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Board of Directors Tuesday 27 October 2015, 8:30am

Flintoff Room, Holiday Inn

Board of

Directors

Quality Committee

Finance & Performance Committee

Nomination / Remuneration

Committee

Audit Committee

Board of Directors

Meeting Board of Directors Meeting

Location Flintoff Suite, Holiday Inn, Bamber Bridge, Preston

Date Tuesday, 27 October 2015

Time 8.30am – 1.00pm

PART ONE:

Reference Item Lead Action Enc FOIA

Exempt

PROCEDURAL ITEMS

TB 081/15 Welcome and opening comments Chair Verbal

TB 082/15 Patient Story Chair Verbal

TB 083/15 Apologies for absence and confirmation of quoracy

Chair Verbal

TB 084/15 Declarations of Interest Chair Verbal

TB 085/15 Minutes of the previous meeting Chair Decision Paper

TB 086/15 Action Tracker Chair Decision Paper

CHAIR AND CHIEF EXECUTIVES REPORT

TB 087/15 Trust Chairs Report Chair Noting Paper

TB 088/15 Chief Executive’s Report Chief Executive Discussion Paper

TB 089/15 Audit Committee Chairs Report Committee Chair Noting Paper

TB 090/15 Quality Committee Chairs Report Committee Chair Noting Paper

TB 091/15 Finance and Performance Committee Chairs Report

Committee Chair Noting Paper

FINANCE AND PERFORMANCE

TB 092/15 Finance Report Chief Finance Officer

Noting Paper

PEOPLE AND LEADERSHIP

TB 093/15 Quarterly Workforce Report Director of HR Noting Paper

GOVERNANCE AND ASSURANCE

TB 094/15 Board Assurance Framework 2015/16 – Quarter Two review

Associate Director of Compliance and Assurance

Decision Paper

TB 095/15 Risk Appetite Statement Associate Director of Compliance and Assurance

Decision Paper

TB 096/15 Academic Health Science Network (AHSN) North West

Chief Executive Noting Paper

PART TWO:

quarter two performance report

TB 097/15 Red Rose Corporate Services (RRCS) Quarterly Report

RRCS Board Directors

Noting Paper

TB 098/15 Use of the Common Seal Director of Governance and Compliance

Noting Paper

TB 099/15 Minutes of the previous meeting Chair Decision Paper

TB 100/15 Chief Executive’s Report Chief Executive Discussion Paper

TB 101/15 Healthier Lancashire Forward View

Chief Executive Discussion Paper

TB 102/15 Any other business Chair Noting Verbal

TB 10315 Date and time of next meeting Chair Noting Verbal

CONFIRMED

BOARD OF DIRECTORS

Minutes of the Part One Board of Directors meeting held on Tuesday 28 July 2015

PRESENT: Derek Brown, Trust Chair

Heather Tierney-Moore, Chief Executive

David Curtis, Non-Executive Director

John McKenna, Associate Medical Director

Naseem Malik, Non-Executive Director, Senior Independent Director

Peter Ballard, Deputy Chair

Bill Gregory, Chief Finance Officer

Dee Roach, Director of Nursing

Damian Gallagher, Director of Human Resources

Sue Moore, Chief Operating Officer

Gwynne Furlong, Non-Executive Director

Diane Halsey, Director of Governance & Compliance

IN ATTENDANCE: Graham Urwin, Director of Commissioning Operations, NHS England

(agenda item 061/15 only)

Julie-Ann Bowden, Associate Director of Compliance & Business

Assurance

Alistair Rose, Project Director

OBSERVERS: Brian Taylor, Public Governor

Brian Spencer, Public Governor

Nicky Collins, Browne Jacobson

Chris Thomas, Otsuka Pharmaceutical

Paul Ducklin, BT

Darren Smith, Smith & Nephew

TB 055/15 WELCOME & OPENING COMMENTS The Chair welcomed all attendees, including members of the public and made introductions as appropriate.

TB 056/15 PATIENT STORY The Chair noted the Patient Story received by the Board immediately prior to the meeting and invited members of the Board to comment on the positive and negative experiences of the service user. The Chief Operating Officer provided an overview of the Dialectical Behavioural Therapy (DBT) service waiting times and allocation of resources following a query from a Non-Executive Director.

A discussion followed around the clinical benefits of DBT as an effective treatment for boarder-line personality disorder (BPD). The Associate Medical Director detailed the care pathways and admission patterns for those with a diagnosis of BPD.

TB 057/15 APOLOGIES FOR ABSENCE & CONFIRMATION OF QUORACY Apologies were received from Max Marshall, Medical Director and Louise Dickinson, Non-Executive Director.

CONFIRMED

TB 058/15 DECLARATIONS OF INTEREST There were declarations of interest received from Gwynne Furlong, Non-Executive Director and Bill Gregory, Chief Finance Officer for the agenda item TB/076/15 Red Rose Corporate Services Update. Heather Tierney-Moore, Chief Executive declared an interest in agenda item TB/073/15 Academic Health Science Network.

TB 059/15 MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on 28 May 2015, and 23 June 2015 were taken as a true and accurate record, subject to two minor typographical amendments.

TB 060/15 ACTION TRACKER The Board reviewed the action tracker and closed items as appropriate.

TB 061/15 DEVOLUTION IN GREATER MANCHESTER The Trust Chair introduced Graham Urwin, Director of Commissioning Operations for NHS England who was attending to provide an overview of the devolution project in Greater Manchester. The Director of Commissioning Operations outlined the background of the macro-economic project and the retention of local authorities and CCGs as part of the project. The 5 year plan to deliver financially sustainable services was described in further detail.

The Director of Commissioning Operations outlined the objective to deliver seven day access to primary care for all of the population and described the expectations for the funding devolved to Greater Manchester. The Board heard an overview of the number and type of organisations involved in the devolution, including provider organisations, and described the positive levels of collaboration between large numbers of local organisations.

The Memorandum of Understanding was outlined in more detail, particularly the importance of using NHS resource more efficiently. It was emphasised that NHS England are not intending to apply a ‘one size fits all’ approach arising out of the Greater Manchester project and would support a variety of different models arising out of other devolution projects.

The Director of Commissioning Operations described the objectives for the vanguard sites across the country. A brief outline was provided of pilots and testing undertaken to support the aspiration for the fastest possible improvements for health and social care for the people of Greater Manchester.

Further to a query from the Chief Executive the Director of Commissioning Operations provided his view on the symbolism of the devolution in Greater Manchester in providing a driver for the collaboration of provider organisations and a positive working arrangement.

A Non-Executive Director prompted a discussion around measuring success of the devolution project and the ways in which early successes could be recognised through improved outcomes for patients and effective use of resources.

The Trust Chair thanked Graham Urwin for his contribution on behalf of the Board.

CONFIRMED

Graham Urwin left the meeting.

TB 062/15 TRUST CHAIRS REPORT The Trust Chair reminded the Board of the purpose of the report and

highlighted the recent re-appointment of a Non-Executive Director by the

Council of Governors.

The Deputy Chair outlined the progress to date of the Trust Chair recruitment

process and intention to advertise online due to the cost of printed adverts.

The dates for interviews and details of the recruitment company appointed

through a due tender process were noted.

The Deputy Chair shared feedback gathered from engagement sessions

across the Trust which widely supported the decision to re-appoint the Trust

Chair.

TB 063/15 CHIEF EXECUTIVES BRIEFING The Chief Executive confirmed the date of the Care Quality Commission

Inspection Quality Summit and outlined the expected date to receive outcome

reports.

An update on the Better Care Together was provided. Progress of the Trust

bids around the urgent care vanguard sites to support the crisis concordat

work was described and the Board noted the development and deadline and

of the acute stroke care bid.

The Healthier Lancashire work was outlined in more detail. The progress of

the collective initiative was noted with work expected to conclude by

September.

The Board of Directors reviewed and approved the Monitor Quarterly

Submission for Quarter One.

TB 064/15 AUDIT COMMITTEE CHAIRS REPORT David Curtis, Non-Executive Director presented the Audit Committee Chair’s

Report and highlighted key elements of the Audit Committee Annual Report

2014/15. The refreshed Terms of Reference were presented to the Board for

approval.

The Board of Directors considered and approved the Audit Committee

Terms of Reference.

The Board received assurance against the Board Assurance Framework risks

through the Audit Committee Chair’s Report.

The Trust Chair highlighted an item within the Audit Committee Chair’s Report

referred up to the Board further discussion and requested that further

discussion be held during the Part Two meeting.

CONFIRMED

TB 065/15 QUALITY COMMITTEE CHAIRS REPORT The Chair of Quality Committee introduced the Chair’s Report and described

the developing provision of assurance to the Committee but noted areas for

further focus and development. The Trust Chair discussed the embedding of

the assurance flows within the new governance structure and emphasised the

importance of the Chair’s Reports as a key mechanism for the provision of

assurance to the Board.

A reduction in the number of serious incidents was reported through the

Quality Committee and it was confirmed the Committee would continue to

scrutinise the reporting of serious incidents.

The Chief Executive expanded on discussions held at Quality Committee

around the decrease in serious incidents. A clear distinction was made

between the ability to establish a reason for the decrease in serious untoward

incidents and the regular thematic reviews which are undertaken for serious

incidents.

TB 066/15 FINANCE & PERFORMANCE COMMITTEE CHAIRS REPORT The Chair of Finance & Performance Committee introduced the Chair’s

Report and reiterated comments from Committee Chair’s around the

development of assurance reports and embedding assurance flows. The

report was taken as read.

TB 067/15 SAFER STAFFING REPORT

The Director of Nursing & Quality outlined recent changes to the safer staffing

agenda and noted the continuing role of NICE in issuing guidance. The

greater emphasis on multi-disciplinary teams with more direct contact time

with patients was noted including less focus on prescriptive staffing numbers.

The Board received the six monthly safe staffing report and the key points

were highlighted. The Director of Nursing & Quality recognised the

challenges to ensuring an effective daily rostering process and described the

importance of completing and embedding the e-rostering system within the

organisation.

The Director of Nursing & Quality explained the interdependencies and

complexities of staffing levels in more detail and referred to the narrative

within the report.

The Director of Human Resources responded to a question from a Non-

Executive Director around staff sickness levels and provided an overview of

the work underway to reduce sickness levels and improve staff engagement

and support. A discussion followed around the involvement of staff side

representation to ensure the fair and consistent application of the managing

attendance policy. The financial savings which can be demonstrated through

reducing sickness absence rates were considered.

CONFIRMED

Following a query from the Trust Chair, the Director of Human Resources

described the quality outcomes which are set for the occupational health

provider in reducing staff sickness levels. A discussion followed around the

Health and Wellbeing Strategy to support growth and development of a

supportive compassionate culture for staff.

TB 068/15 FINANCE REPORT The Chief Finance Officer explained in detail the key points arising from the

Finance Report, including the financial position and Continuity of Service Risk

Rating 3 which was expected. The contributing financial cost of Out of Area

Treatment on the current overspend was acknowledged however the Board

noted the Trust was largely on target with the financial plan.

The Board received a report detailing the financial progress of the Delivering

the Strategy programmes and the Chief Finance Officer highlighted the

successful signing of both the Community & Mental Health contracts.

The Board noted an outstanding district nursing contract with NHS England

which was being progressed.

TB 069/15 QUARTERLY WORKFORCE REPORT The Director of Human Resources introduced the new format quarterly

workforce report and noted new reporting measures including vacancy rates.

The percentage of bank and agency spend as part of the total pay spend was

discussed further in particular the reductions agreed within Networks.

The Director of Human Resources described the work to reduce the current

staff turnover rate and the benefits to recruitment costs and stability of

organisational teams. A discussion took place around effective use of around

exit interviews and it was noted that work was ongoing to review this.

The progress in ensuring all staff have approved objectives as part of

undertaking a quality appraisal was discussed as well as ensuring staff are

appropriately inducted into the organisation. A further discussion was held

around the findings of the cultural assessment survey in providing quality

induction for new staff and allows staff to develop professionally whilst

supporting staff to fully engage with the organisation’s culture.

The Trust Chair discussed the setting of a clear trajectory for the continuing

improvements within the workforce directorate and the measures in place to

monitor transactional processes were described.

TB 070/15 LIVING WAGE SALARY PROPOSAL The Director of Human Resources provided the background to the Living

Wage agenda within the Trust and at a national level and the Board received

assurance that the Trust are compliant with the law on national minimum

wage.

CONFIRMED

The Director of Human Resources went on to describe in detail the wider

reaching impact of implementing the Living Wage on a number of areas

including job evaluations and exposure to risk of fair pay claims. The

significant increase for the Trust’s pay bill was also discussed.

The Chief Executive expressed detailed views on the adoption of Living

Wage, the important role of apprenticeships and commitment to developing

staff on entry level salaries and recommended the adoption of Living Wage be

declined.

The Board considered the recommendation of the Chief Executive and

agreed to decline the adoption of Living Wage.

The Senior Independent Director referred to the detailed consideration and

robust investigation of the Living Wage agenda further to the topic being

raised by the Council of Governors. It was noted that the Board was satisfied

with the process undertaken and the decision reached not to implement Living

Wage.

TB 071/15 BOARD OF DIRECTORS TERMS OF REFERENCE The Director of Governance & Compliance introduced the refreshed terms of

reference for the Board of Directors noting the alignment with the Standing

Financial Instructions and Decision Rights Framework as well as consistency

with the new governance structure.

The Director of Governance & Compliance described the next steps for the

design and implementation of the assurance directory.

The Board of Directors approved the Terms of Reference.

TB 072/15 BOARD ASSURANCE FRAMEWORK 2015/16 – QUARTER ONE REVIEW

The Associate Director of Compliance & Business Assurance provided a brief

background of the Board Assurance Framework and noted the introduction of

heat maps reflecting the quarter one risk profile position.

The detailed movement of risk scores and supporting rationale was provided

by the Associate Director of Compliance & Business Assurance alongside the

15 and above Network risks with key interdependencies to the Board

Assurance Framework risks. The Board noted the ongoing work to review the

framing of risk within the Networks by the Director of Nursing & Quality.

The Board of Directors approved the Quarter One Board Assurance

Framework.

CONFIRMED

TB 073/15 ACADEMIC HEALTH SCIENCE NETWORK (AHSN) NORTH WEST Q1

PERFORMANCE REPORT

The Quarter One AHSN report was provided for information to the Board and

was taken as read. The Chief Executive highlighted the paper development

process and noted there were no areas of concern or discussion required.

TB 074/15 USE OF THE COMMON SEAL The Board of Directors noted the Use of the Common Seal.

The Trust Chair concluded the Part One meeting and members of the public left the meeting.

Board of Directors

Agenda Item TB 087/15 Date: 27/10/2015

Report Title Trust Chairs Report

FOIA Exemption Part Exemption

Prepared by Umme Batan, Corporate Governance Support

Presented by Derek Brown, Trust Chair

Action required Noting

Supporting Executive Director Executive Director of Governance and Compliance

PURPOSE OF THE REPORT:

Report purpose The purpose of the report is to provide the Board with an overview of the activity undertaken by Non-Executive Directors in addition to Board meetings.

Strategic Objective(s) this work supports

To become recognised for excellence

Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence

CQC domain Well-led

1.0 INFORMAL & FORMAL BOARD SESSIONS

Since the formal meeting held on 28 July 2015, Board members attended an Informal Board Development Session on 23 September 2015. The Board Development Session focussed on the Trust’s Leadership Culture and the challenges posed by OATs future.

2.0 PATIENT STORY

The Board invites individuals who have used the Trust’s services to tell their story at the start of

each Board meeting. A patient attended the Board meeting to provide his experience of using

the Trust’s Complex Care and Treatment Team services in Burnley and Pendle. The Board

thanked the patient for sharing their story and the team for their hard work and contribution to

providing high quality care.

3.0 PRESENTATION FROM PROF MICHAEL WEST ON THE TRUSTS LEADERSHIP CULTURE Professor Michael West provided a presentation to the Board on the Trusts Leadership Culture.

4.0

5.0 RISK APPETITE

At the Board Development Session on 5 October 2015, the risk appetite statement was

reviewed with the principle of aligning it to appetite against each of the strategic priorities and

associated blueprint statements. The outcome of this exercise is included as a paper on this

Board agenda.

FOIA Exempt Under Section 43 – Commercial Interest

FOIA Exempt Under Section 43 – Commercial Interest

6.0 CLINICAL VISITS

It has been decided to replace the clinical visits undertaken by Directors following Board

meetings with a regular individually arranged visit to allow more flexible time for Board

meetings.

7.0 CHANGES TO CONSTITUTION

This year the Trust will be embarking on a programme of work to apply for e-Voting to this

year’s Governor Elections alongside the postal voting.

Changes to the constitution have been approved by Governors around the Non-Executive

Directors composition to enable handover and induction time for new NEDs. (There will now be

a minimum of five (5) but no more than six (6) NEDs on the Board of Directors in addition to the

Chair). This could lead to an unbalanced Executive/NED membership in the event that a vote is

required. An SOP has been developed to deal with this situation - a non-voting Executive

member will be called on to vote in the event that this situation arises. The Corporate

Governance and Compliance sub-committee will make a formal recommendation for

acceptance of this SOP to the Council of Governors for approval.

8.0 DIRECTOR ACTIVITY

In addition to the usual Board business, Non-Executive Directors have been involved in their areas of special interest during the period of July-October 2015:

All Non-Executive Directors have been attending the programme of quality board visits following the Board meetings. They have also been attending the Board sub-committee meetings which they are a member of.

Louise Dickinson met with both the Internal and External Auditors and had individual meetings with the Director of Governance and Compliance and the Director of Nursing. She also had her monthly meetings with The Chief Executive. Louise was on the panel for the Clinical Excellence Awards and she had a pre-meet with a HR colleague to discuss the awards. She carried out the Board Quality Visit to HMP Liverpool Prison on a separate day. She also attended and Innovation Incubator Breakfast session. David Curtis attended an InTouch session with the Director of Nursing and also met with her to discuss the Quality Committee agenda and papers. He carried out a Good Practice Visit to the Phlebotomy Service (Central). He attended a Schwartz Round. David attended an external NED training session at NW Academy. He had a meeting with the Network and Clinical Director from Children & Families and carried out a visit at the Early Intervention Service (EIS) in Chorley, he also attended an Eating Disorder Pathway Workshop with them. David carried out a half day visit to the Paediatric Learning Disability service. Naseem Malik attended an InTouch session at the Darwen Health Centre. She had her monthly meeting with the Director of HR. Gwynne Furlong attended an Appeal Hearing and also attended the Out of Hospital Steering Group meeting and the Security Management Forum meeting in August. He met with the Chief Finance Officer and the Project Director to discuss the RRCS accounts. Gwynne deputised for the Chief Executive at the Sports Awards and took part in the panel. He met with the Assistant Director of Nursing (Safeguarding) to discuss the Membership Safeguarding Event which he is deputising for the Chair. As part of recruitment for the new Chair Peter Ballard has been attending meetings and has met with the Chief Executive and the Director of Governance and Compliance. He has been involved in weekly tele-calls with Senior Consultant at GatenbySanderson. He had a catch up meeting with the Director of Nursing and the Medical Director. Peter was a panel member for the AAC Interviews which took place in August.

All NED’s had a tele-call with the Senior Consultant at GatenbySanderson, the recruitment agency who are carrying out the new Chair recruitment. All NEDs attended/dialled in to a Nominations Remunerations Committee meeting.

Peter, David, Naseem and Gwynne attended the Board to Board meeting in August with NHS Chorley and South Ribble CCG. Peter, Louise and Naseem met with the Chief Executive and the Director of Nursing to discuss the Appreciative Leadership Programme which they have attended.

9.0 CHAIRS ACTIVITY

The Chair has been attending Board meetings, Board sub-committee meetings which he is a member of and Council of Governors meetings. He carried out exit interviews with Governors Bill Coulton and Lynne Bax.

He continues to visit the Trust’s services on a weekly basis, has met with the Chief Executive and the Director of Governance and Compliance for their monthly meetings and also to discuss the Governor Elections and Annual Members Meeting.

The Chair had introductory meetings with Isla Wilson newly appointed Non-Executive Director and Graham Burgess the new Chair of NHS Blackburn with Darwen CCG.

Board of Directors


Report Title Chief Executive’s Report


Prepared by Heather Tierney-Moore, Chief Executive

Presented by Heather Tierney-Moore, Chief Executive

Action required Decision

Supporting Executive Director Chief Executive


Report purpose The purpose of this report is to provide Board members with an overall summary of the Trust position and highlight areas for further discussion.


To provide high quality services

Board Assurance Framework risk 2.1 – The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality

CQC domain Well-led

Introduction This report aims to give Board members an overview of the activity undertaken since the last Board meeting, both within the Trust and externally. Board Balanced Scorecard Attached at appendix one is the Board Balanced Scorecard for quarter two. Care Quality Commission Inspection Update The Quality Summit has been confirmed for the 22 October 2015 at which the final inspection reports will be presented by the Care Quality Commission (CQC) to commissioners, stakeholders and regulators. The Trust will be represented by the Chief Executive, Chair and Executive Director of Nursing and Quality. In preparation, a detailed action plan has been developed by Networks and Corporate Services and a summary of high level actions will be presented by the Trust at the Quality Summit. FOIA Exempt Under Section 22 – Information intended for future publication The ratings for all the inspection reports can be seen at appendix two. FOIA Exempt Under Section 22 – Information intended for future publication Community Mental Health Survey Job planning appeal outcome A consultant working for LCFT was unhappy with their Job Plan and requested mediation from the Medical Director. Subsequently they exercised their right to appeal against their Job Plan, under the terms and conditions of the new consultant contract to a mediation panel chaired by the Chief Financial Officer and two external appointed members. This panel met on 24 September 2015 and as per the nationally agreed process, has recommended to the Board that the consultant be awarded 0.5 Programmed Activities, backdated to 18 July 2014. This section of the report is therefore asking the Board to support this recommendation.

FOIA Exempt Under Section 41 – Information provided in confidence Harbour FOIA Exempt Under Section 41 – Information provided in confidence Out of Area Treatments Update FOIA Exempt Under Section 41 – Information provided in confidence Tier 4 Update FOIA Exempt Under Section 22 - Information intended for Future Publication Moss View Healthier Lancashire The work being progressed by the Healthier Lancashire Programme is detailed under a separate agenda item TB 102/15 and attached as part of that item is the Healthier Lancashire Forward View. The Board should note that of the six options put forward by Healthier Lancashire for a Lancashire wide approach, all were agreed with the exception of option two which was considered not feasible at a Lancashire wide level. Board is asked to note that options one, three and four are the ones which have the greatest impact on LCFT. New Trust Vision Staff from across the Trust were asked to complete the Culture Assessment Tool (CAT), the aim of which was to provide a clear description of the culture within the organisation. This, in turn, would inform a programme of Collective Leadership1 to develop a culture of the highest possible quality of care which is compassionate and continually improving. A key element of culture is how well the vision and future direction of the organisation are communicated and understood, providing clarity and a valued sense of identity for those working in the organisation. The average score for the vision across the organisation was the lowest scoring area on the CAT, highlighting that work needs to be done in communicating the Trust’s vision and future direction. A piece of work was commissioned to develop a new vision for the Trust. A small team was brought together with key representation from across the organisation, and led by the Head of Strategy and Business Planning. A detailed process was developed, taking a methodical, evidence-based approach, which would help support the development of a shortlist of options for the new vision, a summary of which is provided below. The full report is available on request from the Head of Strategy and Business Planning. Summary of methodology

Objective Actions

Research

Completed search of the literature to consider what constitutes a vision statement, what makes a vision statement powerful and meaningful, and how the vision statement can be made real for staff.

Reviewed vision statements for other local health care commissioners and providers, as well as a sample of leading non-healthcare organisations.

Gather initial feedback from Trust staff

Considered what had already been said by staff regarding the existing Trust vision, and what a new vision might look like, using information from team meetings/discussions, National Staff Survey, Engage and In-Touch sessions.

Develop options for new vision

Developed a long-list of potential options, taking in to account research and initial staff feedback.

Staff engagement

Tested out the options with 133 members of staff from across the organisation. Developed a final short-list of options, taking account of staff comments and feedback, as well as reference to the evidence base regarding effective vision statements.

Present options Presented options to Chief Executive and EMT for discussion.

Selection of the new vision statement The methodology provided a final shortlist of two prospective vision statements, which were presented to the Chief Executive and discussed with the Executive team. The proposed vision statement is:

A. High quality care, in the right place, at the right time . . . every time.

For the following reasons:

Fidelity to the evidence base for effective vision statements, for example, a simple, single, memorable sentence; future focused but written in the present tense and describing what staff will experience as though the vision had been reached now; one that staff can relate to, wherever they work in the organisation.

References the Trust’s Vision for Quality and would become the leading statement in our quality led strategy.

Talks about “care” as opposed to “services”, rather than following an organisational form. Highlights the importance of care being delivered in the right “place”, which in the future

should be much more embedded in the community. Highlights the importance of getting it right for individuals and consistency of delivery.

Recommendations The Board is asked to endorse statement A. Subject to approval from the Board, it is proposed to

use the statement as a central principle in the next business planning round, finalise the Quality Led Strategy in Quarter 3 with the vision statement, and there will be a comprehensive staff engagement and communication plan to support

the launch of the Quality Led Strategy. FOIA Exempt Under Section 43 – Commercial Interest Operational Delivery and Performance FOIA Exempt Under Section 43 – Commercial Interest Business Development Report

Corporate ServicesCorporate Services

Board Balanced Scorecard

(BSC) Quarter 2

Board of Directors 27th October 2015

Appendix One

Corporate Services

Submission - Quarter 2

Financial Sustainability Risk Rating (FSRR)

PEOPLE AND LEADERSHIP FINANCE

QUALITY AND SAFETY SERVICE DELIVERY

Staff Survey

Business Gained – Business LostMental health communitysurvey

Serious Incidents

Friends & Family Test

(FFT)

NationalAudits &Accred

Schemes

ViolenceReduction

ResearchStudies

Harm Free CareOut of Area Treatments

(OATS)

Monitor Compliance

Contract Performance

CQC Outstanding

Actions

Staff Friendsand FamilyTest (FFT)

Sickness Absence

InductionAttendance

Time to Recruit

CapitalServicingCapacity

LiquidityCost

ImprovementProgramme

CapitalExpenditure

(CAPEX)

Annual benchmarked FFT

Green – Target AchievedRed – Target not AchievedBlank – No Data

Income and Expenditure (I&E)

Margin

Variance from Plan in relation to

I&E Margin

Appendix One

Corporate Services

Quality and Safety ‐ Executive Director of Nursing & Quality and Medical Directorate

Mental Health Comm SurveyNationally reported mental health community (CQC)

Target - top 25% of other trusts

National Audits and Accreditation Schemes No. of National Audits and Accreditation Schemes we

achieved top 50% of performanceTarget 80% of the time

Annual Benchmarked FFTAnnual benchmarked (FFT) position

Target - top 25% of other trusts

The CQC 2015 Community Mental Health Survey Results have now been received by the Trust. The results are embargoed until publication on the CQC website on the 21st October 2015.

National audits are currently on track with no new reports released as yet therefore no data to be submitted for October.

Harm Free Care (Safety Thermometer Tool)Physical Health - keep patients safe from the 4 harms

(falls, catheter acquired urinary tract infections, pressure ulcers, venous thromboembolisms). The

Trust measures the % of patients who are free from all of the harms listed.

Target 95%

PerformanceJul Aug Sept

96% 95% 94%

94% of the 1,026 people seen in September were free from all respective harms. The CQUIN requirement to maintain the pressure ulcer prevalence below 5% for 5 consecutive

months has been achieved between May and September (range 3.04-4.19%).

Harm Free Care (Safety Thermometer Tool)Mental Health - keep patients safe from 5 harms (medication omissions, violence and aggression,

restraint, feeling safe, self-harm). Target 90%

No. people recruited to Research studiesNumber of people recruited to National Institute for

Health Research (NIHR) portfolio studies. Target 100 participants monthly


42% 58% 83%

Note change to the local target in line with the additional reporting and new baseline. 14 inpatient wards now submitting data (4 PICUs. 9 inpatient wards and HMP Liverpool). The

organisational aim has been reviewed and revised to 90%.


