council of governors - aintree university hospital...jun 15, 2016 · which the council of...
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COUNCIL OF GOVERNORS 15 June 2016
12.30pm – 2pm Board Room, Aintree Lodge
AGENDA
d = document v = verbal p = presentation
No Item Reference
Preliminary Business - Chairman
12.30 1. Apologies for Absence
To note the apologies
CG16-17/001 (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
CG16-17/002 (v)
3. Minutes from the last meeting (16 March 2016)
To approve the minutes from the last meeting and discuss any matters arising
CG16-17/003 (d)
Overview
12.35 4. Strategic Update
Deputy Chairman/Chief Executive
To note
CG16-17/004 (p)
12.45 5. Lead Governor Report
To note
CG16-17/005 (d)
Quality & Performance Management
12.50 6. Assurance on Key Indicators:
Quality & Safety
Finance & Performance
Non-Executive Directors
CG16-17/006 (p)
Internal System of Control
1.25 7. Key Issues & Assurances (Audit)
Non-Executive Director
CG16-17/007 (p)
1.30 8. External Auditors Report on the Quality Account
PricewaterhouseCoopers LLP
To note
CG16-17/008 (d)
Governance
1.40 9. Governor Committees:
Membership Committee (3 May 2016) for noting
Quality of Care Committee (18 May 2016) for noting
Nominations Committee (15 June 2016) for approval
CG16-17/009 (d/v)
1.45 10. Council of Governors’ Objectives 2016/17
To approve
CG16-17/010 (d)
Cou
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Aintree University Hospital NHS Foundation Trust
Agenda: Council of Governors’ Meeting 15 June 2016 2/2
1.50 11. Appointments:
Lead Governor – to approve
Deputy Lead Governor – to elect
CG16-17/011 (d)
Concluding Business
2.00 12. Any Other Business
Chairman
CG16-17/012 (v)
13. Date and Time of Next Meeting:
Thursday 13 October 2016 at 5.30pm
PRIVATE BUSINESS
No Item Reference
2.05 1. Appraisal of the Chairman
Senior Independent Director
CGP16-17/001 (d)
2.10 2. Appraisal of the Non-Executive Directors
Associate Director of Corporate Governance/Board Secretary
CGP16-17/002 (d)
Council of Governors – Objectives 2016/17
To further develop skills and knowledge base in order to collectively understand and constructively challenge and support the quality of care agenda provided by the Trust
To improve communication and engagement with members of the Trust in line with the membership strategy objectives
To monitor the performance of the Board of Directors through holding the Non-Executive Directors individually and collectively to account
To deliver its statutory duties in line with regulatory requirements
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Council of Governors
Wednesday 16 March 2016 5.30pm
Board Room Aintree Lodge
MINUTES
Present: Neil Goodwin - Chairman
Pamela Peel - Lead Governor
Tracey Barnes - Public Governor
Sharon Bird - Public Governor
Mike Booth - Public Governor
Tony Byrne - Public Governor
Gerry Hill - Public Governor
John Johnson - Public Governor
Tony Kneebone - Pubic Governor
Brian Lawless - Public Governor
Julie Naybour - Public Governor
Stephen Thornhill - Public Governor
Rosemary Urion - Public Governor
Helen Frankland - Staff Governor (Nursing)
Lorraine Heaton - Staff Governor (AHPs)
Andrew Swift - Staff Governor (Medical)
Paul Cummins - Appointed Governor (Sefton Council)
Barbara Hunter-Douglas - Appointed Governor (Edge Hill University)
John Wilding - Appointed Governor (University of Liverpool)
In Attendance: Steve Warburton - Chief Executive
Joanne Clague - Non-Executive Director
Steve Evans - Medical Director
David Fillingham - Non-Executive Director
Nicola Firth - Director of Nursing & Quality
Michael Games - Corporate Governance Manager
Sue Green - Director of People and Corporate Affairs
Juliet Herzog - Non-Executive Director
Tim Johnston - Non-Executive Director
Ian Jones - Director of Finance & Business Services
Caroline Keating - Associate Director of Corporate Governance/Board
Secretary
Colin Maloney - Non-Executive Director
Kevan Ryan - Non-Executive Director
Angie Smithson - Chief Operating Officer
Nicola Allen - Corporate Governance Officer
Elaine Carter - Member of the Public
Apologies: Mike Bowker - Public Governor
Rose Milnes - Public Governor
Kerry McManus - Staff Governor (Other)
Colin Maloney - Non-Executive Director
Paul Fitzpatrick - Director of Estates & Facilities
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Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 16 March 2016 2/6
Ref Minute
Preliminary Business
CG15-16/043 Apologies for Absence
The apologies were noted as above.
