropriate external assurance on such plans and their delivery; identifies and ensures appropriate oversight of all principal and material risks. Care Organisation/CorporateSRFT & PAT #Risk 274090 Registers established. h) To ensure compliance with all applicable legal requirements. g) Effective business04/27/2019 planning arrangements 16:44:00 in place, embedded within the corporate governance arrangements of the organisation. Approved NCA Service Development Strategy and Annual Business Plan 2019/20. h) Applicable legal requirements, against principal objectives and activities of the 23
23/29 189/232 Appendix 4: Self Certification Template Condition FT4: Corporate Governance Statement
Response Risks and Corporate Governance Statement Current Arrangements/Evidence Mitigating actions organisation reviewed and managed appropriately as part of the NCA’s corporate governance arrangements. The Board is satisfied: SRFT/PAHT: Confirmed a) Board (Group CiC) capability reviewed against strategic direction and business No material risk identified a) That there is sufficient capability at Board level to provide plans. Robust appraisal and performance review arrangements in place at effective organisational leadership on the quality of care provided; Board level (and throughout the organisation). Established leadership arrangements within Care Organisations. Specific focus on capability and capacity of leadership within Group Single Oversight Framework. b) That the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations; b) Quality of care fully integrated within all planning and decision-making processes. Standardised risk assessment of all productivity improvement c) The collection of accurate, comprehensive, timely and up to date workstreams, as part of the NCA Better Care at Lower Cost Programme. information on quality of care; c) (and d) Integrated Performance Dashboards, QI Dashboards, patient d) That the Board receives and takes into account accurate, experience, patient responsiveness reports, and quality of care initiatives comprehensive, timely and up to date information on quality of provided routinely to Group CiC. Outcome of clinical coding and data accuracy care; audits reported and reviewed via Audit Committee. Indicators reviewed via External Audit as part of external audit work plan. Further work required to e) That Salford Royal NHS Foundation Trust/Pennine Acute Hospitals provide assurance that accurate information is readily available within the NES NHS Trust including its Board actively engages on quality of care Care Organisations at Divisional, Directorate and Ward / Department level to with patients, staff and other relevant stakeholders and takes into enable appropriate escalation and review and ensure timely and effective account as appropriate views and information from these sources; scrutiny and oversight of all operations. and e) SRFT has a history of robust quality governance arrangements. These f) That there is clear accountability for quality of care throughout arrangements are being implemented across PAHT. Quality Improvement Salford Royal NHS Foundation Trust/Pennine Acute Hospitals NHS Strategy in place for SRFT/PAHT, with ambitious Trust-wide quality goals. Trust including but not restricted to systems and/or processes for Development of NCA Quality Improvement Strategy in 2019/20. A quarterly escalating and resolving quality issues including escalating them to Quality Improvement Progress Report, including Care Organisation Quality the Board where appropriate. Improvement Dashboard, is reviewed by the Group CiC. At Care Organisation level, the Quality and Patient Experience (QPE) Governance Committees, report directly to the COARC, reviewing a suite of Quality Dashboards that track performanceSRFT against& PAT key # quality 274090 indicators; standardised risk assessment, and04/27/2019 robust arrangements 16:44:00 for staff, patients and members of the public to raise concerns with respect to the quality of care. Nursing Assessment and Accreditation System fully established. Friends and Family Test systems in place. 24
24/29 190/232 Appendix 4: Self Certification Template Condition FT4: Corporate Governance Statement
Response Risks and Corporate Governance Statement Current Arrangements/Evidence Mitigating actions Active engagement between the Group CiC and the Group Council of Governors (CoG)s – two joint meetings per year. Directors attend all CoG meetings and NEDs attend CoG sub-group meetings and training events. Membership and Public Engagement Strategy in place. Patient and Public Engagement Register established.
f) Clear accountability for quality of care throughout the Trust, strong systems for appropriate escalation to Group CiC. The Board of Salford Royal NHS Foundation Trust/Pennine Acute SRFT/PAHT: Confirmed No material risk identified. Hospitals NHS Trust effectively implements systems to ensure that it has SRFT’s Constitution/PAHT’s Establishment Order sets out required numbers for in place personnel on the Board, reporting to the Board and within the Board members. rest of the Licence holder’s organisation who are sufficient in number Established Nominations Committees for Executive Director (ED) and Non- and appropriately qualified to ensure compliance with the Conditions of Executive Director (NED) with Terms of Reference, with responsibility for review of its provider licence. Board composition. ED and NED Job Descriptions and Person Specifications in place as developed via relevant Nominations Committee. NCA People Strategy in place, including Talent Management & Leadership Development Strategies. Code of Conduct and suitable contractual arrangements in place for Board members, incorporating requirements of the Licence condition relating to ‘fit and proper persons’.
SRFT & PAT # 274090 04/27/2019 16:44:00
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25/29 191/232 Appendix 5: Self Certification on Training of Governors
Certification on Training of Governors Response
The Board is satisfied that during the financial year most recently Confirmed ended the Trust has provided the necessary training to its Governors, A Governor Development and Training Programme has been developed to include induction, annual, biennial as required in s151(5) of the Health and Social Care Act, to ensure they and bespoke training. This will provide all governors with two opportunities to undertake training to equip are equipped with the skills and knowledge they need to undertake them with the skills and knowledge to undertake their role in any 3 year term. their role. NHS Providers Guides for Governors and e-newsletter are disseminated to Governors throughout the year. Where a Governor has been unable to attend an internal development session, opportunities for attendance at externally facilitated training is provided.
Event Date Attendance North West Governor Forum 18th October 2018 3 Patient/Service User Experience Strategy 18th October 2018 8 Workshop Governor Listening Event 23rd October 2018 11 Social Media Training 20th November 2018 6 MIAA – Learning from the Model Hospital 1st February 2019 5 Core Skills Refresher/Induction 18th March 2019 17 Governwell - Accountability 20th March 2019 4
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26
26/29 192/232 Appendix 6: SRFT ONLY: Self Certification on Condition CoS7: Availability of Resources (FTs designated CRS only)
3 Continuity of services condition 7 - Availability of Resources (FTs designated CRS only) EITHER: 3a After making enquiries the Directors SRFT: Current Arrangements of the Licensee have a reasonable Confirmed expectation that the Licensee will Review of all Licence conditions, including Continuity of Service (Appendix 2) have the Required Resources available to it after taking account Board of Directors/Group CiC review of work undertaken to develop the Operational and Financial Plan 2019/20 (January distributions which might reasonably 2019). Further review of Operational and Financial Plan 2019/20 prior to submission to NHSI (March 2019) prior to be expected to be declared or paid submission to NHSI on 4th April 2019. It should be noted that the annual plan submitted identifies a potential for the period of 12 months referred requirement for interim revenue support in 2019/20. to in this certificate. Operational and Financial Plan 2019/20 comprised a series of Assurance Statements, templates and declarations, including the Finance, Activity and Workforce returns. Operational and Financial Plan 2019/20 based on understanding of demand and capacity and alignment between commissioners.
Audit Committee detailed mid-year review, in the form of an updated Going Concern Report providing financial outlook to March 2019. The review included overview of: Forecast Income and Expenditure Position Better Care at Lower Cost (BCLC) Commissioning Intentions Working Capital, Capital Expenditure and Borrowing Cash Flow Forecast Hosted Services Risks and Uncertainties
OR 3b After making enquiries the Directors of the Licensee have a reasonable expectation, subject to what is explained below, that the Licensee will have the Required Resources available to it after taking into account in particular (but without limitation) any distribution which might reasonably be expected to be SRFT & PAT # 274090 declared or paid for the period of 12 04/27/2019 16:44:00 months referred to in this certificate. However, they would like to draw
27
27/29 193/232 Appendix 6: SRFT ONLY: Self Certification on Condition CoS7: Availability of Resources (FTs designated CRS only)
attention to the following factors (as described in the text box below) which may cast doubt on the ability of the Licensee to provide Commissioner Requested Services.
OR 3c In the opinion of the Directors of the Licensee, the Licensee will not have the Required Resources available to it for the period of 12 months referred to in this certificate. Statement of main factors taken into account in making the above declaration In making the above declaration, the main factors which have been taken
into account by the Board of Directors are as follows: [e.g. key risks to delivery of CRS, assets or subcontractors required to deliver CRS, etc.]
Signed on behalf of the board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors
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28/29 194/232 Appendix 6: SRFT ONLY: Self Certification on Condition CoS7: Availability of Resources (FTs designated CRS only)
Signature Signature
Name Name
Capacity [job title here] Capacity [job title here]
Date Date
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29/29 195/232 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & The Pennine Acute Hospitals NHS Trust (PAT) Title of Report Standards of Business Conduct: Board Level Directors
Meeting Group Committees in Common Su Statom, Head of Corporate Governance Author (s) Jane Burns, Group Secretary Presented by Jane Burns, Group Secretary Date 29th April 2019
Executive This paper provides information about: Summary the declared interests of all members of Board of Directors of Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute Hospitals NHS Trust (PAHT), Group Committees in Common and Care Organisation Leadership Teams; a brief overview of the review undertaken by T Kark QC regarding the effectiveness of the Fit and Proper Person Requirements processes review of the NCA’s Fit and Proper Person Policy compliance with the Fit and Proper Person Requirements (FPPR) for all Directors; and the independence of Non-Executive Directors in line with the NHS FT Code of Governance (Provision B.1.2). Annual Plan N/A Objective Associated Risks N/A
Recommendations Group Committees in Common is asked to: review and confirm acceptance of the interests registered by Directors; review and determine the independence of each Non-Executive Director; approve the revised Fit and Proper Person Policy; and endorse the Chairman’s annual assessment of the Fit and Proper Person Requirement for all Directors.