120 108 124

Data is subject to 6‐8 week lag as uploaded to national system retrospectively. Therefore to be close to target in September at reporting date (7th Oct) is excellent performance. Overall performance is now

on trajectory to meet 1200 annual target.

Violence Reduction% reduction in the levels of physical violence to staff

compared to the benchmark average month for 14-15Target 10% reduction

PerformanceJul Aug Sept33% 82% 30%

There have been 835 incidents financial year to date compared to 594 in the same period of the last financial year. This is a 42% increase. The Associate Director of Patient Safety and Quality Governance has arranged a summit with Trust Leads for Security, Health & Safety and Violence Reduction to explore

the increased reporting levels. Following this a further Summit is to be arranged with Network clinical representatives to explore the issue further. At this present time no underlying theme or issue has been identified that explains the increase. Security, Health & Safety and Violence Reduction Teams continue

to work with services to tackle violence and aggression.

Serious IncidentsThe number of serious incidents reported.

Target 10% reduction

Friends and Family Test (FFT)Our monthly score on the Friends and Family Test.

Target 95%


-12% -50% -38%

PerformanceJul Aug Sept93% 97% 94%

There have been 89 serious incidents financial year to date compared to 128 in the same period of the last financial year. This is a 21% reduction.

The FFT is not being used as a benchmarking tool but as a quality improvement tool. It has been recommended that this measure will be replaced by Quarter 3.

The FFT is a quality improvement tools and as such individual teams review the feedback and use this to inform quality improvements which they feedback to people who use services in the ‘you said ….we did’ format. Clinical Directors include examples of the “you said… we did” in their monthly report to Quality and Safety Sub-Committee. The number of FFT returns in September was lower than the monthly average -1,005 as opposed to an average monthly return of 1,371. Clinical Directors have also been asked to review and provide a rationale for this

Appendix One

Corporate Services

Contract Performance Measure 2Top contract performance indicator valued by

commissionersTarget IAPT Prevalence 1.25%

Service Delivery – Chief Operating Officer

CQC outstanding actions from inspectionsNumber of outstanding actions in progress following

any CQC inspection. Target - No outstanding actions exceeding

the agreed timescales.

No outstanding actions.The new monitoring system came into effect from 01 October 2015 – data will be available from this point onwards

Out of Area Treatments (OATS)The number of patients placed in out of area beds

(outside of the 10 contracted beds).Target 10 contracted beds

Monitor ComplianceMonitor operational Performance measures currently reported to Board and Executive in line with national

monitor definitions.Target 100% compliance in each quarter

Contract Performance MeasuresTop contract performance indicators valued by

commissioners which include CQUIN, IAPT, MAS, flu uptake & activity levels

Target CQUIN 100%


49 70 70


100% 100% 100%

Jul Aug Sept

75.9% 87.6% 87.3%

The Network has undertaken an extensive review of factors contributing to OATs. An estimated 25% of OATs pressure is considered to be a result of Network processes. Management actions have been

identified to address the pressure. 75% of OATs pressures estimated due to absence of alternatives to admission/step-down facilities.

70 was the lock down position for September but the most recent operational figure for OATS is 57.This data will not be validated until the Operational Delivery Group on the 20 October 2015.

Contract Performance Measure 1Top contract performance indicator valued by

commissionersTarget MAS Waiting Time 70%

Monthly target met

Jul Aug Sept

5.24% 6.39% 6.25%

PerformanceJul Aug Sep

100% <100% <100%

Business Gained – Business LostThe business gained in £’s minus the contracts that we

have attempted to retain and have lost Target – the Trusts growth target for the next

12 months is 1 ½ %

Monthly target met This data will not be validated until the Operational Delivery Group on the 20 October 2015.

This is an accumulative target. Monthly Target MetThis data will not be validated until the Operational Delivery Group on the 20 October 2015.

The trust has not achieved full compliance of its Monitor measures for quarter Q2.Although DTOC (Delayed Transfers Of Care) has shown an improvement from July

to September the measure still indicates a deterioration in performance from previous quarters resulting in non compliance for Q2. A joint action plan between Adult Community and Adult Mental

Health has been developed and agreed with the ops and delivery subcommittee, which is being closely monitored.

This data will not be validated until the Operational Delivery Group on the 20 October 2015.

LCFT have been successful in six bids, which total an annual value of £11.6m for 15/16. These services cover Community IV Therapy, Type 2 Diabetes Structured Education (DESMOND), Offender Healthcare, IAPT and Diversion Services. A number

are outside the Lancashire boundary.These bids constitute new business for LCFT, with no existing contracts lost. We are currently bidding to retain £64m of our

existing business. The Trust’s expected income is 4% higher than at the equivalent point last year

Appendix One

Corporate Services

Finance ‐ Chief Finance Officer

Capital Expenditure (CAPEX)Measures Capital Expenditure against Planned Capital

expenditure.Target 100%


98% 98% 95%


87% 73% 76%

LiquidityRisk assessment score - Measures the ability to meet

short term obligations and compares to plan.Target 4

Capital Servicing Capacity Risk assessment score - Measures the degree to which

generated income covers financing obligations and compares to plan.

Target 2

Financial Sustainability Risk Rating (FSRR)Risk assessment score - Monitors overall

measurement of risk in relation to financial robustness and efficiency, calculated using a weighted average of Liquidity, Capital Service Cover, Surplus Margin and

Variance from Plan ratingsTarget 3

Cost Improvement Program Measures percentage performance of CIPs against plan.

Target 100%


2 2 2

Overall FSRR is rated to 2 against plan of 3 and is forecast to remain so - the rating is constrained by the new Surplus Margin rating which is rated at 1 - any score of 1 limits score to 2. I&E is the main driver for changes from planned ratings.Note a rating of 2 can trigger a regulatory review of the Trust's position.


2 2 1

I&E performance coupled with planned repayment of loans now results in a debt service of 1 against a plan of 2 and this is now expected to continue to the year end


4 4 4

Cash is ahead of plan. Although forecasts show a deterioration, achievement of plan liquidity rating is still expected.

Expenditure to date is behind plan tolerance (15%). The underspend primarily relates to the finalisation of the Harbour.

Performance against monitored and approved schemes is slightly behind CIP programme plan, though Forecasts now indicate a small surplus (£0.2m), new schemes continue to be developed to compensate.

Income and Expenditure (I&E) MarginRisk assessment score – Measures the degree to which

the organisation is operating at a surplus/deficit.Target: 2

Variance from Plan in relation to I&E MarginRisk assessment score – Measures the variance

between a foundation Trust’s planned I&E margin in it annual forward plan and its actual I&E margin within the

year.Target 2


1 1 1


3 3 3

The deficit position results in a rating of 1 and this is forecast to remain so.

The deficit position behind plan and forecast to remain so. Note plan is now based on last years performance

Appendix One

Corporate Services

People and Leadership – HR DirectorStaff Survey

This is the annual staff survey which is sent out to all staff.

Target - Top 25% of other trusts

Staff Friends and Family Test (FFT)A sample of staff who have responded to the FFT

questionnaire in the current monthTarget - The avg score of the sample is at

or above the score that would have achieved upper quartile performance in

the previous years Staff Survey

The Staff Survey is now Live and all 850 employees selected to participate in this years Survey have their paper Survey. The closing date for the 2015 Survey is 30th November 2015.

The month of September has seen a response in the amount of people who completed the FFT. This can be linked to the FFT Communications plan that was initiated at the end of August. The communication for the month of September has been released and there are responses visible for the month of October. Ongoing Improvement Activity: FFT responses from Staff relating to recommending LCFT Services are to be reported into People

Committee for Network Action FFT Responses relating to recommending LCFT as an Employer will be integrated into an recovery action

plan where a combined negative or indifferent response rate of 15% is achieved.

Sickness Absence% of working hours lost due to staff sickness.

Target 4.50%

Induction Attendance% staff who attended the Trust induction within 4

weeks of starting employment with the Trust.Target 95%

Time to RecruitWorking days it takes from the identification of a

confirmed recruitment need to appointment. Target 60 working days

PerformanceJul Aug Sep5.8 6.3 5.7

Sickness Absence has seen a reduction in the month of September to 5.7%. Hot Spots: ACS a gradual reduction though Q2 to 6.05%, AMH a gradual increase through Q2 to 7.34% and a reduction in September to 6.06% for SS. Ongoing Improvement Activity: Additional Absence Management Training is planned for Harbour in October Vacancies and difficult to fill roles are being managed effectively within networks and in Specialist

Services, alternative ways of working are being explored.


20% 21% 56%

It is anticipated that given the current backlog and the additional recruitment drives the % of compliance of those new starters having induction within the first four weeks of employment will remain low. However despite this low %, compliance of staff having induction has increased. An additional 30 places were put in place for September and an anticipated additional 60 in October. It is

envisaged that 100% of the backlog will have been updated by Q4 2015/16. Additional sessions have been arranged and capacity at existing inductions increased in efforts to address

both current requirements in juxtaposition to the backlog. Given we are in Quarter 3 this is an ambitioustarget and I am very proud of the team for thinking creatively about how these issues can be addressed.


67.5 60.5 57.8

The Recruitment Team have put a considerable amount of effort into identifying how they can improve theturnaround lead times in those areas of the recruitment process for which they have direct control:Recruitment Authorisation, Time to Advertising, Time to Shortlisting and Pre-employment checks. This workhas resulted in achievement of the End to End Time to Recruit target of 60 days.Ongoing Improvement Activity: WFI have included Recruitment Lead Time Performance, by process Stakeholder, into the new look

Network report to provide the Network with useful information about where any recruitment delays theyare experiencing are occurring.

Work has been initiated to improve the quality of the information that is being captured by the RecruitmentTeam to enhance the availability of information available to track recruitment process performance

A new Request to Recruit Form is being developed to support future planned improvements to theRecruitment end to end process.


0 0 0

Appendix One

Board of Directors


Report Title Audit Committee Chairs Report

FOIA Exemption Part Exemption Inpatient Reprovision Risks

Prepared by Carrie Tomlinson, Compliance & Assurance Manager

Presented by Louise Dickinson, Chair of Audit Committee




Report purpose To provide an outline of the activity undertaken by the Audit Committee, highlight assurance received and risks identified.



Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence.

CQC domain Well-led

1.0 INTRODUCTION This Chairs Report outlines the activity undertaken by the Board level Audit Committee on 14 October 2015.

2.0 BOARD ACTION The Board of Directors is asked to note the content of the Chair’s Report for assurance.

CHAIRS REPORT

CHAIRS REPORT OF: Audit Committee

DATE OF MEETING: 14 October 2015

BAF Risk:

7.1

Governance & Compliance Sub-Committee Chair’s Report

The Audit Committee noted the assurance received by the Governance & Compliance Sub-Committee around Information Governance activity, in particular that this remains a high risk but progress of mitigating actions is on track. The final audit report from the Information Commissioner Office has been received with a conclusion that there is a Reasonable Level of Assurance that processes and procedures are in place to deliver data protection compliance.

BAF Risk:

7.1

5.1

Breaches and Waivers Report

The Committee received the strengthened report which detailed there were no breaches noted during the quarter and 10 waivers reported, three of which were judged to be avoidable waivers. The Director of Financial Services provided a verbal update of processes which are being formalised with the Procurement Team to prevent further avoidable breaches and waivers. This activity is being reviewed by the Finance Sub-Committee.

BAF Risk:

7.1

Losses and Special Payments

The Committee considered the losses and special payments report which reported 9 losses and 14 special payments during Q2. There were no specific issues arising from these losses and payments.

BAF Risk:

7.1

FOIA Exempt Under Section 41 - Information Provided In Confidence

Inpatient Reprovision Risks

BAF Risk:

7.2

Network Risk Management Assurance Reports

The Committee received reports from Specialist Services and Adult Community Networks. The reports provided assurance that the Trust’s governance and risk management framework is being positively adopted within each of these Networks and that the Network leadership team, managers and front line staff value the framework as an important management and operational tool.

BAF Risk:

4.1

5.1

HR Controls Assurance Report

The Committee received an assurance report around HR Controls providing detail on the strengthening of the controls in place for the safe recruitment of staff into the organisation and exit of the leavers’ which links with losses and special payments. The Committee will receive further assurance on the effectiveness of HR controls as part of the expanded scope of Internal Audit work due to be reported to the Committee later this year.

The report noted that despite strengthened controls delays in terminating staff on ESR still resulted in a higher than acceptable overpayment recovery debtor at each month end. The Committee agreed that the appropriate level of scrutiny has been given to this matter and requested an update in six months time with the hope that assurance will be available that this focus has yielded a positive improvement on the level of overpayments.

BAF Risk:

7.1

7.2

Risk & Assurance Mapping and Assurance System Development

Assurance was provided that the Risk & Assurance Universe was developing on track, an update of the current position and further work was provided. Evidence that the assurance framework is working and being used in the Networks is becoming available, as noted above. The Committee will continue to monitor progress.

BAF Risk:

7.2

Assurance Report on Material Matters Reserved for the Board

The Committee received assurance that the Trusts governance documentation records that decisions on material matters are reserved for the Board, including the Decision Rights Framework and Matters Reserved for the Board. The Committee requested that the definition of ‘significant’ and ‘material’ matters and their use in the DRF and MRB be reviewed and strengthened if appropriate.

BAF Risk:

1.1

Provisional CQC Report: Compliance Items

The Committee received a report detailing the relationship between the findings of the Care Quality Commission (CQC) inspection findings and the existing quality and safety assurance systems within the Trust.

The Committee noted that two new issues identified through the CQC process are now on the Risk Register.

Further reporting was commissioned by the Committee on the governance and risk gap analysis arising from CQC visit and it was agreed that the Director of Nursing, the Director of Governance & Compliance and the Chair of Audit Committee would to meet to discuss the scope of this paper.

BAF Risk:

7.1

7.2

Internal Audit Progress Report

Significant assurance was received from the internal audit report on Safeguarding which highlighted strong processes and effective governance arrangements.

An Internal Audit Follow Up Summary Report provided an overview of the progress to implement risk recommendations from previous internal audit reports. It was noted that the report to the next Committee meeting would provide greater insight on progress.

BAF Risk:

7.1

7.2

Local Counter Fraud Reporting

Assurance was provided to the Committee of the continued progress in raising awareness of Counter Fraud within the organisation. Assurance was provided around the closure of 6 cases since the last meeting.

BAF Risk:

7.1

7.2

External Audit Report

The Committee noted that foundation trusts no longer require explicit authorisation from HM Treasury to run Mutually Agreed Resignation or Voluntary Severance schemes and now have the delegated authority to implement local MAR schemes within the 2015/16 financial year.

BAF Risk:

7.2

Clinical Audit Report

Assurance was received that Clinical Audit is progressing with the plan and delivering the Network Priority Audit Programme on time and to the expected standards.

Updates were provided around specific compliance areas for the High Dose Antipsychotic and Pharmaceutical Audits and assurance provided to the Committee that action areas are being progressed.

RISKS: Risk Ref:

TBC

HR Controls

A risk was identified around the inability to manage overpayments across the Trust. Datix risk reference to be

confirmed.

For noting

Decision

Further discussion

Board of Directors


Report Title Quality Committee Chairs Report

FOIA Exemption No Exemption

Prepared by Catherine Baron, Executive Assistant

Presented by David Curtis, Non-Executive Director


Supporting Executive Director Executive Director of Nursing and Quality


Report purpose To provide an outline of the activity undertaken by the Quality Committee



Board Assurance Framework risk 1.1 The Trust does not protect services users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services

1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

3.1 The Trust fails to deliver the benefits of being a Health and Wellbeing provider.

4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs

4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care

7.3 The Trust does not comply with Mental Health Legislation

CQC domain Well-led

1.0 INTRODUCTION This Chairs Report outlines the activity undertaken by the Quality Committee held on the 5 October 2015.

2.0 BOARD ACTION The Board of Directors is asked to note the content of the Chair’s Report for assurance.

CHAIRS REPORT

CHAIRS REPORT OF: Quality Committee


ASSURANCE:

BAF Risk:

1.1

1.2

3.1

Board Assurance Framework

Members discussed the Board Assurance Framework and assurance was provided against the key risks linked to the Committee. It was noted that following an increase in risk score relating to patient safety, an update and further assurance around controls would be received by the Quality & Safety sub-committee in November. The Quality Committee also commissioned further assurance to be reported back.

The Committee noted the risk scores which had reduced since the report was issued to members and the activity of the Quality and Safety Sub-Committee in seeking assurance around actions which had been put into place.

The Committee were informed of the requirement to improve the articulation of certain risks within Datix and the impact on emerging additional risks. Further assurance was requested by the Committee for the January meeting.

BAF Risk

1.2

Safer Staffing

The Committee were provided with assurance in relation to the mitigating actions undertaken in relation to safer staffing and the key areas of risk, noting that all quarter 2 actions had been completed on target. The monitoring of governance arrangements and Key Performance Indicators (KPIs) is also being measured from September 2015 to provide further assurance to the Committee in future.

The Committee also received assurance on the improvements made to date following the delivery and implementation of the Action Plan.

BAF Risk

3.1

Raising Concerns Assurance was provided that each serious concern received within the reporting period was reported directly to Commissioners and the CQC and investigations had been undertaken. The Committee considered the publication of the Government’s response to the recommendations of the Freedom to Speak Up Review led by Sir Robert Francis ‘Learning not Blaming’. It was noted that some of the Trust’s action plan deadlines had been extended to fit into the overall Government direction and assurance was provided that the Trust had robust systems and processes in place covering raising concerns and no risk had therefore been identified in delaying some of the actions.

BAF Risk

4.1

Employee Staff Survey Report The Committee concluded that the report did not provide assurance in terms of outcomes. The Committee received reassurance of the next steps being undertaken around the Engagement Plan and the new provider. The Committee commissioned further assurance report for January 2016.

BAF Risk

4.1

Human Resources Transformation Programme The Committee concluded that the report did not provide sufficient evidence based assurance around the issues and timescales for delivery and requested that the People Sub-Committee further scrutinise the evidence and provide assurance to the Quality Committee via the Sub-Committee Chairs Report.

BAF Risk

4.2

People Sub-Committee Chairs Report The Chair’s Report outlined a concern around Bank and Agency Improvement Plans and the limited assurance which People Sub-Committee had received in relation to the achievement of activity. Further assurance had been requested and would be presented to the People Sub-Committee to demonstrate the triangulation of the safer staffing work and the Disclosure and Barring Service. Assurance would be further reported back to Quality Committee.

BAF Risk

1.1

1.2

Quality & Safety Sub-Committee Chairs Report There were no areas of concern escalated within the Chair’s Report to the Quality Committee and assurance was received against the delivery of the Liverpool and Kennet action plan and mobilisation plan.

BAF Risk

7.3

Mental Health Law Sub-Committee Chairs Report

The Mental Health Law Sub-Committee Chairs Report provided the assurance of the actions which had been undertaken by the Executive Director of Nursing and Quality. Although a risk had emerged around the delivery of the Mental Health Act Module within Electronic Care Record within the revised timeframe, assurance was provided that this risk had now been reduced following progression with Health Informatics.

RISKS: There were no new risks identified within the meeting.

ACTION REQUIRED:

Decision

Fuller discussion requested

Report provided for information

Board of Directors

Agenda Item TB 091/15 Date: 27/10/2015 Report Title Finance and Performance Committee Chairs Report


Prepared by Jo Alker, Deputy Company Secretary

Presented by Peter Ballard, Deputy Trust Chair


Supporting Executive Director Chief Finance Officer PURPOSE OF THE REPORT:

Report purpose To provide an outline of the activity undertaken by the Finance & Performance Committee



Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence

CQC domain Well-led

1.0 INTRODUCTION This chairs report outlines the activity undertaken by the Board level, Finance & Performance Committee held on 19 October 2015.

CHAIRS REPORT

CHAIRS REPORT OF: Finance and Performance Committee


ASSURANCE:

BAF Risk 2.1, 2.2, 3.2, 5.1, 5.2, 6.1, 6.2

Board Assurance Framework Risks The Finance and Performance Committee considered the BAF risks that were aligned to the remit of the Committee. Particular focus was given to BAF risk 5.2 given the Trust’s current position around Out of Area Treatments. The Committee also noted that BAF risk 3.2 was currently undergoing a review to ensure it accurately reflected the potential risks around reputation recognising the upcoming CQC Quality Summit and potential media interest.

BAF Risk: 2.2, 6.1

Business Planning & Transformation Sub-Committee Chairs report The Committee received the chairs report from the Business Planning & Transformation Sub-Committee and noted the concerns raised around agency staffing spend and the cap being imposed by Monitor. The CIP programme in relation to this had not got the transaction required and a management discussion had been scheduled to understand the issues and rectify. A risk had been identified around the mobilisation of tenders and again a separate management discussion had been scheduled to consider how this might be improved. The Sub-Committee had considered the Strategic Alliance Strategy and feedback was provided and further assurance requested. A risk had been identified in relation to the Midland Heart and Healthcare at Home contracts and as a control, the newly appointed Director of Development would be taking responsibility for the management of the contracts. A conversation took place in relation to the closure to admissions to Byron Ward at the Harbour and the financial impact of this. More detail around this would come through the finance report to Board in October.

BAF Risk: 6.2

Health Informatics Sub-Committee Chairs Report The Sub-Committee focussed on the new EPR programme specifically the governance arrangements being put in place to support procurement through to implementation. Conversations followed around when this would come back to the Board and role the Finance and Performance Committee played in supporting the Board making a decision by consider the business case and recommendation in detail. A further meeting would be arranged to undertake this activity. The Sub-Committee had concerned the ICO audit and assurance was received in relation to the outcome of the audit. The Chief Finance Officer explained that Information Asset Owners were currently being established across the organisation to provide further assurance.

BAF Risk: 1.2

Estates Sub-Committee Chairs Report The Estates Sub-Committee had meet and discussed concerns around pressures on the capital plan following the CQC inspection and required action in relation to estate improvements. There had also been an issue at the Harbour and access being gained to the roof. Assurance was received that temporary measures had been put in place to address the issue but permanent action was planned in due course. A conversation had taken place at the Sub-Committee in relation to the car parking at the Harbour and

thoughts about how that might be addressed. The Committee noted that the Red Rose TUPE had taken place. The Committee received an update in relation to the Pennine Lancashire site and it was requested that a further update and assurance be provided at the next Finance and Performance meeting.

BAF Risk: 2.1, 3.2, 5.2

Operational Delivery & Performance Sub-Committee Chairs Report The Operational Delivery and Performance Sub-Committee had met and focussed on the current Out of Area Treatments position and also Delayed Transfers of Care (DTOC). Further assurance had been requested by the Acting Chief Operating Officer and plans to pull together all impacting activity. The Committee noted that DTOC would be reported as a breach for quarter two. The action plan requested would support the continued improvement of this activity.

BAF Risk: 5.1

Finance Sub-Committee Chairs Report The Finance Sub-Committee chairs report was presented to the Committee and assurance was provided around the development of a case for change to strengthen the commercial input to new and existing contracts. Payment by results had also been considered by the Sub-Committee as it was important that the Trust was able to respond appropriately. The Sub-Committee had looked at the Trust’s insurance arrangements had identified some areas that are currently being reviewed with a potential saving identified. The cap on agency spend had also been discussed at the Finance Sub-Committee including the transition in to the arrangements and the national position.

BAF Risk: 5.2

Delivering the Strategy The Assurance Dashboard relating to the achievement of the Delivering the Strategy programmes was presented to the Committee. The dashboard provided robust assurance in relation to the delivery and savings being identified but highlighted the risk around the achievement of the bank and agency programme. The Committee had discussed the management action being taken to review this.

BAF Risk: 2.1

Early Intervention Service An assurance report was presented to the Committee which outlined the work being undertaken to date to ensure the Trust was able to report compliance with the EIS Monitor target that would be a requirement from April 2016.

BAF Risk: 2.2

Business Development An assurance report was presented to the Committee around the mobilisation activity planned following the successful tender bids for Prison services. The paper also outlined why the Trust had decided to bid outside of this geography and resource requirements needed to ensure sufficient mobilisation.

RISKS:

Reputational risk identified recognising the upcoming CQC Quality Summit BAF Risk Ref: 3.2

Potential increase of the BAF financial risk 5.1 recognising the OATs and DTOC position

BAF Risk Ref: 5.2

Risk around the delivery of the bank and agency programme that forms part of the DTS programme

BAF Risk Ref: 5.2

Risk around the efficient mobilisation of Trust services following successful tender bids

BAF Risk Ref: 2.2

ACTION REQUIRED: Decision

Fuller discussion requested

Report provided for information

Board of Directors

Agenda Item Date: 27/10/2015

Report Title Finance Board Report


Prepared by Shannon Carroll, Financial Services Director

Presented by Bill Gregory, Chief Finance Officer


Supporting Executive Director Chief Finance Officer


Report purpose To report Trust monthly financial position and forecast


To provide excellent value for money in a financially sustainable way

Board Assurance Framework risk 5.1 – The Trust does not achieve financial performance sufficient to maintain resilience and sustainability.

CQC domain Well-led

1.0 INTRODUCTION

The Board is asked to review the attached report which outlines the current and forecast

financial position of the Trust.

TB 092/15

Summary

Actual Plan Var Forecast Plan VarSustainability

EBITDA 1 4,647 5,744 ‐1,097 1 8,759 11,595 ‐2,836 Surplus 1 ‐2,367 ‐1,589 ‐778 1 ‐5,519 ‐3,044 ‐2,475

CIPs (against Trust Plan) 2 5,018 5,263 ‐245 3 11,961 11,792 169Cash and Liquidity 3 25,276 22,359 2,917 3 16,637 17,687 ‐1,050 Capex 2 3,622 4,779 ‐1,157 3 9,686 9,654 32FSRR

Debt Service 1 1 2 1 1 2Liquidity 4 4 4 4 4 4Surplus Margin 1 1 2 1 1 2Variance from Plan 3 3 2 3 3 2Overall 1 2 3 1 2 3

Sustainability

CIPs

Liquidity

Capital and Financing

Financial Sustainability Risk rating (FSRR)

Forecasting

Key Actions

#

• Forecasting assumes a remedial action plan to address OATs based on early costings and a shared risk of 50:50 with commissioners, however the details of this plan will not be finalised until early September, with Commissioner discussions to follow.

• There are a number of upsides which are being reviewed and could improve the position by c£.5m (contract settlements and slippage on reserves). Additionally we are reviewing DTS schemes and Bank and Agency with services being given improvement targets of c£2m with the intention of returning to plan and a risk rating of 3.

Forecasting includes the following base assumption:

• Deliver improvement targets of £2m across all services.

The current position would have to improve by c£0.7m to achieve a 3, and the forecast position by c£2.4m. The Trust is therefore likely to be rated a 2 (see FSRR section) and this could trigger a regulatory review of the Trust's position.

• Address the remaining balance of CIP schemes by DTS and PMO.

Note that the figures contained within this report form the basis of our returns to Monitor.

• Implement the plan to address the use of OATs with commissioners and embed remedial action.

• Some additional potential pressures have been identified but at this time are considered manageable within the overall.

Overall FSRR is rated to 2 against plan of 3 and is forecast to remain so ‐ the rating is constrained by both the Debt Service rating and the new Surplus Margin rating which are forecast to be rated at 1 ‐ any score of 1 limits score to 2.

• Forecast impact of I&E position is considered main driver.

Expenditure to date is behind the plan tolerance of 15%. • The underspends primarily relates to the Harbour though until final account is finalised these will not be anticipated in the forecast outturn.

Current Out‐Turn

Performance against monitored and approved schemes is slightly behind plan( £245k), though at Month 6 the programme is now forecast to generate a small surplus (£169k) ‐ an improvement on the Month 5 position. Additional schemes continue to be developed. See CIP sheet for more details.

• Cash as calculated for liquidity purposes is expected to fall behind plan in Feb/Mar (see also FSRR below).

Month 6 sees a year to date operating deficit of ‐£2,4m, £0.8m behind plan after six months. The full year deficit is projected to be ‐£5.52m against a plan of ‐£3.04m, a deterioration of c£0.31m from last month. The position is undermined by OATs expenditure being in excess of the currently agreed funding, £1.5m over at month 6, which is anticipated to contribute a year end adverse variance after mitigation of £3.4m (assuming the commissioner contributes their agreed 50% share). Note that remedial plans have been shared with Commissioners and Networks are working through detailed implementation plans, with progress being tracked by the Operations sub committee. Further details in the OATs section. The Board Balanced Scorecard demonstrates an EBITDA (earnings before interest, taxes, depreciation and amortisation) of £4.6m against a plan of £5.7m. Full year projection is £8.8m against a plan of £11.6m. FSRR is as forecast at 2, see below.

