council of governors 17 march 2015 5 .30 pm 7 pm · stephen astles - appointed governor (south...

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COUNCIL OF GOVERNORS 17 March 2015 5.30pm – 7pm

Board Room, Aintree Lodge

AGENDA

d = document v = verbal p = presentation

No Item Reference

Setting the Context - Chairman

5.30pm 1. Apologies for Absence

To note the apologies

CG14-15/065 (v)

2. Declarations of Interest

To receive declarations of interest in agenda items and/or any changes to the register of governors’ declarations of interest pursuant to Standing Orders

CG14-15/066 (v)

3. Minutes from the last meetings (17 December 2014 and Extraordinary meeting 20 January 2015)

To approve the minutes from the last meetings and discuss any matters arising

CG14-15/067 (d)

4. Chairman’s Report

To note the report

CG14-15/068 (v)

Where are we going as an Organisation?

5.40pm 5. Strategic Update

Chairman/Chief Executive

To note the update

CG14-15/069 (v)

6. Raising Concerns Update

Chief Executive

Executive Summary of Francis Report on VBR

To discuss and note

CG14-15/070 (p)

7. Key Areas – Director of Finance & Business Services Portfolio

Director of Finance & Business Services

Corporate Performance Report

To note the report

CG14-15/071 (d/p)

(circulated in advance)

How are we treating our patients? - Director of Nursing & Quality

6.10pm 8. Key Issues - Director of Nursing Portfolio

Director of Nursing & Quality

To note the presentation

CG14-15/072 (d/p)

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Aintree University Hospital NHS Foundation Trust

Agenda: Council of Governors Meeting 17 March 2015 2/2

No Item Reference

6.20pm 9. Quality Account – Performance Indicator

Director of Nursing & Quality

To approve

CG14-15/073 (d)

How do we run ourselves? What do others think?

6.30pm 10. Governor Elections 2015 – Results

Chairman

To note

CG14-15/074 (d)

6.35pm 11. Reports of Governor Committee Chairs:

Nominations Committee (20 January 2015)

Membership Committee (3 February 2015)

Quality of Care Committee (12 February 2015)

To note the reports

CG14-15/075 (d)

Other items for Governors to be aware of

6.45pm 12. Council of Governors’ Forward Plan 2014/15 and 2015/16

Chairman

To discuss and note

CG14-15/076 (d)

6.50pm 13. Governor Issues

(to be notified to FT Secretary no later than 24 hours before the meeting)

CG14-15/077 (v)

Concluding Business

14. Any Other Business

Chairman

CG14-15/078 (v)

15. Date and Time of Next Meeting:

Wednesday 17 June 2015 at 12.30pm

CG14-15/079 (v)

Council of Governors – Objectives 2014/15

• To deliver its statutory duties through the Council of Governors

• To assess the competence of the Board and effectively monitor its performance

• To enhance governors’ independence and ability to bring to light and challenge

deficiencies in the services provided by the Trust

• To communicate and engage effectively with members

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Council of Governors

Wednesday 17 December 2014 12.30pm-2.15pm

Board Room, Aintree Lodge

DRAFT MINUTES

Present: Neil Goodwin - Chairman

Maurice Byrne - Lead Governor

Mike Booth - Public Governor

Mike Bowker - Public Governor

David Cowan - Public Governor

John Johnson - Pubic Governor

Peter Mayne - Public Governor

Delyth Meirion-Owen - Public Governor

Rose Milnes - Public Governor

Pamela Peel - Public Governor

Stephen Thornhill - Public Governor

Lorraine Heaton - Staff Governor

Cllr Paul Cummins - Appointed Governor (Sefton MBC)

Mair Ning - Appointed Governor (Edge Hill University)

In Attendance: Catherine Beardshaw - Chief Executive

David Fillingham - Non-Executive Director

Nicola Firth - Director of Nursing & Quality

Paul Fitzpatrick - Director of Estates & Facilities

Carolyn Fox - Deputy Director of Nursing

Michael Games - Corporate Governance Manager

Sue Green - Director of People and Corporate Affairs

Patrick Hackett - Non-Executive Director

Juliet Herzog - Non-Executive Director

Tim Johnston - Non-Executive Director

Caroline Keating - Associate Director of Corporate Governance/Board

Secretary

Colin Maloney - Non-Executive Director

Andrew McLaughlin - Director of Strategy & Transformation

Mike Tomkins - Communications Officer

Richard Ward - Medical Director

Angela Whittaker - Associate Director of Strategy, Service

Development and Business Intelligence

Apologies: Tracey Barnes - Public Governor

Gerry Hill - Public Governor

Brian Lawless - Public Governor

Julie Naybour - Public Governor

Jeanette Wilding - Staff Governor

Stephen Astles - Appointed Governor (South Sefton CCG)

Kim McNaught - Appointed Governor (Liverpool CCG)

John Wilding - Appointed Governor (University of Liverpool)

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Minutes: Council of Governors Meeting 17 December 2014 2/9

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Private Business

CG14-15/041 Non-Executive Director Appraisals

The Chairman advised that the appraisals of the Non-Executive Directors had been

discussed by the Nominations Committee in line with Monitor’s Code of Governance. It

was noted that there had been positive comments received from Governors on the

performance of the Non-Executive Directors.

The Council of Governors noted the outcome of the appraisal of the Non-Executive

Directors.

Ref Minute

Setting the Context

CG14-15/042 Apologies for Absence

The apologies were noted as above.

CG14-15/043 Declarations of Interest

There were no declarations of interest.

CG14-15/044 Minutes from the last meetings (9 September 2014)

The minutes from the previous meetings were approved as an accurate record.

CG14-15/045 Chairman’s Report

The Chairman’s comments were recorded under the Strategic Update below.

Where are we going as an Organisation?

CG14-15/046 Strategic Update

The Chairman commented that it was for the Board of Directors to agree the strategy for

the organisation and outline its intentions in the 5 year plan submitted to the regulators.

Part of that strategy had been for the Trust to work collaboratively with the Royal

Liverpool Hospital to develop more efficient ways of working together as partners. A

Clinical Summit had taken place with over 200 consultants to discuss collaborative

working and the outcome from these discussions was expected to conclude in early

February 2015. It was noted that no firm decisions had been made and that there was

ongoing discussions with the Commissioners in progress. Governors would be kept

informed.

The Chief Executive advised that discussions were also taking place with other providers

across Liverpool and Wirral on partnership working. In addition, the leaders in the City

had recognised that changes were necessary in the provision of healthcare across the

region in order to maintain high quality and safe services and they were keen to be

involved. It was important to ensure that the Trust was capable of competing with other

providers locally whilst developing a collaborative approach across the region.

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Ref Minute

The Council of Governors requested clarification on the following points:

Does any co-joining with Royal Liverpool Hospital have any financial

implications? At this juncture the financial implications were unknown. However,

the financial pressures that were likely to be placed on all Trusts going forward

would increase and so it was important that this was taken into consideration at the

appropriate time.

Was there likely to be an amalgamation of hospitals in an effort to reduce

costs? Whilst discussion had not focussed on this particular element, it was

considered to be unlikely that there would be a single Trust covering a number of

hospitals in the region. However, there was likely to be some amalgamation across

the region.

The Chief Executive then highlighted the following key areas:

A&E continued to underperform against target particularly in the last 3 weeks. Work

had taken place on redesigning internal systems to improve patient flow and whilst

there had been some progress, it had not to date had the desired effect. The Trust

had been in discussion with its community partners and local authorities in an effort

to speed up the discharge process. It was unlikely that the Trust would achieve its

Q3 A&E target and Monitor would be informed accordingly. However, there was

recognition of the difficulties within the system nationally and this would be taken into

account. The Trust had been asked to attend a ‘Star Chamber’ session with NHS

England to discuss the A&E pressures and work was being undertaken to improve

the situation.

Dr Steven Evans had been appointed as the Trust’s new Medical Director and would

commence his duties on 1 February 2015.

The Trust had received the latest mortality report which highlighted that there had

been an increase in the Summary Hospital Mortality Indicator (SHMI) level.

However, when the Trust was measured against the rebased Hospital Standardised

Mortality Ratio, it was below the national average. A meeting was scheduled with the

Commissioners to discuss the position and provide an update on the work of the

Trust in the various mortality workstreams.

The Council of Governors requested clarification on the following points:

What else can be done by other providers in the region? In essence, a strong

community health service was necessary to alleviate the pressure on the Hospital

coupled with more patient access to GPs. There had also been dialogue with Mersey

Care and the Commissioners on the number of mental health patients arriving at A&E

and the support required from them on mental health related issues.

The Council noted the update.

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CG14-15/047 Business Planning 2015/16

A presentation was provided by the Associate Director of Strategy, Service Development

and Business Intelligence which covered the following matters:

Aintree’s vision of the wider health and social care economy – working jointly

with providers to create a centre of excellence in Liverpool.

Delivering Aintree’s vision and priorities – achieved through horizontal integration

with Royal Liverpool Hospital and vertical integration with community care providers

whilst also ensuring sustainable delivery of operational and quality performance

targets.

Priorities for 2015/16 taking account of the strategic direction of the NHS and

commissioning intentions – Divisional business plans were being developed with

particular emphasis on the need for the plans to be financially balanced.

Strategic Direction 5 Year Forward View – the published document predicts a

funding gap of c£30 billion by 2020/21, highlights the radical upgrades needed in

public health and the steps required to break down barriers to care.

Commissioning intentions – changes to the nationally prescribed set of specialist

services. Locally, the work programme was considering the establishment of a single

site for major trauma and reviewing other specialist services. Work continues on

understanding local commissioning intentions via Better Care Fund submissions and

other local opportunities.

The process and timetable for business planning 2015/16 – review meetings had

commenced with Divisions and further face to face meetings were planned for

February 2015 to discuss plans in more detail.

Emerging priorities – these had been split into strategic, operational and tactical to

ensure that all aspects of the emerging business priorities were covered. These

would be further refined into a list of business priorities for the Trust for 2015/16.

The point was made that there was a great deal of reconfiguration in the health care

sector being considered at a time when costs were being reduced. It was, therefore,

important that the Board of Directors and the Council of Governors focus on the most

important issues affecting the strategic direction of the Trust.

The Council requested clarification on the following points:

Did the Trust currently undertake cosmetic breast surgery? The vast majority of

work was breast screening based on rigorous criteria already in place. There was

some cosmetic breast surgery undertaken but this would only be performed if the

patient passed the set criteria.

The Council noted the presentation.

CG14-15/048 Key Areas – Director of Finance & Business Services Portfolio

The Director of Finance and Business Services gave a presentation covering key areas

across all aspects of the portfolio for month 7. The following key points were highlighted:

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Ref Minute

1 Serious Untoward incident reported

No Never Events but 398 Incidents reported once of which resulted in a death

1 Grade 3 pressure ulcer had been reported since the corporate performance report

was issued with 7 at Grade 2

5 C.Difficile cases had been reported culminating in 29 for the year to date although a

number were still the subject of appeal.

A&E continued to underperform against target despite improvement measures being

put in place for patient flow.

All referral to treatment targets had been met in month

Cancer targets had been achieved with the exception of the 62 day screening

(85.7%)

There had been 1 mixed sex accommodation breach in month

Cancelled operations were below target and all patients had been readmitted within

the 28 day deadline

Outpatient cancellations had reduced to 6.71% (6.9% in October)

Mortality – Summary Hospital-level Mortality Indicator (SHMI) continued to be of

concern but the Hospital Standardised Mortality Ratio (HSMR) was better than the

national average

The Trust was behind target on 9 Commissioning for Quality Innovations (CQUINS)

Theatre utilisation for the Hospital was at 71.1% and for the Elective Care Centre was

66.8%

There was a financial deficit of £1.6m for the year to date for the Trust but it

maintained its Financial Risk Rating of 3 with liquidity at 10 days.

The Director of Finance & Business Services reminded the meeting that replies to the

various questions raised in advance had been issued. If Governors required any further

clarification, they were requested to contact him directly. He also reminded Governors

that arrangements had been made for sessions on finance in January 2015 and that the

intention was to go through the corporate performance report in detail including the

section relating to mortality. In addition, arrangements would be made for a bespoke

session on mortality to be provided by D Fillingham Non-Executive Director.


Does the Trust survey patients in A&E on the reasons for not taking advantage

of other health care availability? This had not been factored into the process

because of the busy nature of the Department and the pressure being put on them to

achieve their targets. However, it is something that the Trust may consider going

forward.

Why was theatre utilisation so low? The Trust was fully aware of the need to

improve this particular target but it should be acknowledged that cases can be very

complex which, in turn, creates a backlog, overrunning and/or cancellations.

Why had the financial deficit increased? The Trust continued to have challenges

in achieving its Cost Improvement Plan (CIP) targets and efficiency measures. Cash

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balances had been used to support the revenue of the Trust but this was not

sustainable going forward.

Why had the options on the breakfast menu for patients been reduced? The

Trust was not aware of any cost cutting arrangements put in place to reduce the

breakfast options available for patients. Certain changes may have been made on

Wards for dietary reasons. The matter would be investigated further.

The Chairman commented that the Board was keeping a close eye on the overall

performance of the Trust and acknowledged that improvements were beginning to be

made, particularly in regard to patient flow in A&E. The Board was not complacent and

understood the reputational damage caused by continued poor performance can have on

the Trust. In the circumstances, arrangements were being made to drill down into certain

areas to gain more of an understanding of where improvements can be made.

The Council noted the update.

How are we treating our patients?