Equality Does this paper relate to a matter where equality issues may arise? Y/N If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and can be Information made available to the public. x Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public.
This document is entirely confidential, as the redactionSRFT of &confidential PAT # 274090 information would render the document meaningless.04/27/2019 16:44:00
1/26 196/232 Data Sharing Under the Data Sharing Agreement, the NCA may be required to Agreement with share this paper with MFT. This is distinct from information Manchester disclosed under the FOIA. As MFT will acquire part of PAT they will University NHS FT need to understand a range of matters which may otherwise be (MFT) in relation to exempt under FOI e.g. contracts to be split and specific workforce- the Transaction related issues. Please consider the statements below and indicate which applies in relation to this paper: a) This paper relates solely to PAT and can be released
b) This paper relates solely to SRFT and is therefore not eligible for release
c) This paper contains information relating to both PAHT and SRFT. All information other than that relating to PAHT will be fully redacted.
d) This paper contains reference to both PAHT and SRFT but contains no quality, finance or operational performance data x relating to PAHT which could be relevant to the transaction and is therefore not eligible for release.
SRFT & PAT # 274090 04/27/2019 16:44:00
2/26 197/232 1. Register of Declared Interests
1.1. Members of the SRFT and PAHT Boards of Directors, Group Committees in Common and Care Organisation Leadership Teams are required to declare any interests which are relevant and material.
1.2. Detailed in Appendix A are the declared interests of the SRFT and PAHT Boards of Directors, the Group Committees in Common and Care Organisation Leadership Teams.
1.3 The confirmed interests, as at April 2019, will be recorded in the minutes of the Group Committees in Common meeting as the Board-level Register of Interests for SRFT and PAT.
1.4 The Board-level Register of Interests will be reviewed annually at the end of each financial year. Any changes in the interim should be declared by the relevant member at the next Group Committees in Common meeting following the change occurring. The Group Secretary will retain a contemporary Board-level Register of Interests.
1.4 The Board-level Register of Interests will be further updated should new Board-level Directors commence during 2019/20.
1.5 The Board-level Register of Interests will be publicly available via the Group Committees in Common Meeting Minutes and bi-annual Declarations of Interest Register provided on the respective SRFT and PAT websites.
2. Salford Royal NHS Foundation Trust: Independence of Non-Executive Directors
2.1 Non-Executive Director independence is important to ensure the Group Committees in Common is well balanced, makes good judgements and is able to discharge its duties and responsibilities effectively.
2.2 The NHS FT Code of Governance (Monitor, July 14) includes the following provision:
B.1.2. At least half the board of directors, excluding the chairperson, should comprise non-executive directors determined by the board to be independent.
2.3 The Group Committees in Common should therefore determine whether its Non-Executive Directors, including the Chairman, are independent in character and judgement and whether there are relationships or circumstances which are likely to affect, or could appear to affect, Non- Executive Directors’ judgement.
2.4 The NHS FT Code requires the Board to identify in its Annual Report each Non-Executive Director it considers to be independent. The Board should state its reasons if it determines that a director is independent notwithstanding the existence of relationships or circumstances which may appear relevant to its determination.
2.5 Appendix B provides information to enable the Group Committees in Common to determine the independence of individual Non-Executive Directors.
2.6 The Group Committees in Common has previously considered criteria relevant to the determination of the independence of Non-Executive Directors. The Group Committees in Common acknowledged that some Non-Executive Directors had served terms of more than six years at Salford Royal and that one Non-Executive Director had, within the lastSRFT three &years, PAT a # material 274090 business relationship with Salford Royal as the Chairman of Salford Clinical04/27/2019 Commissioning 16:44:00 Group. The Group Committees in Common acknowledged that uniquely, Non-Executive Directors at SRFT and PAHT were members only of the Board of Directors, Group Committees in Common, Strategy &
3/26 198/232 Investment Committee and Board statutory committees. Non-Executive Directors were not members of any sub-Board operational management, governance or assurance committees and therefore retained significant independence from the operational management of Group. In light of this and no other circumstances existing, the Group Committees in Common has previously determined that all Non-Executive Directors, including the Chairman of SRFT andPAHT were independent.
3. Fit and Proper Person Requirement (FPPR) for Directors
3.1 The FPPR for Directors came into force for NHS bodies on 27th November 2014, under Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It was introduced in response to concerns raised following investigations into Mid Staffordshire NHS Foundation Trust and Winterbourne View Hospital. All providers must assure themselves that all directors (or those in equivalent roles) who are responsible and accountable for delivering care are fit to carry out their responsibility for the quality and safety of care.
3.2 A recent independent review of the effectiveness of FPPR has been undertaken by T Kark QC. The review looked in particular at how effective the FPPT is in preventing unsuitable staff from being deployed or re-employed in the NHS.
The recommendations from the review are as follows. i. All directors (executive, non-executive and interim) should meet specified standards of competence to sit on the board of any health providing organisation. Where necessary, training should be available. ii. A central database of directors should be created holding relevant information about qualifications and history. iii. A mandatory reference requirement for each director should be implemented. This would mean there could not be omissions of information in a reference, even where a settlement agreement is in place. iv. The fit and proper persons test should be extended to all commissioners and other appropriate arms-length bodies (including NHS Improvement and NHS England). v. There should be the ability to disbar directors from further roles where they have engaged in serious misconduct. vi. The term 'privy to' should be removed from the regulations. This is in the context of ensuring that board members have not been responsible, involved or ‘privy to’ any serious misconduct or mismanagement. The review suggests ‘privy to’ is unclear and undefined. vii. Further work should be done to examine how the test works in the context of the provision of social care and whether any amendments are needed to make the test effective. The recommendations are due to be considered as part of the wider workforce review being led by NHS Improvement. NHS Providers are lobbying for full consultation.
3.3 Review of the NCA’s Fit and Proper Person Policy A review of the NCA’s Fit and Proper Person Policy has recently been completed, in line with the previously agreed review date. The revised policy is appended to this paper for review and approval by Group Committees in Common - please see Appendix C. The review was attentive to Kark’s recommendations and, although it was felt inappropriate to respond to the specific recommendations at this stage, it is proposed that a reference request template for information about candidates applying for Director positions should be set within the Policy. A specific reference request for Directors is now referred to at Para 5.1.1 on page 5 of the Policy, and the template is included at Appendix 3.
3.4 Fit and Proper Person Requirement – Chairman’s Annual Assessment In line with the Group’s Fit and Proper Person Policy, the Chairman conducts an annual assessment for each Director, of continued compliance with the FPPR,SRFT in April & PATeach #year. 274090 This assessment includes: Executive and Non-Executive Director members of04/27/2019 Group Committees 16:44:00 in Common and SRFT and PAT Boards (including advisory members); and the core Leadership Team
4/26 199/232 of each Care Organisation (Managing Director, Medical Director, Director of Nursing and Director of Finance. One of whom is the Chief Officer).
3.5 The Chairman’s assessment is recorded on the FPPR Annual Compliance Checklist (Appendix 4). The completed FPPR Monitoring Checklist is archived by the Group Secretary.
3.6 The Senior Independent Director conducts an assessment of the Chairman, with respect to compliance with the FPPR.
3.7 The Chairman (and Senior Independent Director) completed their annual assessments, with respect to compliance with FPPR, in April 2019. This included review of the following for each individual Director:
Director’s FPPR Self-Declaration Enhanced DBS Check or Annual Enhanced DBS Status Check (Directors) Standard DBS Check (Non-Executive Directors) Review against core public information sources Professional registration check (applicable to Nursing and Medical Directors) Undischarged bankrupt or sequestration check Disqualified director check Completion of annual appraisal check
3.8 Comprehensive evidence of all of the above is held securely, in individual personal files, by the Group Secretary.
3.9 All directors have fulfilled all of the above with the exception of the following:
DBS Checks Required: Enhanced DBS check required for North Manchester Care Organisation Medical Director/PAT Executive Medical Director. Registration with the DBS Update Service to be completed on receipt of certificate. (Previous Enhanced DBS Check completed in November 2017)
Enhanced DBS check in progress for Group Chief Medical Officer. Registration with the DBS Update Service to be completed on receipt of certificate. (Previous Enhanced DBS Check completed in April 2018
DBS checks in progress:
Enhanced DBS check in progress for the Oldham Managing Director. Registration with the DBS Update Service to be completed on receipt of certificate.
3.10 All directors have completed the Directors’ FPPR Self-Declaration (Appendix 3, within the Fit and Proper Person Policy). This is supported by additional declarations and checks detailed in 3.6. All of this information is recorded on the FPPR Annual Compliance Checklist (Template at Appendix 4, within the Fit and Proper Person Policy).
3.11 April 2019, FPPR Assessment Outcome The Chairman has concluded that, in light of the above, all Directors are deemed fit and that there is nothing to suggest that any director meets any of the unfit criteria. On receipt of the outstanding DBS checks for the above named directors, the Chairman will report to the Group Committees in Common if this position is to be amended.