Cash has fallen from last month mainly as a result of planned payments of PDC Dividends and Loans. Cash is ahead of plan, though based on I&E projections, is expected to deteriorate to below plan by year end.

Forecast ForecastYTD YTD Out‐turn Out‐turn

Sep 2015 Aug 2015 at Sep 2015 at Aug 20156 5 Note 12 12 Note

Plan ‐1.589 ‐1.324 Plan ‐3.044 ‐3.044

Major Variances Major VariancesCIP Slippage ‐0.245 ‐0.100 ‐ See CIP section CIP Surplus/(Slippage) 0.168 ‐0.535 ‐ See CIP sectionOATs ‐1.529 ‐0.953 ‐ See OATs Section OATs ‐3.390 ‐3.122 ‐ See OATs SectionOther Bud Vars 0.810 0.353 ‐ See Services section Other Bud Vars ‐0.644 0.087 ‐ See Services sectionReserves 0.187 0.132 ‐ See Reserves section Reserves 1.392 1.403 ‐ See Reserves sectionMinor Variances 0.000 0.000 Minor Variances 0.000 0.000

Variance ‐0.778 ‐0.569 Variance ‐2.475 ‐2.168

Actual ‐2.367 ‐1.893 Actual Forecast ‐5.519 ‐5.212

‐‐

Surplus ‐ YTD (£m) Surplus ‐ Out‐turn (£m)

The full year projection is a deficit of ‐£5.5M. This is behind the financial plan of ‐£3.0m deficit, and assumes £3.1m of additional commissioner income to partly offset a the OATs position, which is by £6.5m beyond original plan, and for which the Trust is liable for £3.4m (see Out of Area Activity for details).

This month sees an operating deficit of £2.4m, £0.8m behind plan.

‐8,000.0

‐7,000.0

‐6,000.0

‐5,000.0

‐4,000.0

‐3,000.0

‐2,000.0

‐1,000.0

0.0

Plan CommunityMH CIP

CIP Surplus OATs Other BudVars

Reserves MinorVariances

‐3,044.0 167.7 ‐3,390.0 ‐644.1 1,391.9 0.0

‐4,000.0

‐3,500.0

‐3,000.0

‐2,500.0

‐2,000.0

‐1,500.0

‐1,000.0

‐500.0

0.0

Plan CIP Slippage OATs Other Bud Vars Reserves Minor Variances

‐1,589.0 ‐244.9 ‐1,529.0 810.0 187.3 0.0



Plan 159.312 132.890 Plan 315.545 315.545

Major Variances Major VariancesCommunity Services 3.997 2.817 ‐ Note 1 Community Services 11.066 10.943 ‐ Note 1Mental Health 3.383 2.965 ‐ Note 2 Mental Health 6.523 7.059 ‐ Note 2NHS England 0.253 0.219 ‐ Note 3 NHS England 0.483 0.432 ‐ Note 3R&D 0.009 0.017 R&D 0.061 0.049ETR 0.499 0.287 ‐ Student Income ETR 1.139 0.782 ‐ Student IncomeMiscellaneous 0.826 0.831 ‐ Note 4 Miscellaneous 1.401 1.527 ‐ Note 4

Minor Variances ‐0.001 0.000 Minor Variances 0.000 0.000

Variance 8.966 7.137 Variance 20.672 20.792

Actual 168.278 140.027 Actual Forecast 336.217 336.337

1

234 Major increase is AHSN; major decreases are PIP/ATOS and MHRN ‐ see appendix for detailed impact.

Monthly Income Variances (£m) Cumulative Income Variances (£m)

Major increase is Liverpool and Kennet Prisons (£7m), Supported living and Family Nurse Partnership; major decrease is Offender Bedwatch ‐ see appendix for detailed impact.

Major increases include OATs and Contractual position reached with CCGs (see also reserves); major decrease is Community Dementia ‐ see appendix for detailed impact.Major increases CAMHs Tier 4 and HIV; no significant decreases ‐ see appendix for detailed impact.

0.000

5.000

10.000

15.000

20.000

25.000

30.000

35.000

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

Actual/Forecast

Plan

0.000

50.000

100.000

150.000

200.000

250.000

300.000

350.000

400.000


Actual/Forecast

Plan



Budget 145.634 121.498 Budget 289.796 289.833

Major Variances Major VariancesAdult Mental Health ‐2.228 ‐1.581 ‐ Note 1 Adult Mental Health ‐4.483 ‐4.332 ‐ Note 1Specialist Services 0.006 0.014 ‐ Note 2 Specialist Services ‐0.041 ‐0.039 ‐ Note 2Property Services 0.000 0.000 ‐ Note 3 Property Services 0.000 0.000 ‐ Note 3Corporate ‐0.144 ‐0.245 ‐ Note 4 Corporate ‐0.690 ‐0.576 ‐ Note 4Adult Community 0.688 0.568 ‐ Note 5 Adult Community 0.261 0.202 ‐ Note 5Children & Family 0.593 0.449 ‐ Note 6 Children & Family 0.853 0.953 ‐ Note 6Other Clinical 0.121 0.094 Other Clinical 0.234 0.222

Variance ‐0.964 ‐0.700 ‐3.866 ‐3.570

Actual 146.598 122.198 Actual Forecast 293.663 293.402

1

2

34

5

6 Children and Families has deteriorated slightly on a favourable position due to redundancy provisions and other minor variations. The position is expected to remain positive for the year, particular driven by recruitment difficulties in Health Visitors.

Corporate Services forecast includes non‐recurrent costs in Performance with regard to external support (£0.4m) but also sees pressures emerge in Workforce with regard to staffing in excess of budget (£0.3m). Improved positions in Finance, Director of Quality (vacancies) and the Chief Operating Officer for PIP.

Property Services are about breakeven and are expected to remain so.

YTD Service Net Expenditure Variance (£m) Forecast Service Net Expenditure Variance (£m)

Adult Mental Health overspend is driven by Out of Area Treatment (OATs) costs in excess of funding. The high level of OATs continued throughout April to September but is no longer expected to be managed down during the autumn to the same extent (see OATs section). Actions to review the management of admissions and delayed discharges are in place. Pressures are being experienced across most specialist community teams with regard to pay.

Specialist Services are about breakeven despite overspends from the high use of bank & agency on wards, particularly in male Medium Secure Services, compensated for by underspends in Specialist Community. Offender Health has pay underspends supporting excess drug and escort costs.

Adult Community is currently delivering an underspend, which has increased slightly driven by vacancies and non‐pay underspends.

‐£5,000

‐£4,000

‐£3,000

‐£2,000

‐£1,000

£0

£1,000

£2,000

Adult MentalHealth

SpecialistServices

PropertyServices Corporate

AdultCommunityServices

Children &Family

OtherClinical Total

Service Forecast Variance

‐£2,500

‐£2,000

‐£1,500

‐£1,000

‐£500

£0

£500

£1,000

Adult MentalHealth

SpecialistServices

PropertyServices Corporate

AdultCommunityServices

Children &Family Other Clinical Total

Service Year to Date Variance

CIP Achievement (£)

It should be noted that the Monitor plan included CIP phasing that predated programme finalisation and as such there is a additional phasing variance year to date of £398k (last month £618k) when compared to the Monitor plan. Note also that the year end variances will come in to line and that this has been discussed with Monitor

NotesPerformance against monitored and approved schemes remains behind plan year to date, but is now expected to overachieve both against plan and against the original target for the year. New schemes continue to be developed. See below for specifics.

Key scheme issues:Where schemes are slipping remedial action has been taken to cover shortfalls.

New Schemes transactedAdditional gains against Health Visiting have been applied amounting to £380k in Children and Families, and c£60k against Procurement gains.

ReservesCIP programmes above the original plan are being managed through reserves. Additional savings are expected to accrue for Procurement and Training.

Additional RisksPMG are looking at schemes that have yet to start with a view to ensuring delivery.

Note mapping of individual schemes to projects and programmes may be subject to change.

Delivering the Strategy ‐ 2015/16 PROGRAMMES

Programme No.

Programmes Projects Actual YTD Performance Plan YTD Var

Annual Forecast Performance Annual Plan Var

Moss Vew ‐ ‐ ‐ ‐ ‐ ‐ Gateway ‐ ‐ ‐ ‐ ‐ ‐ Service Redesign 15,163 15,163 ‐ 106,141 106,141 ‐ CRHT and liaison redesign ‐ ‐ ‐ ‐ ‐ ‐ Management on‐call 12,140 12,140 ‐ 30,350 30,350 ‐ Structural Redesign 630,546 630,546 ‐ 1,261,091 1,261,091 ‐ Substitute CIPs 286,922 442,500 155,578‐ 636,156 885,000 248,844‐ Productivity 14,294 122,793 108,499‐ 1,471,520 1,159,550 311,970 Burnley reconfiguration ‐ ‐ ‐ ‐ ‐ ‐ ECT single site 11,200 11,200 ‐ 22,400 22,400 ‐

5 Out of Hospital 190,537 128,000 62,537 500,000 500,000 ‐ CAMHs Tier 3 and 4 redesign 100,942 134,942 34,000‐ 201,884 269,884 68,000‐ Single Inpatient Site CAMHS tier 4 ‐ ‐ ‐ ‐ ‐ ‐

7 Estates 545,500 545,500 ‐ 1,091,000 1,091,000 ‐ Increase annual leave purchase 69,124 69,124 ‐ 138,248 138,248 ‐ Reduced travel costs assoc. with training ‐ ‐ ‐ ‐ ‐ ‐ Bank and Agency ‐ ‐ ‐ ‐ ‐ ‐ Medical Productivity ‐ ‐ ‐ ‐ ‐ ‐ Governance and Quality Business Plans 151,501 151,501 ‐ 303,002 303,002 ‐ Workforce Business Plans 71,650 71,650 ‐ 168,299 168,299 ‐ Workforce review Group ‐ ‐ ‐ ‐ ‐ ‐ Transformation and Innovation Business Plans 50,511 50,511 ‐ 178,437 178,437 ‐ Working differently ‐ ‐ ‐ ‐ ‐ ‐ IM&T Business Plans 160,732 145,732 15,000 321,465 291,465 30,000 Trust Wide Admin 36,551 36,551 ‐ 78,081 78,081 ‐ Petty Cash ‐ ‐ ‐ ‐ ‐ ‐ Leadership Development ‐ ‐ ‐ ‐ ‐ ‐ Consultancy Control ‐ 53,400 53,400‐ ‐ 133,500 133,500‐ Mileage Claim Forms ‐ ‐ ‐ ‐ ‐ ‐ Medical Workforce Business Plans 74,437 21,037 53,400 175,574 42,074 133,500 Pharmacy Business Plans 70,000 70,000 ‐ 140,000 140,000 ‐ ePMA benefits realisation ‐ ‐ ‐ ‐ ‐ ‐ Procurement 56,286 56,286 ‐ 114,619 114,619 ‐ Invoice Discrepancies ‐ ‐ ‐ ‐ ‐ ‐ Finance Business Plans 72,504 72,504 ‐ 145,009 145,009 ‐ Adult Comm Business Plans 800,936 834,181 33,245‐ 1,663,777 1,697,018 33,240‐ Adult MH Business Plans ‐ ‐ ‐ ‐ ‐ ‐ C & F Business Plans 1,062,835 1,053,915 8,920 2,145,230 1,988,351 156,879 SS Business Plans 395,028 395,028 ‐ 790,056 790,056 ‐ Comms & engagement Business Plans 15,500 15,500 ‐ 31,000 31,000 ‐ Successful Bids and Tenders ‐ ‐ ‐ ‐ ‐ ‐ Gov & Compliance Business Plans 23,640 23,640 ‐ 47,279 47,279 ‐

16 Commissioning and Contracts Contract gains 100,000 100,000 ‐ 200,000 200,000 ‐ 5,018,478 5,263,342 244,864‐ 11,960,618 11,811,853 148,765

Reserves 19,000‐ 19,000

Forecast Outturn 11,960,618 11,792,853 167,765

1 Specialist Mental Health Rehab

2 Unscheduled Care

3 Community MH Redesign

8 Workforce clinical

4 Excellence in In‐patient Care

6 CYP Emotional Health and Wellbeing

9 Workforce technical

10 Health Informatics

Administration11

15 Networks

12 Corporate

14 Procurement

13 Pharmacy

Month Month Month MonthSep 2015 Aug 2015 Sep 2015 Aug 2015

6 5 Note 6 5 Note

Agency Spend 957 756 Bank Spend 1,160 1,104

Network Analysis Network AnalysisAdult Network 296 186 ‐ Note 2 Adult Network 616 531 ‐ Note 2Adult Community 141 183 ‐ Note 3 Adult Community 142 163 ‐ Note 3Children & Families 61 67 ‐ Note 4 Children & Families 74 47 ‐ Note 4Specialist Services 268 253 ‐ Note 5 Specialist Services 282 270 ‐ Note 5Corporate Services 191 66 ‐ Note 6 Corporate Services 46 93 ‐ Note 6

Actual 957 756 ‐ Note 1 Actual 1,160 1,104 ‐ Note 1

12

3

45

6

Note: Monitor have asked that the Trust stay below a 3% target for agency usage as a % of tool qualified nurse spend. During month 6, our rate was 4.43% with a cumulative figure of 3.63%. Issues are particularly apparent in Offender Health services where filling shifts with appropriate staff is problematic.

Specialist Services Network bank and agency costs are partly due to the contract for Liverpool and Kennet Prisons and partly due to acuity on inpatient wards. Secure wards have seen bank and agency use increase from previous months.Corporate Services agency costs have increased in September, particularly in IT and Workforce.

Bank and Agency Costs (£'000) Bank and Agency Costs by Clinical Network (£'000)

A high level of vacancies is supported by bank and agency, total staffing deployed has remained just below establishment year to date.Adult Networks bank and agency costs are primarily due to vacancies and acuity on inpatient wards above establishment. The position has deteriorated this month due to having to double staff in instances to cover the high level of new starters being indicted, but this should lead to reduced reliance later in the year.Adult Community bank and agency costs are almost exclusively driven by vacancies and acuity on Older Adult inpatient wards. There has been some improvement particularly in Older Adult and Integrated teams.Expenditure is fairly minor within Children and Families, but bank has increased for CAMHS Tier 4 and Early Intervention.

0

100

200

300

400

500

600

700

800

Apr 1

3

May 13

Jun 13

Jul 13

Aug 13

Sep 13

Oct 13

Nov

13

Dec 13

Jan 14

Feb 14

Mar 14

Apr 1

4

May 14

Jun 14

Jul 14

Aug 14

Sep 14

Oct 14

Nov

14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 1

5

May 15

Jun 15

Jul 15

Aug 15

Adult MH Adult Community Specialist Children & Families Corporate

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2013/14 1342 1375 1541 1478 1439 1631 1470 1686 1632 1640 1763 17712014/15 1974 1764 1785 2032 2191 1974 1925 1877 2065 1837 1847 22592015/16 1787 1927 1978 2201 1860 2118

0

500

1000

1500

2000

2500

Month Month YTD ForecastSep 2015 Aug 2015 Sep 2015 Out‐turn

6 5 Note 6 12 Note

Plan ‐5.5 ‐0.4 Plan 22.4 17.7Major Variances Major Variances

I&E ‐0.3 ‐0.5 ‐ Note 2 I&E ‐1.1 ‐2.8 ‐ Note 2Capital & financing 1.9 ‐0.1 ‐ Note 3 Capital & financing 1.6 0.9 ‐ Note 3PDC Adj 0.7 0.0 PDC Adj 0.0 0.0Contract phasing 0.0 0.0 Contract phasing 0.0 0.0Contract Variations 0.5 0.3 Contract Variations 0.0 0.0Debtors ‐1.9 0.0 ‐ Note 4 Debtors ‐0.7 ‐ Note 4Timing of settlements to suppliers ‐0.4 0.2 ‐ Note 5

Timing of settlements to suppliers 2.0 ‐ Note 5

Provisions and deferred income ‐0.2 0.6 Note 6

Provisions and deferred income 0.0 ‐ Note 6

Opening cash 0.0 0.0 Opening adjustment 1.1 1.1

Minor Variances 0.1 0.1 Minor Variances 0.0 ‐0.2

Variance 0.4 0.6 Variance 2.9 ‐1.1

Actual ‐5.1 0.2 Note 1 ForecastActual/Forecast 25.3 16.6 ‐ Note 1

1 Cash has fallen from last month mainly as a result of planned payments of PDC Dividends and Loans.234

5

6 Most of the timing issues relating to 14/15 were resolved in month 1.

Increases from Timing of settlements to suppliers has fallen slightly from last month contributing some £2.0m (M05 £2.4m) more cash than plan. This largely relates to higher than expected uninvoiced goods and services, the largest of which relates to higher than planned OATs (£0.9m) with the remainder being made up of a large number of small balances.

Monthly Cash and Liquidity Variance (£m) Forecast Cash and Liquidity (£m)

Debtors shows some deterioration from last month, with late payments by NHS England of c£2m (Paid in October) masking the improvements in the underlying position. The resulting deterioration in cash position is offset by decreasing levels of contract variations c£0.5m and the receipt of PDC due of c£0.7m, though as these are in these adjustments bring their respective positions in to line with plan overall Debtors is behind plan by £0.7m.

The major risk to liquidity relates to the I&E position.Capital and financing gains are largely as a result of capital slippage and gains on capital creditors, mainly as a result of the Harbour (see also capital).

‐3.000

‐2.000

‐1.000

0.000

1.000

2.000

3.000

4.000

5.000


Opening cash balance

Financing and Other

Capital and Investment Activities

Changes to WC

Non Cash Flows

Surplus/(deficit) after tax

0.000

5.000

10.000

15.000

20.000

25.000

30.000

35.000


Forecast

Plan

Month Month YTD ForecastSep 2015 Aug 2015 Sep 2015 Out‐turn

6 5 Note 6 12 Note

Plan 0.6 1.7 Plan 4.8 9.7

Major Variances Major VariancesHarbour 0.0 ‐0.9 ‐ Note 1 Harbour ‐1.1 0.0 ‐ Note 1PLMHU 0.0 0.0 Note 2 PLMHU 0.0 ‐0.3 Note 2IT Schemes ‐0.1 0.4 ‐ Note 4 IT Schemes 0.2 0.0 ‐ Note 4Seclusion 0.0 0.0 Seclusion 0.0 ‐0.2OATS 0.0 0.0 Note 3 OATS 0.0 0.5 Note 3Trinity and Space Utilisation 0.0 0.0 Trinity and Space Utilisation 0.0 0.2Other Min Improvements 0.0 ‐0.2 ‐ Note 4 Other Min Improvements ‐0.3 ‐0.3 ‐ Note 4Minor Variances 0.1 ‐0.1 Minor Variances 0.0 0.1

Variance 0.0 ‐0.8 Variance ‐1.2 0.0

Actual 0.6 0.8 Actual Actual/Forecast 3.6 9.7

1

234

Monthly Capex Variance (£m) Forecast Capex (£m)

The Harbour building was opened on time in March. Slippage to 15/16 was allowed for in plan, but overall position is subject to negotiation of final account and commissioning constraints for outstanding work. Underspends are considered likely but have yet to be quantified and are excluded from forecasts. Final account is expected in October.

Detailed programmes and forecasts are largely finalised and though contained within the overall envelope have established some phasing differences from plan more analysis will presented in future months.

PLMHU expenditure is expected to be minimal in 15/16

Expenditure to date is behind plan (tolerance 15%). The underspends primarily relates to the Harbour though until final account is finalised these will not anticipated in the forecast. Some additional potential pressures have been identified but at this time are considered manageable within the overall.

Capital Expenditure on OATs mitigations is expected to be managed within the overall envelope for 15/16

‐5.000‐4.000‐3.000‐2.000‐1.0000.0001.0002.0003.0004.0005.000


The Harbour

PLMHU

YPU

IT Schemes

Minor Improvements

Maintenance

IT

Anti Ligature

Other 0.000

2.000

4.000

6.000

8.000

10.000

12.000


Actual

Plan

Actual/Forecast represents weighted averageOverride represents Actual/Forecast Rating

YTD Forecast YTD Forecast YTD Forecast YTD Forecast YTD ForecastSep 2015 Out‐turn Sep 2015 Out‐turn Sep 2015 Out‐turn Sep 2015 Out‐turn Sep 2015 Out‐turn

6 12 6 12 6 12 6 12 6 12

Plan 3 3 Plan 2 2 Plan 4 4 Plan 2 2 Plan 2 2

Actual/Forecast 2 2 Actual/Forecast 1 1 * Actual/Forecast 4 4 Actual/Forecast 1 1 * Actual/Forecast 3 3

*Scoring a 1 on any metric will cap the weighted rating to 2, potentially leading to investigation.

Key Points

‐ ‐

‐

‐ ‐

‐

Surplus Margin is currently rated 1 against a plan of 2, current projections put the deficit at ‐£5.2m resulting in a Surplus Margin rating of 1 and requiring an improvement in the order of £2.3m to achieve a 2Variance from Plan is currently a 3 and expected to remain so, with a margin of c£1.2m. Note plan rating is now based on last years performance.

FINANCIAL SUSTAINABILITY RISK RATINGS

Overall FSRR is rated to 2 against plan of 3 and is forecast to remain so ‐ the rating is constrained by both the Debt Service rating and the new Surplus Margin rating which are forecast to be rated at 1 ‐ any score of 1 limits score to 2.

I&E is the main driver for changes to planned ratings.

Note that the overall CoSRR would have been a 3 against plan of 3 and with current projections would have remained so (despite a debt service of 1). I&E performance coupled with repayment of loans now results in a debt service of 1 against a plan of 2 and this is now expected to continue to the year end. An improvement in surplus in the order of c£2.4m would be required to achieve a 2. Liquidity is expected to remain at 4, with a margin of c£0.1m

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Apr‐15 Jul‐15 Oct‐15 Jan‐16

FSRR ‐ Overall

Actual/Forecast Plan Overide

0.0

0.5

1.0

1.5

2.0

2.5

3.0


FSRR ‐ Debt Service

Actual/Forecast 4 3 2 1

‐20.0

‐15.0

‐10.0

‐5.0

0.0

5.0

10.0

15.0


FSRR ‐ Liquidity


‐2.5%

‐2.0%

‐1.5%

‐1.0%

‐0.5%

0.0%

0.5%


FSRR ‐ Variance from Plan


‐2.5%‐2.0%‐1.5%‐1.0%‐0.5%0.0%0.5%1.0%1.5%2.0%2.5%


FSRR ‐ Surplus Margin


Reserves

Annual statement of Revenue Reserves

Budget Charge VarianceNon Recurrent Funds ‐1,500 ‐1,714 214 Note 1Drugs 250 200 50 Note 2Contractual Gains 393 60 333 Note 3Dilapidations 0 70 ‐70 Balance of unallocated non‐pay inflationNon Pay Reserve 223 197 26 Charge in Respect of MountcroftLiverpool Prison Non Rec 60 0 60 First Year Surplus on ContractCIP Reserve 19 0 19 Note 4

‐555 ‐1,187 632

Note 1 ‐ Non Recurrent Funds Note 2 ‐ Drugs

Non Recurrent Reserve established at Plan 1,500ChangesAdditional GainsNon Recurrent Income re AHSN 80 Note 3 ‐ Contractual GainsHarvey House rents 50Supply Chain Credits 60PIP/ATOS rent 20Misc. 4

Variance 214 Note 4 ‐ CIP Reserve

Total Charge 1,714

Financial provision was made for new drugs being prescribed in 15/16. These have not been realised to date, but a prudent assumption has been made in case invoicing is merely delayed, but this may be available non‐recurrently.

This now represents the small surplus on transacted CIPs.

The negotiations with commissioners indicate additional support of £867k of which c£470k has now been appropriately allocated to OATs. £60k has been provided for emerging costs.

MATTERS

ID Meeting DaPaper Status

06/02 Sep‐15 VerbalExcluded

06/01 Sep‐15 VerbalExcluded

02/01 Sep‐15 Verbal

Excluded02/02 Jun‐15 Verbal Included

02/03 Jun‐15 VerbalIncluded

02/04 Jun‐15 Verbal Excluded

02/05 Sep‐15 VerbalIncluded

02/06 Jun‐15 VerbalExcluded

02/07 Jul‐14 Verbal

Excluded

02/08 May‐14 VerbalExcluded

Subject

Contracted Out Services Changes‐ VAT COS remain an issue, though less so ‐ letter received from HRMC "we now appreciate that there are some areas where theguidance notes written for government departments are either not relevant to the NHS or can cause confusion for NHS bodies".COS are subject to roundtable discussion at DoH/HMRC. Guidance is still expected though timing is unknown.

On‐going Claims‐ Speculative VAT claims continue to be pursued in relation to older developments and changes in rulings. Up to £2m no gainassumed.

Settlements with regard to the Mental Health and Health Visiting contracts were concluded in September and have resulted in anadditional £380k included in current CIP performance.

The Trust has made appropriate provision for additional redundancies as a result of the Harbour based on a workforce riskassessment.

A paper on agreements with regard to the Inpatient Programme was delivered in July.

The Trust has made appropriate provision for excess travel as a result of the Harbour workforce changes.

The OATs trajectory continues to deteriorate. Bed Forecasts now indicate a potential exposure of an additional £3.4m (beyond the£1.2m provided). The commissioners have agreed to a 50:50 risk share on OATs and this has been assumed in forecasts, andthough the invoice has been raised a response has not yet been received. Forecast is based on the latest information but furtherexposure cannot be discounted at this stage.

Invoices remain outstanding with regard to CAMHs Tier IV OATs recharges with Specialist Commissioners. Net exposure is c£200kbut the Trust considers its position robust. The situation will be resolved over the next couple of months

We are reviewing DTS schemes and Bank and Agency with services being given improvement targets of c£2m with the intention ofreturning to plan and a risk rating of 3.

There are a number of upsides which are being reviewed and could improve the position by c£.5m (contract gains and slippage onreserves). These should be confirmed in month 7.

OUT OF AREA ACTIVITY

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 TotalTotal Cost 757 798 802 798 930 1,099 909 1,062 641 513 300 275 8,886LCFT Funding 276 292 241 169 111 56 55 0 0 0 0 0 1,200Additional Impact to LCFT 103 107 160 230 354 576 464 531 321 257 150 138 3,390

12

34

5

6

7 Without these remedial actions the position will deteriorate a further £2.8m (total OATs cost of £11.7m), of which LCFTs share is £1.4m, which would give a further adverse movement from forecast.

Remedial plans have been shared with Commissioners and Networks are working through detailed implementation plans, with progress being tracked by the Operations sub committee.

Commissioners agreed a 50:50 risk share on OATs as part of the contract agreement.A mitigation plan is currently being finalised which is estimated will reduce OATs costs by £4.2m, but will require investment in alternative service provision of £1.2m revenue and £0.5m capital.

The Networks developed a trajectory against which we have already seen significant slippage ‐ the original forecast assumed a sizable reduction in the summer.The Trust provided £1.2m for OATs, which was the level deemed affordable at planning and not intended to remove all risk. Commissioners matched this to give a funding envelope of £2.4m which, based on the original trajectory, was largely front loaded as indicated in the graph.

The latest trajectory now implies full year expenditure of £8.6m revenue against funding of £2.4m resulting in gross overspend of £6.5m. £0.3m of this has been agreed as LCFT due to the closure of the female PICU. At the agreed 50:50 the balance would indicate a further £3.1m cost pressure on LCFT.