CG14-15/049 Key Issues – Director of Nursing Portfolio

The Deputy Director of Nursing gave a presentation covering key issues across all

aspects of the Nursing Portfolio. The following key points were highlighted:

The themes and observations arising from the Director’s walkabouts and the

challenge of sustaining and making further improvements within the Trust

The outcomes from the Quality Strategy Showcase event held in September 2014

The Trust’s improved performance against MRSA bacteraemia compared to the

previous year

The improved position in the number of C.Difficile cases within the Trust and the

successful number of appeals

The sustained performance for the reduction of Grade 2 pressure ulcers and no

Grade 3 or 4 pressure ulcers reported for over 320 days on an acute ward

The measurements in place for improvement in the prevention of falls with harm

following on from the work of the Falls Collaborative learning sessions

The outcomes from the Aintree Assessment and Accreditation programme which

assess all Wards against 14 standards and rated accordingly

The improvements made in the catering workstream on nutrition and hydration at

mealtimes

The newly established monthly nurse staffing meetings and the twice yearly

overarching staffing report to Board encompassing a wide range of indicators

The improvements against target to meet CQUIN response rate quality goals for the

Friends and Family Test

The achievements made by the Patient Advice and Complaints Team since July

2013 and their action plan for 2014/15.


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There was no mention of the prescribing of medication. Can this be included

for the next meeting? Arrangements will be made to provide Governors with an

update on the prescribing of medication for the next meeting. It was noted that the

Quality & Safety Committee received a quarterly report on this matter on an

exception basis

Was the Trust’s complement of nursing staff sufficient? The Trust’s nursing

workforce was not at its full complement and work continued to be undertaken with

the Divisions to understand the staffing position to ensure that there was sufficient

staff available to look after patients safely. In addition, Human Resources were

working closely with Divisions to recruit appropriate nursing staff to vacant positions

in order to reduce the dependency on agency and bank staff.

The Council noted the presentation.

How do we run ourselves? What do others think?

CG14-15/050 Council of Governors’ Development Plan

The Council of Governors approved the development plan and associated

schedule/timescales.

CG14-15/051 Committee Minutes

The following draft minutes were noted by the Council of Governors

Membership Committee meeting held on 7 October 2014

Nominations Committee meeting held on 26 November 2014.

Other items for Governors to be aware of

CG14-15/052

External Auditors – Extension of Contract

The Chairman confirmed that in April 2012 the Council of Governors approved the

appointment of PricewaterhouseCoopers (PwC) for a term of 3 years with an option to

extend the contract by a further 2 years if felt appropriate. The Audit Committee agreed

to exercise the option to extend the external audit contract to PwC for a further 2 years

and Governors were informed of the decision on 31 October 2014.

The Chairman of the Audit Committee remarked that he and the Director of Finance &

Business Services were scheduled to meet with PwC to discuss improvements to their

audit plans.

The Council of Governors noted the matter.

CG14-15/053 Elections 2015

The Associate Director of Corporate Governance/Board Secretary referred to the paper

and confirmed that a By-Election was required to be held for 2 Staff Governors (Medical

and Other) and arrangements were underway to commence these elections in January

2015.

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In addition, it was confirmed that further vacancies for Public Governors and a Staff

Governor (Nursing) were scheduled to take place in the Summer 2015. In the

circumstances, it was being proposed to hold these election alongside the By-Elections

in January 2015 as this would provide value for money and allow for the newly appointed

Governors to receive appropriate and timely induction whilst in ‘shadow’ form. It was

noted that UK Engage had been appointed to run the elections on behalf of the Trust.

The Council of Governors supported the proposal.

CG14-15/054 Draft Minutes of the Annual Members’ Meeting (30 September 2014)

The draft minutes of the Annual Members’ Meeting held on 30 September 2014 were

noted by the Council of Governors.

CG14-15/055 Schedule of Meetings for 2015/16

The schedule of meeting dates for 2015/16 was noted by the Council of Governors.

CG14-15/056 Council of Governors’ Forward Plan 2014/15

The Council of Governors’ Forward Plan for 2014/15 was noted by the Council of

Governors.

CG14-15/057 Governor Issues

The Lead Governor expressed his appreciation to the Corporate Governance Team for

the changes to the format of the Informal Governors’ Meeting and for providing the

replies to questions on the Corporate Performance Report in a timely manner. He also

reminded Governors that they now had access to Virtual Board Room and all the

documentation required for meetings would be available through this medium and by

email. Paper copies would only be made available on request.

The Lead Governor also commented on the excellent evening for the Aintree Awards

and congratulated the Trust on the recent awards and nominations received for its

services.

One of the Governors then commented on a number of issues he had raised recently

with the Chief Operating Officer that had not been replied to. The Chief Executive stated

that she would take the matter up with the Chief Operating Officer and ensure that a

suitable reply to the queries raised would be provided. The Governor concerned also

mentioned that he had put himself forward as a panel member for the recent Medical

Director appointment process. He added that he had received an email the day before

the panel session and his name had not been included. He had telephoned the Trust to

point out the error but was not contacted further with any explanation. The Associate

Director of Corporate Governance/Board Secretary commented that the procedure for

dealing with Governor queries needed to be tightened and stated that an escalation

process would be developed internally to ensure that queries were dealt with a timely

fashion.

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The Council noted the issues raised.

CG14-15/058 Any Other Business

The Chairman made reference to the recent communication in relation to the retirement

of the Chief Executive. He then placed on record his appreciation for the work she had

undertaken on behalf of the Trust and wished her health and happiness in her retirement.

He confirmed that the process to find a suitable replacement had commenced and that

Governors would be involved at some point.

The Director of People & Corporate Affairs remarked that an advert had been placed in

the HSJ last week and for the following two weeks. The Trust had appointed Gatenby

Sanderson to provide the necessary recruitment assistance. It was the intention to hold

a selection centre in early March and Governors would be written to accordingly for

expressions of interest to be involved in the day.

On behalf of the Governors, the Lead Governor also expressed his appreciation to the

Chief Executive on the occasion of her retirement.

The Council of Governors noted the position.

CG14-15/059 Date and Time of Next Meeting:

Tuesday 17 March 2015 in the Boardroom, Aintree Lodge at 5.30pm.

Chair’s Signature: Date:

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Council of Governors (Extraordinary Meeting)

Tuesday 20 January 2015

2.30pm Conference Room B, 2nd Floor Aintree Lodge

MINUTES

Present: Neil Goodwin - Chairman

Mike Booth - Public Governor

Maurice Byrne - Lead Governor

David Cowan - Public Governor

John Johnson - Public Governor

Brian Lawless - Public Governor

Rose Milnes - Public Governor

Pamela Peel - Public Governor

Jeanette Wilding - Staff Governor

Paul Cummins - Appointed Governor

In Attendance: Caroline Keating - Associate Director of Corporate Governance/ Board Secretary

Steve Warburton Director of Finance & Business Services/ Deputy Chief Executive

Apologies: Tracey Barnes - Public Governor

Mike Bowker - Public Governor Gerry Hill - Public Governor Peter Mayne - Public Governor Delyth Merion-Owen - Public Governor Julie Naybour - Public Governor Stephen Thornhill - Public Governor

Lorraine Heaton - Staff Governor Stephen Astles - Appointed Governor

Kim McNaught - Appointed Governor Mair Ning - Appointed Governor John Wilding - Appointed Governor

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CG14-15/

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Apologies for Absence

The apologies were noted as above.

CG14-15/

061

Declarations of Interest

There were no declarations of interest.

CG14-15/

062

Appointment of Non-Executive Director of the Trust

The Chairman and Lead Governor provided the meeting with an overview of the process

undertaken in regard to the appointment of a Non-Executive Director with particular

reference to the job description and person specification.

The Chairman confirmed that feedback from the focus group session and outcome of the

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Draft Minutes – Extraordinary Council of Governors 20 January 2015: Council of Governors 17 March 2015 2/2

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interview panel were then taken into consideration following which a recommendation was

put to the Nominations Committee.

The candidate being nominated for appointment of Non-Executive Director was Joanne

Clague, University of Liverpool.

The Governors unanimously agreed to the appointment of Joanne Clague to the position of

Non-Executive Director of Aintree University Hospital NHS Foundation Trust with effect from

1 April 2015 for a period of three years subject to the requirements of the fit and proper

persons test being fulfilled.

The Lead Governor placed on record his appreciation to all those involved in the process.

CG14-15/

063

Any Other Business

No further business was raised.

CG14-15/

064

Dates of Next Meetings

Council of Governors Formal Public Meeting – Tuesday 17 March at 5.30pm

Signed: ……………………………………….. Date: ………………………… Chair

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Board of Directors, Update

Corporate Report – 31st January 2015

Key Messages of this Report

Performance against key measures was mixed. Two Serious Untoward Incidents (SUI) reported, with 8 incidents causing moderate harm, 1 severe harm and 1 death. Six C-Difficile infections reported. Referral To Treatment (RTT) performance was positive as was cancer, excepting 62-day screening. AED, stroke and diagnostics performance continued to be at sub-optimal levels, although the latter is improving. Financially the trust is reporting a deficit against plan, albeit improved on last month.

Introduction/Background

1. This paper presents the corporate performance data for January 2015 (Month 10) against Monitor’s, the Care Quality Commissions (CQC) targets, contracts and internal standards.

Key Issues

2. Main issues for January 2015:

2 SUI reported, no never events, 411 incidents, (8 moderate harm, 1 severe harm and 1

death).

Patient thermometer survey of ‘harm free care’ 1.02% above the national median; 1 grade

3/4 pressure ulcer; 7 grade 2 ulcers. Both targets better than cumulative trajectory.

6 cases of C-Diff, within contract target, but outside stretch target for the month. No MRSA.

Friends and Family scores are positive for inpatient and AED, the latter maintaining a score

close to NHS national and Merseyside averages.

AED target missed in month and deteriorated.

All aggregate and specialty level RTT targets met in month.

62-day cancer screening missed in month, a; other cancer targets met.

Diagnostic access target improved, but missed the target at 1.3%; stroke target missed for

the 4th consecutive month; all patients readmitted within 28 days of a cancelled operation.

No breaches of the mixed sex accommodation target

16 new complaints received, 111 concerns, no compliments.

Standard Hospital Mortality Index, (SHMI) 114.76, Hospital Standardised Mortality Rate,

(HSMR) was 90.05.

A number of CQUIN targets behind target.

The suite of efficiency measures for the trust remains below target levels.

Activity throughput was in general above plan. The income surplus grew, offset by

operational budgets overspend and unachieved Cost Improvement Plans (CIP). There is a

reported deficit of -£935K (£313K better than last month), against the planned surplus of

+£59K.

RAF of 4, at plan.

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ical

Ass

essm

ent

28

Acc

ess/

App

oint

men

t/Adm

issi

on/T

rans

fer

30

32

Infr

astr

uctu

re/r

esou

rces

19

Pat

ient

info

rmat

ion

27

Fig

ure

1 –

SU

I’s

an

d n

eve

r eve

nts

by m

on

th

Fig

ure

2 –

in

cid

en

ts a

nd

se

ve

rity

of

ha

rm

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 18 of 80

Pa

ge

6 o

f 54

5.

Pa

tie

nt S

afe

ty T

he

rmo

me

ter

Perf

orm

ance ag

ain

st

the S

afe

ty T

herm

om

ete

r show

ed

the n

um

ber

of

patients

receiv

ing

harm

fre

e c

are

at

the

last

census im

pro

ved to

98.4

8%

(D

ec:

98.7

7%

), better

than the n

ational m

edia

n p

erf

orm

ance (

97.8

6%

).

Seven

gra

de

2

pre

ssure

ulc

ers

w

ere

record

ed i

n m

onth

, above t

he m

onth

ly r

un

-

rate

. C

um

ula

tive

positio

n

rem

ain

s

within

traje

cto

ry t

o d

eliv

er

the a

nnual

obje

ctive o

f

no m

ore

than 7

2 c

ases.

A s

econd g

rade 3

pre

ssure

ulc

er

was a

lso

record

ed,

ag

ain

caused due to

pla

ste

r-of-

paris,

this

tim

e o

n W

21.

The t

rust

rem

ain

s

on tr

aje

cto

ry to

achie

ve

th

e ta

rget

for

the

year.

Actions

Min

i g

rade 2

pre

ssure

ulc

er

colla

bora

tive c

om

menced i

n D

ecem

ber

14 t

o l

ook a

t how

we c

an r

educe t

he n

um

ber

of

gra

de 2

pre

ssure

ulc

ers

within

the t

rust. T

he p

ilot

ward

s w

ill b

e c

arr

yin

g o

ut

test

of

chang

e l

ookin

g a

t re

positio

nin

g a

nd m

anual

handlin

g a

ids,

patient

info

rmation a

nd d

ocum

enta

tion, A

HP

involv

em

ent

in inte

ntional ro

undin

g. N

ext

meeting

takin

g p

lace 1

0th F

ebru

ary

.

As p

art

of

the m

edic

al devic

e w

ork

str

eam

, th

e n

asal cannula

(specs)

have

been c

hang

ed t

o incorp

ora

te a

foam

ear

guard

to r

educe t

he

incid

ence o

f pre

ssure

ulc

ers

.

Fig

ure

4 –

Harm

fre

e c

are

M1

0 2

01

4-1

5

Fig

ure

5 –

Ho

sp

ita

l ac

qu

ired

pre

ss

ure

ulc

ers

Page 19 of 80

Pa

ge

7 o

f 54

6.

Infe

ctio

n C

on

tro

l

MR

SA

F

igu

re 6

– M

RS

A p

erf

orm

an

ce

M1

0 (

20

14

-15

)

Fig

ure

7 s

how

s A

UH

was r

anked 5

7th o

f 159 tru

sts

(1

st b

ein

g t

he w

ors

t).

Fig

ure

7 –

MR

SA

pe

rfo

rma

nc

e M

10

(20

14

-15

)

MS

SA

F

igu

re 8

– M

SS

A p

erf

orm

an

ce

M1

0 (

20

14

-15

)

With

low

num

bers

of

MR

SA

, it

is

pru

dent

to

continue

to

monitor

MS

SA

(M

eth

icill

in-s

ensitiv

e

Sta

phylo

coccus a

ure

us)

on a

reg

ula

r basis

.