CG15-16/044 Declarations of Interest
There were no declarations of interest.
CG15-16/045 Minutes from the last meeting (9 December 2015)
The minutes from the previous meeting held on 9 December 2015 were approved as an
accurate record.
The Chairman made reference to the Governor workshop held on 24 February 2016 at
which the Council of Governors agreed the following Quality Indicator for the purpose of
External Audit:
Emergency Re-admissions to Hospital within 28 days of Discharge.
Where are we going as an Organisation?
CG15-16/046 Strategic Update
The Chief Executive advised the meeting of the following matters:
Strategic Vision: at the Governor Workshop on 24 February 2016 the Trust’s
refreshed strategic vision & objectives were shared, following discussions held by the
Board to have a vision that accurately reflected the Trust’s ambitions and aspirations.
Governors accepted the refreshed vision and objectives.
Partnerships: the Trust continued to hold discussions with the Royal Liverpool &
Broadgreen University Hospitals NHS Trust (RLBUHT) on the proposed merger of
clinical services. A meeting of the two Trusts had taken place with the regulators and
local commissioners and there had been a clear steer from the Liverpool Clinical
Commissioning Group (CCG) on the case for the strategic transformation plan and
the impetus behind that proposal would need to be worked through appropriately.
Liverpool Health Community (LCH) Services: the tenders for the transaction and
transformation of the community services provided in Liverpool and South Sefton by
LCH were being progressed. The Trust was actively reviewing the commissioned
provisions with particular input being sought from specialist community services.
Financial Position: contract negotiations were yet to be agreed with commissioners
but this was being pursued. Nationally, the Trust had been offered the opportunity to
access £9.5m but this was predicated on the Trust achieving a surplus control of
£1.2m. However, on reviewing the Trust’s financial forecasts for 2016/17 and
assuming that the cost improvement plans were met, it was anticipated that there
would be a deficit of £7.4m which would mean that the Trust would not be able
access the funds being made available. The Trust had received a site visit in
February 2016 from Monitor to assess the financial plans and assumptions and
feedback from the visit was awaited.
A&E Performance: the Trust had been invited to meet with Monitor in January 2016
to discuss its poor performance and to outline its plans to improve the situation. A
summit meeting subsequently took place in February 2016 with Trusts who were in a
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Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 16 March 2016 3/6
Ref Minute
similar position in order to discuss and review best practice. However, nothing had
been raised that was not already factored into the Trust’s framework and plans for
improvement. The Trust was now focussed on the delivery and implementation of its
plans to improve its A&E performance which had been developed in conjunction with
the clinical teams. The Trust would also continue to focus on working with its
external partners on the prevention of patients coming to the Hospital and
appropriately discharging patients into the community.
The Council of Governors requested clarification on the following matters:
Concerns over the Trust’s financial position and its A&E performance and
questioned whether appropriate and the right actions had been taken at an
early stage. The Chief Executive commented that the Trust’s deficit position would
be carried over into the next financial year with the cumulative effect of a reduced
tariff and the increased costs of services being the main contributors. However, the
Trust was committed to maintaining quality and safety standards within its services
and would compromise on this regardless of cost. The Chairman advised that the
Board was to undertake a review during March/April 2016 to understand how it got to
this position and reflect on the learning from the experience.
The Council being equally responsible for the poor performance of the Trust.
The Chairman advised that the Board was clear on its responsibility to manage the
business and performance of the Trust and for the Council of Governors to represent
the interests of public and staff members, and local partner organisations in the
governance of the Trust as well as hold the Non-Executive Directors to account. He
believed that the Board had been more open and transparent with the Council but
was more than happy to hear any views on further engagement to ensure that
Governors felt more assured where appropriate.