Appendix 1: Income ScheduleForecast Forecast

YTD YTD Out‐turn Out‐turnSep 2015 Aug 2015 at Sep 2015 at Aug 2015

6 5 12 12Community Services

Urgent Care Planning 0.000 0.000 ‐0.102 ‐0.102Chronic Fatigue Funding 0.025 0.021 0.050 0.050Supported Living 0.000 0.000 1.842 1.842BWD Council Service Reductions ‐0.036 ‐0.028 ‐0.084 ‐0.084Offender Health Bedwatch ‐0.432 ‐0.360 ‐0.864 ‐0.864Liverpool & Kennet Prisons 2.757 2.068 6.893 6.893Offender Health 0.044 0.037 0.193 0.193Family Nurse Partnership 0.390 0.325 0.781 0.781Health Visiting 0.065 ‐0.104 0.130 ‐0.250CERS 0.199 0.173 0.430 0.430Out of Hospital 0.000 0.000 0.119 0.244Rheumatology 0.278 0.228 0.455 0.373Deflator Gain at 0.8% 0.170 0.141 0.339 0.339Other Community 0.537 0.317 0.884 1.098Total 3.997 2.817 11.066 10.943

Mental HealthOATS 2.510 2.236 4.297 4.311PICU Funding 0.000 0.000 0.473 0.473Safer Staffing ‐ Harbour 0.225 0.188 0.450 0.450Rehabilitation ‐ Moss View 0.575 0.486 1.188 1.189Community Dementia ‐0.104 ‐0.086 ‐0.507 ‐0.207Mental Health Resilience 0.157 0.083 0.341 0.341Other Mental Health 0.020 0.058 0.280 0.502Total 3.383 2.965 6.523 7.059

Specialist ServicesCAMHs Tier 4 0.100 0.083 0.133 0.132HIV 0.128 0.107 0.257 0.257Other 0.025 0.029 0.093 0.043Total 0.253 0.219 0.483 0.432

R&DTotal 0.009 0.017 0.061 0.049

ETRStudent Income 0.499 0.287 1.139 0.782Total 0.499 0.287 1.139 0.782

Other Non Healthcare IncomeAHSN 0.428 0.373 1.225 1.227MHRN ‐0.212 ‐0.177 ‐0.424 ‐0.424PIP/ATOS ‐0.055 ‐0.047 ‐0.309 ‐0.429IT ‐0.043 ‐0.048 ‐0.222 ‐0.174HR 0.095 0.057 0.167 0.041Dental 0.005 0.007 0.020 0.024Secure Services 0.170 0.090 0.188 0.361Property Services 0.087 0.062 0.174 0.168Psychology 0.013 0.015 0.053 0.219Other Misc. 0.338 0.499 0.528 0.514Total 0.826 0.831 1.401 1.527

Total 8.967 7.137 20.672 20.792

Board of Directors


Report Title Quarterly Workforce Report – Quarter Two


Prepared by Damian Gallagher, Director of HR & Transformation

Presented by Damian Gallagher, Director of HR & Transformation




Report purpose To support and inform the Board’s delivery of the LCFT Workforce Strategy


To employ the best people

Board Assurance Framework risk 4.1

CQC domain Well-led

INTRODUCTION The attached report provides the Board with an overview of the workforce data for July to September 2015.

Introduction:

The LCFT Workforce Board Report has been designed to provide the Board with a quarterly update on

the organisations performance against ten agreed workforce Key Performance Indicators (KPI’s). The

data presented is supported with narrative highlighting the current workforce management challenges

being experienced by the Business and an outline of the activity in action to manage an improvement in

performance and mitigate the identified workforce management risk.

This report provides performance against the workforce indicators for the Quarter 2 period, 01 July

2015 to 30 September 2015.

The data presented in this report is sourced from the following LCFT Directorates:

Human Resources

Finance

Education, Learning & Development Information to support the preparation of narrative is provided by HR Business Partners in conjunction with Network Management. Members of the Board are invited to note the content of the report and are encouraged to ask any questions, or make requests for further information, with the Director of Human Resources. Workforce KPI’s Performance Headlines: The workforce indicators set out on page 3 of the Workforce Board Report present LCFT’s overall performance against the ten workforce KPI’s in the quarter 2 period. Performance is RG rated against the Trusts defined targets and is supplemented with an indicative performance trend, set against the performance in the previous quarter.

1. Peripheral Workforce Reliance Peripheral workers are individuals engaged to work with LCFT through the LCFT Work Bank or Agencies. LCFT’s use of Bank and Agency has seen an overall reduction in quarter 2 from a quarterly average of 13.7% in quarter 1 to 11.2% for the quarter 2 period. Acuity of patients, number of vacancies and sickness absence are the common reasons cited by the business for the use of Bank and Agency to supplement their core workforce. The DTS programme work continues to be refined with Network trajectories. Performance against these will require monitoring to include the % cap.

2. Operational Gap

Operational Gap considers absences, other than sickness and annual leave, which may also have an impact on service delivery and employee wellbeing. LCFT reports a stable quarterly rate of 2.7% for quarter 2 and the operating gap remains below the current Trust target of 5%. Maternity Leave continues to be the most common absence type in this category. Total operating gap - When combined with sickness absence and annual leave figures for the quarter, the total operating gap is around 13% for LCFT.

3. Sickness Absence The quarterly average sickness absence rate for Q2 is 5.9%. This is a slight increase on Q1 performance and 1.4% above the Trust absence target of 4.5%. Absence in the quarter peaked

at 6.28% in August and fell in September to 5.69%. Absence rates in July and September are in line with 2014 absence rates for July and September 2014 with August presenting an exception peak to the year on year seasonal trend in August 2014. Analysis of sickness absence type for LCFT reveals that 74.4% of all sickness absences within the Trust are attributable to long-term sickness. The DTS Work stream for sickness absence continues to look at best practice management of sickness absence and is currently developing service specific absence reduction targets. This is required to be strengthened to establish Network plans for absence management.

4. Vacancy Rate The board report provides two rates to support the assessment of vacancies. The first is the overall vacancy level – the number of vacancies the business runs with against its Budgeted Establishment and the second looks at the number of vacancies being actively recruited to (this is a count of any vacancy that is within the recruitment process from recruitment authorisation through to starting with the trust. The budgeted establishment vacancy rate for quarter 2 is 10.6%, a slight reduction on the quarter 1 position of 11.2%. 47% of these vacancies are reported as being actively recruited to giving LCFT a trust quarterly active vacancy rate of 4.8% for quarter 2. Networks continue to effectively manage vacancies and are proactively approaching attraction and recruitment to those positions and work areas that present national and local challenges.

5. Safer Employment Compliance Safer Employment monitors the organisations compliance with the national safer recruitment and safer employment standards set for the NHS. The Board report has been enhanced for quarter 2 to include safer recruitment measures for LCFT Bank workers. The first part of this enhancement has focussed on compliance in the recruitment process. Part two development will introduce Mandatory and Statutory training compliance for Bank workers and safer employment performance. Overall compliance for Core Workforce has improved again for this quarter and reports 99% compliance. Four out of the five areas measured achieved 100% compliance. Professional Registrations were still above the trust target of 85% reporting 94% compliance. Networks and the HR Directorate have provided assurance that risks associated with individual non-compliance have been mitigated. Compliance within the Bank Worker population is above target at 90% compliant and the Temporary staffing team have provided assurance to evidence that the organisation is protected.

6. Turnover Rate Turnover reporting has been enhanced for quarter 2 with the addition of two sub-category turnover rates: one provides a ‘business as usual’ (BAU) turnover rate e.g. resignations, dismissals, retirements, redundancy etc. and the other provides the TUPE Transfer turnover rate. This development will allow Board to understand which activity is impacting upon the overall turnover rate and will facilitate the identification of turnover as an area of concern, or not, for LCFT.

The Turnover rate for quarter 2 is 10.8%, which is a slight reduction on the previous quarter. Page 15 of the Board Report demonstrates that the drop in turnover can be attributed to a reducing rate in TUPE Transfer activity. The downward trend in TUPE transfers out of LCFT is reflective of the disappearance of the TUPE activity that took place over 12 months ago that is no longer part of the calculation period the rate is based upon.

7. Mandatory & Statutory Training Compliance Overall mandatory and statutory training compliance is reported at 76% as at the end of quarter 2 and remains below the Trust target of 85% compliance. The People sub-committee continues to monitor this target closely and the Networks each report network level initiatives in place to drive improvements in this area.

8. Induction There has been an improvement in the quarterly average induction rate for quarter 2 with a reported average of 64.2%. The Education, Learning and Development Directorate are currently developing an agreed new approach to induction that will further improve induction attendance and, therefore, compliance across LCFT. This involves linking the start date of the new starter to their attendance at induction and their availability to the business.

Damian Gallagher HR Director

LCFT Workforce Board Report

July to September 2015

HR & L&OD KPIs The LCFT Workforce Board Report has been designed to demonstrate how HR and L&OD key performance indicators support the delivery of the Trust’s Strategic Priorities and Objectives.

To provide high quality services • Operational Gap

• Sickness Absence Rate

To become recognised for excellence • Induction Rate

• Mandatory Training Rate

To employ the best people • Vacancy Rate

• Safer Employment

To provide excellent value for money in a

financially sustainable way

• Agency / Bank / Locum Spend to Workforce Costs

• Turnover

To innovate and exploit technology to

transform care • Appraisal Rate

KPI PERFORMANCE OVERVIEW

The HR and L&OD Key Performance Indicators have been devised to update the Trust Board on the Trusts current performance against the agreed key workforce indicators and highlight any areas of concern and provide assurance by identifying the action taken to mitigate risk and improve performance.

Information in this report is accurate as at 30th September 2015.

Key Performance Indicators Trust TargetPrevious Quarter

Average(Q1: 2015/16)

This Period

Average(Q2: 2015/16)

Trend (Against Previous

Quarter)

Total Workforce Expenditure (Cumulative Spend in Quarter)

£63,160,476

Budget- £63,174,511

Peripheral Workforce Reliance (Bank, Agency & Locum spend % of Total Pay Spend)

6.0% 13.7% 11.2% q

Operational Gap 5.0% 2.7% 2.7% tu

Sickness Absence 4.5% 5.8% 5.9% p

Vacancy Rate 5.0% 11.2% 10.6% q

Of which in Active Recruitment - 5.8% 4.8% q

Safer Employment Compliance

(Core workforce & Bank workers)85.0% 89.3% 94.4% p

Turnover Rate 10.0% 11.4% 10.8% q

Appraisal Performance 85.0% 39.8% 38.2% q

Mandatory & Statutory Training

Compliance 85.0% 76.0% 76.0% tu

Induction (within 3 months of starting) 95.0% 57.1% 64.2% p

WORKFORCE EXPENDITURE

Workforce Expenditure against Established Budget – Quarter 2 Source Data: EFIN Finance Ledger

Business Area Established Budget

£'s

Spend on Core

Workforce £'s

Spend on Peripheral

Workforce £'s

Total Spend on

Workforce £'s

Budget &

Expenditure

Variance £'s

Trust 63,160,476 56,130,233 7,044,278 63,174,511 14,035

ACS 15,266,582 13,927,611 1,289,152 15,216,763 -49,819

AMH 20,025,496 17,875,304 2,580,078 20,455,383 429,887

C&F 11,348,396 10,534,585 587,289 11,121,874 -226,522

SS 8,683,746 6,689,318 1,910,753 8,600,070 -83,676

Corp 7,836,256 7,103,415 677,006 7,780,421 -55,835

0

2

4

6

8

10

12

14

16

18

20

22

24

2015 07 2015 08 2015 09

£ m

illio

ns

Locum

Agency

Bank

Spend

Budget

The HR and L&OD Key Performance Indicators have been devised to update the Trust Board on the Trusts current performance against the agreed key workforce indicators and highlight any areas of concern and provide assurance by identifying the action taken to mitigate risk and improve performance.

Workforce Expenditure against Established Budget – Quarter 2 cumulative figures

VACANCY RATE

The Vacancy Rate presents the % difference between the Trusts budgeted establishment and its actual spent establishment. This measurement has been based on FTE and is one of the measures referenced when assessing core workforce stability.

To enhance this measure, the Active Vacancy Rate has been supplied. This rate highlights the % of budgeted establishment vacancies that are being actively recruited to by the organisation.

Budgeted Establishment Vacancy Rate – 12 Month Trend

Budgeted Establishment & Active Vacancy Rate Comparison – 30 September 2015 position

Source Data: ESR and Finance Ledger

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

22.0%

2014 09 2014 10 2014 11 2014 12 2015 01 2015 02 2015 03 2015 04 2015 05 2015 06 2015 07 2015 08 2015 09

Trust

ACS

AMH

C&F

SS

Corp

Budgeted Est. FTE

(BE)FTE in Post

Budgeted FTE

Vacant

Budgeted Est.

Vacancy Rate

(BE VR)

Vacant FTE in Active

Recruitment

Active Vacancy Rate

(AVR)

6702.16 5992.58 709.58 10.59% 233.96 4.75%

Vacancy Rate & WTE – Quarterly Actuals by Business Area

Hot Spot Analysis:

Children & Families: Vacancy Rate has increased in Q2. High rate of vacancies within Health Visiting (HV) & School Nursing. 9 School Nursing vacancies are of concern to the Network as they are affecting service delivery and are difficult to fill.

Board Assurance: Network confident in attracting candidates to HV vacancies and recruitment

progressing with 15 new HV’s appointed and awaiting PIN registrations. 9 School Nursing Vacancies remain unfilled within East Lancashire and

Blackburn with Darwen Localities. Network experiencing difficulties attracting candidates to these areas:

Action taken by business 1. Network nominated lead with objective to develop a Recruitment &

Retention Strategy 2. National Initiative ‘Call to Action’ to increase visibility, accessibility &

confidentiality for this population.

Source Data: ESR, Finance Ledger, Recruitment



VACANCY RATE

Adult Mental Health: Vacancy Rate has increased in Q2. Network report links in increasing vacancy rate with the establishment of new Clinical Decision Unit. Vacancies predominantly in Qualified Nursing positions within inpatient areas. Network report difficulties in attracting sufficient candidates. Board Assurance: Targeted Recruitment Programme in progress - Dublin Recruitment fair

17 & 18 October 2015, RCN fair 5 & 6 November, Cork Fair 19 November Action Taken by Business Workforce Planning process initiated within Network to inform future

Workforce Development Activity: CIP Plans and development, Clinical Service Development, Opportunities for skill mixing and role redefinition.

Community Mental Health Redesign Programme has commenced and will support Network in defining its true vacancies and skill mix opportunities.

BE FTE FTE In Post BE VR AVR BE FTE FTE In Post BE VR AVR BE FTE FTE In Post BE VR AVR

Trust 6690.55 6041.99 9.69% 6.14% 6707.96 6023.64 10.20% 4.63% 6707.96 5912.11 11.86% 3.49%

ACS 1920.10 1709.19 10.98% - 1694.18 1491.25 11.98% - 1694.18 1464.86 13.54% 2.43%

AMH 1817.37 1648.54 9.29% - 2056.99 1861.28 9.51% - 2056.99 1813.26 11.85% 3.12%

C&F 1220.08 1152.08 5.57% - 1221.52 1135.15 7.07% - 1221.52 1126.95 7.74% 2.66%

SS 897.22 759.29 15.37% - 891.29 773.82 13.18% - 891.29 740.63 16.90% 8.02%

Corp 835.78 772.89 7.53% - 843.98 762.14 9.70% - 843.98 766.41 9.19% 2.93%

2015 08 2015 092015 07

Vacancy Rate & WTE Hot Spot Analysis continued Source Data: ESR and Finance Ledger



VACANCY RATE

Specialist Services: Vacancy Rate has reduced through Q2 but remains high due to difficulties in recruiting B5 RGN Nurses. Board Assurance: Progression of targeted Recruitment Programme: Internal SS

Recruitment day held 17 October 2015 & Dublin Recruitment fair 17 & 18 October 2015

No. of other Recruitment Fairs planned: RCN fair 5 & 6 November, Cork Fair 19 November

Recruitment & Retention Incentives rolled out across 3 service Lines to improve attraction to & sustainability of these roles.

All vacancies at HMP Liverpool recruited to pending consultation launch. Controlled over recruitment to RGN positions continues to support business continuity.

Other action taken by business: 1. Skill mix of existing roles reviewed to include difficult to fill vacancy responsibilities: HMP Preston conversions; 2 WTE RGN to 1 Pharmacy Technician & 2 WTE Healthcare Support Workers 3.2 WTE RMN to 1 WTE Occupational Therapist, 2 WTE Healthcare Support Worker & 1 WTE STAR worker HMP Wymott conversions; 6 WTE RGN to 5 WTE Pharmacy Technician & 2 Healthcare Support Workers

Adult Community Services: Network review of Bank and Agency Usage and Vacancy Rate information indicates that BE Vacancy Rates are high in areas of low Bank & Agency usage activity and BE vacancy rates are low in areas of high Bank & Agency activity. Board Assurance: Network has established a vacancy control panel to review all

Network Requests to Recruit Network review of budgeted establishment by Service underway to

address identified BE Vacancy rate and Bank and Agency Usage anomalies.

Operational Gap is the measure of absences that affect operational performance other than Sickness and Annual Leave. This section of the report considers employees who are absent from operational work for the following reasons: Career Break, Maternity & Adoption, Paternity, Out on External Secondment (Paid), Out on External Secondment (Unpaid), Suspend No Pay, Suspend With Pay.

Operational Gap by Business Area – 12 Month Trend Source Data: ESR

OPERATIONAL GAP

Total Operational Gap Analysis by Reason – 30 September 2015 position

0.00

50.00

100.00

150.00

200.00

2014 10 2014 11 2014 12 2015 01 2015 02 2015 03 2015 04 2015 05 2015 06 2015 07 2015 08 2015 09

F

T

E

ACS AMH C&F SS Corp

Indicator Heads FTE

Total Workforce 6777 6036.13

Mat / Adoption Leave 137 123.15

Career Break 22 16.35

Secondment 4 3.40

Suspension 16 12.49

Sickness Absence 402 356.48

Annual Leave 309 269.26

Total Operational Gap 890 781.13

Active 89.3%

Sickness Absence 4.9%

Annual Leave 3.7%

Mat / Adoption Leave 1.7%

Career Break 0.2%

Suspension 0.2%

Other 0.4%

Operational Gap by Business Area – Quarterly Actuals by Business Area Source Data: ESR

OPERATIONAL GAP

Average

FTE

Average No

Absent

Employees

Gap Average

FTE

Average No

Absent

Employees

Gap Average

FTE

Average No

Absent

Employees

Gap

Trust 6041.99 163.14 2.70% 6023.64 161.88 2.69% 6068.63 157.60 2.60%

ACS 1709.19 47.14 2.76% 1491.25 43.30 2.90% 1499.47 34.60 2.31%

AMH 1648.54 51.48 3.12% 1861.28 56.99 3.06% 1862.37 55.25 2.97%

C&F 1152.08 23.71 2.06% 1135.15 23.07 2.03% 1139.17 31.83 2.79%

SS 759.29 21.04 2.77% 773.82 20.61 2.66% 777.23 17.61 2.27%

Corp 772.89 19.77 2.56% 762.14 17.91 2.35% 790.38 18.31 2.32%

2015 07 2015 08 2015 09

Operational Gap is the measure of absences that affect operational performance other than Sickness and Annual Leave. This section of the report considers employees who are absent from operational work for the following reasons: Career Break, Maternity & Adoption, Paternity, Out on External Secondment (Paid), Out on External Secondment (Unpaid), Suspend No Pay, Suspend With Pay.

The Sickness Absence rate is calculated as follows:

Total absence (hours) during a month ÷ Total actual headcount contracted time (hours) during a month x 100

Sickness Absence Rate – Year on Year 12 Month Trend Analysis Source Data: ESR

SICKNESS ABSENCE

Sickness Absence Rates by Business Area – Quarterly Actuals Rate Rate Rate

2015 07 2015 08 2015 09

Trust 5.84% 6.28% 5.69%

ACS 6.99% 6.84% 6.05%

AMH 6.34% 7.26% 7.34%

C&F 3.97% 4.53% 4.43%

SS 7.43% 8.28% 6.06%

Corp 3.41% 3.33% 2.60%

Trend

12mths

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

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

Current Yr Prev Yr Target

The Sickness absence rate is calculated as follows:


Sickness Absence Hot Spot Analysis Source Data: ESR

SICKNESS ABSENCE

Specialist Services: Sickness has reduced the last month of Q2.

Board Assurance: Continuing to monitor action plans for service lines where sickness is

above 4.5% to drive down absence & sustain reduction. HR clinics implemented across 3 additional service lines where

absence continues to be high.

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%



0.00%

2.00%

4.00%

6.00%

8.00%

10.00%



Adult Mental Health: Sickness Absence has increased in Q2 with Inpatient Services reporting the highest rates. Absence level attributed to high level of vacancies and a notable increase in August following the formal move of all Harbour services Into the Network on 01 August Board Assurance: Network Sickness Absence Improvement Plan has been launched

which provides a local targeted approach to the management of Sickness Absence relevant to each service. This activity is in addition to the work that is being undertaken under the DTS Programme.

Network analysis of the key reasons for Sickness reveals highest reported reason for absence is ‘Anxiety/Stress/Depression/other Psychiatric Illness’. This is a Network focus for Local Sickness Absence Improvement Plan.

The Sickness absence rate is calculated as follows:


Sickness Absence Hot Spot Analysis Source Data: ESR

SICKNESS ABSENCE

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%



Adult Community Services: Sickness Absence has fallen in Q2. Network analysis of Sickness Absence has identified that 63% of absence is attributable to Long Term Sickness (LTS). Board Assurance: HRBP working with Network to develop service and team level

specific sickness absence improvement trajectories with an action plan for achievement

Network Focus on Management of LTS cases with an increasing focus on managing returns or appropriate exits.

AGENCY & BANK SPEND

Agency & Bank spend is calculated as a percentage of the total salary spend. Usually, a link can be seen between the level of expenditure on peripheral workforce (Bank, Agency and Locum), the vacancy rate, Sickness Absence and Operational Gap.

Bank & Agency Pay Spend by Business Area Source Data: Finance, Healthroster & ESR

Spend £ % Spend £ % Spend £ %

Trust 18,285,051 1,226,017 5.9% 1,038,160 5.0% 222,492 1.1% 20,771,720 11.97%

ACS 4,493,897 232,889 4.7% 198,389 4.0% 35,797 0.7% 4,960,972 9.41%

AMH 5,485,735 531,410 8.4% 304,433 4.8% 30,132 0.5% 6,351,710 13.63%

C&F 3,586,486 75,221 2.0% 74,690 2.0% 47,442 1.3% 3,783,839 5.22%

SS 2,202,298 277,681 9.7% 287,707 10.0% 109,121 3.8% 2,876,807 23.45%

Corp 2,516,635 108,817 3.9% 172,940 6.2% 0 0.0% 2,798,392 10.07%

Flexible

Labour

Reliance

%Total Spend £

Business

Area

2015 07

Core

Workforce

Spend £

Bank Agency Locum


Trust 19,647,998 1,180,937 5.4% 756,282 3.5% 167,897 0.8% 21,753,113 9.68%

ACS 4,800,263 225,269 4.3% 183,176 3.5% 33,905 0.6% 5,242,613 8.44%

AMH 6,418,355 548,008 7.6% 186,845 2.6% 30,809 0.4% 7,184,017 10.66%

C&F 3,515,333 47,192 1.3% 67,428 1.8% 42,996 1.2% 3,672,949 4.29%

SS 2,257,772 268,039 9.4% 252,729 8.9% 60,187 2.1% 2,838,726 20.47%

Corp 2,656,276 92,429 3.3% 66,104 2.3% 0 0.0% 2,814,808 5.63%

Flexible

Labour

Reliance

%Total Spend £

2015 08

Business

Area

Core

Workforce

Spend £

Bank Agency Locum

AGENCY & BANK SPEND

Bank & Agency Pay Spend by Business Area Source Data: Finance, Healthroster & ESR


Trust 18,197,185 1,222,150 5.9% 957,088 4.6% 273,255 1.3% 20,649,678 11.88%

ACS 4,633,451 203,229 4.1% 141,246 2.8% 35,253 0.7% 5,013,178 7.57%

AMH 5,971,215 615,638 8.9% 295,754 4.3% 37,048 0.5% 6,919,656 13.71%

C&F 3,432,766 75,516 2.1% 60,851 1.7% 95,953 2.6% 3,665,086 6.34%

SS 2,229,248 282,498 9.8% 267,790 9.3% 105,001 3.6% 2,884,537 22.72%

Corp 1,930,505 45,269 2.1% 191,447 8.8% 0 0.0% 2,167,221 10.92%

Flexible

Labour

Reliance

%Total Spend £

2015 09

Business

Area

Core

Workforce

Spend £

Bank Agency Locum

Hot Spot Analysis:

Specialist Services: Network report Acuity of Service Users and Vacancy Rate as key contributors to the level of spend on Bank and Agency.

Board Assurance: Vacancies are being managed effectively –

please refer to Vacancy Rate slide for further information.

Adult Mental Health: Network report Acuity of Service Users, Vacancy Rate and sickness absence as key contributors to the level of spend on Bank and Agency.

Board Assurance: Vacancies are being managed effectively –

please refer to Vacancy Rate slide for further information.

Network Action Plan in place to Improve Sickness Absence – please see Sickness Absences Slides for further information.

Adult Community Services: Network review of Bank and Agency usage has revealed that usage of Bank and Agency is high in areas where the Vacancy Rate is low and Bank and Agency usage is low in areas where the Vacancy Rate is high. Board Assurance: Network review of budgeted establishment

by Service underway to address identified BE Vacancy rate and Bank and Agency Usage anomalies and focus the Network activities for establishing greater control on Bank and Agency Usage.

Agency & Bank spend is calculated as a percentage of the total salary spend. Usually, a link can be seen between the level of expenditure on peripheral workforce (Bank, Agency and Locum), the vacancy rate, Sickness Absence and Operational Gap.

TURNOVER

The Turnover Rate is one of the indicators used to assess employee satisfaction with the Trust. It is presented as a rolling 12 month figure, calculated at the end of each reporting period and is calculated as follows:

Total number of leavers ÷ total number of contracted employees.

To provide the Board with a true picture of turnover activity in the Organisation, three measures of turnover are reported: Overall Trust Turnover, BAU Turnover and TUPE Transfer Turnover.

Turnover Rate – 12 Month Trend Analysis Source Data: ESR

Business

AreaHeadcount

2015 092015 07 2015 08 2015 09

Trust 6,768 11.75% 11.61% 10.77%

ACS 1,778 11.26% 12.59% 11.98%

AMH 2,005 9.66% 8.37% 8.13%

C&F 1,331 13.30% 13.94% 11.12%

SS 808 13.80% 11.26% 11.76%

Corp 846 12.91% 13.97% 13.00%

Leaving Reasons for Quarter

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

2014 10 2014 11 2014 12 2015 01 2015 02 2015 03 2015 04 2015 05 2015 06 2015 07 2015 08 2015 09

BAU Turnover TUPE Turnover All Turnover

Turnover by Business Area

Resignation 60.6%

End of FTC 19.2%

Retirement 10.3%

TUPE 6.6%

Dismissal 1.9%

Ill Health Retirement

0.9% Other 0.5%

APPRAISAL RATE

The Appraisal Data presented has been designed to highlight the % initiation of Annual Performance Objectives (Appraisal) for the relevant Performance Review Year. There are two measures: 1. The number of Appraisals that have been Initiated and recorded by the employee 2. Of those initiated in 1. above, those that have been approved by the Line

Manager

Quarter 2 Appraisal Rate, by Business Area

General Information: This data has been extracted from the current Learning and Development performance review system. Trust use of this system has reported some challenges and each Network has reported usage of a paper based PDR system in place of this system in some areas.

Positive Action: New ePDR System development update: The New ePDR System has been shared with the Learning and Development Directorate and a facilitated developmental review of the product and its future fit with the organisation vision for PDR and NMC introduction of Revalidation for Nurses and Midwives in April 2016 undertaken. A number of system enhancements have been suggested by the group to ensure system flexibility and clear, supportive linkages with the Revalidation process and system and a new rollout date has been scheduled, to facilitate the enhancements of the system, for February 2016.

Source Data: Learning & Development

0%

20%

40%

60%

80%

100%

Trust ACS AMH C&F SS Corp

PDR Started

Manager Sign Off

TRAINING & INDUCTION

The Induction rate calculation is as follows: Total Number of New Starters ÷ Total Number of New Starters with Completed Inductions within 3 months.