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5/26 200/232 Appendix A
Northern Care Alliance NHS Group
Register of Declared Interests: Members of the Salford Royal NHS Foundation Trust (SRFT) Board of Directors, Pennine Acute Hospitals NHS Trust (PAT) Board of Directors, and Group Committees in Common (Group CiC) Updated: April 2019
Name and Position Declared Interests Mr Jim Potter Chairman, Pennine Acute Hospitals NHS Trust/Salford Chairman Royal NHS Foundation Trust (SRFT, PAT) Mrs Christine Mayer CBE Associate of Fiona MacNeill Associates, Leadership Non-Executive Director facilitation & Coaching Non-Executive Director, Pennine Acute Hospitals NHS Trust/Salford Royal NHS Foundation Trust With respect to the long term solution for PAHT: o Designated Independent Non-Executive Director on PAHT Board of Directors, and o Member of the GM Transaction Board. Professor Chris Reilly Scientific Advisor: Welcome Trust, Alderley BioHub, Non-Executive Director BioVictriX Karus Therapeutics Professor of Practice KCL Board of Directors of Medicines Discovery Catapult and NHS Transformation Unit Dr Hamish Stedman Wife is Diabetes Specialist Nurse Manager at SRFT Non-Executive Director Sister in law Paediatric Specialist Nurse at SRFT Primary Care Neighbourhood Lead for Salford Primary Care Together Non-Executive Director, Pennine Acute Hospitals NHS Trust/Salford Royal NHS Foundation Trust Mr John Willis CBE Trustee and distributor of The Booth Charities, Salford Vice-Chairman Life Patron of The Lowry, Salford Non-Executive Director Non-Executive Director, Pennine Acute Hospitals NHS Trust/Salford Royal NHS Foundation Trust Mr Kieran Charleson Regional Director of BT Group Non-Executive Member of CBI NW Council NED Salford Red Devils RL Club Member of Institute of Directors Mrs Carmen Drinkwater Non-Executive Director East Lancashire Financial Non-Executive Director Services Mr Tim Crowley Independent Audit CommitteeSRFT member & PAT of SCOPE# 274090 Non-Executive Director Affiliated with AQuA 04/27/2019 16:44:00 Member of Public Sector Internal Audit Standards Board
6/26 201/232 Name and Position Declared Interests Mr Raj Jain Director North West eHealth Chief Executive Officer Board Member, MIMIT
Mr Chris Brookes Chief Medical Officer, England and Rugby Football Executive Chief Medical Officer League Deputy Chief Executive Officer Director, Wigan Warriors Rugby League Director, Chris Brookes Sports Medicine Ltd Principal Medical Advisor to the GM HSCP Mrs Elaine Inglesby-Burke CBE Trustee of the Willowbrook Hospice: a Specialist Executive Chief Nursing Officer Palliative Care Unit set up as an Independent Charity, governed by a Board of Trustees and run on a day to day basis by a CEO and management team Executive Nurse – Governing Body of St Helens Clinical Commissioning Group Non-Executive Director, Advancing Quality Alliance (AQUA) Non-Executive Director, National Institute for Health and Care Excellence (NICE) Executive Nurse Director, Pennine Acute Hospitals NHS Trust/Salford Royal NHS Foundation Trust Mr Ian Moston Director, RS-Chime Ltd Executive Chief Financial Officer Council Member, University of Salford Partner is Interim Director of Workforce, Christie NHS Foundation Trust Mrs Judith Adams None Executive Chief Delivery Officer Pat Crowley None Executive Director – Pennine Transaction Mr Jack Sharp None Group Director of Service Strategy and Planning Mrs Nicola Firth None Interim Chief Officer – Oldham Care Organisation Director of Nursing – Oldham Care Organisation Mr Damien Finn None Chief Officer – North Manchester Care Organisation (Executive Director of Finance, PAT) Mr Steven Taylor Governor - Hopwood Hall College Chief Officer - Bury & Rochdale Care Organisation Mr James Sumner Member of Healthcare Advisory Board (UK) for OCS Chief Officer - Salford Care Organisation Group UK
Dr Peter Turkington Private and Medico-Legal Practice at Spire Hospital Medical Director, Salford Care Manchester SRFT & PAT # 274090 04/27/2019 16:44:00 Organisation Director. Turkington Ltd Mrs Diane Morrison None
7/26 202/232 Name and Position Declared Interests Director of Finance, Salford Care Organisation Mr Tyrone Roberts None Director of Nursing, Salford Care Organisation Mr Jawad Husain Provides consultation and treatment for NHS Choose Medical Director, Oldham Care and Book patients at Beaumont Private Hospital Organisation Mr Dan Grimes None Managing Director, Oldham Care Organisation Mr David Jago None Director of Finance, Oldham Care Organisation Mrs Stephanie Gibson None Managing Director, North Manchester Care Organisation Professor Matthew Makin Honorary Professor Bangor University North Manchester Medical Director NED at Support Care UK (Executive Medical Director - PAT) Mr Simon Featherstone None Director of Nursing, North Manchester Care Organisation Dr Shona McCallum Husband is the Clinical Chair for HMR CCG Medical Director, Bury and Rochdale Care Organisation Mrs Jacqueline Burrow None Director of Nursing, Bury and Rochdale Care Organisation Mr Craig Carter None Director of Finance, Bury and Rochdale Care Organisation
SRFT & PAT # 274090 04/27/2019 16:44:00
8/26 203/232 Appendix B: Independence of Directors, as at April 2019
Relationships or circumstances which may be relevant to the Board’s determination of the independence of Non-Executive Directors JP JW CM CR HS KC CD TC (The NHS FT Code of Governance, Monitor, July 14) (In post (In post until 31 from May 1 June 2019) 2019) Has been an employee of the NHS FT within the last five years N N N N N N N N Has, or has had within the last three years, a material business relationship with the NHSFT either directly, or as a partner, shareholder, director or senior N N N Y Y N N Y employee of a body that has such a relationship with the NHS FT
Has received or receives additional remuneration from the NHS FT apart from a director’s fee, participates in the NHS FT’s performance-related pay scheme, or is N N N N N N N N a member of the NHS FT’s pension scheme
Has close family ties with any of the NHS FT’s advisers, directors or senior employees N N N N N N N N
Holds cross-directorships or has significant links with other directors through N N N N N N involvement in other companies or bodies (Chair (NED: (NED: (NED: (NED: (NED: (Cross-directorships are where: an executive director of organisation A serves as SRFT SRFT SRFT N SRFT N SRFT SRFT a NED in organisation B and, at the same time, an executive director of and & & & & & organisation B serves as a NED at organisation A.) PAHT) PAHT) PAHT) PAHT) ELFs) PAHT) Has served on the board for more than six years from the date of their first Y Y Y appointment N N N N N (SRFT) (SRFT) (PAHT) SRFT & PAT # 274090 Is an appointed representative of the NHS FT’s university medical or dental 04/27/2019 16:44:00 school. N N N N N N N N
9/26 204/232 Appendix C – Revised Fit and Proper Person Policy
Northern Care Alliance Fit and Proper Persons Policy Draft for Approval NHS Group
Classification: Policy Lead Author: Jane Burns, Director of Corporate Services and Group Secretary Additional author(s): Su Statom, Head of Corporate Governance Authors Division: Trust Executive
Unique ID: TWGOP03 (18) Issue number: 2 Expiry Date: May 2021
Contents
Section Page
Who should read this document 2 Key Messages 2 What’s new in this version 2 Background/Scope 2 Policy 3 What is a Fit and Proper Person 3 Code of Conduct 4 Fit and Proper Persons Requirement: Procedure 4 Removal of a Director under the Fit and Proper Person 5 Requirement
Appendix 1 Pre-Employment Checks 7 2 Reference Request Form 8 3 Fit and Proper Person Directors’ Self Declaration 13 4 Fit and Proper Person Annual Compliance Checklist 15
Who should read this document?
All Board-level Directors. For the purposes of this document this includes: Executive and Non- Executive Director members of Group Committees in Common and SRFT and PAT Boards SRFT & PAT # 274090 (including advisory members); and Directors of individual Care Organisations04/27/2019 (Managing 16:44:00 Director, Medical Director, Director of Nursing and Director of Finance). Group Secretariat Human Resources Department
10/26 205/232 Key Messages
The Fit and Proper Persons Requirement (FPPR) set out in Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 came into force on 27th November 2014. The intention of this regulation is to ensure that people who have director level responsibility for the quality and safety of care, and for meeting the fundamental standards are fit and proper to carry out this important role.
This policy has been produced to ensure compliance with the FPPR within the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; it is not intended to be a comprehensive guide to the regulations themselves.
Further information on the required standards can be found in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
What is new in this version?
This policy has been reviewed alongside the Kark review recommendations and will be updated once advice from NHSi has been received. In the interim adherence to current policy will continue and will be applicable to all Board-level Directors of Group (as defined above), and its constituent organisations (Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust)
Background & Scope
1. Preface
1.1 Salford Royal NHS Foundation Trust (SRFT) Board has set out parameters to establish a Group, with Pennine Acute Hospitals NHS Trust (PAT) being the first member.
1.2 It is intended that in due course Group will be established as a single NHS foundation trust, however it is important to note that currently SRFT and PAT remain sovereign statutory bodies.