Aft

er

hig

her

num

bers

in

th

e

pre

vio

us

quart

er,

M

SS

A n

um

bers

fell

back i

n J

anuary

, w

ith j

ust

1

case r

eport

ed.

No M

RS

A c

ases w

ere

report

ed i

n J

anuary

. T

he p

ost

Infe

ction

revie

w f

or

the D

ecem

ber

case,

confirm

ed t

he p

lan o

f care

for

the p

atient

was a

ppro

priate

, but

assig

ned t

he c

ase t

o t

he t

rust

as t

here

were

lapses in s

cre

enin

g a

nd d

ecolo

nis

ation.

Th

e t

rust

still

aw

aits a

re

sponse f

rom

NH

SE

for

the J

uly

case,

how

ever

this

is u

nlik

ely

to lead to a

reassig

nm

ent.

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 20 of 80

Pa

ge

8 o

f 54

7.

Infe

ctio

n C

on

tro

l (c

on

’t)

Fig

ure

10 a

bove

show

s

C-D

iff

Fig

ure

9 –

C-D

iff

pe

rfo

rma

nce

M10

(2

01

4-1

5)

aft

er

su

cce

ss

ful

ap

pe

als

Bed d

ays lost to

infe

ction

Fig

ure

11

– B

ed

da

y s

lo

st

M1

0 (

201

4-1

5)

During

January

3

bed days

were

lo

st

to in

fection,

repre

senting

0.0

1%

of

availa

ble

beds (D

ec:

0.0

1%

and 2

beds,

adju

ste

d s

ince last

month

’s r

eport

).

Fig

ure

10

– C

-Dif

f b

en

ch

ma

rkin

g M

10

(2

01

4-1

5)

Six

cases of

C-D

iff

we

re re

port

ed in

January

, bring

ing

th

e

cum

ula

tive p

ositio

n t

o 3

9,

well

within

the c

ontr

actu

al

traje

cto

ry

of

68,

but

8 hig

her

than th

e in

tern

al

str

etc

h ta

rget. N

ational

report

ing

will

continue t

o a

ssig

n t

he 1

5 s

uccessfu

lly a

ppeale

d

cases to the tru

st (5

4 in tota

l).

Fig

ure

10 a

bove s

how

s A

UH

was r

anked 1

7th o

f 159 t

rusts

, (4

3rd w

hen

accounting

for

successfu

l appeals

)

Page 21 of 80

Pa

ge

9 o

f 54

Co

mp

lain

t F

ree

:- o

ve

rall

RA

G r

ati

ng

8.

Po

sitiv

e E

xp

erie

nce

9.

4 C

’s

Inpatients

Net P

rom

ote

r S

core

Fig

ure

12

– F

rie

nd

s a

nd

fa

mil

y t

es

t in

pa

tie

nts

Mo

nth

10

(2

01

4-1

5)

AE

D N

et

Pro

mote

r S

core

Fig

ure

13

– F

rie

nd

s a

nd

fa

mil

y t

es

t A

ED

Mo

nth

10

(20

14

-15

)

Fig

ure

14

- T

ren

d i

n 4

Cs

mea

su

res

by m

on

th

The

inpatient

net

pro

mote

r w

as

sta

ble

at

84

pts

. and

rem

ain

s

consis

tently a

bove t

he N

HS

Eng

land a

nd M

ers

eysid

e a

vera

ge f

or

this

measure

.

AE

D n

et

pro

mote

r re

duced f

rom

52 t

o 4

7,

but

rem

ain

s a

bove t

he 1

2

mth

avera

ge.

Last

month

s’

positio

n w

as clo

se

to

M

ers

eysid

e and

National avera

ges f

or

the f

irst tim

e in 1

2 m

ths.

7 c

om

ments

, 0 c

om

plim

ents

, 111 c

oncern

s,

incl

9 f

rom

GP

s,

and 1

6 n

ew

com

pla

ints

receiv

ed.

2 o

ld c

om

pla

ints

re-o

pened.

January

is t

he 2

nd c

onsecutive m

onth

were

no

com

plim

ents

have b

een r

eceiv

ed.

The b

reakdow

n o

f th

e 4

C’s

by d

ivis

ion f

or

January

is:

Fig

ure

15

– 4

C’s

by d

ivis

ion

– M

on

th 1

0 (

20

14

-15

)

Div

isio

n

Com

ment

Com

plim

ents

C

oncern

s

Com

pla

int

Med

ical

1

0

27

5

Surg

ical

4

0

65

10

Sup

port

0

0

3

1

Oth

er

2

0

16

0

Tota

l:

7

0

111

16

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 22 of 80

Pa

ge

10

of 5

4

10.

Co

mp

lain

ts (

co

n’t)

The tr

end in

com

pla

ints

by D

ivis

ion is

sho

wn belo

w.

Surg

ical

com

pla

ints

have ste

adie

d aft

er

an in

itia

l blip

as a

re

sult of

the tr

ansfe

r of

manag

em

ent contr

ol of A

ED

fro

m M

edic

ine

. M

ed

icin

e’s

rate

is r

ela

tively

sta

tic.

Fig

ure

16

– c

om

pla

ints

by d

ivis

ion

M10

201

4-1

5

T

he tru

st has a

n inte

rnal ta

rget to

respond to c

om

pla

ints

within

25 d

ays,

with a

national ta

rget th

at all

com

pla

ints

should

be r

esponded t

o w

ithin

6

month

s.

Perf

orm

ance a

cro

ss the tru

st ag

ain

st th

e inte

rnal ta

rget continues t

o r

un a

t an a

vera

ge o

f 34%

to 3

8%

. W

eekly

meeting

s w

ith D

ivis

ions

on c

om

pla

int re

sponses/r

ate

s a

re e

sta

blis

hed w

ith a

vie

w t

o d

rivin

g p

erf

orm

ance u

pw

ard

.

Fig

ure

17

– r

es

po

nse

ra

te a

ga

ins

t 25

da

y i

nte

rna

l ta

rge

t M

10

20

14

-15

In

the last

12 m

onth

s,

no c

ases h

ave e

xceeded t

he n

ational re

quirem

ent fo

r re

spondin

g t

o c

om

pla

ints

.

Sin

ce A

pril 2014, th

ere

have b

een 1

2 O

mbudsm

an c

om

pla

ints

, of

whic

h,

1 w

as u

pheld

, 1 p

art

ially

upheld

, 2 d

ism

issed, and 8

rem

ain

as o

n-g

oin

g

investig

ations.

Page 23 of 80

Pa

ge

11

of 5

4

De

lay F

ree

Ca

re:-

o

ve

rall R

AG

ra

tin

g

11. 4

Ho

ur

Wa

it in

AE

D

F

igu

re 1

8 –

AE

D t

arg

et

Mo

nth

10

(20

14

-15

)

The

95%

ta

rget

was

mis

sed,

with

perf

orm

ance

continuin

g

to

dete

riora

te

to

84.7

8%

, (D

ec:

86.5

3%

) in

clu

din

g

Kirkby

WIC

,

(79.0

1%

on A

UH

site, -2

.06%

).

Fig

ure

19

– A

ED

cli

nic

al

ind

ica

tors

Mo

nth

10

(20

14

-15

)

Excepting

am

bula

nce

HA

S

data

captu

re,

all

AE

D clin

ical

indic

ato

rs

dete

riora

ted

in

Decem

ber,

w

ith 5 of

7 belo

w

targ

et.

The

trust

als

o

faile

d

the

am

bula

nce handover

tim

e fo

r

the f

irst tim

e in o

ver

2 y

ears

.

An

excep

tio

n

rep

ort

is

sh

ow

n a

t A

pp

en

dix

1 o

f th

is

rep

ort

.

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 24 of 80

Pa

ge

12

of 5

4

12.

RT

T 1

8w

ee

ks

All

RT

T targ

ets

were

met in

January

, both

in a

gg

reg

ate

and a

t specia

lty level.

The a

dm

itte

d m

edia

n w

ait indic

ato

r w

as m

arg

inally

above t

he s

tandard

at 11.5

weeks.

No p

atients

are

waitin

g o

ver

52 w

eeks.

Fig

ure

20

: s

um

ma

ry R

TT

pe

rfo

rma

nc

e –

M1

0 (

20

14

-15

)

Page 25 of 80

Pa

ge

13

of 5

4

13.

Ca

nce

r S

tand

ard

s

F

igu

re 2

1 –

tre

nd

in

ca

nce

r p

erf

orm

an

ce M

10

(2

01

4-1

5)

Pro

vis

ional data

for

January

indic

ate

s t

hat

all

targ

ets

were

met

with t

he e

xception

of

the 6

2 d

ay s

cre

enin

g t

arg

et, w

ith 2

bre

ach in t

he c

ohort

of

4 e

ligib

le p

atients

. A

n e

xcep

tio

n r

ep

ort

on

62

-day c

an

cer

scre

en

ing

is s

ho

wn

at

Ap

pen

dix

2 o

f th

is r

ep

ort

.

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 26 of 80

Pa

ge

14

of 5

4

14.

De

lays a

nd

ca

nce

llatio

ns

Outp

atients

cancelle

d

Fig

ure

23

– O

utp

ati

en

t c

an

ce

lla

tio

ns

– M

on

th 1

0 (

20

14-1

5)

Cancella

tions i

ncre

ased t

o 7

.20%

fro

m 6

.20%

, (4

,441 a

ppoin

tments

).

The t

rend o

ver

the l

ast

12 m

onth

s i

ndic

ate

s l

ittle o

vera

ll chang

e i

n t

he

cancella

tion n

um

bers

and r

ate

.

In J

anuary

the t

rust

pla

nned 8

,077 o

utp

atien

t clin

ic s

tream

s,

of

whic

h

496 w

ere

cancelle

d,

a r

ate

of

6.1

% (

Dec:

683 fro

m 8

,350, 8.2

%).

Opera

tions c

ancelle

d

Fig

ure

22

– O

pe

rati

on

s c

an

ce

lle

d f

or

no

n-c

lin

ica

l re

aso

ns

– M

on

th 1

0 (

201

4-1

5)

In t

ota

l 17 o

pera

tions w

ere

cancelle

d,

(24

last

month

), o

f w

hic

h 1

0 w

ere

cancelle

d

for

lack

of

theatr

e

tim

e,

4

as

no

bed

availa

ble

and 3

for

oth

er

reasons.

Perf

orm

ance w

as bett

er

tha

n th

e 0.8

0%

targ

et

at

0.4

7%

(D

ec:

0.7

2%

).

All

cancelle

d

patients

w

ere

re

-adm

itte

d

within

the 2

8 d

ay d

eadlin

e.

Med

icin

e’s

and S

urg

ery

’s c

ancella

tion r

ate

s s

how

little c

hang

e o

ver

the last 12 m

onth

s.

The tr

ustw

ide re

vie

w of

outp

atient

clin

ics,

waitin

g lis

ts,

capacity,

cancella

tions

etc

. continues.

This

is

a

long

-term

pro

ject

and

to

reduce r

isk a

nd b

e r

eflective o

f specia

lty n

eeds i

s b

ein

g c

om

ple

ted

one d

epart

ment

at

a tim

e.

Fig

ure

24

– D

ivis

ion

al

ca

nc

ell

ati

on

s –

Mo

nth

10

(20

13

-14

)

Page 27 of 80

Pa

ge

15

of 5

4

15.

Oth

er

Dia

gnostics

Fig

ure

25

– D

iag

no

sti

c w

ait

s –

M10

(2

01

4-1

5)

Echocard

iogra

phy p

erf

orm

ance r

ecovere

d,

meeting

the t

arg

et

for

January

, how

ever

Endoscopy

wa

its

incre

ased

to

5.7

%,

trip

pin

g t

he tru

st

over

the 1

.0%

targ

et

at

1.3

%.

An

excep

tio

n r

ep

ort

is s

ho

wn

at

ap

pen

dix

3 o

f th

is r

ep

ort

.

Str

oke

Fig

ure

26

– %

of

pa

tie

nts

sp

en

din

g 9

0%

of

the

ir t

ime

on

a s

tro

ke

un

it –

M10

(2

01

4-1

5)

Str

oke p

erf

orm

ance w

ors

ened a

nd w

as b

elo

w t

he r

eq

uired

sta

ndard

at 6

4.7

%. T

he targ

et fo

r th

e q

uart

er

was m

issed.

The m

ain

reason f

or

the c

ontinued p

erf

orm

ance f

ailu

re,

are

late

refe

rrals

to t

he s

troke t

eam

and b

ed c

apacity c

onstr

ain

ts

within

the u

nit.

A f

ull

serv

ice r

evie

w i

s i

n p

rog

ress,

inclu

din

g

the e

sta

blis

hm

ent of

a h

yper

acute

str

oke u

nit.

T

he

latter

has

been

put

befo

re

com

mis

sio

ners

fo

r

consid

era

tion

of

investm

ent

as

part

of

the

2015/1

6

contr

acting

round.

An

excep

tio

n

rep

ort

is

sh

ow

n

at

ap

pen

dix

4

of

this

rep

ort

.

Dela

yed t

ransfe

rs o

f care

Fig

ure

27

– D

TO

C’s

, M

10

(2

01

4-1

5)

DT

OC

s w

ere

sta

ble

at

2.8

3%

, re

pre

senting

597 bed

days l

ost

and a

contr

ibuto

ry f

acto

r in

the p

roble

ms o

f

manag

ing f

low

thro

ug

h the h

ospital.

The p

rocesses a

nd c

om

munic

ation lin

ks t

hro

ug

h w

eekly

meeting

s

with

the

com

munity

health

care

te

am

s

continue to

develo

p a w

ho

le syste

m appro

ach.