Induction Completion Rate – Quarter 2 Performance Source Data: Learning & Development

New

Starters

2015 04

Inductions

Completed

Within

3mths

Inductions

Completed

After 3mths

Not

CompletedIC Rate

New

Starters

2015 05

Inductions

Completed

Within

3mths

Inductions

Completed

After 3mths

Not

CompletedIC Rate

New

Starters

2015 06

Inductions

Completed

Within

3mths

Inductions

Completed

After 3mths

Not

CompletedIC Rate

Trust 70 41 3 36 58.6% 40 33 1 13 82.5% 101 52 0 55 51.5%

ACS 13 9 0 4 69.2% 3 3 0 0 100.0% 17 13 0 4 76.5%

AMH 25 11 3 11 44.0% 16 13 1 2 81.3% 25 21 0 4 84.0%

C&F 7 6 0 1 85.7% 2 1 0 1 50.0% 2 2 0 0 100.0%

SS 22 12 0 10 54.5% 12 12 0 0 100.0% 50 13 0 37 26.0%

Corp 3 3 0 0 100.0% 7 4 0 3 57.1% 7 3 0 4 42.9%

2015 092015 082015 07

0

20

40

60

80

100

120

2015 07 2015 08 2015 09

Not Completed

>3 Months

<3 Months

<2 Months

<1 Month


Mandatory Training covers 10 core skills courses.

Mandatory Training Rate by Business Area – September Position Source Data: Learning & Development

Co

nfl

ict

Re

solu

tio

n

E&D

Fire

Saf

ety

Ad

min

Fire

Saf

ety

Clin

ical

He

alth

& S

afe

ty

ILS

Infe

ctio

n C

on

tro

l

Ad

min

Infe

ctio

n C

on

tro

l

Clin

ical

Man

ual

Han

dlin

g 1

Man

ual

Han

dlin

g 2

Man

ual

Han

dlin

g 3

Re

susc

itat

ion

Safe

gura

rdin

g

Ch

ildre

n 1

Safe

guar

din

g

Ch

ildre

n 2

Safe

guar

din

g

Ch

ildre

n 3

Safe

guar

din

g A

du

lts

1

Info

rmat

ion

Go

vern

ance

Trust 53% 86% 77% 71% 84% 49% 72% 67% 75% 79% 43% 57% 77% 62% 62% 83% 83%

ACS 44% 87% 87% 72% 84% 51% 80% 70% 79% 77% 55% 60% 85% 64% 82% 80%

AMH 59% 90% 88% 72% 87% 48% 81% 62% 83% 82% 42% 53% 86% 42% 86% 80%

C&F 69% 93% 95% 78% 92% 43% 95% 78% 93% 84% 8% 69% 94% 93% 91% 90%

SS 46% 85% 82% 69% 84% 51% 74% 66% 74% 72% 0% 47% 81% 57% 85% 79%

Corp 23% 70% 60% 50% 66% 46% 54% 48% 61% 60% 0% 41% 62% 64% 100% 65% 88%

Hot Spot Analysis:

Children & Families: Network track their own Mandatory Training compliance and report their level of compliance as follows.

Board Assurance: CR 89%, E&D 97%, Fire Safety 94%, H&S 97%, ILS 100%, Infection Control 93%, Manual Handling 1 92%, Manual Handling 2 97%, Resuscitation 92%,

Safeguarding Children 1&2 98% & 96%, Safeguarding Adults 96%, IG 94%. Corporate Partners from L&OD attended C&F Network Assurance Group to discuss data discrepancies. L&D advised C&F to continue to report

compliance locally until April 2016.


Mandatory Training covers 10 core skills courses.

Mandatory Training Rate by Business Area – Hot Spot Analysis Continued Source Data: Learning & Development

Adult Mental Health: Network have engaged with L&D to develop a Network specific compliance improvement plan.

Board Assurance: L&D attended AMH People Group Meeting and agreed a programme of

support for the Network to improve their compliance levels with Mandatory and Statutory Training. Support Plan will focus on increasing Network compliance and data quality.

Adult Community Services: Network have raised concerns about their level of compliance and data quality. Board Assurance: ACS People Meeting has agreed to centrally track Mandatory and

Statutory Training Compliance to better understand critical areas of non-compliance, assess data quality and develop a service focussed improvement plan.

Board Reporting Improvements: Bank Workers are the preferred peripheral workforce source for the organisation where the business needs additional staffing support to ensure delivery of safe and effective services. The provision of an internal work Bank provides a source of cost effective additional cover from a pool of workers who are engaged, supported and trained to the standards set by the organisation. The Board report is being enhanced to provide Board assurance against the compliance of this population with the Safer Employment Standards. Quarter 3 reporting will provide enhanced assurance for this population, reporting Active Bank Worker compliance with:

1. Mandatory Training Compliance for Active Bank Workers 2. Safer Employment Assurance for Active Bank workers

Hot Spot Analysis:

Please see detailed slides that follow this summary for a Hot Spot Analysis that provides the Board with assurance against those areas reporting less than 100% compliance. Core Workforce Hot Spots

Right to Work DBS New Starters DBS Renewals Professional Membership Registrations

SAFER EMPLOYMENT

Safer Employment reports the Trusts compliance with its legal obligations as an employer, for recruiting and providing Safe Staff. It also covers the trusts compliance with Safer Recruitment standards and Safer Staffing frameworks in place within the NHS (Right to Work, DBS, Professional Membership Registration, Visa’s and Work Permits).

Source Data: ESR & Recruitment Team Core Workforce – Quarter 2 Compliance

Bank Work Hot Spots

Right to Work DBS New Starters

Bank Worker – Quarter 2 Compliance

Business Area % Compliant % Compliant

Right to Work 100%

DBS New Starter 100%

DBS Renewals 100%

Visas & Work Permits 100%

Professional Membership

Registrations94%

Overall Compliance 99%

Business Area % Compliant % Compliant

Right to Work 89%

DBS New Starter 91%

DBS Renewals -

Professional Membership

Registrations-

Overall Compliance 90%

Right to Work & DBS Compliance by Business Area - Core Workforce Quarter 2

SAFER EMPLOYMENT

Source Data: ESR & Recruitment Team


Quarter 1 – Compliance Hot Spot Update DBS New Starters: 9 of the 29 TUPE Transferees into SS from Q1 remain non compliant with DBS Safer Employment requirements

Board Assurance 1 Stage 3 Final Notification of DBS non Compliance 1 Form error, form returned for re-processing 7 submitted to DBS - 5 issued with DBS certificates awaiting

presentation to Manager, 2 Stage 2 formal Notification of non compliance issued - awaiting DBS certificates (certificates delayed)

DBS Renewals: 3 of the 10 that expired in Q1 are still outstanding

Board Assurance 3 in disciplinary measures for non compliance.

Right to Work: 8 of the 32 TUPE Transferees into SS from Q1 are non-compliant with their right to work re-check.

Board Assurance Outstanding re-checks escalated to the HRBP and Management within the affected

area for resolution.

Business

Area

Total

New

Starters

Total Right

to Work

Entries

% Compliant

Total New

Starters

Requiring

DBS

Total No

Blank

Entries

% Compliant

Total DBS

Renewals

Required

Total

Number of

Expired

Entries

%

Compliant

Trust 200 200 100% 190 0 100% 159 0 100%

ACS 55 53 100% 55 0 100% 0 0 -

AMH 30 30 100% 28 0 100% 0 0 -

C&F 28 28 100% 28 0 100% 145 0 100%

SS 49 49 100% 49 0 100% 14 0 100%

Corp 37 37 100% 20 0 100% 0 0 -

TUPE 1 1 100% 0 0 - 0 0 -

Business

Area

Right to

Work Non

Compliant

Q2

Update

New Starter

DBS Non

Compliant

Q2

Update

DBS

Renewals

Non

Compliant

Q2

Update

C&F - - - - 93% 100%

SS 66% 91% 70% 89% 64% 73%

Visa and Work Permits Compliance by Business Area – Quarter 1

SAFER EMPLOYMENT


Safer Employment reports the Trusts compliance with its legal obligations, as an employer, for recruiting and providing Safe Staff. It also covers the trusts compliance with Safer Recruitment standards and Safer Staffing frameworks in place within the NHS (Right to Work, DBS, Professional Membership Registration, Visa’s and Work Permits).

Business Area

Total No. New

Starters requiring

Visa / Work

permit

Total No. Work

Permit / Visa

Entries on ESR

%

Compliant

Total No of Work

Permit & Visa

Renewals

Required

Total Number of

Expired Entries

on ESR

% Compliant

Trust 7 7 100% 2 0 100%

ACS 1 1 100% 0 0 100%

AMH 5 5 100% 2 0 100%

C&F 0 0 100% 0 0 100%

SS 0 0 100% 0 0 100%

Corp 1 1 100% 0 0 100%

Professional Membership Registration Compliance by Business Area – Quarter 2

SAFER EMPLOYMENT

Source Data: ESR, Medical & Dental, Employee Relations

Safer Employment reports the Trusts compliance with its legal obligations, as an employer, for recruiting and providing Safe Staff. It also covers the trusts compliance with Safer Recruitment standards and Safer Staffing frameworks in place within the NHS (Right to Work, DBS, Professional Membership Registration, Visa’s and Work Permits).

Hot Spot Analysis:

Professional Membership Registrations: Of the 299 Professional Registrations due for renewal in Quarter 2, 94% have been successfully renewed. 18 Professional Registration Renewals have expired.

Board Assurance: 1 on Maternity Leave (ACS) 1 has left employment on expiry (ACS) 11 have lapsed. Appropriate measures have been taken to

protect the business and its patients and the cases passed to ER for Investigation (AMH)

2 on long term Sick Leave (1 ACS, 1 AMH) 2 no longer a practicing Nurse (1 SS, 1 Corp) 1 on Annual Leave (SS)

Business Area

Total Professional

Membership Renewals

Required

Total Number of

Expired Entries on ESR% Compliant

Trust 299 18 94%

ACS 59 3 95%

AMH 76 10 87%

C&F 121 0 100%

SS 23 3 87%

Corp 20 2 90%

Quarter 1 – Compliance Hot Spot Update

Business

Area

Professional

Membership

Renewals Expired

Q2 Update

C&F 98% 100%

SS 95% 100%

ACS 99% 100%

AMH 91% 100%

SAFER EMPLOYMENT



Hot Spot Analysis:

Right to Work: 14 New Bank Starters are reported as non compliant with Right to Work safer employment checks

Board Assurance: Investigated non compliance and: Right to work checks have been undertaken but recording procedures

have not been followed. Recovery plan in action for ESR to be updated with all checks and checks being reviewed for quality to ensure LCFT is fully protected.

A 3 phase training programme is planned for all HR Directorate employees involved in identity checking. Training will commence in November 2015.

New Bank Workers - Safer Employment Compliance – Quarter 2

DBS Checks: 10 New Bank Starters in Bank Roles that required DBS checks are reported as non compliant.

Board Assurance: Investigated non compliance and: 6 - substantive leavers who joined the Bank. The Substantive ESR

Record confirms a valid DBS check is in place and remedial action to update the Bank ESR record is underway.

1 - DBS check is complete and we are awaiting presentation of the DBS certificate.

3 - DBS checks have been completed and a copy of the certificate received. ESR is being updated.

Total New

Bank Workers

Total Right to

Work Entries% Compliant

Total New

Starters

Requiring DBS

Total No DBS

Entries% Compliant

130 116 89% 118 108 91%

Board Reporting Improvements: Bank Workers are the preferred peripheral workforce source for the organisation where the business needs additional staffing support to ensure delivery of safe and effective services. The provision of an internal work Bank provides a source of cost effective additional cover from a pool of workers who are engaged, supported and trained to the standards set by the organisation. The Board report is being enhanced to provide Board assurance against the compliance of this population with the Safer Employment Standards. Quarter 3 reporting will provide further assurance for this population, reporting Active Bank Worker compliance with Safer Employment standards:

1. Mandatory Training Compliance for Active Bank Workers 2. Safer Employment Assurance for Active Bank workers

BOARD OF DIRECTORS


Report Title Board Assurance Framework


Prepared by Carrie Tomlinson, Compliance and Assurance Manager

Presented by Julie-Ann Bowden, Associate Director: Compliance and Business Assurance




Report purpose To provide assurance in relation to the Q2 review of the BAF risks in preparation for presenting to Board of Directors on 27 October 2015.



Board Assurance Framework risk This report contains an update relating to all 2015/16 BAF risks.

CQC domain Well-led

PAPER DEVELOPMENT PROCESS:

Meeting Presented Action Date

All sub-committees within the governance framework over the course of Q2 have reviewed BAF risks and 15 and above risks

NA NA NA

Governance and Compliance Sub-Committee

Julie-Ann Bowden

For noting 19.10.15

1.0 INTRODUCTION 1.1 The Board Assurance Framework (BAF) has been reviewed for Quarter 2 in detail with each

Director Lead for 2015/16 supported by the review of BAF risks and 15 and above risks across the sub-committee governance environment.

In these discussions the following was considered:

The need to review the strategic objectives against the key risk areas to reflect theoutputs from the strategic planning process.

The need to consider the re-scoring of the BAF risks taking account of an assessment ofthe assurances and controls and any gaps identified during Q2. This takes particularaccount of assurances delivered through the governance meetings.

The interdependency of risks scoring 15 and above with the BAF risks and the impact ofthis in terms of risk profile which has been supported by the Q2 ongoing risk profilingexercise.

Work to strengthen the analysis of mitigating actions required to close the gap betweenthe current risk score and the target risk score.

Ensuring that systems and controls are in place that are adequate to mitigate anysignificant strategic risks which threaten the achievement of the strategic objectives.

1.2 The report provides an opportunity for the Trust Board to review the position for 2015/16 BAF risk register at the end of the Q2 position.

2.0 BAF HEAT MAPS 2015/16 2.1 This is the third iteration of the BAF Heat Maps for 2015/16 which can be viewed in

Appendix 1. These demonstrate our position as at 1st April 2015, Quarter 1 2015/16 and Quarter 2 2015/16. In addition, the heat maps also provide the Risk Target for all risks at the end of Q4, demonstrating the trajectory of the overall BAF risk profile and where we are aiming to be by the end of 2015/16.

4.0 BOARD ASSURANCE FRAMEWORK END OF QUARTER 2 4.1 The risk profiling activity is now an ongoing piece of work that is currently undertaken by the

Governance and Compliance Team. This process is still currently led corporately as the Datix risk module access is still limited across Directorates and Networks which prevents consistent sharing of risks. A solution to this is being taken forwards currently by the Associate Director of Patient Safety and Quality Governance.

4.2 The risk profiling process and the review of the BAF risks for the end of Q2 has been undertaken to ensure that an assured view is taken in assessing the current level of risk. Appendix 2 provides an overarching update for each BAF risk. In terms of the movement of risks during Q2, two BAF risks have increased score during Q2:

4.3 The BAF 2015/16 Risk Register final position for Q2 can be reviewed in Appendix 3. The interdependent 15 and above risks can be reviewed against each BAF risk with the caveat that these risks are dynamic in nature and those included in this report represent a snap shot position shot at a point in time (9 October 2015).

5.0 RECOMMENDATION 5.1 The Board are requested to:

a) Approve the BAF 2015/16 Risk Register at Q2.

Julie-Ann Bowden Associate Director: Compliance and Business Assurance

Appendix 1 – BAF Heat Maps 2015/16 (Q2 position)

Risk Score as at 1 April 2015 Risk Score as at end of Q1

Risk Score at end of Q2 (as at 7 October 2015) Q4 Risk Target (31 March 2016)

Insignificant

Almost Certain

Likely

Possible

Unlikely

Rare

ZONE B

ZONE C

RISK APPETITE REFERENCE

ZONE A

Minor Moderate Major Catastrophic

7.1

5.2

6.1

7.2

2.1 4.1

1.2

1.14.2

2.2

5.1

3.1

Likelihoo

d

Consequence

5

4

3

2

1

1 2 3 4 5

3.2

6.2

7.3

Catastrophic

Unlikely

Rare

Insignificant Minor Moderate Major

Almost Certain

Likely

RISK APPETITE REFERENCE

ZONE A

Possible

ZONE B

ZONE C

7.1

5.2

6.1

7.2

2.1

4.11.2

1.14.2

2.2

5.13.1

Likelihoo

d

Consequence

5

4

3

2

1

1 2 3 4 5

3.2

6.2

7.3

Insignificant

Almost Certain

Likely

Possible

Unlikely

Rare

RISK APPETITE REFERENC

ZONE A

ZONE B

ZONE C

Minor Moderate Major Catastrophic

3.2

7.37.1

5.2

6.1

7.2

2.1

4.1

1.2

6.2

1.1

4.2

2.2

5.1

3.1

Likelihoo

d

Consequence

5

4

3

2

1

1 2 3 4 5

Risk Appetite Statement

Zone A Unacceptable Risk

Zone B Balance Risk with Reward

Zone C Risk Positive

APPENDIX 2

BAF Risk Ref

Description Quarter 1 Scoring

Risk Direction

Quarter 2 Scoring

1.1 (5982)

The Trust does not protect service users from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services.

Risk Update Lead DoN 4(L)x4(C)=16 4(L)x4(C)=16

1.2 (5983)

The Trust does not deliver safer, appropriate and therapeutic environments to deliver high quality services

DoN 3(L)x4(C)=12 4(L)x4(C)=16

2.1 (5984)

The Trust does not receive assurance of the accuracy, timelines and consistency of data and reporting with the potential to compromise decision making and service quality.

COO Networks are now fully accountable for their Operational Performance delivery and associated reporting, which will enhance the operational grip of information. There still remain gaps in assurances relating to the systems resilience being in place.

3(L)x4(C)=12 3(L)x4(C)=12

The Quality and Safety Sub-committee is monitoring the associated interdependent risks closely.

There remains an action plan in place to manage this and assurance is provided to the Quality and Safety Sub-committee. In addition, there remains a gap in assurance relating to the quality of incident and complaint investigations and assurance around lessons learned and quality improvements in relation to incidents, risks and complaints. There is work underway to review the current model of quality surveillance which features as both a gap in assurance and in control.

BAF Risk Ref

Description Risk Lead

Update Quarter 1 Scoring

Risk Direction

Quarter 2 Scoring

2.2 (5985)

The Trust’s ability to address and meet service demands is affected by uncertainty and inconsistency of commissioning arrangements

CFO A new risk has been reported during Q2in relation to sustainability of lead commissioners position. Contract agreements are in place in most areas.

2(L)x5(C)=10 2(L)x5(C)=10

3.1 (5986)

The Trust fails to deliver the benefits of being a Health and Wellbeing provider.

MD During Q2 a piece of work has been undertaken to triangulate Physical Health Care risks for in-patients across the organisation which is being led by Medical Director. This is supporting the review of the risk profile in this area which in turn will support the management of this risk and the delivery of assurances through to Quality and Safety Sub-committee.

4(L)x4(C)=16 4(L)x4(C)=16

3.2 (5987)

The Trust does not build its communication andreputation with all stakeholders

COO The implications of the impact on the Trust’s reputation has been considered in relation to media interest in a number of inquests scheduled between Oct 15 and Jan 16 as well as the CQC Inspection Reports. As a result, this risk has increased during Q2.

3(L)x4(C)=12 4(L)x4(C)=16

4.1 (5988)

The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs.

HRD This risk is being managed through a number of high priority scheduled reviews and early interventions plans. The assurance to provide evidence that the Fit and Proper Persons Test is embedded in HR systems and processes is due to be reported to People Sub-committee in December 2015.

3(L)x5(C)=15 3(L)x5(C)=15

4.2 (5991)

The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care.

DoN Work is underway to develop strategies and programmes that deliver effective education, training and leadership opportunities. The Quality Academy has been launched and the organisational development function has now been transferred to the Nursing and Quality Directorate.

4(L)x3(C)=12 4(L)x3(C)=12

BAF Risk Ref

Description Risk Lead

Update Quarter 1 Scoring

Risk Direction

Quarter 2 Scoring

5.1 (5992)

The Trust does not achieve financial performance sufficient to maintain resilience and sustainability.

CFO The increase of this risk during Q2 is as a result of the escalating situation in relation to OATs and the change in the Monitor Risk rating.

4(L)x(5)=20 5(L)x(5)=25

5.2 (5993)

The Trust does not achieve the required efficiency savings whilst delivering and improving quality.

COO Performance against monitored and approved CIP schemes has experienced a marginal amount of slippage however this is expected to be more than compensated by additional and non-recurrent schemes in the process of being transacted.

4(L)x4(C)=16 4(L)x4(C)=16

6.1 (5994)

The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence.

CFO Work is currently being undertaken around the quality of bids and the impact this can have on not winning business. Action Plans are in place looking at the internal capacity to manage pressures of the bidding process on support functions and the mobilisation of services when bids are won.

4(L)x4(C)=16 4(L)x4(C)=16

6.2 (5995)

The Trust does not implement an IT enabled transformational programme that ensures transition to a clinical system which is used across all services and supports the Trust in the realisation of its strategic objectives.

CFO Work is being undertaken to underpin the Trust’s Strategic Objectives to ensure cohesive communication between teams, services and stakeholders to deliver assured information with which the Trust can confidently make decisions.

4(L)x4(C)=16 4(L)x4(C)=16

7.1 (5996)

The Trust does not comply with the Monitor Licence.

DoGC This risk remains the same as work is still ongoing around the assurance system. Work has undertaken around the Business planning Framework which was completed with Executives and Corporate leads within Q2.

2(L)x5(C)=10 2(L)x5(C)=10

BAF

Risk Ref Description Risk

Lead Update Quarter 1

Scoring Risk

Direction Quarter 2 Scoring

7.2 (5997)

The Trust does not comply with statutory legislative requirements.

DoGC Corporate Governance and Compliance Technical updates are now being provided to Corporate Governance and Compliance Sub-committee on a monthly basis.

4(L)x4(C)=16 4(L)x4(C)=16

7.3 (5998)

The Trust does not comply with Mental Health Legislation.

DoN The level of maturity with some of the Network Mental Health Forums, in particular Adult Mental Health, is not developed which means the Sub-Committee cannot take assurance that mental health law is being consistently applied – the Board Assurance Framework (BAF) score has been increased to reflect this and the Executive Director of Nursing and Quality has written to networks in relation to this. The Mental Health Legislation Sub-committee is monitoring this position and has recommended that the BAF risk is increased until assurance is evidenced.

3(L)x4(C)=12 4(L)x4(C)=16

Key: = Risk level escalated

= Risk level unchanged

= Risk level de-escalated

= Risk achieved target

Board Assurance Framework

Q2 - 2015/16

Executive Risk Lead: Risk Appetite Reference

CCO: Chief Operating Officer CFO: Chief Finance Officer HRD: HR Director

CoGC: Director of Governance and Compliance DoN: Director of Nursing MD: Medical Director ZONE A

ZONE B

ZONE C

Strategy Priority BAF Risk Sub-committee

Exe

c R

isk

lad

Risk Score 01.04.15

Risk Score End of Q1

Risk Score End of Q2

Risk Appetite Position at Q2

Risk Target Risk Target Gap

O1 Quality 1.1 The Trust does not protect service users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services.

Quality & Safety DoN 16

Extreme 16

Extreme 16

Extreme Zone A 8

Significant 8

Close Monitoring

1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services. Quality & Safety DoN

16 Extreme

12 Significant

16 Extreme

Zone A 4 Moderate

12 Serious

O2 Outcomes 2.1 The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality

Operational Delivery & Performance COO

12 Significant

12 Significant

12 Significant

Zone B 8 Significant

4 Tolerable

2.2 The Trust's ability to address and meet service demands is affected by uncertainty and inconsistency of commissioning arrangements.

Business Planning & Transformation CFO

15 Extreme

10 Significant

10 Significant

Zone B 5 Moderate

5 Tolerable

O3 Excellence 3.1 The Trust fails to deliver the benefits of being a Health and Wellbeing provider

Quality & Safety MD 12

Significant 16

Extreme 16

Extreme Zone A 8

Significant 8

Close M it i

3.2 The Trust does not build its communication and reputation with all stakeholders


12 Significant

12 Significant

16 Extreme

Zone B 8 Significant

8 Close

MonitoringO4 People

4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs.

People HRD 15

Extreme 15

Extreme 15

Extreme Zone A 10

Significant 5

Tolerable

4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care

People DoN 12

Significant 12

Significant 12

Significant Zone B 9

Significant 3

Tolerable

O5 Money 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability Finance CFO

25 Extreme

20 Extreme

25 Extreme

Zone A 10 Significant

15 Serious

5.2 The Trust does not achieve the required efficiency savings whilst delivering and improving quality


16 Extreme

16 Extreme

16 Extreme


8 Close

Monitoring

O6 Innovation 6.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence

Business Planning & Transformation

CFO 16

Extreme 16

Extreme 16

Extreme Zone A 8

Significant 8

Close Monitoring

6.2 The Trust does not implement a transformational IT programme that ensures transition to a new intuitive clinical system across all services Health Informatics CFO

16 Extreme

16 Extreme

16 Extreme


4 Tolerable

O7 Compliance 7.1 The Trust does not comply with Monitor Licence. Governance & Compliance DoGC

10 Significant

10 Significant

10 Significant

Zone B 5 Moderate

5 Tolerable

7.2 The Trust does not comply with statutory legislative requirements Governance & Compliance DoGC

16 Extreme

16 Extreme

16 Extreme

Zone A 4 Moderate

12 Serious

7.3 The Trust does not comply with Mental Health Legislation MH Legislation DoN 12

Significant 12

Significant 16

Extreme Zone A 4

Moderate 12

Serious

BOARD ASSURANCE FRAMEWORK 2015/16

1.1 The Trust does not protect service users from avoidable harm and fails to comply with the CQC's standards for the quality and safety of services.

DIRECTOR LEAD: Director of Nursing DATIX NO: 5982

STRATEGIC PRIORITY: SO1 Quality ASSURANCE COMMITTEE TO REVIEW: Quality & Safety

GRAPH RATIONALE FOR RISK TARGET: The Trust Board does not tolerate failure in basic standards of compliance which could compromise care quality, statutory requirements and licence conditions.

RISK RATING:

Original Score01.04.15

Score at end of Q1

Current Scoreend of Q2

Target Score

16 16 16 8 4x4 4x4 4x4 2x4

RATIONALE FOR CURRENT RISK SCORE The Trust has in place established policies, procedures and systems for the reporting, investigation and management of risks and incidents that could impact on patient safety. A number of patient safety initiatives are underway such as the Harm Free Care Programme, Sign up to Safety Campaign and the Reducing Restrictive Practices Programme. However, additional work has been commissioned to improve the quality of complaint and incident investigations and the development of systematic learning and quality improvement. The Trust is experiencing high levels of acuity and throughput that requires service redesign.

CONTROLS 1. Risk Strategy, Safeguarding Strategy, Risk Policy, Incident Policy, Being Open Policy and

Complaints Policy 2. Use and development of the Datix integrated risk management system3. Governance processes and oversight groups4. Engagement with commissioners5. Development of a centralised investigation function6. Patient safety initiatives - Harm Free Care, Reducing Restrictive Practices, Physical Health

in Mental Health, etc7. Systems to support and demonstrate compliance with CQC and monitor quality

governance requirements - Quality SEEL8. Effective management of new CQC registration processes9. Safer Staffing project and reporting

ASSURANCES 1. Six-monthly Serious Incident Report and quarterly Complaints Reports2. Network governance oversight of incidents, risks and complaints3. Serious Incident Advisory Group oversight4. Complaints Review Panel oversight5. Serious Incident Oversight Panel review of completed SI reports6. Safeguarding Committee oversight7. Quality Assurance and Quality Governance initiatives8. Quality Assurance Visits - LCFT and Commissioner9. Quality SEEL and Datix systems10. Team level Integrated Quality Reports/Team Information Boards11. Quality Tile and Quality Surveillance Reports12. Clinical Audit Programme and Internal Audit Programme

GAPS IN CONTROLS1. Lack of integration between Quality SEEL and Datix systems2. Lack of a robust quality surveillance system

GAPS IN ASSURANCES 1. There is a lack of quality in relation to many incident and complaint investigations, and

concerns around data quality and reliability 2. The Trust cannot centrally provide assurance that lessons have been learned and

associated quality improvements made from incidents, risks and complaints 3. The current model of quality surveillance is reactive with a range of quality data

collected, reviewed and analysed across a range of systems resulting in theming or correlation being a manual task

05

10152025

April June Sept Dec Mar

RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services.