How was the Trust performing compared to its peers? The Trust was at the
lower end in terms of performance but this was expected to improve once the
approved Emergency and Acute Care Plans had been implemented.
The Council noted the update.
How are we performing?
CG15-16/047 Finance & Performance – Report on Key Issues & Assurance Received
David Fillingham (Non-Executive Director), Chair of the Finance & Performance
Committee, gave a presentation covering the progress and achievements made and the
key challenges faced for December 2015 to February 2016. Particular mention was
made of the deteriorating performance in A&E and the development of a key set of
principles as a framework for implementation to improve the position, together with the
revised governance structure. Reference was also made to the presentations received
from the Divisions on their financial and clinical performance together with plans for
improvements going forward. The scrutiny of the Trust’s challenging financial position
continued to be a major factor in the Committee’s deliberations with particular emphasis
on progress against the achievement of the Cost Improvement Programme as well as
the financial planning and budgets for 2016/17.
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Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 16 March 2016 4/6
Ref Minute
The Council of Governors requested clarification on the following matters:
What were the contributing factors to the Trust’s deficit? The cost of agency
staff has been one of the factors but rigorous controls had been put in place to limit
the amount of agency staff used when other options may be more efficient. The
Trust’s financial position also been impacted by a change made to the tariff by
Commissioners on non-elective admissions which was unforeseen at the time the
budget and revenue setting process was undertaken. There continued to be plenty
of rigour and challenge from the Committee on the robustness of the financial
planning and budget process. However, it was anticipated that future savings would
be more difficult to achieve particularly as the tariff received by the hospital was likely
to become insufficient to cover costs at some point.
Has theatre productivity improved? Unfortunately a number of operations had to
be cancelled during January 2016 due to the Junior Doctors strike and any further
strikes would also have an impact on productivity levels. It was noted that the
Committee was to receive a presentation from the Surgery Division at the end of
March which would include information relating to theatre productivity.
What impact is the ageing population having on the Hospital? There continued
to be a huge demand on health services at a time when the Trust was not receiving
sufficient funding on a year by year basis. The ageing population placed a strain on
the Trust particularly as people were living longer despite having a number of co-
morbidities to contend with. The effect of GP closures locally placed further pressure
on the Trust as well as community services and the local authority. Furthermore, the
closure of residential homes for economic reasons also had an impact the health
economy within the City.
The Council noted the presentation.
How are we treating our patients?
CG15-16/048 Quality & Safety – Report on Key Issues & Assurance Received
Juliet Herzog (Non-Executive Director), Chair of the Quality & Safety Committee, gave a
presentation covering its key challenges, specific items presented during December
2015 to February 2016 and progress against the Quality Strategy objectives. Specific
mention was made of the degree of scrutiny undertaken by the Committee on serious
incidents and the challenges and concerns raised to receive assurance that appropriate
lessons had been learned, recommendations and actions identified and acted upon to
mitigate future incidents occurring; the continued monitoring of the Ophthalmology risk
and the monitoring of progress for mitigation; and the examination of performance of the
Trust’s infection prevention and control programme. Reference was also made to the
presentations received by the Committee on Assaults, Complaints, Laparotomy audit and
the quality of patient care in A&E.
The Council of Governors requested clarification on the following matters:
Have the changes made to the recruitment process realised any benefits and
was there any confidence that the changes had not adversely affected patient
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Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 16 March 2016 5/6
Ref Minute
care? The Trust had a level of vacancy control in place but following a review the
process had been tightened to provide Divisions with the opportunity to exhaust all
other options before putting their final recommendations to the panel. There was no
evidence to suggest that any delays in recruitment to genuine vacancies had
impacted on performance. The Trust’s vacancy rate was around 6% and further
recruitment drives were planned to reduce this further. It was noted that the Quality
& Safety Committee received a number of reports relating to staffing levels and
scrutinised the level of bank and agency staff being used to fill vacant posts. The
Staff Governor who raised the question was still concerned that the revised process
appeared to hinder the recruitment of staff into established posts. It was agreed that
the Staff Governor would meet with the Director of People & Corporate Affairs to
discuss this matter further.