T

he

trust

is l

ookin

g c

losely

at

inte

rnal

pro

cesses t

hro

ug

h a

n

eff

ective d

ischarg

e p

roje

ct

to e

nsure

min

imal

dela

ys t

o

dis

charg

e a

re s

een a

nd t

he p

atient

experience r

em

ain

s

positiv

e.

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 28 of 80

Pa

ge

16

of 5

4

Cli

nic

al

Eff

ec

tive

ne

ss

:-

o

ve

rall

R

AG

rati

ng

16. M

ort

alit

y

Fig

ure

30

– C

rud

e M

ort

ali

ty /

ac

tua

l d

ea

ths

HS

MR

sta

nds a

t 9

0.0

5.

AU

H’s

rela

tive p

ositio

n a

cro

ss

the N

ort

h W

est

sta

nds a

t 17

th o

f 22, (p

revio

usly

14

th).

F

igu

re 2

9 –

HS

MR

In m

onth

cru

de m

ort

alit

y a

nd n

um

ber

of

death

s f

ell

slig

htly

in January

and a ro

ug

hly

com

para

ble

to

th

e sam

e t

ime

last

year.

T

he rise in

death

s in

D

ecem

ber

and January

has b

een l

inked t

o a

n i

ncre

ase i

n t

he n

um

ber

of

patients

pre

senting

w

ith

pneum

onia

, (s

imila

r to

2014),

and

a

conseq

uential in

cre

ase in r

eport

ed d

eath

s.

SH

MI

reduced m

arg

inally

to 1

14.7

6 a

nd t

he 3

rd h

ighest

in t

he r

eg

ion (

pre

vio

usly

2nd).

The

gra

ph b

elo

w s

how

s t

he S

HM

I score

over

tim

e a

nd t

he n

um

ber

of

in-h

ospital

and o

ut

of

hospital

death

s.

Work

continues w

ith C

CG

s t

o l

ook a

t out

of

ho

spital

death

s i

n m

ore

deta

il by p

rom

oting c

om

munity led m

ort

alit

y r

evie

ws a

nd im

pro

vin

g join

t care

path

ways.

Fig

ure

28

– S

HM

I

Page 29 of 80

Pa

ge

17

of 5

4

17.

Re

ad

mis

sio

ns

18.

Mix

ed

Se

x A

cco

mm

od

atio

n

Com

para

tive

28

day

readm

issio

n

data

(c

ase

mix

adju

ste

d a

nd a

sub s

et

of

all

HE

S d

ata

) show

s t

hat

the a

ctu

al re

adm

issio

n r

ate

for

Jul 14 d

ata

, (t

he late

st

availa

ble

),

is

som

e

0.4

7%

hig

her

than

would

be

expecte

d b

y D

FI, a

t 8.2

8%

.

There

were

no b

reaches o

f th

e m

ixed s

ex a

ccom

modation s

tandard

during

Novem

ber.

Th

ere

were

162 c

linic

ally

justified b

reaches,

pre

dom

inantly

within

critical care

.

Fig

ure

31

– D

r F

os

ter

rea

dm

iss

ion

s J

ul

13

to

Ju

l 1

4

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 30 of 80

Pa

ge

18

of 5

4

19. W

ard

Nu

rsin

g –

Fill

Ra

te

It is a

n e

xpecta

tion s

et

out

in N

ational Q

ualit

y B

oard

(N

QB

) g

uid

ance p

ublis

hed in N

ovem

ber

2013 t

hat

Board

s w

ill t

ake f

ull

responsib

ility

for

the

qualit

y o

f care

pro

vid

ed t

o p

atients

, and a

s a

key d

ete

rmin

ant

of qualit

y,

take f

ull

responsib

ility

for

nurs

e s

taff

ing

. T

he N

QB

guid

ance s

pecific

ally

sta

tes t

hat

the B

oard

will

be a

dvis

ed o

f th

ose w

ard

s w

here

sta

ffin

g c

apacity a

nd c

apabili

ty f

req

uently f

alls

short

of

what

is p

lan

ned,

the r

easons w

hy,

any im

pact

on q

ualit

y a

nd t

he a

ctions t

aken t

o a

ddre

ss g

aps in s

taff

ing.

This

will

be p

resente

d e

ach m

onth

as

an E

xception R

eport

. T

his

month

a s

hort

fall

in t

he n

um

bers

of

nurs

es o

n d

uty

on s

even w

ard

s w

as d

ue t

o R

eg

iste

red a

nd U

nre

gis

tere

d N

urs

e v

acancie

s,

short

term

sta

ff s

ickness a

nd s

taff

bein

g r

edeplo

yed f

ollo

win

g a

ssessm

ent of

patient acuity a

nd d

ependency levels

.

Pla

ns a

re in p

lace w

ithin

each D

ivis

ion t

o a

ddre

ss a

ny s

hort

falls

in n

urs

e s

taff

ing

on a

daily

basis

, a

nd t

his

is a

lso

dis

cussed a

nd a

ddre

ssed d

uring

Matr

on’s

Safe

ty H

uddle

. A

ny s

hort

fall

in n

urs

e s

taff

ing

out

of

hours

is n

ow

escala

ted a

nd a

ddre

ssed b

y t

he C

linic

al M

anag

er

on s

ite.

T

his

month

there

was o

ne m

odera

te h

arm

incid

ent

on a

n i

npatient

ward

within

the D

ivis

ion o

f M

edic

ine,

and t

hre

e m

odera

te h

arm

incid

ents

on

inpatient

ward

s w

ithin

the D

ivis

ion o

f S

urg

ery

.

All

had a

concis

e R

oot

Cause A

naly

sis

investig

ation c

om

ple

ted a

nd w

ere

not

directly lin

ked to n

urs

e s

taff

ing levels

.

The m

onth

ly s

ubm

issio

n to D

oH

on n

urs

e f

ill r

ate

s is s

how

n b

elo

w.

Page 31 of 80

Pa

ge

19

of 5

4

19. W

ard

Nu

rsin

g –

Fill

Ra

te (

co

n’t)

Fig

ure

32

– M

10

(2

014

-15

)

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 32 of 80

Pa

ge

20

of 5

4

20.

Clin

ica

l G

ove

rna

nce

CQ

C ‘

Should

/ M

ust

Do’, a

ction p

lan w

as p

resente

d a

nd s

igned o

ff a

t th

e Q

ualit

y &

Safe

ty C

om

mitte

e.

The ‘G

ood t

o G

reat’ a

ction p

lan is b

ein

g

update

d a

nd w

ill b

e p

resente

d to the

Safe

ty a

nd R

isk E

xec led G

roup o

n 3

rd M

arc

h.

CQ

C p

lan t

o r

etu

rn t

o t

he T

rust

befo

re t

he e

nd o

f F

ebru

ary

to u

ndert

ake a

follo

w u

p a

nnounced v

isit.

Aw

are

ness r

ais

ing

of

this

im

pendin

g v

isit

has c

om

menced a

cro

ss the tru

st.

There

have b

een n

o n

ew

com

pla

ints

logg

ed w

ith the C

QC

sin

ce t

he last re

port

.

Patient

Safe

ty/P

ublic

Health A

lert

s -

monitore

d m

onth

ly b

y t

he S

afe

ty a

nd R

isk S

ub C

om

mitte

e a

nd s

um

marised in the table

belo

w:

Fig

ure

33

– p

ati

en

t s

afe

ty a

lert

s M

10

201

4-1

5

Ale

rts i

ssu

ed

Ap

ril

req

uir

ing

acti

on

A

lert

s c

losed

Ap

ril

all a

cti

on

co

mp

lete

d

Ale

rts o

pen

w

ith

in

Tim

escale

A

lert

s o

pen

ou

tsid

e o

f

tim

escale

8

5

8

3

Page 33 of 80

Pa

ge

21

of 5

4

21.

CQ

UIN

S

Fig

ure

34

- C

QU

IN r

ed

/am

ber

rati

ng

– M

10

(2

014

-15

)

The f

inancia

l im

pact

of

non

-achie

vem

ent

of th

e C

QU

IN targ

ets

in 2

014/1

5 is e

stim

ate

d a

t £0.6

M,

but m

ay b

e r

ecovere

d.

A furt

her

£0.6

M is r

isk

rate

d a

mber

but

inclu

de c

om

mis

sio

ner

issues r

e v

alid

ation o

f data

results.

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 34 of 80

Pa

ge

22

of 5

4

Eff

icie

nc

y:-

o

ve

rall R

AG

ra

tin

g

22. P

rod

uctivity

23. O

utp

atie

nt

DN

A’s

Pro

ductivity -

Weig

hte

d O

utp

uts

per

WT

E –

The g

raph

show

s t

he c

orr

ela

tion b

etw

een

the 1

2-m

th r

olli

ng

avera

ge

in p

roductivity a

nd t

he i

ncre

ase i

n h

eadcount

(princip

ally

ward

are

as).

Sta

ffin

g l

evels

ha

ve n

earl

y r

etu

rned t

o A

pr

10 levels

, pre

the £

20M

cost savin

g p

rogra

mm

e.

Fig

ure

36

– W

TE

mo

ve

men

ts s

inc

e A

pr

20

10

DN

A’s

for

new

and follo

w-u

p p

atients

reduced.

DN

A’s

for

firs

t attendances h

as s

how

n n

o i

mpro

vem

ent

over

the la

st

12 m

onth

s.

The sam

e can be note

d fo

r

follo

w-u

p

appoin

tmen

ts

if

this

m

onth

s’

impro

vem

ent

is

exclu

ded.

A r

efr

esh o

f actions t

o r

educe D

NA

’s f

orm

s p

art

of

the

Outp

atient w

ork

pro

gra

mm

e.

Fig

ure

35

– 1

2 m

th w

eig

hte

d O

utp

uts

pe

r W

TE

M1

0 (

20

14-1

5)

Fig

ure

37

– t

ren

d i

n o

utp

ati

en

t D

NA

s –

M1

0 2

01

4-1

5

Page 35 of 80

Pa

ge

23

of 5

4

24. A

LO

S a

nd

Pre

-inte

rve

ntio

n B

ed

Da

ys

Fig

ure

41

– P

re-i

nte

rve

nti

on

be

d d

ays

Mo

nth

10

(20

14

-15

)

T

he t

ime a

patient

sta

ys i

n h

ospital

befo

re a

n i

nte

rvention o

ccurs

, as

record

ed t

hro

ug

h t

he p

re-inte

rvention b

ed d

ay r

ate

, is

show

n a

bove.

Ele

ctive

ep

isodes

incre

ased,

but

non

-ele

ctive

epis

odes

of

care

reduced. O

vera

ll th

ere

is little im

pro

vem

ent in

the p

ositio

n.

Fig

ure

38

– L

OS

an

d o

cc

up

ied

be

d d

ays

O

vera

ll A

vera

ge Length

of

Sta

y re

duced m

arg

inally

to

6.8

8,

and is

0.3

5 d

ays l

ow

er

tha

n t

he c

om

para

ble

period l

ast

year.

Occupie

d b

ed

days w

ere

up s

lightly t

hro

ug

h J

anuary

. A

t a d

ivis

ional le

ve

l A

LO

S incre

ased f

or

Medic

ine

to 8

.19 d

ays,

but

fell

for

Surg

ery

to 5

.11 d

ays.

Fig

ure

39

– L

OS

by d

ivis

ion

Fig

ure

40

– L

OS

vs

DF

I ex

pec

ted

T

he g

ap b

etw

een D

FI

observ

ed L

oS

(6.4

days)

and e

xpecte

d L

oS

(5.8

days)

is 0

.1 d

ays lo

wer

than last

month

. T

he t

rust

rem

ain

s c

onsis

tently

above e

xpecte

d r

ate

s,

avera

gin

g a

full

day m

ore

per

month

over

the

period s

how

n.

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 36 of 80

Pa

ge

24

of 5

4

25.

Th

eatr

e U

tilis

atio

n a

nd D

ayca

se

Rate

Fig

ure

44

– o

bs

erv

ed

vs

ex

pe

cte

d d

ayc

as

e r

ate

Theatr

e u

tilis

ation d

ete

riora

ted a

t both

EC

C a

nd

U

HA

, w

ith

month

ly

run

ra

te

avera

gin

g

aro

und

73%

over

the p

ast 24 m

onth

s.

Pro

cedure

s

undert

aken

in

pla

nned

sessio

ns

to

the end of

Decem

ber

are

som

e -8

45 dow

n on

2013 at

UH

A,

and -2

7 in

th

e E

CC

. 85 fu

nded

sessio

ns i

n U

HA

/ E

CC

did

not

take p

lace d

uring

January

, 13.6

% o

f availa

ble

sessio

ns.

The t

rust

has 1

5 e

lective t

heatr

es (

exclu

din

g t

he

Seft

on

Suite)

on

whic

h

it

has

set

a

utilis

ation

targ

et

of

85.5

%,

resultin

g in

an expecte

d 12.8

2

availa

ble

th

eatr

es

per

week.

Actu

al

utilis

ation

(excl

overr

uns)

rem

ain

s

sig

nific

antly

belo

w

tha

t

leve

l, w

ith a

n a

vera

ge o

f 1.9

2 t

heatr

es p

er

month

lost

due to u

nder

utilis

ation a

gain

st ta

rget.

A

n a

naly

sis

of

exis

ting

job p

lans h

as p

rovis

iona

lly

identified a

short

fall

in s

urg

ical consultant

capacity

ag

ain

st

funded t

heatr

e s

essio

ns.

If c

onfirm

ed t

his

wou

ld b

e a

facto

r in

the c

ontinued l

ow

utilis

atio

n

of

theatr

es.