1.3 From 1st April 2017, the Trust Boards of both SRFT and PAT delegated their functions to a Group Committees in Common (Group CiC).
1.4 To enable the delivery of high quality care at scale, a leadership team of directors (Managing Director, Medical Director, Director of Nursing and Director of Finance) will have clear accountability and authority to govern each Care Organisation within the Group. The four Care Organisations are: Salford, Oldham, Bury/Rochdale and North Manchester.
1.5 The Fit and Proper Persons Policy is equally applicable to both SRFT and PAT. Where no specific reference to an organisation is made or a reference is made to the “organisation” it is applicable to, and incorporates, both SRFT and PAT. For the purpose of the Fit and Proper Persons Policy the term ‘Director’ includes Executive and Non-Executive Director members of Group Committees in Common and SRFT and PATSRFT Boards & PAT(including # 274090 advisory members); and Directors of individual Care Organisations (Managing04/27/2019 Director, Medical 16:44:00 Director, Director of Nursing and Director of Finance).
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11/26 206/232 2. Introduction 2.1 Regulatory standards for the FPPR for directors came into force for all NHS provider organisations from 27th November 2014. This was a direct response to the Francis Report. 2.2 The regulation is intended to ensure that all individuals with overarching responsibility for an organisation are held accountable for the overall quality and safety of the care that the organisation provides. 2.3 It will be the ultimate responsibility of the Chairman to discharge the requirement placed on the organisation to ensure that all directors meet the FPPR and do not meet any of the unfit criteria.
2.4 A recent review of the effectiveness of FPPT has been undertaken by T Kark QC which identified a number of issues. Mainly: the variation in which the requirements are interpreted, it did not necessarily ensure directors were fit and proper for the posts they held and it did not prevent people, who were unfit, from moving around the system.
2.5 Kark concluded that a system was required to ensure those at senior Board level were equipped with the necessary skills and that they were critically assessed to ensure they had those skills with assessment continuing throughout their career and that support should be available to improve skills when / if required. 2 key recommendations have been accepted by the Secretary of State for Health and Social Care. These being: all directors should meet specified standards of competence to sit on the Board and a central database should be created, holding relevant information about qualifications and history about each director (including Non-Executive Directors)
2.6 NHSi, in consultation with other bodies, such as the Leadership Academy and the Royal Colleges, are to define, design and set high level core competencies and look at developing a central database to hold information about directors accessible to potential employers, the NHSi and CQC.
2.7 The Fit and Proper Person Requirement policy will be reviewed and updated to reflect advice received from NHSi. In the interim we will continue to strictly adhere to the policy to ensure that the Northern Care Alliance only employs individuals who are fit for their role. The FPPR must be applied for all new directors; and there must be systems and processes in place to provide ongoing assurance that the requirements are met. There is a duty on the organisation to take such action as is necessary and proportionate to ensure ongoing compliance.
Policy
3. What is a ‘fit and proper person’
3.1 In order for a director to be deemed ‘fit’ he/she must: be of good character; have the qualifications, core competencies, skills and experience which are necessary for the relevant office or position or the work for which they are employed; be capable, by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the office or position for which they are appointed or to the work for which they are employed; SRFT & PAT # 274090 not have been responsible for, privy to, contributed to or facilitated04/27/2019 any serious misconduct16:44:00 or mismanagement (whether unlawful or not) in the course of carrying on a regulated
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12/26 207/232 activity or providing a service elsewhere which, if provided in England, would be a regulated activity; and not be prohibited from holding the position under any other law (e.g. under the Companies Act or Charities Act)
3.2 A director can be deemed ‘unfit’ if he/she: is an undischarged bankrupt or a person whose estate has had sequestration awarded in respect of it and who has not been discharged; is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland; is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986; has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it; is included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland; or is prohibited from holding the relevant office or position, or in the case of an individual for carrying on the regulated activity, by or under any enactment.
4. Code of Conduct for Board-level Directors
4.1 In addition to meeting the FPPR, the Code of Conduct for Board-level Directors sets out clear guidance and standards that all directors must meet. It states that high standards of corporate and personal conduct are an essential component of public services. All foundation trust/NHS trusts are required to comply with the principles of best practice applicable to corporate governance in the NHS/health sector and with any relevant code of practice.
5. Fit and Proper Persons Requirement: Procedure
5.1 New Appointments
5.1.1 In addition to the employment checks carried out for staff generally (as included in the organisations policy regarding employment checks), the following checks will be carried out for directors by the employing organisations Recruitment Team to confirm that an individual meets the FPPR: Appendix 1
− Full enhanced DBS check (with request for registration to the Disclosure & Barring Service Update Service alert system to notify of any change in status for any Directors acting in a role that falls within the definition of Regulated Activity)
− Standard DBS check for the Non-Executive Directors
− Review of core public information sources regarding providers that the appointee has had a role with SRFT & PAT # 274090 − Check with appropriate professional bodies if the person to be appointed has been 04/27/2019 16:44:00 erased, removed or struck off a register of professionals maintained by a regulator of healthcare or social work
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13/26 208/232 − Check on Gov.UK if the person to be appointed is an undischarged bankrupt or a person who has had sequestration awarded in respect of it and who has not been discharged or similar restrictions in Northern Ireland or Scotland
− Check with Companies House if the person to be appointed is a disqualified director
− A minimum of two reference checks will be requested using the Directors reference request form, Appendix 2. References will be required to validate a minimum period of 3 consecutive years of continuous employment or training, one of which must be the most recent employer. The reference from the most recent employer must be signed by a Board-level Director, within the out-going organisation, who is covered by the FPPR.
− Skills and competencies will be tested through the appointments process.
5.1.2 On appointment, the individual will be required to complete an Annual Fit and Proper Person Directors Self-Declaration, Appendix 3, sign the Board of Directors Code of Conduct and submit an Annual Declaration of Interest. These will be retained on the individual’s personal file which will be held by the Director of Corporate Services / Trust Secretary.
5.1.3 Outcomes of the pre-employment checks and copies of ID, Qualifications and DBS number will be placed on the individual’s personal file which will be reviewed by the Chairman to satisfy him that appropriate checks have been undertaken to reach the judgement that the proposed director meets the FPPR before employment or engagement is confirmed.
5.2 On-going Review of Existing Directors
5.2.1 An assessment of on-going fitness will be undertaken each year by the Corporate Services Team as part of the annual review of Standards of Business Conduct for Directors. This will include noting date / outcome of the Directors appraisal, checking DBS update service, completion of a self-declaration of Fitness by the Director, checks for bankruptcy / insolvency and search of Core Public information sources e.g. Google , news searches. The Fit and Proper Person Annual Compliance Checklist is updated to reflect assessment outcomes, Appendix 4.
5.2.2 The outcome of the completed Fit and Proper Person Annual Compliance Checklist will be reviewed by the Chairman to enable him that all appropriate checks have been undertaken and support his judgement that the Directors continues to meet the FPPR.
6. Removal of a Director under the Fit and Proper Person Requirement
6.1 If the organisation discovers at any point, information that suggests an individual director does not meet the FPPR (e.g. through annual checks or through information provided to, or discovered by, the organisation) then appropriate and timely action will be taken to investigate and rectify the matter. Immediate action will be takenSRFT to protect & PAT people # 274090 receiving services from risk or potential risk. 04/27/2019 16:44:00
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14/26 209/232 6.2 Non-Executive Directors
6.2.1 For concerns regarding a SRFT Non-Executive Director, the SRFT Council of Governors Nominations, Remuneration and Terms of Office (NRTO) Committee, supported by an appropriate director or other nominated person, will investigate the concerns ensuring any issues are dealt with in accordance with the organisations HR policies.
The Chairman (or Senior Independent Director if the concern is regarding the Chairman), in discussion with the NRTO Committee, will put in place interim arrangements, if required, during any period of investigation.
The NRTO Committee and the supporting director or nominated person will make a recommendation to the Chairman (or Senior Independent Director if the concern is regarding the Chairman) and the SRFT Council of Governors on the continued fitness of the Non-Executive Director where concerns are substantiated.
Where the Non-Executive Director is deemed not to be a fit and proper person then action, as is proportionate, up to and including the termination of their engagement with immediate effect will be considered.
The removal of any Non-Executive Director will be in accordance with the Constitution, with final decision for removal resting with the SRFT Council of Governors.
6.3 Executive Director or other Director level position
6.3.1 For concerns regarding an Executive Director or other Director level position, then an Investigating Officer will be appointed by the Chief Executive (or by an Executive Director if the concern is regarding the Chief Executive). The Investigating Officer may be an employee or director of the organisation, or may be a person or organisation engaged to undertake this role.
The Chairman, in discussion with the Chief Executive (or Executive Director if the concern is regarding the Chief Executive) will put in place interim arrangements, if required, during any period of investigation.
The Investigating Officer will investigate, ensuring any issues are dealt with in accordance with the organisations HR policies, and present a case to the Chairman and Chief Executive (or Executive Director if the concern is regarding the Chief Executive) who will determine an outcome to be recommended to the Group Committees in Common, and as appropriate to the Board of Directors of SRFT and/or PAT. Proportionate action up to summary dismissal will be taken as appropriate.