STRATEGIC PRIORITY: S01 Quality ASSURANCE COMMITTEE TO REVIEW: Quality & Safety

GRAPH RATIONALE FOR RISK TARGET: The Trust Board does not tolerate failure in basic standards of compliance which could compromise care quality, statutory requirements and licence conditions.

RISK RATING: Original Score

01.04.15 Score at

end of Q1 Current Score

End of Q2 Target Score

16 12 16 4 4x4 3x4 4x4 1x4

RATIONALE FOR CURRENT RISK SCORE The Trust has in place a number of regular safety activities, and a number of environmental improvement initiatives such as ligature reduction capital works. Some of the ligature reduction work is behind the originally planned schedule. New facilities such as the Orchard and the Harbour provide a significantly improved care environment. There has been a noticeable decreased in the admission of young people to adult wards. The risk profile that supports this BAF risk is significant in relation to environmental safety risks.

CONTROLS 1. Quarterly reporting to EMT in relation to Ligature Improvement Plan2. Estates linking into Network meetings in relation to ligatures3. Annual testing of anti-ligature environment through Hard FM contract4. Ligature Improvement Plan reviewed at Minor Capital Group5. Mintor Capital report to Property Services Governance Forum in relation ligatures6. Annual Health and Safety Audit of all Inpatient Wards7. Annual Ligature Audit of all Inpatient Wards8. PLACE Assessments of all Inpatient Wards9. Annual IPC Audits of all clinical areas not covered by PLACE Assessments10. Clinical policies and procedures11. Safer staffing project

ASSURANCES 1. Estates Sub-Committee oversight2. Quality and Safety Sub-committee oversight

GAPS IN CONTROLS 1. Lack of an electronic audit tool with action planning capabilities

GAPS IN ASSURANCES 1. Assurances around correct staffing levels

05

10152025


RiskScore

RiskTarget


2.1 The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality.

DIRECTOR LEAD: Chief Operating Officer DATIX NO: 5984

STRATEGIC PRIORITY: S02 Outcomes ASSURANCE COMMITTEE TO REVIEW: Operational Delivery & Performance

GRAPH RATIONALE FOR RISK TARGET: The first phase of data improvement work addressed operational performance to enable regulatory compliance reporting. It is crucial that we are able to align workforce data with quality and financial metrics therefore the risk is assessed as above.

RISK RATING: Original Score01.04.15

Score at end of Q1

Current ScoreEnd of Q2

Target Score

12 12 12 8 3x4 3x4 3x4 2x4

RATIONALE FOR CURRENT RISK SCORE The top 50 indicators now being reported on a quarterly basis to Operational Delivery and Performance Sub-Committee and there has been a heavy emphasis on the improving quality of performance data.

CONTROLS 1. Operational Delivery Group established to performance manage emerging

performance breaches with agreed trajectories and recovery actions e.g. IAPT recovery.

2. The reconfiguration of the BI and performance team in light of the PerformanceImprovement Plan will address this issue.

3. The consolidated data warehouse is now a key feature of the PerformanceImprovement Plan.

4. The revised performance structure will be presented to EMT in December 2014.

ASSURANCES 1. Top 50 indicators are being monitored by the Managed Service.2. Managed Service is now in place and providing core monthly reports to Exec, Board and

Commissioners.3. Strategic Performance Management function will commence the audit programme for

key measures to ensure compliance with the SOPS as of Q2.4. Managed Service is working with the Trusts Head of Performance to develop an

interactive App to support access and transparency of information.5. Networks now own their Operational Performance delivery within the Networks, thus

providing enhanced Operational grip of information.

GAPS IN CONTROLS 1. Improving data quality via the Performance Improvement Plan (i.e., reduction of

unallocated patients)

GAPS IN ASSURANCES 1. Undertake Network and Corporate reviews to ensure that full accountability and

system resilience is in place to minimise the likelihood of reoccurrence. 2. Ensure that there is Trust Board scrutiny of performance with focus on corrective

actions plans and agreed improvement trajectories where there are regulatory compliance failures.

3. Fully articulate the system requirements to deliver operational performance are in situand clearly articulate the external factors that are not within our control but that may impact on future reporting.

05

10152025


RiskScoreRiskTarget


2.2 The Trust's ability to address and meet service demands is affected by uncertainty and inconsistency of commissioning arrangements.

DIRECTOR LEAD: Chief Finance Officer DATIX NO: 5985

STRATEGIC PRIORITY: S02 Outcomes ASSURANCE COMMITTEE TO REVIEW: Business & Planning Transformation

GRAPH RATIONALE FOR RISK TARGET: The Trust Board wants the Trust to grow in-line with its strategic plans but failure to recognise the changing commissioning landscape and influence it, coupled with the Trusts inability to reposition itself in the market and adopt a market focused culture will lead to loss of income, market position and impact on the Trusts reputation.

RISK RATING: Original Score01.04.15

Score at end of Q1


Target Score

15 10 10 5 3x5 2x5 2x5 1x5

RATIONALE FOR CURRENT RISK SCORE As we now have contract agreements in place in most areas it has been deemed that the impact of not signing contracts in the remaining areas is greatly reduced and therefore the risk score has been decreased accordingly to more accurately reflect the current situation.

CONTROLS 1. Key contracts signed, therefore, commissioning intentions finalised.2. Operational Plan 2015/16 completed, informed by market analysis, which include commissioning intentions3. Business Development Pipeline4. Business Development Framework including Bib/No Bid Criteria, Opportunity Decision Point, Review and

Submission process5. Business Development meeting held fortnightly (to strengthen review process) between CFO and COO to

support commercial review of opportunities identified in pipeline, to aid early discussion of approach,partnership arrangements, and potential barriers

6. Monthly meeting between Heads of Corporate teams to review and co-ordinate tender activity7. Annual Planning Framework for 2015/16 and 2016/17 now in place8. Strategy & Transformation Business plan9. Marketing Strategy10. Standard Operating Procedures

ASSURANCES 1. Business Planning & Transformation Sub Committee2. Finance & Business Performance Committee3. Business Planning Quarterly Review process4. TAS provide weekly Business Development update to EMT5. TAS update Balanced Scorecard with wins/losses for each quarter

GAPS IN CONTROLS 1. Alignment of plans across local health economy and 598Lancashire need further development.2. Market analysis for 16/17 not yet undertaken3. Priority list for each Network, identifying which service lines can grow (list to be developed by Business

Development Forum)4. Management of in-patient beds (TAF and OATs)

GAPS IN ASSURANCES NONE

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BOARD ASSURANCE FRAMEWORK 2015/16 3.1 The Trust fails to deliver the benefits of being a Health and Wellbeing provider. DIRECTOR LEAD: Medical Director DATIX NO: 5986

STRATEGIC PRIORITY: S03 Excellence ASSURANCE COMMITTEE TO REVIEW: Quality & Safety

GRAPH RATIONALE FOR RISK TARGET: The Trust Board accepts a degree of risk when pursuing a programme which will lead to multiple benefits.


01.04.15 Score at end

of Q1 Current Score


12 16 16 8 3x4 4x4 4x4 2x4

RATIONALE FOR CURRENT RISK SCORE People with mental health problems have increased morbidity and mortality and as a wellbeing Trust we are committed to doing everything we can to recue this. We would be more likely to lose business as we would not be able to show that it is beneficial to have mental and physical health services in the same Trust.

CONTROLS 1. Public Health Strategy defined with component implementation plan2. Medical Director operational plan for 2015-163. Parity of Esteem Group meets six weekly to share best practice and improve communication4. Invitation for the Trust to be a partner in the Well North proposition being developed for West

Lancs CCG for Skelmersdale5. Physical Health Care Lead (Mental Health) in post6. Sustainability ratings for implementation of Smokefree

ASSURANCES 1. Implementation of strategy monitored at Quality Committee2. Tracking of achievement of objectives and analysis of evidence. Quarterly reporting

to EMT3. MECC programme board4. NMP Clinical Leadership Group5. Physical healthcare groups to amalgamate to form a new committee chaired by the

Medical Director. MECC will also report into this.

GAPS IN CONTROLS 1. Areas of non-compliance impacting on achievement of operational plan (e.g. Smokefree)2. No clear pathways of care for in-patients with chronic conditions to ensure appropriate

management alongside mental health treatment. Similarly, no clear pathways for ensuringprovision of mental health support if patient is transferred to an acute hospital.

3. Staff training required to ensure competencies to manage physical health needs.4. Local authority public health funding cuts may impact on the way in which public health services

are commissioned from the Trust (e.g., health visiting, sexual health)5. No overview of what physical healthcare issues there are across the Networks (especially

inpatient units)6. Lack of physical health monitoring for patients on mental health drugs7. Inappropriate management of medicines (e.g., warfarin, injected insulin) if admitted for acute

mental health episode

GAPS IN ASSURANCES 1. Further monitoring of inpatient units required to determine NMP implementation

status. 2. Leadership of project for physical health care at the Harbour requires clarification.3. Failure to recognise importance of physical healthcare needs.

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BOARD ASSURANCE FRAMEWORK 2015/16 3.2 The Trust does not build its communication and reputation with all stakeholders. DIRECTOR LEAD: Chief Operating Officer DATIX NO: 5987

STRATEGIC PRIORITY: S02 Excellence ASSURANCE COMMITTEE TO REVIEW: Organisational Delivery & Performance

GRAPH RATIONALE FOR RISK TARGET: The Board will seek to ensure that the Trust strengthens relationships with key stakeholders through effective communication and engagement.



of Q1 Current Score


12 12 16 8 3x4 3x4 4x4 2x4

RATIONALE FOR CURRENT RISK SCORE This risk is being managed as a number of controls have been added to the risk. Work is taking place around connecting with Commissioners, CCG, Third Sector organisations and GPS etc to assist in building the Trusts reputation. The impact of a number of inquests in terms of media interest between Oct 15 and Jan 16 has been considered alongside the potential reputational impact as a result of the CQC Inspection reports being released into the public domain at the beginning of November 15.

CONTROLS 1. Monthly contract and performance meetings2. Transition oversight group to oversee inpatient transition programme3. Chorley Public Service Reform Board4. Mental Crisis Concordat Working Group5. Pennine Lancs Transformation Programme6. Central Lancs Clinical Senate7. Vanguard Programmes across Blackpool Fylde and Wyre8. North Lancs Better Care Together9. Developing engagement with the Third Sector.10. Communicating and engaging with GP Practices, Healthwatch, CCGs and MPs11. Overarching Comms and Engagement Framework

ASSURANCES 1. Development of shared services with Chorley Council2. Part of the two Vanguard programmes that are listed in Controls.3. Won a number of tenders:

Childhood Flu Immunisation & Vaccination Framework Wave 2 Criminal Justice Liaison and Diversion Services Type 2 Diabetes Structured Education Services Midlands and East of England Prison in-patient review Offender Health-Merseyside (HMP Liverpool and HMP Kennet) Mental Health of Military Veterans

GAPS IN CONTROLS 1. Commissioners approach the middle management tier at locality level rather than using the

construction of the contract (physical health, GP&SR; mental health, BwD). 2. No clear contracting process for Sub-Contracting arrangements with providers

GAPS IN ASSURANCES1. Process for service development by passes the main contractual route and is

developed at locality level which can potentially impact on consistency of service model development .

2. No communication with GPs at locality level. GPs aren’t federated so they are allindividual practices within 7 CCGs.

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BOARD ASSURANCE FRAMEWORK 2015/16 4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs.

DIRECTOR LEAD: Human Resources Director DATIX NO: 5988

STRATEGIC PRIORITY: S04 People ASSURANCE COMMITTEE TO REVIEW: People

GRAPH RATIONALE FOR RISK TARGET: The Trust Board wants appropriate staffing targets to be achieved and staff to be developed to the highest of standards of what would be expected of a top preforming Trust.



of Q1 Current Score


15 15 15 10 3x5 3x5 3x5 2x5

RATIONALE FOR CURRENT RISK SCORE The Directorate has completed a number of high priority scheduled reviews and early intervention plans have either been completed or are in progress therefore the Directorate has made a decision to leave the current risk score at 15 until further progress has been made.

CONTROLS 1. KPIs – Operational HR and Financial Targets2. HR SMT3. HR policies and procedures4. HR functional SOPs5. Performance management policy and procedure6. HR Transformation Programme (PMO)7. HR Interim engaged to cover functional governance and MI data quality8. Data governance standard operating procedures9. Functional governance framework.10. Employment Law11. Data Protection Act12. PSL for Temporary Staffing

ASSURANCES1. HR Delivery and Governance Group2. Safer Staffing Executive Committee3. PMO Board4. People Sub-Committee5. Employee Staff Survey6. Compliance with Data Protection Act7. Compliance with Employment Law8. ESR Data Quality Working Group

GAPS IN CONTROLS1. HR KPI framework agreed but not yet implemented2. HR governance framework phase 1 implemented, phase 2 in development3. HR systems and data governance procedures require update4. Having a fit for purpose PDR recording system for use in LCFT5. Recruitment team procedural compliance gaps6. Temporary Staffing procedural compliance gaps within HR and the wider business7. Lack of cross functional establishment control procedure

GAPS IN ASSURANCES1. No SOP in place for Establishment Control2. No functional Internal Audit procedures3. No regular reconciliation between Finance Ledger and ESR4. There is a limited use of internal service performance KPIs to ensure

compliance with HR policy and procedure5. Evidence that Fit and Proper Persons Test is embedded in HR systems and processes.

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4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care.


STRATEGIC PRIORITY: S02 People ASSURANCE COMMITTEE TO REVIEW: People

GRAPH

RATIONALE FOR RISK TARGET: The Trust Board does not tolerate failure in basic standards of compliance which could compromise care quality, statutory requirements and licence conditions



of Q1 Current Score


12 12 12 9 4x3 4x3 4x3 3x3

RATIONALE FOR CURRENT RISK SCORE Work is underway to develop strategies and programmes that deliver effective education, training and leadership opportunities resulting in a workforce who deliver consistently high quality, safe care. The Quality Academy has been launched and the OD function has been transferred to the Nursing and Quality Directorate.

CONTROLS 1. Training policies and procedures 2. Appraisal and performance processes 3. Mandatory training requirements 4. Revised clinical risk tool and training 5. Individual professional development requirements

ASSURANCES1. People Sub-committee 2. Quality and Safety Sub-committee

GAPS IN CONTROLS 1. Lack of a clearly defined Organisational Development Strategy

GAPS IN ASSURANCES 1. Access to training and performance development data

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5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability.


STRATEGIC PRIORITY: S05 Money ASSURANCE COMMITTEE TO REVIEW: Finance

GRAPH

RATIONALE FOR RISK TARGET: The Trust must be sustainable and resilient to remain viable, but given the inherent uncertainties in the environment it is unlikely to eliminate all risks to the Trusts long term position.


01.04.15 Score at end of

Q1 Current Score


25 20 25 10 5x5 4x5 4x5 2x5

RATIONALE FOR CURRENT RISK SCORE The risk has been escalated during Q2 due to concern with regards to OATs position and the now changed to Monitor Risk rating.

CONTROLS 1. Executive Accountability 2. Regulatory Monitoring 3. Planning and Budgetary Control (inc CIPs) 4. Policy procedure and process controls 5. All Healthcare contracts agreed and signed 6. Monitor quarterly assurance reporting 7. Monitor monthly statistical reporting 8. CIPs signed and agreed with Networks 9. Risk sharing agreement in place for OATs, specifying an equal share beyond the identified Trust

resource for this area 10. Establishment of a joint Task and Finish group to oversee and manage OATs position, delivery

trajectory and minimise any risks 11. Commissioner led group established to oversee a review of the inpatient rationalization

programme 12. Monthly reporting to Monitor in respect of Agency costs 13. Programme Management Group monitoring of DTS programme

ASSURANCES1. Monthly Board Reports 2. Quarterly Monitoring Returns 3. Management Accounts 4. Budgetary and CIP Reporting System 5. Audit and Review 6. OATs Reporting 7. DTS Reporting 8. Reporting at all levels of management for key issues

GAPS IN CONTROLS 1. Controls over unfunded expenditure 2. Fully developed 2016/17 CIP Plan

GAPS IN ASSURANCES 1. Uncertainly over future OATs position 2. Application and rationale of Monitor’s new financial risk ratings, and

subsequent impact. 3. Uncertainty in relation to Major Capital Projects – Pennine Lancs and Central

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5.2 The Trust does not achieve the required efficiency savings whilst delivering and improving quality. DIRECTOR LEAD: Chief Operating Officer DATIX NO: 5993

STRATEGIC PRIORITY: S05 Money ASSURANCE COMMITTEE TO REVIEW: Operational Delivery & Performance

GRAPH

RATIONALE FOR RISK TARGET: The Board will seek to ensure that the Trust strengthens relationships with key stakeholders through effective communication and engagement.



Q1 Current Score


16 16 16 8 4x4 4x4 4x4 2x4

RATIONALE FOR CURRENT RISK SCORE DTS is being delivered using the principles of Project Management within a robust governance structure that provides clarity of roles, responsibilities, accountabilities and escalation. This approach to delivering CIPs has not been undertaken previously within LCFT, but neither has the Trust been required to make such significant savings until now. Paper that went to EMT in June 15 outlines extensive controls in place.

CONTROLS 1. Executive Accountability. 2. Board/EMT. 3. Regular Monitoring. 4. Planning and Budgetary Control (inc CIPs). 5. Policy procedure and process controls. 6. Regular Network Accountant engagement with their Networks.

ASSURANCES 1. Quarterly reporting to the Business Planning and Transformation Sub-

Committee 2. Monthly reporting to the Operational Delivery and Performance Sub-Committee 3. PMO Office 4. Programme Management Group 2x monthly 5. Quarterly reporting to the Finance Sub-Committee 6. Devising the assurance Dashboard for Sub-Committees, Committees and Board 7. Programme specific highlight reports which are RAG rated and report into PAGS

and PMG 8. All DTS risks are aligned within DATIX and linked as appropriate 9. All DTS projects and programmes are linked to BAF risks

GAPS IN CONTROLS 1. Understanding of the impact on budgets with the delivery of CIPs YTD as reporting being developed

still in this area. i.e. CIPs are being extracted from budgets but are budgets overspent or balanced as a direct result of the CIP plan and actions

2. Reporting is being planned to accurately show the amount of recurrent vs non-recurrent savings delivering the CIP values for 2015/16. This will demonstrate what risk is attached to future year’s delivery.

3. DTS is being delivered using the principles of project Management within a robust governance structure.

GAPS IN ASSURANCES 1. Reporting is subject to the Chief Operating Officer reporting to Board.

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6.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence.


STRATEGIC PRIORITY: S06 Innovation ASSURANCE COMMITTEE TO REVIEW: Business Planning & Transformation

GRAPH

RATIONALE FOR RISK TARGET: The Trust Board while encouraging research and innovation will not sanction risky ventures that put the Trust reputation or finances in jeopardy.



Q1 Current Score


16 16 16 8 4x4 4x4 4x4 2x4

RATIONALE FOR CURRENT RISK SCORE Working being undertaken around the quality of bids and the impact this can have on not winning business. Looking at the internal capacity to manage pressures of the bidding process from other corporate services and the mobilization of other departments in the Trust when bids are won, in particular the Networks and Quality and Safety.

CONTROLS 1. Strategic alliance strategy approved by Board 2. Business Development Framework, including BID/No bid criteria, Opportunity Decision Point,

Review and Submission Process 3. Business Development Pipeline shared with EMT regularly to ensure strategic overview of current

and potential opportunities, ensuring strategic priorities are identified. 4. Business Development Forum meeting held fortnightly (to strengthen review process) between

CFO and COO to support commercial review of opportunities identified in pipeline, to aid early discussion of approach, partnership arrangements and barriers.

5. Monthly meeting - Head of Corporate teams to review and co-ordinate tender activity. 6. Developing partnerships with commercial organisations on product development, research and

grants applications in collaboration with HEIs or other third parties (e.g., Regenerate Pennine Lancashire, Lancashire Enterprise Partnership)

7. Working closely with the NWC AHSN to establish LCFT as a Trust that has embraced innovation and is actively setting the innovation agenda in its market

ASSURANCES 1. DTS dashboard 2. Board Balanced Scorecard indicators 3. Business Planning & Transformation Sub-Committee 4. CQUIN reporting to Commissioners 5. Intellectual Property registered by LCFT and third parties in collaboration with

LCFT 6. Monitoring cost savings and quality improvements from innovations 7. Annual Innovation Survey will determine the state of the Innovation Culture.

GAPS IN CONTROLS 1. Alignment of plans across local health economy and Lancashire need further development. 2. Market analysis for 16/17 not yet undertaken. 3. Strategic alliance tools and methodologies to developed and tested with Network and Corporate

functions. 4. Uncertainty of tender pipeline in respect of commissioning intentions

GAPS IN ASSURANCES None

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6.2 The Trust does not implement an IT enabled transformational programme that ensures transition to a clinical system which is used across all services and supports the Trust in the realization of its strategic objectives.


STRATEGIC PRIORITY: S06 Innovation ASSURANCE COMMITTEE TO REVIEW: Health Informatics

GRAPH

RATIONALE FOR RISK TARGET: Low risk appetite as this is strategically critical.

RISK RATING:


Score at end of Q1


Target Score

16 16 16 12 4x4 4x4 4x4 3x4

RATIONALE FOR CURRENT RISK SCORE There is an ongoing need to underpin and enable several of the Trusts Strategic Objectives, ensure cohesive communication between teams and services and to deliver assured information with which the Trust can confidently make decisions. The ePR will enable this to happen but these deliverables are at risk if the approach is not well managed, controlled and assured, and does not involve stakeholders at all levels to ensure that key outcomes are delivered and that the benefits of new technology are fully exploited. Current position is that Programme Manager has just been appointed and will be in position as soon as possible (potentially in this calendar year) Plan is to implement controls under the ePR Programme management group. This will bring about the development of the planning and implementation of the programme and the production of the associated assurances.

CONTROLS 1. Oversight of the programme by the HI Sub-Committee 2. Programme Management and Governance 3. Follow procurement good practice

ASSURANCES 1. Documentation resulting from management boards and other governance and control

mechanisms

GAPS IN CONTROLS 1. Project management approach and governance 2. Stakeholder management can communications strategy and plan 3. Business change strategy and implementation of approach 4. Data migration strategy and plan 5. Resource management strategy and plan 6. Integration approach (Partners, GP's, LA's, 3rd sector etc) 7. Configuration of forms, workflows, protocols 8. Testing of solutions

GAPS IN ASSURANCES 1. Documentation resulting from management boards and other governance and control

mechanisms 2. Project and Program plans with tranches and agreed (targeted) capability 3. Integration with partners embedded in PID and Programme Plan 4. Detailed map of stakeholders, Mapped with influence, interest and key messages 5. Evidence of communication of messages and effectiveness 6. Testing strategy and plan and current/future state maps and gap analysis 7. Documentation of test scripts and sign off by Networks / deployment teams 8. Design, build and test of forms / workflows ect in response to agreed future state and

benefits matrix 9. Regular (quarterly) statistics / reporting on benefits 10. Information Management - Inputs mapped against outputs / gap analysis and gaps

addressed - evidence of this 11. Reports tested and tests documented 12. Documentation of DM Strategy and plan and testing by Services/Networks

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7.1 The Trust does not comply with the Monitor Licence. DIRECTOR LEAD: Director of Governance & Compliance DATIX NO: 5996

STRATEGIC PRIORITY: S07 Compliance ASSURANCE COMMITTEE TO REVIEW: Governance & Compliance

GRAPH

RATIONALE FOR RISK TARGET: The Trust must be able to evidence compliance with all conditions of the Provider Licence. It is unlikely to eliminate all risks as the impact of any non-compliance will be high.



Q1 Current Score


10 10 10 5 2x5 2x5 2x5 1x5

RATIONALE FOR CURRENT RISK SCORE The compliance with key Monitor reportable targets is currently evidenced however, a range of licence conditions are not currently monitored for compliance and therefore we are unable to evidence the assurance in these areas at this stage.

CONTROLS 1. Executive Accountability - through agreed portfolios. 2. Review and implement the revised governance and assurance framework – transition through Q4

into 2015/16. 3. Access to Portal 4. Revised Business Planning Framework completed with Executives and Corporate leads

ASSURANCES 1. Quarterly Governance Return 2. Chief Executive Assurance Report 3. Board Balanced Scorecard & Executive Dashboard 4. Audit Committee 5. Finance Report has been refreshed and Finance Sub-committee is established 6. Corporate Governance and Compliance Sub-committee is established 7. Quality & Safety sub-committee is established 8. Internal Audit MIAA reported in Q1 – robust management process in place 9. Audit of Governance System and Flow information is embedded and Action Plan

completed 10. Completed Internal Audit of Provider Licence – Significant Assurance

GAPS IN CONTROLS 1. Processes to monitor compliance with policy. 2. Action Plan from Internal Audit – Provider Licence 3. Assurance Systems fully implemented across all network and departments (2016/17)

GAPS IN ASSURANCES 1. Full Board evaluation scoping to be undertaken in preparation for the

evaluation to take place in 2015/16. 2. Ensuring that reporting to the Board is robust – timely accurate and

supports effective decision making with risk driven agendas

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7.2 The Trust does not comply with statutory legislative requirements. DIRECTOR LEAD: Director of Governance & Compliance

DATIX NO: 5997

STRATEGIC PRIORITY: S07 Compliance ASSURANCE COMMITTEE TO REVIEW: Governance & Compliance

GRAPH

RATIONALE FOR RISK TARGET: There is an unsatisfactory assurance around statutory legislative requirements within LCFT which could result in our regulatory bodies, such as Monitor and CQC, taking action.

RISK RATING:

Original Score 01.04.15

Score at end of Q1

Current Score End of Q2

Target Score

16 16 16 4 4x4 4x4 4x4 1x4

RATIONALE FOR CURRENT RISK SCORE The Trust cannot provide evidence based assurance that meets all Statutory Legislative requirements across the organisation.

CONTROLS 1. Development of the Policy Framework and Standard Operating Procedures (SOPs) are now in place 2. Three year Health & Safety Improvement Plan now in place. 3. Corporate Governance and Compliance Technical Update in place.

ASSURANCES 1. Assurance Framework and Risk Management Internal Audit 2014/15 provided

significant assurance 2. Annual organisational audit return to NHS England. 3. Network governance oversight of health and safety incidents and risks. 4. Oversight by Executive Quality Committee and Health and Safety.

GAPS IN CONTROLS 1. No IG Governance Structure in place. 2. Assurance Systems fully implemented across all network and departments (2016/17)

GAPS IN ASSURANCES 1. There is a limited audit and inspection programme, and no self-assessment of

compliance - this means most health and safety performance measurement is reactive based on incident data.

2. Policies may not reflect the Statutory Legislative Requirements. 3. No systematic evidence to support compliance with policy. 4. No corporate assurance.

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7.3 The Trust does not comply with Mental Health Legislation. DIRECTOR LEAD: Director of Nursing DATIX NO: 5998

STRATEGIC PRIORITY: S07 Compliance ASSURANCE COMMITTEE TO REVIEW: MH Legislation

GRAPH

RATIONALE FOR RISK TARGET: The Trust Board does not tolerate failure in basic standards of compliance which could compromise care quality, statutory requirements and licence conditions.

RISK RATING:


Score at end of Q1

Current Scoreend of Q2

Target Score

12 12 16 4 3x4 3x4 4x4 1x4

RATIONALE FOR CURRENT RISK SCORE The Mental Health Law Team is now centralised within the Nursing and Quality Directorate, a new manager appointed and new Trust-wide governance arrangements have been implemented. A new Mental Health Act computerised system is being rolled out. The risk score reflects the position that whilst improvements are being made to the governance of Mental Health Law, the new arrangements are not fully embedded and errors continue to occur or historical errors are being identified through new systems and processes. Additionally, concern has been raised in August 2015 around the capability and performance of the Network Mental Health Law Forums.