Options

wou

ld

then

need

to

be

consid

ere

d,

as

the

trust

has

sta

ffed

theatr

es,

(subje

ct

to

vacancie

s

and

sic

kness),

but

no

surg

eon to p

ut

in t

hem

.

Fig

ure

43

– u

tili

sed

ele

cti

ve

th

ea

tre

s a

ga

ins

t a

va

ilab

le t

hea

tres

(e

xc

l. o

ve

rru

ns

)

F

igu

re 4

2 –

tre

nd

in

Ele

cti

ve

Th

ea

tre U

tilis

ati

on

(e

xc

l. o

verr

un

s)

DF

I data

show

s

the

trusts

’ daycase

rate

at

81.5

9%

is

bett

er

than

the

expecte

d

rate

of

80.9

0%

based o

n its

casem

ix.

Page 37 of 80

Pa

ge

25

of 5

4

Wo

rkfo

rce

:- o

vera

ll R

AG

rati

ng

26.

Dash

bo

ard

Fig

ure

45

– S

um

ma

rise

d w

ork

forc

e d

as

hb

oa

rd –

M1

0 (

201

4-1

5)

As n

ote

d l

ast

month

, th

e a

bove d

ashbo

ard

is u

nder

revie

w.

Work

is c

ontinuin

g o

n a

revis

ed s

uite o

f w

ork

forc

e i

nfo

rmation,

with t

he e

xpecte

d

inclu

sio

n in t

he c

orp

ora

te r

eport

revis

ed fro

m t

his

month

to n

ext m

onth

.

8. C

G14

-15/

071

- C

orpo

rate

Per

form

ance

Rep

ort

Page 38 of 80

Pa

ge

26

of 5

4

Fin

an

ce

:-

ove

rall R

AG

ra

tin

g

27. I&

E O

ve

rvie

w

YT

D v

ari

an

ce a

ga

inst

bu

dg

et

po

sit

ion

The T

rust

has an o

pera

ting deficit of

-£935K

, ag

ain

st

a pla

nned surp

lus of

£59K

, an im

pro

vem

ent

on last m

onth

.

Fig

ure

46

– S

um

ma

rise

d I

nco

me

& E

xp

en

dit

ure

Ac

co

un

t –

M10

(2

01

4-1

5)

B

ud

get

£000

Actu

al

£000

Vari

an

ce

£000

(%)

Last

mo

nth

var

£000

Clin

ica

l In

co

me

228,4

53

233,0

06

4,5

53

2.0

%

4,5

08

2.2

%

Oth

er

incom

e

20,8

07

20,3

09

-498

-2.4

%

-358

-1.9

%

Costs

-2

49,2

01

-254,2

50

-5,0

49

2.0

%

-5,4

55

2.5

%

I&E

Su

rplu

s

59

-935

-994

-1

,305

EB

ITD

A %

4.5

%

4.0

%

I&E

surp

lus

marg

in

0.0

%

-0.4

%

Fig

ure

47

– c

um

ula

tive

tre

nd

in

I&

E p

erf

orm

an

ce 2

014

-15

Med

icin

e’s

opera

tional

befo

re C

IP i

mpro

ved t

o +

£3,0

35K

, th

e C

IP s

hort

fall

sta

nds a

t -£

1,7

72K

. A

ctivity i

n J

anuary

was a

bove p

lan f

or

non

-

ele

ctive s

erv

ices,

with a

dete

riora

tion i

n o

vera

ll outp

atient

work

load.

Incom

e s

urp

lus w

as u

p a

s a

result.

Underlyin

g e

xp

enditure

budg

ets

are

belo

w p

lan,

once a

ccounting f

or

the incre

ased c

osts

of

exclu

ded d

rug

s. C

IP d

eliv

ery

rem

ain

s a

n issue in

-year

and m

ovin

g forw

ard

into

2015/1

6.

Su

rgery

’s o

pera

tional

positio

n b

efo

re C

IP d

ete

riora

ted t

o -

£3,5

93K

, fr

om

-£2,2

93K

. C

IP d

eliv

ery

is s

om

e -

£1,1

82K

behin

d t

arg

et. E

lective

activity w

as d

ow

n i

n m

onth

a p

ositio

n i

n p

art

bro

ug

ht

on b

y t

he n

on

-ele

ctive i

ssues f

aced i

n t

he m

onth

. N

on

-ele

ctive a

dm

issio

ns w

as u

p a

s a

result o

f th

e n

ew

path

wa

y c

hang

es (

EA

U a

dm

itte

d a

rea)

and n

eeds t

o b

e c

onsid

ere

d i

n c

onju

nction w

ith t

he s

hort

fall

in C

DU

activity.

Incom

e

was d

ow

n.

Despite t

he d

rop i

n e

lective a

ctivity,

costs

continued t

o r

un a

bove p

lan a

nd t

he d

ivis

ion s

pent

£124K

on W

LIs

, (c

um

ula

tively

at

£1.4

M a

gain

st

£0.8

M in

2013/1

4).

Non

-pay c

osts

are

up,

with t

heatr

e s

pend b

ein

g a

bove p

lan.

Overa

ll th

eatr

e a

ctivity is d

ow

n,

althoug

h T

&O

activity is u

p.

C

on

tract

qu

ery

receiv

ed

on n

on-e

lective a

ctivity h

as b

een w

ithdra

wn.

Liv

erp

oo

l C

lin

ical

Lab

ora

tori

es:

AU

H s

till

aw

aits a

com

pre

hensiv

e r

esponse f

rom

RLB

UH

as t

o h

ow

the o

vers

pend h

as a

risen a

nd w

hat

ele

ment, if

any,

is a

ttributa

ble

to A

UH

. O

ther

are

as a

cro

ss the tru

st

are

opera

ting w

ithin

budg

ete

d levels

. A

more

deta

iled f

inancia

l re

port

is s

how

n a

t A

ppendix

5 o

f th

is r

eport

.

Page 39 of 80

Pa

ge

27

of 5

4

28.

CIP

Fig

ure

48

– C

IP s

um

ma

ry

M1

0 (

201

4-1

5)

The C

IP p

rogra

mm

e c

urr

ently c

onsis

ts o

f id

eas c

urr

ently b

ein

g g

enera

ted t

hro

ug

h d

ivis

iona

l/depart

menta

l te

am

s.

In-y

ear

the p

ositio

n i

s m

ore

assure

d, as t

he b

ulk

of th

e d

eliv

ery

is m

et th

rough n

on

-recurr

ent bala

nce s

heet

are

as a

nd n

on-r

ecurr

ent re

serv

e s

lippag

e.

Mo

vin

g f

orw

ard

the r

ecurr

ent

deliv

ery

of

the 2

014/1

5 t

arg

et

has b

een w

rapped u

p i

n t

he f

inancia

l pla

nnin

g f

or

2015/1

6,

wh

ich i

nclu

des t

he

consolid

ation o

f in

com

e o

ver

perf

orm

ance in t

he c

ontr

act

for

next

year.

This

by d

efa

ult,

net

of

any a

ssocia

ted c

ost

incre

ases t

o d

eliv

er

it,

could

be a

ssig

ned a

gain

st

the 2

014/1

5 p

ositio

n.

This

has b

een e

stim

ate

d a

t £2.1

M,

whic

h i

ncre

ases t

he r

ecurr

ent

deliv

ery

fro

m t

he £

3.8

M n

ote

d i

n

table

5 to £

5.9

M into

2015/1

6.

For

2015/1

6 the p

rovis

ional financia

l pla

n h

as identified a

gap o

f -£

26.4

M

A p

rovis

ional

CIP

targ

et

of

£13.5

M h

as b

een s

et

and D

ivis

ions a

re i

n t

he p

rocess o

f popula

ting

the e

PM

O w

ith t

heir i

nitia

l C

IP p

rogra

mm

e

initia

tives a

nd p

roje

cte

d f

inancia

ls f

or

2015

/16,

with q

ualit

y i

mpact

assessm

ents

and a

ppra

isal

of

schem

e v

iabili

ty t

o b

e u

ndert

aken i

n e

arly

Marc

h.

8. C

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Rep

ort

Page 40 of 80

Pa

ge

28

of 5

4

29. B

ala

nce

Sh

ee

t a

nd

Ca

sh

Flo

w

Bala

nce S

heet

and C

apital

- F

ixed assets

to

talle

d £180.2

M,

work

ing capital

£11.1

M a

nd long t

erm

lia

bili

ties t

ota

lled -

£43.8

M.

Tota

l assets

were

£147.5

M.

Cash -

Cash b

ala

nces t

ota

lled £

31.8

M,

£1.4

M b

elo

w p

lan,

with c

apital

spend

bein

g behin

d pla

n,

off

set

by contr

act

paym

ents

not

reflecting

contr

act

over

perf

orm

ance,

tog

eth

er

with t

he r

eport

ed d

eficit o

n I

&E

. D

espite t

his

, liq

uid

ity i

s

healthy a

nd t

he t

rust has s

uff

icie

nt

cash r

esourc

es t

o m

eet

its o

blig

ations.

F

igure

49 s

how

s t

he r

evis

ed c

ashflow

pro

jections b

ased o

n t

he s

trate

gic

pla

n

subm

issio

n,

whic

h

inclu

des

the

£10M

re

lease

from

th

e

bala

nce

sheet

in

2014/1

5 a

nd a

bala

nce

d p

ositio

n f

or

2015/1

6.

Th

e p

ositio

n r

eflects

the l

ate

st

appro

ved c

apital pro

gra

mm

e t

hro

ug

h to M

arc

h 2

016.

T

he

gra

ph

als

o

show

s

the

pro

jecte

d

cash

fore

cast

based

on

the

curr

ent

financia

l pla

n f

or

2015/1

6 w

hic

h p

redic

ts a

-£12.9

M d

eficit f

or

the y

ear

based o

n

deliv

ering

CIP

savin

gs o

f £13.5

M.

Cash b

ala

nces r

em

ain

positiv

e d

uring

the

year,

but fa

ll to

neg

ligib

le a

mounts

by M

arc

h 2

016.

Fig

ure

49

– R

ollin

g 1

2 m

th c

as

h f

low

fo

rec

as

t

Capital

spend f

or

the p

eriod t

ota

lled j

ust

under

£10.9

M,

som

e £

1.5

M b

ehin

d

pla

n aft

er

takin

g in

to account

anticip

ate

d slip

pag

e m

odelle

d in

to th

e in

-year

fore

casting

, (s

ee a

ppendix

iv).

Page 41 of 80

Pa

ge

29

of 5

4

30.

Ris

k A

sse

ssm

en

t F

ram

ew

ork

Re

co

mm

en

da

tio

n

32.

The B

oard

of

Directo

rs a

re a

sked t

o n

ote

the info

rmation c

onta

ined w

ithin

this

report

. R

efe

ren

ces

an

d f

urt

he

r re

ad

ing

33.

Appendix

1:

E

xception r

eport

A

ED

access

34.

Appendix

2:

Exception r

eport

C

ancer,

scre

enin

g 6

2 d

ays

35.

Appendix

3:

Exception r

eport

D

iag

nostics a

ccess

36.

Appendix

4:

Exception r

eport

S

troke

37.

Appendix

5:

Fin

ance r

eport

38.

Appendix

6:

Glo

ssary

Au

tho

r Ia

n J

on

es

, D

ep

uty

Dir

ec

tor

of

Fin

an

ce

O

wn

er

Ste

ve

Wa

rbu

rto

n,

Dir

ec

tor

of

Fin

an

ce

& B

us

ine

ss

Serv

ice

s

Date

2

0/0

2/2

01

5

Fig

ure

52

– R

AF

M1

0 2

013

-14

At

the e

nd o

f D

ecem

ber

the T

rust

is r

eport

ing

a R

AF

of

3.

As n

ote

d l

ast

month

, b

y u

tilis

ing

the £

10M

of

funds h

eld

in t

he b

ala

nce

sheet,

incom

e s

ourc

es f

rom

national re

sili

ence f

undin

g £

1.5

m a

nd r

eserv

e

slip

pag

e,

the t

rust

continues t

o f

ore

cast

a b

reakeven p

ositio

n b

y t

he e

nd o

f

the

year.

H

ow

eve

r th

e

slo

wdo

wn

in

incom

e

gro

wth

, alo

ng

sid

e

the

continued

overs

pend

within

S

urg

ery

, p

laces

a

degre

e

of

risk

in

the

deliv

era

bili

ty of

this

fo

recast.

B

ased on th

e im

pro

vem

ent

in m

onth

, th

e

dow

nsid

e p

ositio

n h

as b

een r

evis

ed u

pw

ard

fro

m a

pote

ntial deficit o

f -£

3M

report

ed last m

onth

to £

2.5

M.

Based o

n t

he f

ore

cast, t

he t

rust

should

main

tain

a m

inim

um

RA

F r

ating

of

3 t

hro

ug

h to the e

nd o

f th

e y

ear

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of 54

Appendix 1 OPERATIONAL PERFORMANCE EXCEPTION REPORT

REPORT TO: Board of Directors

DATE: Month 10 - January 2014

REPORT BY: Angie Smithson, Chief Operating Officer

AUTHOR: Nigel Lee, DCOO Surgery, Anaesthesia & AED

SUBJECT: A&E 4 hour Performance

1.0 Present state

The Trust aims to achieve the 4 hour maximum A&E wait for Type 1 and 3 patients. The Trust

continues to have challenges in being able to achieve the standard, and did not achieve the 95%

required in January 2015.

Aintree performance

The overall performance for January 2015 is given below. The month saw significant pressures on

the Trust, and surrounding health economy, especially in the first 2 weeks immediately after New

Year.

Percentage of patients waiting no more than 4

hours (all types)

79.01 %

Percentage of patients waiting no more than 4

hours (Type 1 only)

84.78 %

Year to date Performance

YTD, for types 1 & 3, total attendances are 93,101, with 9049 breaches which equates to 90.28%.