Where concerns are substantiated but an individual is retained as a Director, the rational for this will be recorded and retained in the Directors personal file, and made available to those that need to be aware of this. SRFT & PAT # 274090 6.4 Where appropriate, findings in relation to a person’s fitness may be04/27/2019 referred to the 16:44:00 relevant professional/regulatory body/bodies.
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15/26 210/232 Appendix 1 to Fit and Proper Person Policy : Pre- Employments Checks
Pre - Employment Checks and Fit and Proper Person Requirements
Name: Position: Date:
Requirement Checked / Satisfactory Comment
Enhanced / Standard DBS
Review of core public information sources
Regulator of Health Care / Social Care Professional bodies check
UK Gov - Undischarged bankruptcy / sequestration
Companies house – disqualified director
References
Skills and Competences
Code of Conduct
Self-declaration FPPR
Declaration of Interest
Qualifications – as per job spec
ID Passport Driving Licence Proof of address
Occupational Health Clearance
All appropriate employment checks and Fit and Proper Person RequirementsSRFT & PAT # (FPPR) 274090 have been reviewed, considered and certified satisfactory. 04/27/2019 16:44:00 Name: Date: 7
16/26 211/232 Appendix 2: Reference request form
Director Reference Request Form Strictly Confidential The candidate to whom this reference refers has applied for a senior post and has given your name as a referee. We would be grateful if you would provide the information requested below.
This reference should verify factual information and comment on the strengths and weaknesses of the candidate as an indicator of his/her suitability for appointment. This is not a personal testimonial but an objective assessment of competencies based on the person specification provided and to support the Fit and Proper Requirements (FPPR), Regulation 5 of the Health and Social Care Act 2008 (regulated activities).
Candidate Details
Name
Post applied for
Relationship to
Candidate
Please state the dates the candidate worked for you:
Date Started
Date ended or due to end
Position held
Location
Was the candidate subject to any disciplinary procedure, formal or otherwise, during the time with you? Yes / No If yes please give details…..
Are there any current warnings on the candidate’s record? Yes / No. If yes please give details…..
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17/26 212/232 Is the candidate currently under investigation for any matter (including; conduct capability and performance) under any of your employment policies or have they been referred to any professional bodies? Yes / No. If yes please give details…..
With respect to this candidate, are there any outstanding or upheld complaint(s) including grievances and whistleblowing complaints or complaints under any of the Trust’s policies and procedures (for example under the Trust’s equal opportunities policies)? Yes / No. If yes please give details…..
Please confirm the candidate’s reason for leaving (if known)?
Attendance Please provide details of sickness absence in the last two years, from the date of receipt of this reference request. How many days...... and on how many occasions……………….
Knowledge, Skills and Personal Attributes
Please give your opinion regarding the candidate’s present knowledge, skills and personal attributes and / or indicate if with support and / or training become competent, by circling the appropriate letter and using the space provided to give examples of the candidate’s behaviour that support the rating you have given them.
Knowledge and Expertise 1. Is knowledgeable and has an understanding of Board Governance, Clinical Governance and Financial Governance. A. Development needed B. Continually meets C. Exceeds expectations
Comments / Evidence:
2. Is knowledgeable in their own specialist area and keeps up to date with advances in their field A. Development needed B. Continually meets C. Exceeds expectations
Comments / Evidence: SRFT & PAT # 274090 04/27/2019 16:44:00
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18/26 213/232 Learning and Personal Development 3. Strives to continuously improve, is committed to professional development A. Development needed B. Continually meets C. Exceeds expectations
Comments / Evidence:
Safety 4. Can demonstrate a commitment to putting patient safety at the heart of all activity; recognises the importance of information on clinical outcomes, responds to serious clinical incidents and learns from errors A. Development needed B. Continually meets C. Exceeds expectations
Comments / Evidence:
5. Understands the importance of learning from ‘whistleblowing’ and ‘speaking up’ and conforms with and encourages compliance with ‘duty of candour’ A. Development needed B. Continually meets C. Exceeds expectations
Comments / Evidence:
Developing Team and Partnership Working 6. Is able to build effective teams and partnerships, empower staff and support autonomous decision making and understands and values the role and contribution of others. A. Development needed B. Continually meets C. Exceeds expectations
Comments / Evidence:
SRFT & PAT # 274090 04/27/2019 16:44:00
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19/26 214/232 Motivational Leadership 7. Is able to promote a culture of innovation and continuous improvement; is able to lead and drive change and can lead by example A. Development needed B. Continually meets C. Exceeds expectations
Comments / Evidence:
Personal Attributes 8. Complies on a personal basis with the Nolan principles of: selflessness, integrity, objectivity, accountability, honesty, transparency and leadership A. Development needed B. Continually meets C. Exceeds expectations Comments / Evidence:
Managing Delivery 9. Is able to ensure delivery of a quality service; effectively review and allocate resources, review and manage progress, process and implementation of plans and policies. A. Development needed B. Continually meets C. Exceeds expectations Comments / Evidence:
Managing and Developing Performance 10. Has a clear understanding of performance management and supports a performance culture; is accountable for the performance of self and others and empowers others to take responsibility; is able to develop and recognise the performance of others A. Development needed B. Continually meets C. Exceeds expectations Comments / Evidence:
Would you be happy to work with this candidate again? Yes / No? SRFT & PAT # 274090 04/27/2019 16:44:00 Comment
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20/26 215/232 Would you be happy to recommend this candidate for the post? Please circle A, B, C or D
A: Could not recommend for the post B: Would have some reservations C: Could recommend as competent D: Strongly without reservation
Comment
Are you aware of anything in the applicant’s background or current circumstances that could possibly infer that they may not meet a fit and proper persons test within an NHS organisation? Yes / No
Comment
Has the candidate been responsible for, privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity? Yes / No
Comment
Referee Statement
I confirm that the information contained within this reference is true to the best of my knowledge and does not exclude any information I am aware of that is relevant to the suitability of this candidate to work within the Northern Care Alliance
I understand that the reference is given in confidence and will not be disclosed without prior discussion with myself.
I understand that the content of the mandatory reference will form part of the material to be assessed by the CQC in its ‘well-led’ reviews and will lead to the referral of the director signing off the reference to the Trust or the HDSC for Serious Misconduct (as defined in Recommendation Five) where there is evidence of deliberate concealment of relevant information or dishonesty.
Referee Signature…………………………………………… Date………………………….
Referee Relationship to candidate ……………………………………………………………………………………………………………….SRFT & PAT # 274090 04/27/2019 16:44:00 Referee please complete the following:
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21/26 216/232 Referee Details
Surname:
First Name:
Position Held:
Is your position that of a Board-level Director covered by the FPPR? Yes / No
On behalf of (Organisation), if applicable:
Contact Tel No:
If this is a reference from the candidate’s most recent employer it must be signed by a Board-level Director, within the out-going organisation, who is covered by the FPPR.
If the referee is not a Board-level Director covered by the FPPR the following box must be completed:
Countersignature of Board-level Director covered by the FPPR:
I have read and fully understand the referee statement above.
Signature……………………………………… Date……………………………………
Full Name:
Position Held:
On behalf of (Organisation):
Contact Tel No:
Please return this form, marked strictly confidential, to: The Group Secretary Northern Care Alliance NHS Group Group Executive Offices 3rd Floor, Mayo Building Salford Royal, Stott Lane SALFORD M6 8HD
This reference will be treated strictly confidential and shared only with persons responsible for the assessment of Directors, with respect to conducting appropriate employment checks and testing compliance with the Fit and Proper Person Requirements. SRFT & PAT # 274090 We appreciate you taking the time to complete this form and thank you for04/27/2019 your cooperation 16:44:00 The Northern Care Alliance
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22/26 217/232 Appendix 3: Fit and Proper Person – Directors’ Self-Declaration
Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust
STRICTLY PRIVATE AND CONFIDENTIAL
Fit and Proper Person Regulations - Directors’ Self Declaration
All Board-level Directors are required to complete the following ‘Fit and Proper Person Declaration’ prior to appointment, and annually thereafter.
In line with Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Fit and Proper Persons Requirement for Directors, I declare:
Declaration Response: or x
I have read the current Code of Conduct for Directors and understand its requirements, in particular, the Fit and Proper Person Requirements (as set by the Care Quality Commission).
I am of good character by virtue of the following: − I am not an undischarged bankrupt or a person whose estate has had sequestration awarded in respect of it and who has not been discharged. − I am not the subject of a bankruptcy order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland. − I am not a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986(1).
− I have not made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it.
− I am not included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland.
− I am not prohibited from holding the relevant office or position, or in the case of an individual from carrying on the regulated activity, by or under any enactment.
− I have not been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committedSRFT in any & PAT # 274090 04/27/2019 16:44:00 part of the United Kingdom, would constitute an offence
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23/26 218/232 − I have not been erased, removed or struck-off a register of professionals maintained by a regulator of health care or social work professionals.
I hold the necessary qualifications, skills and experience to undertake the role I hold as a Director
I am able by reason of my health, after any reasonable adjustments have been made, of properly performing tasks which are intrinsic to my position.
I have not at any time been responsible for, privy to, contributed to, or facilitated, any serious misconduct or mismanagement in the carrying on of a regulated activity.
I am not prohibited from holding the relevant position under any other law e.g. under the Companies Act.
If any of the above statements cannot be confirmed, Directors must notify the Chairman or Group Secretary immediately.