CONTROLS 1. Mental Health Law Sub-committee oversight 2. eLearning training for Practitioners 3. Mental Health Law Administrators Group for standardisation and sharing learning 4. Multi Agency Mental Health Oversight Group for collaborative working across the health economy 5. Associate Managers Forum for engagement and sharing of learning 6. Mental Health Act policies and procedures 7. Local Authority Partnership Working 8. Improved Engagement with Clinical Commissioning Groups 9. Independent Mental Health Advocacy Services 10. Locality Police Mental Health Champions 11. Clear and consistent governance reporting systems across the Networks and within the Trust 12. Network Mental Health Law Forums 13. Clinical Audit Programme

ASSURANCES1. Quality Committee oversight 2. Mental Health Law Sub-committee scrutiny 3. Network Mental Health Law Forums scrutiny 4. Associate Managers Forum 5. Mental health law data reports i.e. KP90 6. Clinical audit

GAPS IN CONTROLS 1. Lack of a computerised system for administration of the Mental Health Act

GAPS IN ASSURANCES 1. Delay in deploying the electronic Mental Health Act Module of ECR 2. Variation in the capability and performance of Network Mental Health Law

Forums

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Board of Directors

Agenda Item TB 095/15 Date: 27/10/2015 Report Title Refresh of the Risk Appetite Statement


Prepared by Julie-Ann Bowden, Associate Director of Compliance and Assurance

Presented by Julie-Ann Bowden, Associate Director of Compliance and Assurance



PURPOSE OF THE REPORT: Report purpose To provide the Board of Directors with the refreshed Risk

Appetite statement following the Board Development Session on 5 October 2015 for approval.


To meet our statutory/compliance obligations

Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence.

CQC domain Well-led

1.0 Background 1.1 Every organisation has a different perception of the level of risk that it is comfortable.

Risk appetite goes to the heart of how an organisation does business and how it wishes to be perceived by key stakeholders including employees, regulators, commissioners and the public Factors such as the external environment, people, business systems and policies will all influence an organisation’s risk appetite and the Boards of organisations have a fiduciary duty to be clear about what is and what is not acceptable within this context.

1.2 An organisation’s risk appetite is defined as ‘the amount and type of risk that an organisation is prepared to seek, accept or tolerate’. Specifically in relation to NHS organisations the consideration is ‘What levels and types of risk do our stakeholders expect us to accept (and not accept) in pursuance of our goals?’. In real terms, the goals of the organisation are expressed through the strategic priorities.

1.3 The principles of governance require the Board to formulate a Risk Appetite Statement which will then articulate the Board’s attitude to risk taking and tolerances which in turn is critical for influencing and directing the strategy of the organisation. This can also be a method through which the Board communicates expectations for risk-taking to the wider organisation and improves oversight of risk by the Board.

2.0 Lancashire Care’s Risk Appetite Statement and Association with the Annual Planning Process

2.1 The Risk Appetite Statement approved by the Board of Directors in January 2014 was refreshed in April 2015, where a key focus was aligning part of the statement with the

strategic priorities (Appendix 1). A full review was not considered appropriate at this point.

2.2 The Annual Business Planning Framework has since been reviewed and reframed within the context of the new governance arrangements which were formally established on 1 April 2015. On this basis, it is now considered appropriate to review the Risk Appetite Statement which has a particular influence on the planning process.

2.3 A strong focus of this review has been to ensure alignment of risk management to the development of the Trust’s Operational Plan. This leads into the review of the Risk Appetite Statement having a key focus on the risk appetite being aligned primarily to the Trust’s strategic priorities.

3.0 Focus of the development session 3.1 The Board Development Session provided an opportunity to consider the risk appetite

against each of the strategic priorities and the associated Blueprint Statements.

3.2 In addition, the Board considered the current opening statement and agreed that this was still relevant but recognised the importance of testing the belief in this. Some wording has been added to provide more clarity in relation to the application of risk appetite within the organisation.

3.3 Key areas of risk were presented against each strategic priority and discussion took place to align a risk appetite statement against each area. The risk appetite categories can be viewed in Table 1.

AVERSE Prepared to accept only the very lowest levels of risk, with the preference being for ultra-safe delivery options, while recognising that these will have little or no potential for reward/return.

CAUTIOUS Willing to accept some low risks, while maintaining an overall preference for safe delivery options despite the probability of these having mostly restricted potential for reward/return.

MODERATE Tending always towards exposure to only modest levels of risk in order to achieve acceptable, but possibly unambitious outcomes.

OPEN Prepared to consider all delivery options and select those with the highest probability of productive outcomes, even when there are elevated levels of associated risks.

HUNGRY Eager to seek original/creative/pioneering delivery options and to accept the associated substantial risk levels in order to secure successful outcomes and meaningful reward/return.

Table 1

3.4 The risk appetite alignment exercise was completed by the end of the session in terms of the strategic priority risk areas. The Director of Governance and Compliance was requested to review the outcome and consider whether an overall risk appetite could be aligned to each priority. The outcome of this consideration is provided in Appendix 2.

4.0 Methodology 4.1 In order to reach an overall risk appetite for each strategic objectives, the approach

adopted has been to consider all risk appetites within the objective and take an average median position within the defined scale. The breakdown of how this has been considered for one of the strategic priorities can be reviewed in Table 3.

Strategic Priority: To provide high quality services

• Compliance with

Statutory Legislation

• Patient Safety• Service User andCarer Experience

• CQCCompliance

and Guidance

• TransformingClinical Services

Averse Cautious Moderate Open Hungry Prepared to accept only the very lowest levels of risk, with the preference being for ultra-safe delivery options, while recognising that these will have little or no potential for reward/return.

Willing to accept some low risks, while maintaining an overall preference for safe delivery options despite the probability of these having mostly restricted potential for reward/return.

Tending always towards exposure to only modest levels of risk in order to achieve acceptable, but possibly unambitious outcomes.

Prepared to consider all delivery options and select those with the highest probability of productive outcomes, even when there are elevated levels of associated risks.

Eager to seek original/creative/pioneering delivery options and to accept the associated substantial risk levels in order to secure successful outcomes and meaningful reward/return.

Table 3

4.2 On the basis that the Risk Appetite has been aligned against each of the six priorities, it is proposed that the Board of Directors should set an overarching single risk appetite for the Trust of ‘Open’. This is on the basis that 4 of the 3 objectives have Open aligned against them and the remaining two are Cautious and Moderate.

5.0 Next Steps 5.1 The Associate Director for Compliance and Assurance has already met with Network

Directors at a recent Senior Management Team to discuss with them how the risk appetite statement will be implemented and embedded within the Trust’s risk management and assurance processes. Initial feedback has been very positive with a recognition that the risk appetite alignment against the strategic objectives will have the following benefits:-

a) Improve the articulation of risk based decisions;b) Engage teams through discussions of the overall Board risk appetite and how this

impacts within Network business decisions and risk management;c) Support application of the risks appetite with the decision making relating to new

business opportunities.

5.2 Further guidance will be developed to support how the risk appetite is utilised within the risk management and assurance processes as well as the business planning process which is currently underway for 2016/17.

5.3 The Risk Appetite Statement does provide an element of structure to decision making within the context of the risk appetite aligned to strategic objectives and key risk areas. This does not negate the opportunity to potentially take risks outside the risk appetite.

Where this is considered to be the case, it is proposed that these decisions will be referred to the Board.

5.4 The Terms of Reference for the Governance and Compliance Sub-committee has been adjusted to ensure that this governance meeting receives assurance that the risk appetite statement is reviewed on an annual basis and reports a recommendation to Board in Quarter 2. The sub-committee will also consider any in-year requirement to review the Risk Appetite Statement as a result of internal or external factors. This process will be in place for the 2016-17 review.

6.0 Conclusion 6.1 The Risk Appetite Statement has been fully reviewed for 2015-17 to ensure that the risk

appetite is aligned to the strategic objectives which will support decision making within the organisation. The establishment of a risk appetite in this way can also address areas of excessive or low risk taking in organisations.

6.2 The clear articulation of the risk appetite in the way proposed will ensure that the Board’s expressed attitude to taking, accepting, tolerating and avoiding risks across a spectrum of risk taking is communicated within the organisation. The interdependence with the strategic priorities and blueprint statement further supports the application across all Networks and Support Functions. Collectively, the risk appetite provides a form of risk compass within the Trust to guide judgement and optimal decision making.

6.3 With the proposed Risk Appetite Statement laid down within the organisation, the Board will be better placed to seek assurance from executive and senior management that key decisions are being taken accordingly and consistently in line with the risk appetite.

7.0 Recommendations 7.1 The Board is requested to consider the proposal that where decision making is outside of

the risk appetite, then these decisions will be referred to Board for consideration.

7.2 The Board is requested to receive assurance that the Governance and Compliance Sub-committee will be accountable for the annual review of the Risk Appetite Statement and also the consideration of any factors that have the potential to impact on the existing approved statement in-year.

7.3 The Board is requested to approve the Risk Appetite Statement 2015-17 in Appendix 2 of this report.

Risk Appetite Statement 2015/16

The Board recognises the complexity of risk issues in decision-making. There is no absolute formulaic approach to establishing whether the Board considers that an activity is or is not an acceptable risk. E1ach case requires the exercise of judgement (applied in line with the Decision Rights Framework). However, there are some indicators on the limits that the Board would see as outside of their tolerance and the following framework can be used to inform decision making in connection with risk.

The Board accepts that there is an element of risk in every activity it undertakes and the Trust’s appetite for particular risk areas will depend on factors such as the likelihood of the risk occurring, the impact of the risk (before and after controls) and also the effects of the risk on the Trust’s strategic goals and initiatives should the risk materialise.

Zone A – Unacceptable Risk (The Board is not prepared to operate in Zone A)

Zone B – Balance Risk with Reward

Zone C – Risk Positive

Quality Impact of a decision means that the Trust will not achieve the stated minimum quality standards.

The Trust will not plan to engage in activity that results in financial loss. Value for Money is the primary concern, but the Board will consider other benefits or constraints.

The Trust would want to be actively pursuing activities/opportunities where rewards are high but risk is limited, provided that this does not impact on the organisation’s overall resource capacity to deliver the planned objectives/aims.

Financial Impact of decision means that the Trust will not achieve 1% surplus over a rolling 3 years.

Compliance Impact of the decision: • Does not support the position that

the Trust will knowingly do harm to anyone;

• Means that the Trust’s ability tomaintain its Monitor Licence/CQC regulation is compromised.

Reputation Impact of a decision does not support the Trust’s values.

Where activity falls in Zone A/B the Trust will plan to recover the position as soon as is possible in order to move the activity into Zones B and A. If this is not possible the Trust will plan to discontinue the activity.

The Zonal risk matrix is reflected in the graph.

Risk Appetite Statement – refresh approved by Board of Directors on 28.04.15

Appendix 1

Quality Outcomes Excellence

Would do (Zone C)

The Trust will continually improve quality and safety whenever feasible.

The Trust will ensure we have systems that openly and accurately reflect our performance.

The Trust will accept risk where pursuing an excessive standard is judged to deliver benefits.

The Trust will build resource to understand stakeholder needs and to manage expectations.

The Trust will deliver to quality standards and to the contract specification.

The Trust will seek to focus on priority options that will deliver the biggest impact.

The Trust will achieve upper quartile at comparable cost to peers.

The Trust will not tolerate substantial failure where it is within our control.

Not do X (Zone A)

The Trust will not knowingly take decisions to reduce safety or ignore safety issues.

The Trust will not tolerate failure in basic standards of compliance which could compromise license conditions.

The Trust will not adhere blindly to delivery plans that no longer make sense.

The Trust will not seek to maintain the ‘status quo’ in an ever changing market place.

The Trust will not knowingly take a decision to compromise standards of care.

The Trust will not compromise integrity of information.

People Money Innovation

Would do (Zone C)

The Trust will ensure every staff member is clear on their contribution to the organisation.

The Trust will pursue competitiveness through appropriate reducing unit cost.

The Trust will extend service delivery capacity.

The Trust will ensure it learns from all its experience and applies the learning in future decision-making.

The Trust will develop different/innovative delivery options in line with market needs.

Not do X (Zone A)

The Trust will not tolerate management process-behaviour which does not engage staff.

The Trust will not seek to reduce unit costs at the expense of minimum quality standards.

The Trust will not over-extend its resources in a way that compromises delivery as a whole.

The Trust will not limit the frame of reference.

The Trust will not plan not to achieve contractual obligations.

Risk Appetite Statement 2015 - 2017

The Board recognises the complexity of risk issues in decision-making. There is no absolute formulaic approach to establishing whether the Board considers that an activity is or is not an acceptable risk. Each case requires the exercise of judgement (applied in line with the Decision Rights Framework). However, there are some indicators on the limits that the Board would see as outside of their tolerance and the Risk Appetite Statement can be used to inform decision making in connection with risk.

The Board accepts that there is an element of risk in every activity it undertakes and the Trust’s appetite for particular risk areas will depend on factors such as the likelihood of the risk occurring, the impact of the risk (before and after controls) and also the effects of the risk on the Trust’s strategic goals and initiatives should the risk materialise.

The Risk Appetite Statement provides the Board’s appetite for risk taking and tolerances and is mapped against the Strategic Objectives and Blueprint Statements. This clear understanding of the Board’s tolerances and appetite for risk taking is necessary to steer and influence the development of appropriate risk mitigation strategies and systems of control.

The Risk Appetite Statement does not negate the opportunity to potentially take make decisions that result in risk taking that is outside of the risk appetite. Where this is considered to be the case, it is proposed that these decisions will be referred to the Board.

The risk appetite categories are defined as follows:-

AVERSE Prepared to accept only the very lowest levels of risk, with the preference being for ultra-safe delivery options, while recognising that these will have little or no potential for reward/return.

CAUTIOUS Willing to accept some low risks, while maintaining an overall preference for safe delivery options despite the probability of these having mostly restricted potential for reward/return.

MODERATE Tending always towards exposure to only modest levels of risk in order to achieve acceptable, but possibly unambitious outcomes.

OPEN Prepared to consider all delivery options and select those with the highest probability of productive outcomes, even when there are elevated levels of associated risks.

HUNGRY Eager to seek original/creative/pioneering delivery options and to accept the associated substantial risk levels in order to secure successful outcomes and meaningful reward/return.

The risk appetite aligned against the strategic priorities is provided in the table on page 2 of this document. The table also provides some high level indication of specific areas of risk within the strategic objective parameters.

The overall risk appetite that the Board considers appropriate taking all strategic objective risk appetite alignment into consideration is ‘Open’. This means that the Board is prepared to consider all delivery options and will select those with the highest probability of productive outcomes, even when there are elevated levels of associated risks.

Appendix 2

Strategic Priority Risk Appetite Area of Risk Risk Appetite Strategic Blueprint Strategic Risks C

ompa

ssio

n

To provide high quality services Cautious

Patient Safety Cautious We will protect people from harm, give them treatments that work and make sure that they have a good experience of care. We will collect useful information on quality and share this information quickly with the people who are best placed to improve care. We will empower our people to get things done and will be constantly vigilant in keeping quality standards high. We will take every opportunity to compare ourselves with other providers so that wecontinue to strive for excellence. We will put patient experience at the heart of what we do and report consistently high quality experiences.

1.1: The Trust does not protect service users from avoidable harm and fails to comply with the CQC’s standards for the quality and safety of services

1.2: The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

7.3: The Trust does not comply with Mental Health legislation

7.2: The Trust does not comply with statutory legislative requirements

Service User and Carer Experience Cautious

CQC Compliance & Guidance Moderate

Compliance with Statutory Legislation Averse

Transforming Clinical Services Open

Inte

grity

To provide accessible services delivering

commissioning outputs and outcomes

Moderate

Protecting Health Cautious We will deliver integrated mental and physical health care services. We will reduce waiting times across all services andlocalities. We will deliver increased volume to meet demand and increase productivity. We will focus our efforts on key servicesand initiatives and change services that do not deliver agreed outcomes. We will ensure patients are cared for in appropriate environments and services and will pilot innovative services earlier in patient pathways.

2.1: The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality

2.2: Uncertainty and inconsistency of commissioning arrangements affects the Trust’s ability to address and meet service demands

7.1: The Trust does not comply with Monitor Licence

Business Transformation Hungry

Contract Management Cautious

Service Sustainability Open

Team

wor

k

To become recognised for excellence Open

Service User and Carer Experience Hungry Our service users and carers will tell us that our services are of

high quality. Our local GP colleagues will regard us as a willing and responsive partner. Our people will recommend us to family and friends. We will be respected by our commissioners and other providers as a co-producing partner in shaping new service models that deliver our aligned strategies. We will have achieved a national reputation for excellence and will build a multi-region secure services business.

3.1: The Trust fails to deliver the benefits of being a Health and Wellbeing provider

3.2: The Trust does not build its communication and reputation with all stakeholders

Reputation Moderate

Promoting Health Open

3rd Party/Joint Venture Arrangements Open

Res

pect

To employ the best people Open

Learning and Organisational Development

Hungry We will have effective and appreciative leadership throughout the organisation, creating a high performance environment. Our people will be clear about what is expected of them, receive regular feedback and understand that poor performance will be addressed. Our employees will be engaged, supported to reach their potential and embrace change. People will want to work here.

4.1: The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staff and safe staffing levels, affecting quality of care, and financial costs

4.2: The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care

Performance and Talent Management Open

Recruitment and Retention Open

Workforce Planning Moderate

Acc

ount

abili

ty

To provide excellent value for money in a financially

sustainable way Open

Financial Sustainability of Services Moderate

We will operate at, at least our current scale. We will provide services that offer excellent value for money without compromising financial stability. Local accountability and decision-making will enable services to sustain margins to fund investment. We will be outward looking and actively seeking business opportunities to expand and serve new geographies, whilst concentrating on things that add value for our customers and for local people. We will succeed by competing on quality.

5.1: The Trust does not achieve financial performance sufficient to maintain resilience and sustainability

5.2: The Trust does not achieve the required efficiency savings whilst delivering and improving quality

CIP Development Hungry

Business Growth Open

Value for Money Hungry

Exc

elle

nce

To innovate and exploit technology to transform care Open

Research and Development Moderate Research and innovation will enhance patient care, reduce costs

and/or improve quality. We will have a culture where staff are given the time, training and resources to research and innovate. Research will validate innovations and innovations will direct research. Partnerships with third party organisations will enablerapid execution and exploitation of innovation projects.

6.1: The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence

6.2: The Trust does not implement a transformational IT enabled programme that ensures transition to a new intuitive clinical system across all services

Innovation and Transformation Hungry

3rd Party/Joint Venture Arrangements Open

IT and Health Informatics Moderate

Averse Prepared to accept only the very lowest levels of risk, with the preference being for ultra-safe delivery options, while recognising that these will have little or no potential for reward/return.

Cautious Willing to accept some low risks, while maintaining an overall preference for safe delivery options despite the probability of these having mostly restricted potential for reward/return.

Moderate Tending always towards exposure to only modest levels of risk in order to achieve acceptable, but possibly unambitious outcomes.

Open Prepared to consider all delivery options and select those with the highest probability of productive outcomes, even when there are elevated levels of associated risks.

Hungry Eager to seek original/creative/pioneering delivery options and to accept the associated substantial risk levels in order to secure successful outcomes and meaningful reward/return.

Risk Appetite against key areas of Strategic Priority 2015‐17

Board of Directors


Report Title Academic Health Science Network (AHSN) North West quarter two performance report


Prepared by Liz Mear, AHSN Chief Executive

Presented by Heather Tierney-Moore, LCFT Chief Executive




Report purpose To appraise the Board of performance to date and update on key work streams



Board Assurance Framework risk 7.2 the Trust does not comply with statutory legislative requirements

CQC domain Well-led

BOARD ACTION

The LCFT Board is asked to note:

- the performance of North West Coast AHSN

- progress against the campaigns

- the funding streams being applied for

- the results of the first national AHSN survey

Funding [The funding section must be completed from information collected from the AHSN on their projected revenue and spend. Annual allocations and PSC funding information will be populated by NHS England’s AHSN team.

Overall AHSN Contract Value*

Patient Safety Collaborative

Additional Funding (inc membership fees,

partnerships, projects etc)

Total Projected Revenue for 2015/16

Allocation £3,952,500

Allocation £682,064

Projection for 2015/16 £294,555

Total for 2015/16 £4,247,055

Total additional funding received £110,790

Patient Safety Collaborative

Total Spend to date

£115,421 £1,562,272

Additional Information: The AHSN has a number of funding bids live at present. This includes a bid to the Connecting Health Cities programme for c£4 million over a 3-year period and three test bed proposals for c£1million each. It is not anticipated that all of the three test bed bids will be successful as a maximum of 6 will be funded nationally.

*To note – PSC funding is included within the overall AHSN contract value.

Overall delivery of the Matrix of Metrics

COMMERCIAL PROGRAMME

Aim: The commercial programme drives engagement with SMEs with NHS and academic partners. Key deliverables are the number of companies supported, new technologies developed and adopted, inward investment and job creation. We are targeting support for a minimum of 50 regional SMEs, 20 new products evaluated in practice with a view to wider dissemination in 2016 of those that impact on efficacy and efficiency. The procurement work will focus on training partners in innovative procurement processes and two projects will receive intense mentoring and support to deliver a forward commitment procurement project.

Strategic Goal Project Details Indicative budget Q1 – Milestones 4 stage RAG rating

Q2 - Milestones 5 stage RAG rating

Liverpool LEP Business Assist Programme. Business support for SMEs in Liverpool City Region.

Support advice aligned with the New Markets programme in Liverpool City region

£30k

Drop in sessions completed at OpenLabs. Attendance at Funding Workshop planned. Company supported with successful Phase 2 SBRI bid

Lancashire LEP Business Assist Programme. Business support for a minimum of 18 SMEs in Lancashire.

Business Support for SMEs in the areas of business. This includes any or all of the following: • Guidance for new product development programmes to ensure the product concept meets a clinical need and

£100k

Multiple workshops held for Health Economics, Business Case development and Procurement advice 20 businesses supported.

that regulatory requirements are, or can be, met • Evidence gathering • Designing studies that will provide evidence for health economic analysis; • Health economics studies • Focus groups, customer / site visits and expert meetings to understand market and clinical needs • Access and introductions to potential customers and facilitation of meetings • Producing case studies to support future sales activities • Meetings with commissioners and / or procurement leads • Identifying and establishing collaboration partners within academia and / or the NHS for trials and evaluations, co-development and funding applications • Bid writingsupport and collaboration on bids if appropriate • Tender writingsupport

Cheshire & Warrington LEP Business Assist Programme

Agreed a series of Business Breakfast Meetings and Business Advice Surgeries for the rest of the year

£50k

Series of Business Breakfasts planned (first held in July, next event planned 9 October) 30 companies attending.

Stop & Go EU Project

A European consortium to deliver procurement of telehealth services.

The STOPandGO (Sustainable Technologies for Older People - Get Organised) consortium is a group of buyers and associated experts which offers an innovative procurement process aimed at securing cost-effective, care pathway oriented, sustainable and scale ICT-based

£10k plus additional £36k for LSE work packages

Re-allocation of resources following withdrawal of LSE, assisting Eastern Cheshire CCG in SME Engagement for Procurement of Diabetes Services. Presented at S&G Workshop, AAL Forum, Ghent Sept. €17m budget across partners for procurement.

telehealth and telecare services which will achieve clearly defined clinical and social outcomes. The target population to benefit from these products and services are frail and dependent elderly people, perhaps living with long term conditions such as Chronic Heart Failure and Diabetes, and their carers.

ENSAFE EU Project

ENSAFE envisages the creation of a supportive platform integrating the following different components, which were conventionally thought of as independent devices: • mobile communication and sensing through the GoLivephone device • home environment monitoring through the CARDEAdomus system, • tele-medicine products and physiological sensors, developed by METEDA.

£86k plus £86k as match

Kick-off Meeting 22 September complete. Survey tool and methodology agreed and survey participant identified.

General Business Engagement Activities

Ongoing enquiries from numerous business sources from within region, national and international

Commercial Pages written and prepared for new content on our website. Potential consortium partners identified for European projects

Excellence in Supply (EIS) Awards and Conference. Recognising excellence in procurement and supply.

NWPD Open Competition for NHS Suppliers in the Region together with a conference on procurement in November

£10k

Joint sponsors with GM. Judged the Small Business and Supplier of the Year categories and presenting at conference.

Health Hubs Business Activities. To drive collaboration between SMEs, academia and NHS partners.

AHSN has provided support to several of the Health Hubs in the Region

First business meeting held at CIHS Chester in August (Semitae) - follow up meeting planned with Charles McKinnon

Red Rose Awards. Recognising healthcare

Sponsoring Health award. Acting as Judge on Awards

£5k Planning Phase

companies in Lancashire

Bionow/Medilink Awards and Support. Recognising excellence in technical services

Sponsorship £4k

Planning Phase

Procurement

Regional project on needs based procurement and support from NWPD for business support and procurement activities.

£40k

1st workshop complete and 2nd planned for Nov. 2 projects will be identified for mentoring. Local SME supported to win national supply contract.

Inward investment

Promote assets of region at national level and work towards securing investment into region

Visits from UKTI and Innovate UK

Innovations with Impact

Competition to pump prime

£500k 21 pilots will be supported (20

different technologies)

Alder Hey Hackathon to engage SMEs with developing innovative solutions for Alder Hey.

MIT team sponsored to visit from Boston to facilitate 2 day hackathon

£12k

Planning Phase

STROKE/AF PROGRAMME Aim: There are three strands to this programme: raising awareness, identification of AF; and the management & treatment of AF. The programme’s success measures include: to reduce the number of strokes caused by AF by 5% in 3 years; for the NWC this will equate to 100 strokes and a saving of £2,331,500



Deliver an awareness campaign for AF (Lancashire)

Public facing Campaign (9 events) Symposium for clinicians

£15K

All events delivered

Support the development of genotype guided dosing for warfarin (Royal Liverpool, Countess, Arrowe Park, with University of Liverpool and LGC) Evaluation. Led by Professor Munir Pirmohamed

Project management and leadership support to a CLAHRC funded project

In kind support and a small budget £1,000 for travel and catering at events

Delays due to issues with the testing device

Support the development of telemedicine (Walton/Alder Hey) Management

Support for the development of a pilot system to look at telemedicine

£4K

Currently reviewing this project

Support the improvement of identification and management in

Projects underway in both areas. Supported by industry

0

Training and audits are ongoing

Primary Care (Wirral, West Lancs, South Sefton & Formby, and East Lancs).

Identify and support training for primary care (AF & anti-coagulation)

Piloting online training for AF

£5K

Five anti-coagulation specialists are reviewing the e-learning package

Support for IAPT ADOPTs Study - Led by Professor Caroline Watkins

Identification and evaluation of the Access to Psychological Therapies for Stroke Survivors

Supported project in kind by leadership and project management

Support for scoping is ongoing

Support for Medtronics implantable loop Treatment

Working with the Royal and Countess hospitals to pilot this loop device on patients who have had a stroke

Supporting discussions with CCGs

Support is ongoing

My Stroke Guide – Stroke Association, Evaluation

Working with the Stroke Association, UCLAN, Countess, Research and Evaluation

5K

Support is ongoing

Using MyDiagnostick in Primary Care, Care Homes and Community Pharmacy. Evaluation by UCLAN

Working with East Lancashire CCG to evaluate the roll-out of a technology to better identify AF in a range of community settings

£30K

Project is on track

Using Alive Cor in Primary Care to better identify AF patients

Deployment of Alive Cor devices to GPs across our area

£5K

Project is on track and phase 2 in development

Work on AF pathway with C&M SCN

Contribution to the electronic Care Pathway for C&M

Project is complete and launch is in November

Work on AF took-kit with GM,L&SC SCN

CCG tool-kit

Project is complete

Development work in hospitals to establish and evaluate how AF patients move through the pathway

Improving care for identifying patients with AF and ongoing management

£1K

Audit work is underway with the possibility of extending further

Develop and deliver a test-bed application with NHS England to use technology to support the Hypertension regional strategy and AF pathway

Greater identification of patients with AF and Hypertension in Cheshire & Merseyside, harnessing innovation and technology

£3K

Project is ongoing with bid deadline in November

Developing a pilot with Cardiocity

Supporting the early identification of patients with AF

Project is ongoing

Training for primary care reception staff on identification of Stroke

Supporting the early identification of patients with Stroke

£2,000

Project is ongoing

Support self-management

Developing and evaluating Self

Discussions ongoing with Roche

Management Management devices for people prescribed warfarin

REDUCING ALCOHOL RELATED ADMISSIONS TO A&E AIM: We aim to reduce the attendances and admissions by 2% across the NWC area by 2017



Engagement & Partnerships

Developing a network of partners and engagement in the region

Eco-System event organised and held in July. Outcomes agreed: support the Dry January Campaign; pilot breathalyser technology. Film of event used at the international ecosystem meeting as a model of best practice

Identification and assessment of innovations

Examining and scoping innovations

Ongoing

Identifying industry/SME partners

Partners identified to develop joint working and mutually beneficial activities

Ongoing

Support for Dry January Campaign

Supporting the National campaign and using it as a vehicle to promote innovation and health in the workplace

£30K

Project started October 2015. Associate working 2 days per week.