Monthly breakdown is included in the table below.

Page 43 of 80

of 54

AED performance

2014/15 Kirkby Aintree Total breaches

%

Performance

excluding

WIC

%

Performance

including

WIC

Apr 2518 6,641 9,159 548 91.75% 94.02%

May 2699 8,184 10,883 969 88.16% 91.10%

Jun 2574 6,167 8,741 790 87.19% 90.96%

Jul 2786 7,012 9,798 864 87.68% 91.18%

Aug 2339 6,754 9,093 709 89.50% 92.20%

Sep 2531 6,544 9,075 583 91.09% 93.58%

Oct 2468 6,748 9,216 853 87.36% 90.74%

Nov 2339 6,397 8,736 1095 82.88% 87.47%

Dec 2682 6,613 9,295 1252 81.07% 86.53%

Jan 2503 6,602 9,105 1386 79.01% 84.78%

Total 25439 67,662 93,101 9,049 86.63% 90.28%

Ambulance Turnaround

Whilst HAS compliance remains higher than others in the region, our numbers of longer waits for

ambulance turnaround remained high. The numbers of ambulance turnaround times above 30 and

60 minutes were high, with more recorded in the first 2 weeks of the month. NWAS demand

remained high during this period.

Hospital Arrival Screens (HAS) - Achievement against compliance standards with Handover time banding

REPORTING PERIOD: 01/01/15 to 31/01/15clinicattended AE DeptincludeasHASCandidateY

HOSPITAL NAME OVERALL ATTENDANCES AND COMPLIANCE INFORMATION

AVERAGE

NOTIFICA

HospitalArea HAS_Candidate_Site

All

Attendances

ACUTE

compliance vs

candidates%

Avg

Notificati

on to

Handover

Time

30m-

45m

45m-

60m

60m-

75m >75m

Cheshire & Mersey Aintree University 2872 85.0% 18:04 130 53 43 76

Alder Hey Childrens 552 77.5% 03:26 1 1 0 0

Arrowe Park 2836 64.8% 15:27 93 45 16 31

Countess of Chester 1660 79.8% 20:16 130 65 34 24

Leighton 2243 76.8% 09:17 26 3 0 1

Macclesfield District General 1255 74.3% 10:06 32 4 1 1

Royal Liverpool University 3176 78.2% 11:51 88 23 10 9

Southport District General 1565 83.5% 30:58 96 43 32 121

Warrington General 2509 68.1% 16:24 80 34 16 33

Whiston 3037 85.5% 15:52 151 71 35 44

Cheshire & Mersey Total 21705 77.8% 15:56 827 342 187 340

Causes of underperformance

The causes remain multi-factorial, but remain largely due to capacity to assess and make decisions

promptly in AED (either through lack of physical capacity or inefficient processes), and ability to

maintain flow into assessment areas and through to wards. Discharge of patients from the Trust

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also remains a challenge and delays have increased over December/January. Other issues include:

- Variable performance in admission processing and discharges from wards, with a general

shortfall in medical ward capacity.

- Increase in delayed discharges and delays in assessments across health and Social

Services, with some pathways experiencing delays re-commencing in January after the

Christmas break.

- System pressures across the sector (NB – all neighbouring Trusts experienced similar

pressures throughout the month)

2.0 Action Plan

The operational teams have continued to progress with the 4 hour action plan and the

recommendations from ECIST (ECIST clinical lead is returning to the Trust in February, and with

the ED ECIST lead again in March). Progress continues to be made on implementation of Acute

Physician cover but there is still work to complete on rotas, expansion of short stay capacity, and

changing culture and practice to ensure the full benefits of the changes can be realised. Other key

areas include:

Progress continues on the Discharge project which is being led by the Assistant Director of

Nursing/AHPs and project managed by a manager seconded from Liverpool Community

Health (LCH).

Joint work with LCH, Merseycare and Social Services is being undertaken as part of the

winter resilience planning, with established meetings with Merseycare. The Trust has

progressed expansion of Aintree @ Home, development of 7 day working to increase

medical, nursing, AHP and social services presence at weekends and the implementation of

a transfer team. There is work to complete with Liverpool Social Services on 7 day working.

The Trust 4 hour action plan continues to be monitored, updated, and performance

managed internally by the Trust/CCGs monthly 4 hour review meeting.

Page 45 of 80

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The GP hotline for acute medical patients went live on 9th Feb 15.

The Ambulatory Emergency Care Unit went live on 11th Feb 15, with 2 bays in AMU being

dedicated to AEC patients.

Work is in progress within the Trust and by the CCGs to increase the transitional bed

capacity across the community.

In addition, the ED team are reviewing the patterns of activity, including ambulance attendances, to

ensure that ED, and other departments such as AMU and SAU, are staffed and prepared

accordingly. January’s data, shown below, illustrates the days, and times of day for peak

attendances. In addition, the patterns of ambulance arrivals are evident.

3.0 Date when recovery of target or standard is expected

The achievement of the standard remains a challenge in the context of the pressures across the

whole community, the number of actions to completely embed and the change of practice and

culture required. The Trust has a revised plan for Q4 2014/15 and Q1 2015/16 for both types of:

Q4 92%

Q1 93.5%

Q2 95.5%

Risks:

The risk remains high. The risks to the achievement of the standard remain and requires all areas

within the Trust and the wider health and social care community to work together to improve &

sustain performance.

4.0 Details of senior responsible officer

Divisional SRO: Tristan Cope, Clinical Head of Division

Nigel Lee, Divisional Chief Operating Officer

Corporate SRO: Jennifer Carden, Head of Performance

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AUTHOR: Phil Downey, Divisional Chief Operating Officer (Diagnostic & Support

Services)

SUBJECT: Cancer, 62-day screening

1.0 Present state

The Trust is required to deliver 90% for the 62 day screening target, as set by the DoH.

Aintree performance

Performance is greatly influenced by patient choice, especially in the early (pre-diagnosis) phase,

and hampered by low numbers of treatments (meaning that even a single breach will give rise to a

performance below the agreed standard, as seen in previous months). In addition, the initial stage

of the pathway is directly managed by the Central HUB and as such is difficult to influence by the

Trust. The provisional performance for January is given below.

January 2015

Percentage of patients waiting no more than 62 days from referral from an

NHS Screening service to first definitive treatment for all cancers – 90%

2/4

50%

Causes of underperformance

Patient choice to delay first OPD, following this further delay to Colonoscopy being completed due

to a combination of capacity constraints and patient choice. Patient was referred across to the

treating Trust on day 99 of pathway. The surgery was completed on day 144 of pathway. 2nd patient

had decision to treat on day 42 but treatment delayed due to pre-existing medical condition, so

surgery postponed while cardiology review took place and condition stabilised

2.0 Action Plan

A number of key actions have taken place as per the 62-day target action plan. Please see

appended action plan at the end of this report.


The target remains fragile, given the low denominator and the high level of patient choice

associated with breaches. The denominator was reduced further with the loss of activity due to

the split of the screening centre into 2 separate centres at Aintree and RLUH. Whilst the team

have worked to reduce any administrative delays, including close liaison with external agencies,

performance is likely to remain variable.


Divisional SRO: David White, Clinical Head of Division

Phil Downey, Divisional Chief Operating Officer


Page 47 of 80

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AUTHOR: TONY KAY, HEAD OF AUDIOLOGY SERVICES

LYNDSEY BURKE, ASSISTANT CBM, DDU

LESLEY BLACK, CBM, SURGICAL SPECIALTIES

DAVID WARWICK, INTERIM HEAD OF PERFORMANCE

SUBJECT: Diagnostics Access

1.0 Present state

The Trust aims to deliver the DM01 target of less than 1% of patients waiting no more than 6 weeks

from date of referral to diagnostic test. During January 1.3% of all diagnostic procedures were not

performed within 6 weeks (60 patients).

Cystoscopy exceeded the standard at 3.8% and endoscopy waits exceeded the standard for

colonoscopy at 3.8%, Flexible sigmoidoscopy at 12.7%, and gastroscopy at 4.9% (see separate

report). Audiology Assessment also failed to deliver the standard at 7.1% as demonstrated below.

Cystoscopy

3.8% of patients waited over 6 weeks at month end for Cystoscopy against a target of 1% (2

patients failed the target).

Previous performance for 2014/15 has been positive and validation of the waiting list revealed that

the 2 patients waiting in excess of 6 weeks have failed to respond to requests to book

appointments. The specialty have again contacted the patients and requested GP support. Neither

have been removed from the waiting list due to clinical urgency.

Causes of Underperformance

Patient choice/non compliance

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Audiology

7.1% of patients were reported to have waited over 6 weeks for Audiology Assessments at the end

of January. This related to 5 patients.

Causes of Underperformance

Validation of the waiting list was not carried out prior to the national submission deadline. The

specialty reported that they did not receive a request to undertake the validation process. Post

validation there are 2 patients (2.9%) waiting in excess of 6 weeks and these relate to 1 patient who

has cancelled their appointment twice and 1 patient who has asked to wait for their test until seen in

their already planned future ENT clinic appointment.

Endoscopy - Causes of underperformance

Colonoscopy – The reason for underperformance was due to:

1 x DNA (appointment not fully booked and unable to contact patient via phone) received their

original appointment within the 6 week target, but subsequently unable to re-accommodate within 6

weeks following DNA due to capacity constraints.

4 x patient cancellations (appointment not fully booked, as unable to contact patients via phone)

received appointments within 6 week target, but unfortunately unable to re-accommodate within 6

weeks following patient cancellations due to capacity constraints.

3 x patients requested appointments outside of 6 the week target.

1 x patient declined offer of an appointment within the 6 week target, and unfortunately the

department were unable to offer another appointment within the 6 weeks due to capacity

constraints.

Flexi Sigmoidoscopy - The reason for underperformance was due to:

10 x DNAs (appointment not fully booked, as unable to contact patients via phone) who received

appointments within the 6 week target, but unfortunately the department were unable to re-

accommodate those patients following DNA within the 6 week target.


who had received appointments within the 6 week target, but on cancelling requested appointments

to be made outside of the 6 week target.


who received appointments within the 6 week target, but on cancelling they were unable to be re-

accommodate within the 6 week target.

Gastroscopy – The reason for underperformance was due to:

11 x DNAs (appointments not fully booked, as unable to contact patients via phone) who received

appointments within 6 week target, but unfortunately unable to re-accommodate those patients

following DNA within the 6 weeks due to capacity constraints.

1 x patient declined offer of an appointment within 6 weeks, and on re-booking was unable to be

Page 49 of 80

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accommodated within 6 weeks.

8 x patient cancellations (appointments not fully booked, as unable to contact patients via phone)

that were booked within 6 weeks, but unfortunately on re-booking patients were unable to be re-

accommodated within 6 weeks due to capacity constraints.

Endoscopy has experienced increased pressures due to the new rotation of SpRs being

inexperienced in undertaking colon procedures. There has also been increased pressure due to

Gastroenterologists taking compensatory rest following cover of the Gastrointestinal Bleed Rota

(this rota was historically covered by the Gastro SpRs prior to it being requested that they

contribute to the Medical SpR Rota).

In December, endoscopy activity was also cancelled to support the medical outliers on Ward 3,

which has also contributed to January’s under-performance. There was also 1 x long-term sickness

within the endoscopist team for 4 weeks in December, and although that member of staff has

returned, they are still unable to scope at present which is resulting in their lists being covered by

the rest of their team, where possible.

Below is performance from the past 3 months:

October November December

Colonoscopy 0.00% 2.30% 8.2%

Flexi Sig <1% <1% <1%

Gastroscopy 1.70% 1.60% 5.7%

2.0 Action Plan

Urology

The following actions are in place:

Patients contacted again and support requested from GP to increase compliance.

A clinical review of both patients will be undertaken if they again fail to respond to invites in

the next 14 days.

Audiology

A weekly DM01 will now be circulated to all relevant business/service managers to allow on-

going validation of the diagnostic waiting times. This commenced on 11th February 2015.

Endoscopy

Weekly Capacity Meeting – Capacity issues will continue to be discussed at the weekly

meeting, implementing any actions where necessary to achieve target.

Continue to train SpRs on colon lists, so that they become competent in undertaking the

procedure.

Business case for 2 Consultant Gastroenterologists agreed. Once appointed, they will assist

with endoscopy activity. Likely to be in post by the end of Q2 2015/2016

Colorectal Consultant Business Case (currently being compiled). If agreed, they will also be

able to assist with endoscopy activity.

Review of endoscopy SOPS / booking processes. Introduction of inviting patients for

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endoscopy procedures to assist with waiting list pressures / effective use of capacity.

Due to the common theme associated with the booking process and patient DNA the CBU

will assess the feasibility of implementing an invite system (similar to OPD system), to assist

with waiting list pressures / effective use of capacity.


The Cystoscopy and Audiology targets are expected to be achieved from February 2015.

Risks:

Patient choice

.

Endoscopy - Whilst Endoscopy is experiencing the current constraints, there continues to be a risk

of not achieving the 1% target until the above actions can be implemented however improvement is

expected month on month with achievement aimed for delivery by end of March 2015.

Risks:

Timescale for training SpR’s

Recruitment lead time for Consultant posts

Booking process


Divisional SRO: Audiology Tristan Cope, Clinical Head of Division


Endoscopy - Tristan Cope, Clinical Head of Division


Urology - Tristan Cope, Clinical Head of Division


Corporate SRO: David Warwick, Interim Head of Performance

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Appendix 4

OPERATIONAL PERFORMANCE EXCEPTION REPORT




AUTHOR: Claire Cullen, Clinical Lead Stroke

SUBJECT: Stroke

1.0 Present state

51 patients were discharged from the Trust in January 2015 with a diagnosis of stroke.