Signed: Name:
Position: Date:
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24/26 219/232 Appendix 4: Fit and Proper Person Annual Compliance Checklist
Fit and Proper Person April 2019
Name Disclosure and Barring Check Annual Checks Recruitment checks Enhanced – Annual check Standard – On appointment or reappointment for further term of office
Type Date Certificate Executive Confirmation Fit and Review Professional Undischarged Disqualified Annual DOI Board of Recruitment CV ID Refs OH Appt DOB Enhanced Number Director Only: no concerns Proper complete Registration Bankrupt or Director Appraisal Directors Docs / 3 forms letter (E) Confirmation raised to HR Person against Check (if Sequestration Check Complete Code of Advert App Passport Payroll Standard registered for (on issue Self- Core Public applicable) Check (Date) Conduct Interview Driving (S)) Annual DBS and/or in Dec Information Signed details licence Update year) Sources Checked √ Checked √ JD Utility Service bill
Group Committees in Common (Executive Directors)
Disclosure and Barring Service Check − Enhanced – All Executive Directors/Chairman registered to annual update service. Annual check to be completed − Basic – All Non-Executive Directors excluding Chairman. To be completed on appointment and reappointment.
Review against Core Public Information Sources includes: − Any provider whose registration had been suspended or cancelled due to failings in care in the last five years or longer if the information is available because of previous registration with CQC predecessor bodies. (www.cqc.org.uk) − Public inquiry reports about the provider (Gov.UK) − Serious case reviews relevant to the provider. − Homicide investigations for mental health trusts. − Criminal prosecutions against providers. − Ombudsmen reports relating to providers (http://www.ombudsman.org.uk)
Undischarged bankrupt or sequestration check – Check with gov.uk if the person to be appointed is an undischarged bankrupt or a person who has had sequestration awarded in respect of it and who has not been discharged or similar restrictions in Northern Ireland or Scotland and annual re-check
Disqualified Director Check - Check with Companies House if the person to be appointedSRFT is a disqualified & PAT director # and 274090 annual re-check. 04/27/2019 16:44:00
Reviewed and Confirmed compliance with FPPR by Chairman …………………………………………………………: Date………………………………………. 1
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26/26 221/232 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & The Pennine Acute Hospitals NHS Trust (PAT)
Title of Report Summary: Group Risk and Assurance Committee (GRAC)
Meeting Group Committees in Common
Author (s) Jane Burns, Group Secretary
Presented by Chris Brookes, Deputy Chief Executive Date 29 April 2019
Executive A summary is provided of the key matters and decisions from the Summary Group Risk and Assurance Meetings held on 24 April 2019
Annual Plan N/A Objective Associated Risks N/A
Recommendations The Group Committees in Common is asked to: Review and confirm the outcomes of the Group Risk and Assurance Committee meeting held on 24 April 2019
Equality Does this paper relate to a matter where equality issues may arise? Y/N If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and can be Information made available to the public. x Please ‘cross’ one of This document contains some confidential information that would the boxes need to be redacted before the document was made available to the public. This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
Data Sharing Under the Data Sharing Agreement, the NCA may be required to Agreement with share this paper with MFT. This is distinct from information Manchester disclosed under the FOIA. As MFT will acquire part of PAT they will University NHS FT need to understand a range of matters which may otherwise be (MFT) in relation to exempt under FOI e.g. contracts to be split and specific workforce- the Transaction related issues.
Please consider the statements below and indicate which applies in relation to this paper: a) This paper relates solely to PAT and can be released
SRFT & PAT # 274090 b) This paper relates solely to SRFT and is therefore04/27/2019 not eligible 16:44:00 for release
Page 1 of 11 1/11 222/232 c) This paper contains information relating to both PAHT and SRFT. All information other than that relating to PAHT will be x fully redacted.
d) This paper contains reference to both PAHT and SRFT but contains no quality, finance or operational performance data relating to PAHT which could be relevant to the transaction and is therefore not eligible for release.
SRFT & PAT # 274090 04/27/2019 16:44:00
Page 2 of 11 2/11 223/232 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust
Group Risk and Assurance Committee (GRAC) Summary of meeting on Monday 24 April 2019, at 1pm, Seminar Rooms 11 & 12, 2nd Floor, Mayo Building, Salford Royal
Present Chris Brookes, Chief Medical Officer (as Chair) Raj Jain, Chief Executive Officer Judith Adams, Chief Delivery Officer Jym Bates, Associate Director of Digital & Assurance Jane Burns, Director of Corporate Services and Group Secretary Jacqui Burrows, Director of Nursing, Bury & Rochdale Care Organisation Beverley Cooke, Head of Patient Safety, NCA Jayne Downey, Director of Governance and Corporate Nursing Simon Featherstone, Nurse Director, North Manchester Care Organisation Damien Finn, Chief Officer, North Manchester Care Organisation Nicola Firth, Chief Officer, Oldham Care Organisation Shona McCallum, Medical Director, Bury and Rochdale Care Organisation Lindsay McCluskie, Group Director, Capital, Estates and Facilities Andrew Montgomery, Group Associate Director of Estates Ian Moston, Chief Financial Officer Tyrone Roberts, Director of Nursing, Salford Care Organisation Chris Sleight, Director of Diagnostics and Pharmacy James Sumner, Chief Officer, Salford Care Organisation Alison Talbot, Head of Legal Services, (NCA) Emma Wright, Director of Information & Business Intelligence Tina Chrysochou, Renal Consultant and Freedom to Speak Up Guardian
Apologies for Absence Jawed Husain, Medical Director, Oldham Care Organisation Paul Downes, Director of Patient Safety and Professional Standards Su Statom, Head of Corporate Governance Steve Taylor, Chief Officer, Bury and Rochdale Care Organisation Elaine Inglesby-Burke CBE, Chief Nursing Officer Pete Turkington, Medical Director, Salford Care Organisation
1. Apologies for Absence As above
Chris Brookes acted as Chair for the meeting.
2. Declarations of interest The Chair asked Directors to declare any interest relevant to the business of the meeting. No interests were declared.
3. Minutes from Previous Meeting Held on 18 March 2019 The minutes from the meeting held on 18 March 2019 were confirmed as an accurate record. SRFT & PAT # 274090 04/27/2019 16:44:00 4. Patient Safety Progress Reports
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3/11 224/232 4.1 Biliary Stent Removal GRAC received the updated paper regarding Biliary Stent removal, which provided detail about improvement actions. It was highlighted that it was approximately one year since an issue had been detected and significant improvement progress had been made. There remained limited capacity to conduct clinical notes reviews for deceased patients, and it was agreed that support would be sought from Commissioners to assist with this. Significant learning had taken place during this process, and there was now greater confidence regarding capacity and culture in the relevant teams. An area identified for improvement was the development of a monitoring process for biliary stent insertion follow up and removal and it was reported that work was now ongoing to implement the required solution. On enquiry, the Associate Director of Digital & Assurance informed GRAC that it was anticipated that a full electronic solution would be available for implementation in late Autumn. In the interim period, the digital team were exploring how an electronic reminder application could implemented, reported at cost of £12k, plus £1k per annum running costs.
Action: Update to next GRAC meeting. Digital Team To discuss with Commissioners whether they resource could be provided for clinical notes reviews – Chief Officer, Oldham Care Organisation To confirm to next GRAC meeting whether to implement the interim electronic solution for biliary stent tracking, or to continue with the paper-based tracker until a full electronic solution was implemented – Biliary Stent Group.
4.2 Management of Follow-up Review Group Progress Not discussed. Deferred to the next meeting.
5. Internal Audit Limited Assurance Reports
5.1 PAT Data Security and Protection Toolkit Assurance The Associate Director of Digital & Assurance presented the outcome of the 2018/19 Data Security and Protection Toolkit Assurance internal audit. This was a new toolkit that had replaced the previous Information Governance toolkit as of 2018. The review had shown that a number of areas needed to be addressed, some involving the underlying Pennine infrastructure, and a deadline of two months had been set for the most urgent of these. On enquiry, the Associate Director of Digital & Assurance informed the GRAC that this was a highly challenging piece of work with an equally challenging deadline, although work was now ongoing. It was agreed that an update paper should be brought to the next meeting of GRAC in order to provide further assurance that effective progress was being made.
Action: To bring a progress update report on the actions to improve the PAT Data Security and Protection Toolkit Assurance to the May 2019 meeting of GRAC - Associate Director of Digital & Assurance
5.2 Volunteers Management Review The Director of Governance and Corporate Nursing introduced the outcome from the Volunteers Management Review. The review had been commissioned by the NCA, and its objective had been to examine the systems and processes in place for the management of volunteers who provide support to the NES. On enquiry, the Director of Governance and Corporate Nursing informed GRAC that all work was underway to ensure volunteers were subject to the appropriate level of DBS checks, as it was likely that advanced DBS checks were not necessary for all volunteers. It was highlighted that the primary consideration was to ensure consistency in the volunteering process across the NCA.SRFT Following & PAT a short # 274090 discussion, it was agreed that progress against the recommendations04/27/2019 in this report 16:44:00would be monitored by the Group Workforce, Organisational Development, and Talent Management
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4/11 225/232 Committee. The Director of Governance and Corporate Nursing was asked to provide confirmation to GRAC in July 2019 that all management actions had been completed.