Developing and App for young people

Working with Red Ninja to support work for Dry January

£5K

Project ongoing – hack day held in August

Support for national event in partnership with Drinkwise

Developing a series of workshops with feedback from national experts

Project revisions due to the Drinkwise Charity closing. Working with PHE on forthcoming events

Using scratch cards with community pharmacy

In development

Project curtailed due to Lundbeck withdrawing marketing support for Nalphene

N/A

Developing Connected Health Cities Programme to focus on Alcohol

Submission of a bid and a project outline to look at Alcohol as an exemplar

Bid due on 28th October

MEDICINES OPTIMISATION PROGRAMME

AIM: AIM: To support the adoption of evidence into practice of innovative products, approaches

and solutions to support the Royal Pharmaceutical Society principles of Medicines Optimisation,

driving improved outcomes and/or efficiencies. The RPS principles are

Making medicines optimisation part of routine practice

Evidence based choice of medicines

Safe use of medicines

Aim to understand the patient experience



Supporting the adoption of evidence into practice RPS - Making medicines optimisation part of routine practice

Development of a knowledge hub for sharing joint working initiatives between industry and NHS. Case studies approved by a multidisciplinary editorial board and endorsed by the AHSN. Details of the project / how it was implemented/ tools to implement/ barriers and enablers/ lessons leant / impact and evaluation

£15k

2 Industry stakeholder events with 25 companies in attendance. Concept developed and local SME commissioned to develop interface

Identification and evaluation of innovation RPS- Evidence based choice of medicines

Proteus Digital Health - Commercial sensitivity Creating opportunities for Proteus Digital Health to undertake proof of concept evaluations

Funding through Innovation with Impact awards

Issues regarding ethics, information governance and informatics have been identified during the RLH - Project Manager will be taking a lead to address the barriers and inform a national approach for Proteus Digital Health

Identification and evaluation of innovation RPS Evidence based choice of medicines

STEPSelect - Commercial sensitivity Safe. Therapeutic, economic, pharmaceutical selection

£50K

Meeting with heads and chiefs across Mersey region held on 9/9/15. Opportunity with recommendations from Carter Report being followed up through Ann Jacklin at the DoH

Supporting the adoption of evidence into practice AND new models of care RPS - Making medicines optimisation part of routine practice

Collaboration between Boots/ Rowlands/ Lloyds and Well (formerly CO OP Pharmacy) Outcomes from a pilot study in Wirral demonstrating the impact of intervention by community pharmacy in supporting patients with COPD - uptake to Blackpool CCG

£3K

Meeting held with Head of Commissioning and Medicines Optimisation team. Neighbourhood identified and targeted intervention to be confirmed in October 2015

Supporting the adoption of evidence into practice RPS - Evidence based choice of medicines

Collaborative development of new clinical pathway for the treatment of IDA involving Countess of Chester , West

£7k - with other funding sources being sought

Meeting with Commissioner at West Cheshire and Lead Clinician in Countess of Cheshire

Cheshire CCG , NWC AHSN and Vifor pharmaceuticals

Supporting the adoption of evidence into practice Aim to understand the patient experience

Diabetes - Business Summit engaging industry and stakeholders to support for patients with diabetes who drive for a living. Call to action. DVLA to provide clear guidance Empower people to take charge of their health and wellbeing. HCP to ask patients with type 2 diabetes if the driving is part of their work and to consider this when prescribing. Ambulance service to collect data. Business Summit - LEPs/Health and Wellbeing Boards/ENWAS Commercial sensitivity

£15k - shared funding and ownership

Stakeholder engagement plan with kick off meeting held on September 10th

Identification and evaluation of innovation RPS Aim to understand the patient experience

Evaluation of Pharmacy First - minor ailments scheme. Fylde and Wyre CCG and Lancaster University

Introduction to Lancaster University for evaluation. Outcome of evaluation reviewed in Q4

Create a culture of innovation Aim to understand the patient experience Safe use of medicines

Refer to Pharmacy Supporting Alistair Gray in region - Liverpool CCG scoping and feasibility study for transfer of patients from hospital to community pharmacy

£3K

Project manager appointed to support initiative to understand IT requirements to implement

Identification and evaluation of innovation Making medicines optimisation part of routine practice

Robotic dispensers and digital adherence aids Commercial sensitivity Supporting Medicines Management Solutions- local SME.

£3k

Delay to evaluation of the robot


Amgen Commercial Sensitivity

Bone Health Campaign

Capacity to deliver - potential partnership to be established


West Cheshire CCG Pathway redesign for dressings

Project continuation being reviewed


Developing Collaborative Partnerships with the Centre for

TBC (new international initiative)

Invited to join European Partnership for MO with ECHAlliance. PR- partner with Prof Mike Scott

Pharmacy Innovation Belfast


Medication waste Commercial sensitivity Gilead Pharma in partnership with the RLH

£7k with shared input

Planning meeting September 2015


Johnson and Johnson /Janseen Pharma Commercial sensitivity Patient Knows Best - Cancer /HIV

£3k

Meeting with HIV lead RLH to agree outcomes measures across NWC

Evidence based choice of medicines

Collaboration between ABPI and northern AHSNs re uptake of NICE approved medicines

£10k

Project focused on AF across the care pathway Support meeting for Medicines Safety Officers Jan 2016


Alder Hey Children's NHS Foundation Trust - evaluation of point of care testing for infection in partnership with Lancaster University

Time costs

Decision TBC

Aim to understand the patient experience – project ceased

Merck Commercial sensitivity Working with pharma

Time and health economic costs

Industry pulled out of the project

N/A

MUSCULOSKELETAL START BACK PROGRAMME

AIM: To improve waiting times by 50% and patient satisfaction by 50% through the introduction of

novel digital products to support people with musculoskeletal problems

Strategic Goal Project Details Indicative budget Q1 – Milestones

4 stage RAG rating Q2 - Milestones 5

stage RAG rating

Engage and develop partnerships

Expert group convened and

structures developed

Development of a CCG engagement group

Project ongoing

Engagement with ARUK

Discussions with the Medical

Director Underway

Introduction of effective medications, including biologic treatments, for inflammatory polyarthritis

Discussions underway, but no clear focus yet

Increased emphasis on self-management and interdisciplinary working

£30K

Digital solution in development in West Lancs, but with wider applicability to the region.

Home delivery of medications and treatments

Project being revised

A system for 2. Enhancing the Not due to start until later this

delivering physiotherapy in the home (Y&H AHSN)

consultation (e.g. PCI, real time PROMS, appointment management system)

year

A system to support improved management of back pain (StartBack)

Event due in November. Key priorities identified

Using technology to support MSK eg patient concerns inventory

£10k

Explorations with a company to develop this are underway

Precision Medicine

AIM: to implement the 100,000 Genomes Project across the North West Coast by recruiting

patients with rare diseases and cancer

- for the North West Coast to become the fastest place in the UK to develop and commercialise

quality research in precision medicine



Work with Commissioners and Public Health, Build a culture of partnership and collaboration, Rapid spread of Research and Innovation into Practice, Improving economic growth

Cross Cutting Workstream - Precision medicine: Implementation of the 100,000 Genome Project RARE DISEASES

59K Year 1 2014/15 and 59K Year 2 2015/16

Patient recruitment trajectories for rare diseases continue to be on target

Work with Commissioners and Public Health, Build a culture of partnership and collaboration, Rapid spread of Research and Innovation into Practice, Improving economic growth

Cross Cutting Workstream - Precision medicine: Implementation of the 100,000 Genome Project CANCERS

As above

Cancer go-live status awarded 14/10/2015. Cancer patients will now be recruited into the IIP part of the programme. Main programme to start January 2016

Build a culture of partnership and collaboration, Improving Economic Growth

Precision medicine - PrIMe Action Plan

Further detail added to action plan. Timelines and lead names also agreed and identified

Mental Health

AIM: to collaborate and share best practice in Mental Health by identifying and spreading

innovative ways in the assessment and treatment of mental health conditions

Strategic Goal Project Details Indicative budget Q1 – Milestones Q2 - Milestones 5 stage

4 stage RAG rating RAG rating

Work with Commissioners and Public Health, Build a culture of partnership and collaboration

MENTAL HEALTH-Zero Suicide - Innovate Depression

75K

2nd workshop held. Awaiting papers to confirm work streams and projects for delivery, with appropriate timelines

Rapid spread of Research and Innovation into Practice, Work with Commissioners and Public Health, Build a culture of partnership and collaboration

MENTAL HEALTH-REACh - Routine Enquiry into Adverse Events in Childhood

(50K)

Steering Committee meetings in place to occur monthly

Rapid spread of Research and Innovation into Practice, Build a culture of partnership and collaboration, Cross Cutting with Innovation Culture workstream

MENTAL HEALTH-Innovation Scouts MH Forum, dedicated MH Action Learning Set for current MH Innovation Scouts

Meeting to be rearranged for November. Supporting innovation test bed innovation scout in Merseycare trust and was part of assessment process for identifying industry partners

Build a culture of partnership and collaboration

MH Transition CAMHS to AMHS, cross cutting with Safety

Completed

Developing a culture for innovation

AIM: provide evidence of increased uptake of innovations within and across partner organisations and contribute to the evidence base. Create the culture to embrace innovation, by the creation of a community of Innovation Champions who will each attend a minimum of 3 events pa, with 60% attendance at each event;

Strategic Goal Project Details Indicative budget Q1- Milestones 5 stage RAG

rating Q2 - Milestones 5 stage

RAG rating

To increase the capability & capacity within the NHS for diffusing innovation to maximise the impact for patients and carers

Establish an Innovation Forum

3rd core event taken place

Agreed set of values and behaviours

4th Core event to focus on industry engagement, resulted in a blueprint for the NHS in working with industry

Developmental event held on the Change Model and whiteboard animation. Final preparations being made for a number of events in Qtr 3, including prezi training, Helen Bevan Masterclass, joint Lean workshop with BAE and Lilly, Creating a Culture for Innovation

workshop

Innovation Scout recognition scheme being finalised in preparation for a launch in Qtr 3

Presentations on a culture for innovation taken place: to a South African delegation visiting Lancaster University at the launch of the China Connected Health Alliance, R&D North West Annual Conference; prelaunch of the Polish Connected Health Alliance and the ECHAlliance leads meeting.

Undertook a study trip to Austrian to learn lessons on interoperability; lessons learnt report produced

Sponsored the NWC Excellence in Informatics Awards

To increase the capability & capacity within the NHS for diffusing innovation to maximise the impact for patients and carers

Design a workshop in collaboration with NHS IQ

Workshop co-designed and date set for Q2

Workshop held, approach being built into AHSN business planning cycle

Partner in the National Innovation Accelerator Fellow Programme

Participated in all 3 national co-design workshops

Active participants in the recruitment process

Fellows announced on 6 July, contributed to national communications

In discussion with UCLP to inform a possible second cohort, aligned to NWC priorities

Mentoring a NIA fellow

3 NIA fellows have signed up to our Helen Bevan Masterclass in November

Specific Examples of progress/success to share

Stakeholder engagement

First survey finds 72% of stakeholders recognise ‘clear and visible leadership’

The first survey of our stakeholders has been published, showing that the majority of respondents (72 per cent) agree that the North West

Coast Academic Health Science Network (AHSN) has ‘clear and visible leadership’ and would recommend working with us.

The results also show a bigger response from stakeholders in the North West Coast than any other region.

Carried out by NHS England, the aim was to gauge opinions about the country’s 15 AHSNs two years after we were established.

All AHSNs circulated the survey to their own databases of stakeholders in health, academia and business and also through social media to

the wider public, so the proportion of respondents in each sector varied between AHSNs.

Nationally, 1,200 people from across health and social care, patient groups, academia, industry, and the charity sector took part to share

their views on how the AHSNs are delivering on increasing the adoption and diffusion of innovation and research, and spreading best

practice across the NHS.

Our own AHSN had the biggest response of all, with 166 completing the survey during the summer. We were pleased to have a lot of

responses from our partners in local businesses, who told us they approved of the way we are working with them. We believe the

relatively high response rate reflects the high level of commitment and interest from our stakeholders and a serious appetite to engage

and do business with our AHSN from NHS, academia and industry partners.

As all AHSNs had very different sample sizes we have presented the results in a way that makes them more understandable. The table

below shows the number of positive responses for each question, for all AHSNs; and for the North West Coast AHSN.

Ave all NWC

To what extent do you feel you understand the role of the AHSN? 62 133

And thinking about the past 12 months, to what extent has the role of the AHSN become more or less clear? 48 110

To what extent, if at all, do you understand the AHSN's plans and priorities? 51 115

Overall, how would you rate your working relationship with your AHSN? 51 95

Thinking back over the past 12 months, would you say your working relationship with the AHSN has got better, worse, or is about the same? 41 80

To what extent do you agree or disagree with the following? The AHSN has clear and visible leadership 48 111

To what extent do you agree or disagree with the following? I have confidence in the AHSN to deliver its plans and priorities 42 82

To what extent do you agree or disagree with the following? AHSN staff are knowledgeable 51 92

To what extent do you agree or disagree with the following?: AHSN staff are helpful 56 109

To what extent do you agree or disagree with the following? AHSN priorities are aligned to local priorities 43 86

To what extent do you agree or disagree that in the last 12 months? You have felt involved in the AHSN 42 73

To what extent do you agree or disagree that in the last 12 months? The AHSN has listened to your views 41 70

To what extent do you agree or disagree that in the last 12 months? The AHSN has engaged with you effectively when developing its plans and priorities 35 60

The AHSN aims to work with organisations on the following themes. For each theme, how valuable or not has been the support from the AHSN in the last 12 months? Patient safety 32 65

The AHSN aims to work with organisations on the following themes. For each theme, how valuable or not has been the support from the AHSN in the last 12 months? Quality improvement 34 56

The AHSN aims to work with organisations on the following themes. For each theme, how valuable or not has been the support from the AHSN in the last 12 months? Commercial development 24 65

The AHSN aims to work with organisations on the following themes. For each theme, how valuable or not has been the support from the AHSN in the last 12 months? Commissioning support 17 44

The AHSN aims to work with organisations on the following themes. For each theme, how valuable or not has been the support from the AHSN in the last 12 months? Identification, adoption and spread of innovation 42 77

The AHSN aims to work with organisations on the following themes. For each theme, how valuable or not has been the support from the AHSN in the last 12 months? Facilitating collaboration 45 92

The AHSN aims to work with organisations on the following themes. For each theme, how valuable or not has been the support from the AHSN in the last 12 months? Providing leadership to the local health economy 31 66

Overall, how would you rate the AHSN’s Accessibility 44 89

Overall, how would you rate the AHSN’s Responsiveness 44 83

Overall, how would you rate the AHSN’s Quality of advice 44 83

Overall, how would you rate the AHSN’s Quality of support 43 81

Overall, how would you rate the AHSN’s Knowledge of the local landscape 46 96

Overall, how would you rate the AHSN’s Promoting change in the local health economy 37 74

How effective or ineffective is the AHSN in doing each of the following? Focusing on the needs of patients and local populations 40 77

How effective or ineffective is the AHSN in doing each of the following? Building a culture of partnership and collaboration? 44 85

How effective or ineffective is the AHSN in doing each of the following? Speeding up adoption of innovation into practice 34 67

How effective or ineffective is the AHSN in doing each of the following? Creating wealth 18 45

Thinking about the last 12 months to what extent would you agree or disagree that the AHSN has helped you / your organisation achieve your objectives? 37 59

Has the AHSN achieved more or less than you expected in the last 12 months? 46 99

Would you recommend involvement in /working with the AHSN to others? 49 91

Now, we are using the results to give more focus to the areas where we need to improve.

The majority of respondents (72 per cent) agree that the North West Coast Academic Health Science Network (AHSN) has ‘clear and visible

leadership’ and would recommend working with us.

We were told that we are doing well in explaining our role, but we know we can do better and this is something we constantly try to do.

On a question about quality improvement, the feedback was that we are lower than the national average, which may reflect the fact that

we deliver our quality improvement work through partners and up until now haven’t co-branded this work.

Overall, the survey results show that we have a good reputation for facilitating collaboration and supporting partners to address the needs

of our local communities. They also highlight clear demand for greater visibility of the AHSNs and our role in championing the uptake of

innovation in the NHS. AHSNs are working together to address this demand, including by collaborating on the NHS Innovation Accelerator

programme, supporting NHS England’s test beds initiative and providing input to the government’s Accelerated Access Review.

The NHS needs to deliver a step-change in the way it identifies, adopts and spreads best practice, clinical innovations and new

technologies more quickly and at scale in order to meet the enormous challenges set out in the Five Year Forward View. AHSNs have a

critical role to play in equipping the NHS to do this, in particular by making productive connections between the NHS, industry, researchers

and patients. Our impact is achieved by working with and through thousands of individuals and by acting as catalysts, brokers,

coordinators, sponsors and knowledge-sharers.

Patient Safety Collaborative Activity

We have engaged strategic support to develop a ‘Safe Environment’ Strategy for the NWC, from Helen Speed (former Director of Nursing) and Dr Mike Bewick (former Medical Director). The Strategy will be developed in collaboration with key stakeholders during 2015 and ‘tested’ at a number of engagement events during January. OVERACHING AIM: to create a culture of safety at all levels.



Essential Programme 1 Patient Safety leadership and culture

Developing capacity and capability - Board level /equivalent development in patient safety leadership and culture to include: 1. Safety Culture baseline assessment 2. Human Factors & Error 3. Measurement 4. Safety cases 5. Sign up to Safety Campaign Across the care delivery system - Break through collaboratives

£104k

AQUA and partners presented the proposed programme LOT1 Board development to the PSC Forum. Contract negotiations took place over the course of September and this has now been signed off by all parties.

Patient leader for Patient Safety Two leads recruited

the PSC Recruit a patient leader to inform and work with the patient safety collaborative programmes of work.

Associate lead

Sustain and embed patient safety networks and champions from 2014/15 programme of work Outreach model utilising existing PS infrastructure such as PS Champions and Q fellows to build on safety and learning network delivered at a local level - recruiting champions

£76,500

Q.Fellows routinely invited and attend the AHSN Innovation Culture Programme of developmental activities Exploratory work to establish innovation/ improvement models across the NWC region

Essential Programme 2 A regional strategy for patient safety measurement Essential Programme 2 A regional strategy for patient safety measurement

A NWC Measurement strategy Analysis of available data through a safety dashboard Peer review and capability building: Film Reports Capability building: Workshops

Time Costs

Feeding into the national work. Local measurements will be aligned to local priorities

Building and sustaining a NWC regional strategy on patient safety measurement to relict Sign Up to Safety Campaign - Local improvement plans develop a patient safety dashboard ELearning and film Measurement Workshop

£25,500

We have now entered phase 2 of safety measurement strategy. Exploration of a web-based tool rather than just excel spreadsheets. This will provide live feeds which will be more useful for stakeholders

Providing safety training and development to staff working at patient care level

Develop capability through E- learning package for each one of the four clinical safety priorities: 1. Medicine optimisation (professions focused) 2 Hydration including Acute Kidney Injury (Care worker

Time Costs

Sepsis e-learning package completed. Hydration e-learning package completed. Transition e-learning package completed. Medicines Optimisation e-learning package has experienced delays and the PSC Forum have agreed to promote the Royal College package as an alternative

focused) 3. Transition of Care (CAHMS to AMHS) 4. Sepsis ( care home focused)

Setting up learning networks around safety improvement theme

NWC learning and improvement network NWC - Patient Safety Collaborative Network Events (up to 50 attendees) 1xCapability Building Module: Measurement (up to 40 attendees) 1x Capability Building Module: Human Factors (up to 40 attendees) 1xCapability Building Module: Culture (up to 40 attendees)

Time Costs

Setting up learning networks around safety improvement themes

Sign up to Safety National Campaign Pledge Sign up to Safety -Lancashire Su2S collaborative – Explore developing Su2S collaboratives across other health economies

Time Costs

Workshop plans developing. Exploring Paediatric PSC collaborative network with Alder Hey Children's Hospital as part of their patient safety and quality strategy

Acting for Patient Safety learning from Serious Incidents Consultation with PSGF for questionnaire development Academic input into Questionnaire design and impact & outcomes assessment Pilot of AfPS1 to test system and collect data for academic intervention Pilot new system in Women’s and some units in Royal

Time Costs

Ongoing

Q Initiative is part of the PSC programme -NHS England- organise a national system of NHS Improvement Fellowships, to recognise the talent of staff with

Time costs

NWCPSC have successfully bid for £20k funding from the Health Foundation as part of a joint bid with GM who also received £20k

improvement capability. Recruit 10 Improvement Fellows across the NWC

Technology reviews to identify solutions to safety issues

Sepsis technology review Reviewing the best technology and innovations to find patient safety solutions in Sepsis identification and management

£5K

Ongoing, need to agree an alternative resource

Clinical Safety Programme 1 Residential Care Homes safety

Cross ref P 1 leadership P3 E learning a. Building safety capability across the care home system b. Developing an integrated clinical risk assessment tool c. Evidence of using Learning from health and social care from other countries d. Collaborating with small and medium enterprises to explore what supportive equipment is available for patients so they can live independently e. Exploring how we adopted telemedicine in the care home setting and develop implementation plan Lancashire CC QA programme Explore telemedicine in the residential care home setting ) Care home safety/inequalities event in partnership with St Helen's CCG Partnership working with EMASHN and learning from other countries

£80k

Some e-learning infrastructure is required for the PSC to host the Anticipatory Care Calendar. Virtual Learning Environments allow for organisations to hold the e-learning packages in a platform which then allows analysis and outputs to be monitored and analysed as well as ensuring the functionality of the package. We have been exploring potential solutions for this. This VLE is crucial for any e-learning to be hosted. Reviewing scope of programme in light of emerging care home vanguard sites and the good work happening in East Lancs. Closer alignment to key messages from work recently undertaken by the Lancashire HealthWatch, the information is due to be released shortly

(Maastricht)

Clinical Safety Programme 2 AHSNs PSC Sepsis Cluster

Cross ref P 2 ELearning P3 Measurement P6 technology reviews To undertake a technology review to identify gaps in the body of knowledge and engage with local research networks and NIHR to determine the best way to close the gaps The cluster output will be a single set of clearly documented recommended actions and interventions

£15K

Analysis of sepsis monitoring thematic review nearing completion

Clinical Safety Programme 4 Hydration including Acute Kidney Injury Clinical Safety Programme 4 Hydration including Acute Kidney Injury

Cross ref P3 ELearning PSC E Newsletter Contribute to AHSN PSC Cluster leads UCL AKI workshop & event for Commissioning and Primary Care

Time Costs

AKI Hydration event took place with good attendance. Full written report and evaluation is now available and has been shared with C&M SCN. Follow on actions to be agreed ELearning package now complete and awaiting launch

Community Hospital – Hydration programme – Hydrate for Health

Time Costs

Considering options for increasing the evidence base

Clinical Safety Programme 5 Transition of Care Clinical Safety Programme 5 Transition of Care

Cross ref P3 ELearning package CAMHS to AHMS

Time Costs

Cross ref P3

E-referral systems to address patient flow in South Cumbria and North Lancashire, delivering co-ordinated and streamlined approach to patient transitions (Learning from Canada & expansion of interoperability across the Region

Time Costs

We are exploring potential metrics to enable baseline assessments to be realised so that we can measure impact

Routine Enquiry into Adversity in Childhood

Steering Committee date in place (monthly)

Active Engagement and Communication

Working Collaboratively Cross ref P4 NWC Patient Safety Collaborative E Newsletter Webpage Blogs Twitter Patient Safety Governance forum Clinical advisory groups AHSN Patient Safety Leads network Peer reviews Publications Conferences National working

Time costs

Newsletter being produced on a routine basis, has received positive feedback Programme of meeting with CCGs has been agreed

Active Engagement and Communication

On behalf of the NWC AHSN lead on developing a Stakeholder Engagement and Participation Strategy, by March 2016

Time Costs

This will underpin the NWC Safe Environment Strategy

PSC evaluation An evaluation of PSC 2014/15 programmes

Time Costs

Exploring a software application that will enable us to define and record impact through engagement and levels of intervention 1-4 with level 4 being the most complex intervention and impact

Barriers/challenges identified and support required

RISK (Impact) (Likelihood) MITIGATION

Annual funding cycle creates lack of confidence with stakeholders and potential job applicants, which makes it difficult for the AHSN to attract appropriate staff.

H H NHS England funding structure unlikely to change. AHSN will mitigate by strong communications and marketing of the valuable contribution of its work.

Lack of agreement across the region on implementation of annual plan.

L H Extensive engagement from the start with all relevant stakeholder organisations through the Industry forum around position statements.

Executive timeout to consider the future sustainability of the AHSN and to refocus into four strategic objectives

Relevant stakeholders (e.g. industry, academia, local authorities) do not feel sufficiently engaged in determining the priority improvement areas.

M M Extensive engagement around selection of priority improvement areas through a variety of forums. Also other engagement tools e.g. NHS Access, NW AHSN Innovation Expo.

Trusts do not implement AHSN approved innovations and service improvements.

H M Extensive engagement encouraging nominations for AHSN approved innovations and service improvements, as well as concerning the evaluation and selection of AHSN approved innovations and service improvements. Liaison with CCGs as appropriate to incorporate commitments within contracts to incorporate the implementation of approved innovations and service improvements.

Innovation scouts appointed in Trusts do not have the responsibilities capabilities and skills to make sure NWC AHSN innovations and service improvements implemented.

L M NWC AHSN has supported organisations to choose the most appropriate staff to be Innovation Scouts by providing a role descriptor. Ongoing training is supporting the Scouts

Recruitment Champaign commenced and recognition scheme being finalised

Lack of integration with LEP plans. M H LEP representation on AHSN board already and also helping to shape business plan.

Lack of engagement from local partners causing unco-ordinated regional plans

M M Strong representative Board, widely published stakeholder events and various forums for each sector of the triple helix

Delivery against some digital health targets and systems interoperability targets may need support and may divert attention from regional and national spread of good practice.

M H Mi project and the integrated IT projects have dedicated teams and AHSN will support via Programme/ Project Leads

Conduct of one neighbouring AHSN may affect the performance of NWCAHSN/ the reputation of Northern AHSNs

H M Strong work of NWC AHSN

Support of AHSN Network for a collaborative way of working

AHSN staff on short term contracts, lose motivation to work on programmes and be collegiate

A significant number of our programme staff have fixed term contracts end dates in the next six months

H M Strong team spirit has been built up with supportive policies and procedures for staff in place

Posts have been advertised on NHS Jobs and HSJ

Only one risk has been categorised as having a ‘high’ likelihood and ‘high’ impact, this is the annual funding cycle which creates a lack of confidence with stakeholders and potential job applicants, which makes it difficult for the AHSN to attract appropriate staff. As the NHS England funding structure unlikely to change, the AHSN is mitigating by strong communications and marketing of the valuable contribution of its work

Board of Directors


Report Title Use of the Common Seal


Prepared by Umme Batan, Corporate Governance Support

Presented by Diane Halsey, Director of Governance and Compliance




Report purpose To note the Use of the Common Seal


To become recognised for excellence

Board Assurance Framework risk 7.2 the Trust does not comply with statutory legislative requirements

CQC domain Well-led

1.0 EXECUTIVE SUMMARY

To inform the Board that the Common Seal has been used as follows since the Board meeting

on 28 July 2015:

08 October 2015 - Lease renewal – LCFT and Rydon Relating to Tinsmith Building,

Guild Park, Cumeragh Lane, Goosnargh, Preston, PR3 2JH

2.0 BOARD ACTION

To note the use of the Common Seal.

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