65% of these patients (33) spent 90% of their stay on the Stroke Unit, against a standard of

80%.

35% of these patients (18) failed the standard.

Of the 18 patients who failed the standard, 18 arrived by ambulance, 2 patients were referred by

their GP direct to Acute Medicine and admitted to the Ambulatory Acute Medical Unit.

Of the 18 patients who failed the standard:

- 1 was admitted to the Stroke Unit within 4 hours of arrival but was discharged to the Walton

Centre for surgery before they had spent 90% of their admission on the Stroke Unit

- 1 was admitted for palliative care (there was no stroke bed available at the time).

- 2 patients were only referred to the Stroke team after an MRI confirmed a diagnosis of stroke.

- 2 patients were referred late to the Stroke team several days into their stay as arrived with

atypical presentation

- 1 patient had a Stroke bed identified on admission but there was a delay in transfer to the

Stroke Unit

- 2 patients had in-patient Strokes and there were no ASU beds available at the time to

transfer

- 9 patients were identified as requiring direct admission to the Stroke Unit on admission but no

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stroke bed was available.

Quarter 3 performance is 71%

Year to date performance is 76%

AQ Stroke ACS (YTD 72%) (Target 59.5%)

April 75.00%

May 72.34%

June 73.91%

July 87.23%

Aug 60.38%

Sept 77.50%

Oct 59.38%

2.0 Action Plan

A number of actions are in progress, these include:

On-going work with bed management team to ensure a minimum of one stroke bed is always

available. This has been challenging in January 2015 and has resulted in 9 patients not being

admitted directly to the Stroke Unit.

On-going work with A&E team to ensure appropriate initial assessment and stroke calls are

made.

On-going work with stroke team to ensure pathway is followed; patients with a possible

diagnosis of stroke to be admitted to the stroke until alternative diagnosis confirmed.

Stroke physician on site from 9am to 8pm to facilitate timely assessment and transfer of stroke

patients. Door to needle time consistently achieved.

Audit of every stroke admission continues to take place to identify learning where the pathway

has not been followed.

Work is in progress to create a hyper acute stroke unit (HASU) so that all new stroke patients

are admitted to a hyper acute stroke bed for up to the first 72 hours. Nurse recruitment has

commenced and minor building works are due to commence in February 2015.

Therapies staffing is being reviewed using the latest BASP guidelines.


Expectation that pathway will be embedded and improvements in performance achieved by

January 2015. This has been challenging as the number of Strokes exceeded 50 this month and

medical outliers to the unit have reduced our capacity.

While the current bed pressures remain and until the work to expand the Stroke Unit is complete

the risk of failing to achieve direct admission to the Stroke Unit remains. To mitigate this, the Stroke

Team agreed to develop a ‘full protocol’ to be implemented by the end of January 2015. The

Clinical Leadership of the Stroke team changed in January 2015 and the new lead is developing the

protocol to be implemented by the end of February 2015.


Divisional SRO: Claire Cullen, Clinical Lead

Lisa Roberts, Clinical Business Manager


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Appendix 5



REPORT BY: Steve Warburton, Director of Business Services & Deputy Chief

Executive

AUTHOR: Ian Jones, Deputy Director of Finance

SUBJECT: Finance report, Month 10 2014-15

Overview

1. The Trust has an operating deficit of -£935K, against a planned surplus of £59K, an

improvement on last month.

Table 1 – Summarised Income & Expenditure Account – M10 (2014-15)

Budget

£000

Actual

£000

Variance

£000

(%)

Last month var

£000

Clinical Income 228,453 233,006 4,553 2.0% 4,508 2.2%

Other income 20,807 20,309 -498 -2.4% -358 -1.9%

Costs -249,201 -254,250 -5,049 2.0% -5,455 2.5%

I&E Surplus 59 -935 -994 -1,305

EBITDA % 4.5% 4.0%

I&E surplus margin 0.0% -0.4%

2. Of the reported deficit, -£2,500K relates to unachieved CIP, reflecting a proportion of the

current forecast gap for the year.

3. Income was only up marginally in the month, with elective activity down on plan as a result of

non-elective pressures. Operational budgets were overspent in the month, with WLI spend

and consumable costs in Surgery continuing to increase and agency medic costs within

Medicine impacting on the bottom line. This was offset by an improvement in the CIP position.

Figure 1 – cumulative trend in I&E performance 2014-15

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I&E Performance

4. I&E performance of Medicine and Surgery is shown in table 2.

Table 2 –I&E Performance – M10 (2014-15)

Medicine

M10

£000

Surgery

M10

£000

Medicine

M9

£000

Surgery

M9

£000

Income activity variance 2,933 472 2,252 1,410

Income block arrangements

Income drugs variance 1,073 1,758 1,138 1,569

Expenditure variance, inc PbR drugs (971) (5,823) (745) (5,272)

Operational variance 3,035 -3,593 2,645 (2,293)

CIP variance (1,772) (1,182) (1,613) (1,074)

Net Contribution 1,263 (4,775) 1,032 (3,367)

Combined contribution (3,512) (2,335)

CIP (net of balance sheet) (454) (166)

CSS, Labs, corporate, reserves

2,972 1,196

Operating I&E variance (994) (1,305)

Medicine

5. Medicine’s operational position before CIP improved to +£3,035K. The CIP shortfall stands at

-£1,772K.

6. Activity in January was above plan for non-elective services, with a deterioration in overall

outpatient workload. Income surplus was up as a result.

Figure 2 – activity variance by POD (Medicine) Month 10 (2014-15)

7. Underlying expenditure budgets are below plan, once accounting for the increased costs of

excluded drugs. CIP delivery remains an issue in-year and moving forward into 2015/16.

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Surgery

8. Surgery’s operational position before CIP deteriorated to -£3,593K. CIP delivery is some -

£1,182K behind target.

9. Elective activity was down in month a position in part brought on by the non-elective issues

faced in the month. Non-elective admissions jumped significantly in-month as a result of the

new pathway changes (EAU admitted area) and needs to be considered in conjunction with

the shortfall in CDU activity as there is no longer any activity assigned against this area.

Income from activities was down.

Figure 3 – activity variance by POD (surgery) Month 10 (2014-15)

10. Despite the drop in elective activity, costs continued to run above plan and the division spent

£124K on WLIs, which cumulatively stand at over £1.4M for the year, (2013/14 £0.8M). Non-

pay costs are also under pressure, with theatre spend being above plan. Overall theatre

activity is down, although T&O activity is up.

11. As reported last month, a major factor in the divisional position is the performance of the

Sefton Suite. A report on a new model of working will be submitted to F&P in March, following

approval by F&P last month to move towards an integrated unit with private capacity aligned

to demand and the remainder allocated to dedicated NHS work.

12. Divisional I&E performance by specialty (service line) is shown at Appendix iii.

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Income (trustwide summary)

13. Contract income increased to +£4,553K above plan, driven by an increase in non-elective

admissions (net of CDU), excluded drugs recharges and inclusion of 3/5ths of national

resilience funding. This was offset by a fall in income from elective work.

Table 3 - Summarised Income Variance – M10 (2014-15)

14. Non-elective activity and income remains significantly above plan +£6.4M for the 10 months,

but is offset by the loss of CDU activity -£3.0M.

15. The contract query the trust received has been withdrawn

Operational expenditure budgets

16. Underlying expenditure budgets were over spent by -£377K in January, bringing the

cumulative position to a deficit of -£3,084K. This is offset by a projected £2,785K release

from reserves.

17. Costs of excluded PbR drugs amount to -£2,748K above plan for the 10 months of the year

to-date, (offset by an over performance in income).

18. CIP delivery remains dominated by the non-recurrent release from the balance sheet

(expected to be £10M for the year) and reserves. Progress continues on formulating work

programmes to bridge the gap, with a number of schemes having been uploaded onto the

system for review and approval. These are factored in to the divisional CIP projections.

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Table 4 - Summarised Divisional Budget Variance – M10 (2014-15)

Liverpool Clinical Laboratories

19. Included within the operational position is a deficit of -£611K relating to clinical labs which

forms part of the joint venture, Liverpool Clinical Laboratories, (LCL), with RLBUH, marginally

offset by an over achievement on contract income (direct access).

20. As reported last month, the deficit at RLBUH totals some -£2.2M, which on the basis of the

agreement Aintree would share 40%. This would increase the reported deficit for Aintree by -

£0.9M on current projections.

21. Further clarification has been sought from LCL and RLBUH to understand the specific

elements that constitute the overspend and what management decisions may have

contributed to it, recognising one of the purposes of the joint venture was to derive

economies of scale and provide a significant contribution to the savings plan for both

organisations. A comprehensive analysis with explanations has yet to be received despite

continued correspondence being sent and it has proved difficult to arrange a meeting to

discuss it further.

22. At present the trust does not accept any increase to its position, but recognises this is a risk

to the forecast position for the year.

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Cost Improvement Programme (CIP)

23. The CIP programme currently consists of ideas currently being generated through

divisional/departmental teams. In-year the position is more assured, as the bulk of the

delivery is met through non-recurrent balance sheet areas and non-recurrent reserve

slippage.

Table 5 - Summarised Divisional CIP position – M10 (2014-15)

24. Moving forward the recurrent delivery of the 2014/15 target has been wrapped up in the

financial planning for 2015/16, which includes the consolidation of income over performance

in the contract for next year. This by default, net of any associated cost increases to deliver it,

could be assigned against the 2014/15 position. This has been estimated at £2.1M, which

increases the recurrent delivery from the £3.8M noted in table 5 to £5.9M into 2015/16.

25. For 2015/16 the provisional financial plan has identified a gap of -£26.4M.

Balance Sheet, Capital and Cash

26. Balance Sheet and Capital - Fixed assets totalled £180.2M, working capital £11.1M and long

term liabilities totalled -£43.8M. Total assets were £147.5M.

27. Cash - Cash balances totalled £31.8M, £1.4M below plan, with capital spend being behind

plan, offset by contract payments not reflecting contract over performance, together with the

reported deficit on I&E. Despite this, liquidity is healthy and the trust has sufficient cash

resources to meet its obligations.

28. Figure 4 shows the revised cashflow projections based on the strategic plan submission,

which includes the £10M release from the balance sheet in 2014/15 and a balanced position

for 2015/16. The position reflects the latest approved capital programme through to March

2016.

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29. The graph also shows the projected cash forecast based on the current financial plan for

2015/16 which predicts a -£12.9M deficit for the year based on delivering CIP savings of

£13.5M. Cash balances remain positive, but fall to negligible amounts by March 2016.

Figure 4 – Rolling 12 mth cash flow forecast

30. Capital spend for the period totalled just under £10.9M, some £1.5M behind plan after taking

into account anticipated slippage modelled into the in-year forecasting, (see appendix iv).

Risk Assessment Framework

31. Monitor’s Risk Assessment Framework requires a quarterly submission of financial and

performance data which identifies the overall level of risk facing the Trust. The financial risk

ratings are measured from ‘1’ (high risk) through to ‘4’ (low risk).

32. For 2014/15 the Trust is reporting a RAF of 4.

Table 6 – RAF M10 2014-15

Forecast

33. As noted last month, by utilising the £10M of funds held in the balance sheet, income sources

from national resilience funding £1.5m and reserve slippage, the trust continues to forecast a

breakeven position by the end of the year. However the slowdown in income growth,

alongside the continued overspend within Surgery, places a degree of risk in the deliverability

of this forecast. Based on the improvement in month, the downside position has been revised

upward from a potential deficit of -£3M reported last month to £2.5M.

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Appendix i

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Appendix ii

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Appendix iv

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Appendix 6

GLOSSARY

Acronym Meaning Definition / Other information

95th

Percentile

The value below which 95% of all other numbers fall.

AED Accident and

Emergency

Department

This is also referred to as the ED - Emergency department,

or A&E -Accident and Emergency.

ALOS Average length of

stay

The average time a patient stays in a ward, department or as

an inpatient. Usually measured by dividing the total number

of patient days by the total number of discharges.

AQUA Advancing Quality

Alliance

The Advancing Quality Alliance (AQuA) is a health care

quality improvement body. It is funded by its Members who

include: Foundation Trusts, Mental Health Trusts, Clinical

Commissioning Groups, Commissioning Support Services

and the North West Strategic Health Authority. AQuA has a

unique opportunity to act as a catalyst for change across the

North West of England and beyond

AUH Aintree University

Hospital

CAI Community

Acquired Infection

An infection, although detected in hospital is deemed to have

occurred in the community (usually less than 48 hours post

admission).

CBM Clinical Business

Manager

The manager responsible for the operations of a Directorate

in the Trust

CCG Clinical

Commissioning

Group

The name for the new health commissioning organisation

which will replace Primary Care Trusts in April 2013.

Commissioning organisations are responsible for planning

and buying of healthcare across the area to meet the needs

of our local population.

CDT Clostridium Difficile

Toxin

Clostridium difficile (C. difficile) is a bacterium (germ). It lives

harmlessly in the gut of many people. C. difficile bacteria

make toxins that can cause inflammation and damage to the

inside lining of the lower gut (the colon, also known as the

large bowel). There are different strains of C. difficile, and

some can cause a more serious illness than others. The

severity of the infection and illness can vary greatly.

DFI Dr Foster

Intelligence

An independent private sector supplier of benchmark

information.

DNA Did Not Attend When a patient fails to cancel an appointment or give prior

notice of their intention not to attend they are deemed to

have DNA'd.

ENT Ear Nose and

Throat services

FCE Finished Consultant

Episode

An Episode where the patient has completed a period of

care under one consultant within the hospital. A patient may

have multiple FCE's in a single spell of admission to

discharge.

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H&N Head and Neck

Directorate

A Trust directorate encompassing, upper body Surgery,

including Ophthalmology, Audiology, Breast Surgery, Ear

Nose and Throat Surgery and Maxillo Facial Surgery

HAI Hospital Acquired

Infection

An infection that is deemed to have occurred in hospital

(usually greater than 48 hours post admission).