Action: To bring a progress update report on the actions to address all recommendations within the Volunteers IA Report to the May 2019 meeting of GRAC - Director of Governance and Corporate Nursing.
6. Statements of Assurance and Board Assurance Framework Q4 Position
GRAC received and noted the Statements of Assurance and 2018/19 Q4 Board Assurance Framework positions from the three North East Sector Care Organisations, and the Statement of Assurance from Salford Care Organisation. Key highlights for each Care Organisation included:
6.1 North Manchester Care Organisation Quality: reported as satisfied that that the plans in place are sufficient to ensure ongoing compliance with all existing quality standards and targets for the current quarter and year end. Two cases of C-Diff were declared in March 2019; overall, however, the Care Organisation ended 2018/19 under its target of 16 cases, with 14 in total. There was a small spike in pressure ulcers in Q4, although there remained a year-on-year reduction of 20%. This was being addressed. Improvement work for non-elective caesarean sections remained ongoing, and regional discussions regarding variance in reporting across the North West were due to take place in the following weeks. Finance: reported as satisfied that the plans in place have been sufficient to deliver the agreed financial control total for the current quarter and year end outturn. The control total for 2018/19 had been met, and focus had now shifted toward 2019/20 financial planning. Operational Performance: reported as not satisfied that the plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the current quarter and year end. Emergency Department 4 hour performance: improvements in the absolute numbers of patients treated within four hours had been off-set by significant increases in activity. It was agreed that discussion was needed with commissioners regarding this, as activity had previously been expected to fall. A year on year improvement for RTT was reported, and it was noted that NMCO achieved 92% compliance per speciality for Manchester patients, as agreed with MHHC. The Care Organisation had not met the 62-day standard for Cancer in February 2019, and performance in several areas remained fragile. The pathways for Lung and Urology tumour sites had been altered, and improvement was expected in Q1 2019/20. Oversight on performance was being provided by the NMCO Cancer Improvement Board.
Risks highlighted and discussed included workforce recruitment, ensuring accurate mandatory training reporting, and the proposed surgical pathway from B&RCO to NCMO. It was noted that there had been positive progress made in agency spend, through transferring doctors onto the organisation’s own Bank. The Chief Delivery Officer raised a query regarding delivery of the planned trajectories for 2019/20, and was informed by the NMCO Chief Officer that, despite some initial challenges at the start of the year, he expected NMCO to return on track to meet the Q1 2019/20 trajectories. The Chief Delivery Officer and Group Secretary confirmed that the Statement of Assurance template would be amended to facilitate accurate reporting of this expectation. ACTION: Group Secretary
Surgical Pathway from B&RCO to NMCO It was anticipated that the revised surgical pathway would commence 1st May 2019, with ongoing monitoring to determine the effect on patient flow. It had beenSRFT decided & PAT to # maintain 274090 the risk scoring as 13 until implementation of the new pathway, but was04/27/2019 confirmed to16:44:00 GRAC that the commentary supporting the risk score was being updated on a weekly basis. The GRAC discussed potential risks to the new pathway, with particular focus on the need to
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5/11 226/232 ensure that urgent transfers wouldn’t be delayed by unnecessary investigation. In response to this concern, it was confirmed that the proposed pathway allowed clear surgical patients to be transferred without the need for a CT scan, and work was ongoing to address any cultural and communicative impediments to the new pathway. It was agreed that this risk would be added to the North Manchester BAF as well as being on the B&RCO BAF.
Action: To add the Surgical Pathway between B&RCO and NMCO to the NMCO BAF – Nurse Director, North Manchester Care Organisation
6.2 Bury & Rochdale Care Organisation Quality: The report was satisfied that the plans in place are sufficient to ensure: ongoing compliance with all existing quality standards and targets for the current quarter and following quarter. Six C-diff cases had been declared at Fairfield. VTE work was ongoing and a new VTE incident management process was expected to go live soon. A deep dive was being planned to investigate and address an issue with data provided by the complaints team. Finance: The report was not satisfied that the plans in place are sufficient to deliver the agreed financial control total for the current quarter. Action: Through concern raised by the Chief Financial Officer, it was confirmed that where some Care Organisations had been unable to confirm expected delivery against financial plan for current quarter, this related to Q4 2018/19. It was agreed that the Statement of Assurance would be adjusted to make this clear going forwards – ACTION: Group Secretary Operational Performance: reported as not satisfied that the plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the current quarter and following quarter. A business case had been submitted to increase capacity in Ophthalmology, as it was anticipated that this would significantly improve income in this area. The Chief Financial Officer confirmed to GRAC that this had been reviewed at Group Capital Committee and had been approved, subject to recovering the recurrent £950k as set out in the paper. Modelling was underway to determine the effect of rising acuity on the bed base at Fairfield, and it was agreed that the outcome of this would be reported to GRAC in May 2019. Engagement and Workforce: The report was satisfied that plans in place are sufficient to ensure effective staff engagement and communications. Staff-side representation was now in place at each of the Care Organisation’s Assurance Committees.
Action: To bring the outcome of the modelling exercise regarding the effect of acuity on Fairfield’s bed base to the next meeting of GRAC – Medical Director, Bury and Rochdale Care Organisation
6.3 Salford Care Organisation Quality: reported as satisfied that the plans in place are sufficient to ensure: on-going compliance with all existing quality standards and targets for the current quarter and following quarter. A Never Event had taken place in Dermatology; this had been reported, but was not yet included in the Statement of Assurance. Finance: reported as satisfied that the plans in place were sufficient to deliver the agreed financial control total for the current quarter and planned year end forecast outturn. On enquiry, the Chief Financial Officer confirmed that the upcoming HMRC compliance check to review NHS increased contracted out services VAT recovery was part of normal business and not in response to a particular issue. Operational Performance: reported as not satisfied that the plans in place were sufficient to deliver the capacity requirement to meet demand and achieve coreSRFT NHS &access PAT #targets 274090 for the current quarter and following quarter. A&E performance in April had04/27/2019 improved in 16:44:00 the last ten days, and the general trajectory was noted to be similar to the same period in the previous year. Based on the current situation, it was anticipated that the Q1 performance
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6/11 227/232 would be close to, or match, the planned trajectory. The RTT waiting list size was better than the internal NCA target, but had not met the national target to hold the March 2018 position. Validation had now confirmed a number of 52-week breaches, including 3 breaches in April 2019. Following the validation exercise, actions had now been taken to mitigate further the risk of patients waiting >52 weeks for treatment. Work was also taking place to determine cause of deterioration in serious patient falls. Recovery of the 6-week target standard was dependent on successfully completing the recovery plan related to MR capacity issues.
The Chief Officer for Salford Care Organisation informed GRAC that the BAF would be completed and circulated after the meeting.
6.4 Oldham Care Organisation Quality: reported as not satisfied that the plans in place are sufficient to ensure: ongoing compliance with all existing quality standards and targets for the current quarter and following quarter. Positive assurance was received for Sepsis, Falls, and Urgent Care. A mortality action plan had been developed and was being implemented. The Chief Medical Officer highlighted the importance of coding to ensure that focus was directed appropriately and to prevent confusion, and noted the positive work to address this that had been included in the action plan. Root Cause Analyses were underway to investigate the 1 MRSA and 2 C- Diff infections. Finance: reported as not satisfied that the plans in place are sufficient to deliver the agreed financial control total for the current quarter and planned year end forecast outturn. The key driver of below-plan performance for month 12 was the non-delivery of the BCLC stretch target. While it was anticipated the 2019/20 BCLC target was achievable, work was needed to split the trajectory appropriately between quarters as, on an even split, it was not expected that the Q1 BCLC target could be achieved. Operational Performance: reported as not satisfied that the plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the current quarter and following quarter. Cancer performance was meeting the Care Organisation’s improvement trajectory. There were significant delays in imaging, and imaging reporting, which had been flagged at the Oldham COARC. Weekly monitoring meetings were taking place to maintain progress against recovery plan.
6.5 Diagnostic and Pharmacy Governance: reported as satisfied that the plans in place are sufficient to ensure: ongoing compliance with all existing quality standards and targets for the current quarter and following quarter. A positive outcome for the new model for andrology was highlighted, as it had now been inspected and accredited. Finance: reported as not satisfied that the plans in place are sufficient to deliver the agreed financial control total for the current quarter and planned year end forecast outturn. The key drivers for the financial pressures were a shortfall in BCLC delivery, and a continued reliance on outsourcing to meet the demand on Radiology services at SRFT. Operational Performance: reported as not satisfied that the plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the current quarter due to slippage against turnaround times within Radiology and Cellular Pathology across the NCA. It was anticipated that this would be addressed for Q1 2019/20, however. Engagement and Workforce: reported as satisfied that plans in place are sufficient to ensure effective staff engagement and communications. However the need for senior HR support is crucial to support completion and delivery of Group Transformation plans.
Request for reduction to PA activity - Radiology SRFT & PAT # 274090 As a result of changes to taxation on pensions, consultants in radiology04/27/2019 had requested 16:44:00 reduction in job planned activity. Appropriate action was being taken to mitigate, but this remained a key risk for the service. The GRAC discussed in detail, and emphasised the
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7/11 228/232 need to encourage colleagues to attend information sessions across the NCA in order to gain a fuller understanding of the implications, and whether it affected their own circumstances. GRAC discussed how extensive the issue was and whether it only affected a limited number of staff; the potential negative effect on recruitment to medical leadership roles, and how this could be addressed; and potential alternatives that could be implemented. It was agreed that an update on the areas affected and potential solutions would be brought to the next meeting of GRAC.