HAS Hospital Arrival

Screen

The system used to record the arrival and departure of

ambulances and the handover of patients to the AED

HPA Health Protection

Agency

The Health Protection Agency is an independent UK

organisation that was set up by the government in 2003 to

protect the public from threats to their health from infectious

diseases and environmental hazards. It does this by

providing advice and information to the general public, to

health professionals such as doctors and nurses, and to

national and local government. From April 2013 the HPA will

become part of Public Health England.

HSMR Hospital

Standardised

Mortality Ratio

An indicator of healthcare quality that measures whether the

death rate at a hospital is higher or lower than you would

expect.

IMAS Interim

Management and

Support

A NHS centrally based team that provides support,

assessment and interventions to NHS organisations when

required,

IP Inpatient A patient receives care following admission to the hospital

IST Intensive Support

Team

A team from IMAS that has a particular focus upon a

specialist area in an NHS organisation needing support such

as cancer or AED teams.,

LOS Length of Stay The time a patient stays in a ward, department or as an

inpatient. Usually measured by dividing the total number of

patient days by the total number of discharges.

MDT Multi Disciplinary

Team

A team of clinical professionals from a range of disciplines

who get together to discuss a patients care and agree on a

coordinated treatment path.

Median The middle number The middle number in a sorted list of numbers

MFU Maxillo Facial Unit

MONITOR An organisation that authorises and regulates NHS

Foundation Trusts and supports their development, ensuring

they are well governed and financially robust.

MRSA Methicillin resistant

Staphylococcus

Aureus

A bacterium that causes infections in different parts of the

body that does not respond to antibiotics that are commonly

used.

NCPOD National

Confidential Enquiry

into Patient

Outcome and Death

Registered Charity / Company set up in 1982 as a joint

venture between surgical and anaesthetic specialties. Work

commissioned by the Health Care Quality Improvement

Partnership.

NWAS North West

Ambulance Service

OP Outpatient A patient receives care without being admitted to hospital

PIBD Pre intervention bed

days

The number of days a patient stays in hospital before they

receive treatment or a major diagnostic examination.

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RR Relative risk This is the risk level of a set of data relative to the national

average or expected.

RTT Referral to

Treatment

The range of targets relating to the requirement for Trusts to

provide treatment for those people referred to them within 18

weeks. There are 3 main target areas - admitted patients,

non admitted patients and incomplete (or open ie not treated

yet) pathways.

SBAR Situation,

Background,

Assessment,

Recommendations.

Tool used in the review of breaches or incidents

SHA Strategic Health

Authority

SHMI Summary Hospital

Mortality Indicator

The SHMI measure is based on a statistical model

developed from a national hospital dataset, which calculates

for each hospital how many deaths would be expected to

occur if they were like the national average at that point in

time.

SMDT Specialist Multi

Disciplinary Team

A highly specialised team of clinical professionals from a

range of disciplines who get together to discuss a patients

care and agree on a coordinated treatment path.

SSNAP Sentinel Stroke

National Audit

Programme

Stroke data collection programme.

T&O Trauma and

Orthopaedics

TCI To Come In A date given to a patients for admission to hospital

YTD Year to Date A figure or amount that is measured from the 1st April the

previous year to today’s date.

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Governor Elections 2015 Results – Council of Governors 17 March 2015

Council of Governors – 17 March 2015

Governor Elections 2015 Results

Key Messages of this Report:

Candidates appointed to the Public constituency and the Nursing and ,Medical classes

within the staff constituency

The candidate for the Staff – Other class was elected unopposed

Introduction/Background

1. The aim of this report is to provide an update on the process undertaken for the by-

election to the Council of Governors of the Trust for two posts within the Staff

Constituency (Medical and Staff - Other) following resignations being received from

two staff governors. In addition, an update on the process undertaken for election to

the posts becoming vacant in Summer 2015 alongside the by-election is also provided.

2. The report provides details of the outcome of the results of the various elections and

the terms of office for each of the successful candidates.

Key Issues

Process

3. The election process follows national election rules. Full details are contained in the

Trust Constitution (Model Election Rules) and are available on the website. The Trust

appointed UK Engage as the independent scrutineers to support the election process.

UK Engage had previously supported the Trust with the summer 2014 elections.

4. UK Engage had advised that the election process for the seats that will become vacant

in the summer was capable of being undertaken at the same time as the election for

the two staff governor vacancies.

By-Election

5. A by-election for two staff governors was required to take place from January 2015 due

to the Trust’s constitution rules stating that the process must start 3 months following

the resignation being received. The by-election commenced in January 2015 for the

following two vacancies:

Medical

Other

6. Arrangements were made with UK Engage to facilitate the election and voting process

whilst the Trust undertook a campaign to raise awareness of the Council of Governors

and, in particular, the role of the Staff Governor.

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2

Full Election

6. The posts that fell vacant in summer 2015 were in the following constituencies/classes:

Staff x 1 (Nursing)

Public x 6

Governors not eligible to stand for election next summer due to completing two

consecutive terms of office were:

Public

Peter Mayne

David Cowan

Staff

Jeanette Wilding (NB. The role of Deputy Lead Governor will, therefore, also

become vacant. An election for this post will be held by Governors during

June/July 2015).

Communication Campaign

7. A communications and engagement campaign was undertaken during

January/February 2015, led by the Trust’s Communications Department with the

involvement of the Corporate Governance Team.

8. In addition, a Governor Information Session was arranged In January 2015 to allow

prospective candidates the opportunity to further understand the role of the Council of

Governors. This proved to be a successful event with around 20 people attending.

Nominations

9. Following the closure of the deadline for nominations on 27 January 2015, the number

of candidates for each of the constituencies/classes was as follows:

Staff Other – 1 candidate (for 1 seat) – no election required

Medical – 3 candidates (for 1 seat) – election required

Nursing – 2 candidates (for 1 seat) – election required

Public – 20 candidates (for six seats) – election required

10. The candidate for the Staff (Other) position was elected unopposed and was

automatically appointed to the Council of Governors on the date of the declaration of

the results of the elections within the other constituencies.

Elections

11. Elections for the 3 other constituencies took place between 11 February 2015 and 6

March 2015 with the result declared on 10 March 2015.

12. The results of the elections were as follows (for a 3 year term of office):

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3

Staff (Other) – Kerry McManus (elected with immediate effect)

Medical – Andrew Swift (elected with immediate effect)

Nursing – Helen Frankland (elected with effect from 1 August 2015)

Public – Tracey Barnes, Sharon Bird, Tony Byrne, Tony Kneebone, Julie Naybour,

Rosemary Urion (all elected with effect from 1 August 2015)

13. Full details of the results for each constituency are attached at Appendix 1.

14. In regard to the Public election, it should be noted that two current Governors will be

standing down from 31 July 2015, namely:

Maurice Byrne

Delyth Meirion-Owen

Recommendation

17. The Council is asked to note the update on the process of the by-election for two staff

governors (Medical and Other) and for the full election (Nursing and Public) to the

Council of Governors as indicated above.

18. The Council is also asked to note the outcome of the Governor elections for 2015.

References and further reading

Trust Constitution - http://www.aintreehospitals.nhs.uk/Foundation Trust/FT Documents/Trust

Constitution (2013).pdf

Authors Michael Games, Corporate Governance Manager

Owner Caroline Keating, Associate Director of Corporate Governance/Board

Secretary

Date 11 March 2015

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Printed and published by the Returning Officer, UK Engage, Image House, 10 Acorn Business Park, Heaton Lane, Stockport SK4 1AS

As Returning Officer for the Election to the Council of Governors of Aintree University Hospital NHS Foundation Trust, I hereby declare that the following candidate is duly elected with immediate effect: Kerry McManus

Tony Slater Returning Officer 9 March 2015

Declaration of Candidates Elected Unopposed Aintree University Hospital NHS Foundation Trust

Election to Council of Governors

Staff - Other

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As Returning Officer at the election of members to the Council of Governors for the Staff - Medical

Constituency held between Wednesday, 11th February and Friday, 6 March 2015, I hereby give notice that

the number of votes recorded for each candidate was as follows:

Name of Candidates Number of Votes

Jamshed Bashir 12

Andrew Swift 49 Elected

David Wile 15

I declare that Andrew Swift is duly elected to the Council of Governors with immediate effect. The number of ballot papers rejected was as follows:

No unique identifier 0

0 Voting for more than one candidate 0

Writing or other identifying mark 0

Unmarked ballot paper 0

Tony Slater Returning Officer UK Engage, Image House, 10 Acorn Business Park, Heaton Lane, Stockport

SK4 1AS

Tel: 0345 209 3770 Fax: 0161 209 4804

Email: [email protected]

9 March 2015

Electorate 577

Total number of votes cast 76

Turnout 13.17%

Invalid votes cast (see below) 0

Total valid votes 0

Declaration of Result Aintree University Hospital NHS Foundation Trust

Staff - Medical

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As Returning Officer at the election of members to the Council of Governors for the Staff - Nursing

Constituency held between Wednesday, 11th February and Friday, 6 March 2015, I hereby give notice that

the number of votes recorded for each candidate was as follows:


Helen Frankland 68 Elected

D. Shackcloth 22

I declare that Helen Frankland is duly elected to the Council of Governors with effect from 1 August 2015. The number of ballot papers rejected was as follows:


0 Voting for more than one candidate 0




SK4 1AS

Tel: 0345 209 3770 Fax: 0161 209 4804


9 March 2015

Electorate 1,414


Turnout 6.36%


Total valid votes 0


Staff - Nursing

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As Returning Officer at the election of members to the Council of Governors for the Public Constituency

held between Wednesday, 11th February and Friday, 6 March 2015, I hereby give notice that the number

of votes recorded for each candidate was as follows:


Tracey Barnes 348 Elected

Sharon Bird 465 Elected

David Blanchflower 139

Maurice Byrne 247

Tony Byrne 268 Elected

Jean Campbell 233

Jonathan Desmond 219

Paul Denny 218

Joe Hedgecock 87

Gerry Jones 186

George Jackson 208

Tony Kneebone 258 Elected

Robin McGrath 116

Dave McKenna 186

Julie Naybour 253 Elected

Delyth Owen 217

Stephen Percy JP 142

John Roberts 119

Gabriella Tait 252

Rosemary Elizabeth Urion 322 Elected


Public

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I declare that the candidates indicated above are duly elected to the Council of Governors with effect from 1 August 2015. The number of ballot papers rejected was as follows:

No Declaration of Identity received 0

4


Voting for more than 6 candidates 0




SK4 1AS

Tel: 0345 209 3770 Fax: 0161 209 4804


9 March 2015

Electorate 8,153


Turnout 10.43%


Total valid votes 846

Page 75 of 80

1/1

Nominations Committee Report

Report to Council of Governors

Date 17 March 2015

Committee Name Nominations Committee

Date of Committee Meeting 20 January 2015

Chair’s Name& Title Neil Goodwin, Chairman

Summary of Meetings

20 January 2015

The Nominations Committee met to discuss the outcome of the interview held to appoint a Non-

Executive Director of the Trust as a successor to Patrick Hackett. The Committee recommended to the

Extraordinary meeting of the Council of Governors on 20 January 2015 that Joanne Clague should be

appointed to the post with effect from 1 April 2015 for a period of three years. Joanne represents the

University of Liverpool.

Recommendation

The Council of Governors is asked to note the report.

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Membership Committee Report


Date 17 March 2015

Committee Name Membership Committee

Date of Committee Meeting 3 February 2015

Chair’s Name& Title Jeanette Wilding – Staff Governor

Summary of Meeting

An update was provided on the Aintree Hospital signage on public transport. It was noted that

Merseytravel continued to update the Trust name where appropriate but they had little influence with

private bus companies. The Associate Director of Communications agreed to contact Merseytravel

regarding an update on the signage at Fazakerley train station.

Volunteer inductions continue to take place and Governors were to be encouraged to attend when

possible.

The Operating Theatres Open Day took place on 15 November and proved to be a successful event

with over 200 people attending. The feedback received on the day was very positive.

An update was received on the election process and it was noted that there had been significant

interest particularly in the public constituency.

The membership database had been cleansed which had resulted in a decrease in membership

numbers from 9045 to 8140.

It was agreed to defer the review of the Membership Strategy until the next meeting on 5 May. This

would allow for more time for it to be considered internally.

It was noted that consideration was being given to increasing the number of members who read the

Aintree E-Life magazine online.

The Committee considered the series of ‘Focus On’ events and agreed to the following:

o Dementia

o Hearing Loss

o Ophthalmology

o Diabetes

o Occupational Therapy

The Committee noted the revised membership of the Committee. It was also agreed to identify

another Governor to replace Mair Ning who had asked to stand down due to work commitments.

Paul Cummins had agreed to become a member of the Committee.

The Committee terms of reference were being reviewed internally and would be presented to the

Committee for consideration at its next meeting on 5 May.

Recommendation


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Quality of Care Committee Report


Date 17 March 2015

Committee Name Quality of Care Committee

Date of Committee Meeting 12 February 2015

Chair’s Name& Title Maurice Byrne – Lead Governor

Summary of Meeting

This was the first meeting of the Committee and the terms of reference were approved. Maurice Byrne

was appointed as Chairman.

A paper was provided on the quality improvement structures in place to deliver the Quality Strategy.

It was explained that there was a portfolio of projects covering a 3 year period which were being

progressed in each year and that the Committee would receive updates at future meetings.

The Committee discussed the Quality Priorities and a range of topics for consideration at future

meetings were agreed.

Discussion took place on the development of a performance dashboard to enable the Committee to

be satisfied that its duties were being addressed, particularly in relation to the key indicators.

Recommendation


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