Action: Update re areas affected and potential solutions to requested reduction in radiology consultant PAs to be provided to GRAC in May 2019 – Director of Diagnostics and Pharmacy/Chief Delivery Officer
BAF/Risks Significant work had taken place to merge and amalgamate the Diagnostics & Pharmacy risks across the NCA into a single BAF, with the next step being to review and update the risk scoring to ensure consistency and accuracy. In response to a query regarding the mortuary capacity risk (Risk 2059), the Director of Diagnostics and Pharmacy informed the GRAC that this risk was well-controlled, as existing capacity was sufficient to flex to demand in routine use and, in an emergency, an alternative was available. It was acknowledged that the scoring was currently too high for this risk.
A concern was raised regarding risk 2112 (replacement of the 3T Scanner), and why the likelihood score was currently marked as 5. In response, the Director of Diagnostics and Pharmacy informed GRAC that the 3T MR business case had now been approved, subject to funding availability; however, following discussion with clinical colleagues, it had been decided to keep the likelihood score at 5 until the new 3T scanner had been purchased and implemented.
Another risk discussed was the impact of insufficient medical capacity on provision of interventional radiology service (risk 901). While the immediate risk had been mitigated, the service remained fragile. GRAC discussed some initial options and agreed that further discussion would need to take place outside of the meeting, to enable key personnel to contribute.
The Chief Medical Officer raised a concern that had been received regarding medical equipment in North Manchester. The issues had arisen during the due diligence for the transaction. During discussion, it was highlighted that there was a disparity between the issues raised and CQC’s assessment of the same matters. It was agreed that response would be made once the full report was available.
The Chief Delivery Officer requested that the statements of assurance be clear that non- delivery of targets was against the NCA’s submitted annual plan and not against national targets. It was also requested that, wherever unforeseen/exceptional circumstances had affected delivery of the annual plan, the reasons be made clear in the narrative. It was agreed that the wording in the SoA template would be updated to refer to achievement against the annual plan trajectories
Action: To update the wording on the SoA template to refer to achievement against NCA annual plan trajectories - Director of Corporate Services and Group Secretary
Action: To update the confirmed/not confirmed section of the SoAs to match the updated template, and submit them to Group CiC – Care Organisation ChiefSRFT Officers & PAT # 274090 04/27/2019 16:44:00
7. Quality and Patient Safety Reports
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8/11 229/232 7.1 Group Learning from Experience The Head of Patient Safety (NCA) introduced the Learning from Experience Report for complaints, PALs, and incident management for the Northern Care Alliance. The report covered the period Q2 and Q3 2018/19, and combined the Learning from Experience reports of each of the four Care Organisations.
Key highlights included: zero Never Events reported in Q2 and Q3; Duty of Candour for concise investigations was >=97% for Q2/Q3 2018/19; Duty of Candour for Serious Incident investigations remained at 100% for all Care Organisations within Q2/Q3; and, in response to learning and themes analysis, there was work taking place to improve both falls management and blood glucose monitoring.
Areas that required further work included; investigating the themes and learning from falls resulting in low/no harm; improving incident reporting from Junior Doctors; and theming and sharing compliments. The GRAC acknowledged the positive progress being made, and highlighted the importance of learning from experience. It was suggested that the importance of focusing on learning be fed back through the Care Organisation Clinical Effectiveness Committees. The importance of sharing compliments, to help support and improve staff morale, was also highlighted.
The Chief Executive Officer complimented the report authors on the quality of the report, and for the work taking place to develop an open reporting culture within the Care Organisations.
7.2 Learning from Deaths Report The Head of Patient Safety (NCA) introduced the Q2-Q3 2018/19 Learning from Deaths report. The report provided information on compliance with national guidance, the uptake of training across the NCA, the development of a new bereavement leaflet, which incorporated the National Learning from Deaths Guidance on information and support to provide to bereaved families and carers, mortality indicators across the NCA, and Oldham Care Organisation’s action plan to support with HSMR.
Oldham’s significant positive progress in Q2 in ensuring that structured judgements reviews were conducted where needed and were learned from, was highlighted and acknowledged by GRAC.
The Chief Executive Officer enquired how the wishes of the preferred place of death were recorded. The Director of Governance and Corporate Nursing informed GRAC that this information was collected, and agreed to arrange for it to be reported at Group level via the Executive Quality Committee.
Action: To arrange for information with respect to ho the organisation complied with patient’s/families’ preferred place of death to be reported via the Executive Quality Committee – Director of Governance and Corporate Nursing
7.3 Patient and Service User Experience Progress Reports GRAC received a paper providing an update on the delivery and progress of patient/user experience across the four Care Organisations and corporate led programmes of work.
Key highlights included: Pennine’s improved ranking in the Adult Inpatients Picker reports; discrepencies in previous data provided by Picker for Salford, for which an investigation had been requested; all Care Organisations now had established local SRFTpatient & experience PAT # 274090 meetings, with summary reports provided in the appendices; and the04/27/2019 SRFT Volunteers 16:44:00 Service had received £75k from Helpforce, to be spread across the four Care Organisations, in order to deliver a dining companions project. The GRAC acknowledged the importance of
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9/11 230/232 both patient and staff experience and the Chief Executive Officer noted that the Board’s intention was to have people be the prime driver of the NCA’s activities, with a Patient Experience Strategy to be a key element of this, and to be developed through engagement at local level.
8. Quality Reports
8.1 Salford Royal Foundation Trust Quality Report GRAC received and noted the draft 2018/19 SRFT Quality Report
8.2 Pennine Acute Hospitals NHS Trust Quality Report GRAC received and noted the draft 2018/19 PAHT Quality Report.
On behalf of the GRAC, the Chief Medical Officer thanked all the people who had contributed to the SRFT and PAHT 2018/19 Quality Reports.
9. Freedom to Speak Up (FTSU) Guardian Update Report Dr Chrysochou presented an update report on Freedom to Speak Up for GRAC’s information and assurance, including developments in staffing, and progress with ongoing concerns raised within the organisation.
Significant progress had been made in appointing Lead FTSU Guardians across the organisation, and ensuring that staff members were aware of how they could raise concerns. In addition, Carmen Drinkwater had been appointed as the new Non-Executive Lead for FTSU. The NCA had also been selected as one of 6 case study sites to take part in an NIHR research project on ‘’Evaluation of the implementation and normalisation of ‘Freedom to Speak Up Local Guardians’ in NHS England Acute and Mental Health Trusts’’. It was acknowledged that work remained to communicate the difference between hospital sites and Care Organisations, as this affected the staff hierarchies involved when concerns were raised.
On enquiry, it was confirmed that the FTSU team would be supporting the new appointments. GRAC was also informed that there was a clear line of communication available for the Guardians to contact relevant leaders.
The GRAC thanked the team for their work, noting the importance of Freedom to Speak Up and the ability to raise concerns through this route, and highlighting the significantly improved visibility of the process over the past few months. It was agreed that the Director of Corporate Services and Group Secretary would meet with Dr Chrysochou to review the connection between the FTSU team, the Chief Executive Officer and nominated Non- Executive Director, and to consider possible reporting to the Group CiC.
Action: To meet with Dr Chrysochou to review connections to the CEO and nominated NED, and whether regular reports should be provided to Group CiC - Director of Corporate Services and Group Secretary
10. Fire Assurance Update Paper GRAC received and discussed a paper providing a high level overview of fire safety across the Northern Care Alliance, along with updates on key risks that were forming part of the work plan for the NCA Fire Strategy Group.
11. Group Board Assurance Framework Q4 Position SRFT & PAT # 274090 The Group BAF Q4 position had not yet been completed. It was agreed04/27/2019 that it would 16:44:00 be presented at the following meeting alongside the scheduled opening position for Q1 2019/20.
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10/11 231/232 12. Joint Highlight Report from Sub-committees The Joint Highlight Report from GRAC’s Sub-committees was received for assurance and information.
13. For Approval
13.1 External Agencies Visiting Policy GRAC received and approved the External Agencies Visiting Policy.
14. Items to be referred to Audit Committee GRAC considered all items discussed and agreed that on this occasion there were no items for referral to Audit Committee.
15. GRAC Annual Performance Review GRAC received and approved the GRAC Annual Performance Review.
16. GRAC Action Tracker GRAC reviewed the action tracker and were satisfied that all actions were completed or working towards completion.
Action 69 – Report on risks relating to Mandatory Training Records The Chief Executive Officer requested that an update be provided to the Exec Team Meeting in the following week
Action 67 and 68 – Unopened Mail The Director of Governance and Corporate Nursing confirmed that systems were now in place at all Care Organisations. An SOP had now been created, and it was agreed that this would be provided for information to the next meeting of GRAC.
17. Any Other Business No other business was raised or discussed.
18. Date and Time of Next Meeting The next meeting would be held on 20th May 2019, 1pm – 2.30pm, in Seminar Rooms 5 & 6, Level 2 Mayo Building
SRFT & PAT # 274090 04/27/2019 16:44:00
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