What was the impact of using agency staff to fill gaps? The Trust was
committed to filling all its vacancies but there was national challenges being faced in
the recruitment of nursing and clinical staff. The intention was to only use agency
staff on an exception basis but this was not going to be achievable at this point in
time. However, one in place there would be a saving of around £2m.
What was the outcome of the Laparotomy Audit? A national audit had been
undertaken which highlighted that the Trust had not performed well compared to
national standards against the process indicators. An Emergency Laparotomy
Improvement Group had been established and was focussing on improvements to
data completion and lessons learnt. In addition a new Standard Operating Procedure
had been developed which conformed to the national guidelines.
The Council noted the presentation.
How do we run ourselves? What do others think?
CG15-16/049 Report from Audit Committee
Tim Johnston (Non-Executive Director), Chair of the Audit Committee, gave a
presentation covering the key items covered by the Committee and its main challenges
from December 2015 to February 2016. Specific mention was made to the review of the
clinical audit performance and the assurance received on the robust governance process
for project cancellation/abandonment. Reference was also made to the information
governance breach and request for a wider review to be undertaken to investigate
whether there were any other potential gaps or system issues.
The Council noted the presentation.
CG15-16/050 Governor Activity
Governors provided an overview of the activities they had been involved in during the
last quarter with specific reference to the following:
Multi-Disciplinary Accelerated Discharge Events (MADE)
North West Governors’ Forum
North West Coast Academy Health Science Network event
Nutrition & Hydration Collaborative
Patient Led Assessments of the Care Environment (PLACE)
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Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 16 March 2016 6/6
Ref Minute
The Council noted the update.
CG15-16/051 Reports of Governor Committee Chairs
Membership Committee – 2 February 2016
Pam Peel, Chair of the Committee, referred to the report and advised that it was the
intention to organise a World Café type event for Governors to discuss member
engagement. Further details would be issued in due course.
The Council noted the report.
Quality of Care Committee – 11 February 2016
Mike Booth, Chair of the Committee, referred to the report and advised that there had
been encouraging trends provided in the indicators. However, as the Medical Director
had been unable to attend the meeting, the Committee had experienced difficulty in
understanding the context of the data in relation to the Mortality Report.
The Council noted the report.
CG15-16/052 Terms of Reference for Governor Committee
The Council of Governors reviewed the revised terms of reference for the Quality of Care
Committee. It was noted that the change related to the attendance of deputies at the
meetings in the absence of the Director of Nursing & Quality and/or the Medical Director.
The Council approved the revised terms of reference.
Other items for Governors to be aware of
CG15-16/053
Council of Governors’ Forward Plan 2016/17
The Forward Plan for 2016/17 was approved by the Council.
Concluding Business
CG15-16/054 Any Other Business
No further business was raised.
Date and Time of Next Meeting:
Wednesday 15 June 2016 in the Board Room Aintree Lodge at 12.30pm.
The meeting closed at 7pm Chair’s Signature: Date:
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Lead Governors Report
Report to Council of Governors
Date 15 June 2016
Committee Name Council of Governors
Chair’s Name & Title Pamela Peel, Lead Governor
Core Governor Activity
Attendance at Board meetings
Director Walkabouts – considered a valuable and informative opportunity by Governors
Participation in annual NEDs appraisals
Quality of Care Committee
Membership Committee
Nominations Committee
Informal Council of Governors
Wider Trust Activity
Investors in People, 10 March – 6 Governors attended a session with the assessor and discussed
how the Council is able to influence and contributes to the success of Aintree
Quality Accounts, 13 April & 14 May – 2 Governors took part in the development and review of the
draft Quality Account,
Focus On...events. Two of four have taken place so far: 23 May Kidney 4 Governors attended;
Discharge 4 Governors attended
Celebration event for Aintree Volunteers (Volunteers’ Week 1-12 June) in the Chapel on 7 June –
Lead Governor attended and did the Thank you
PLACE assessments – a number of Governors have already been involved, and this is ongoing
Nutrition & Hydration Workstream – please see note from Mike Booth below
Infection Control Collaborative – both sessions were cancelled and no new dates have been issued
Integrated Clinical Network – please see note from Sharon Bird below
Falls – review event for the Falls Prevention Collaborative scheduled for earlier this year has not yet
taken place
Aintree Volunteer Induction each month – this is an opportunity for Governors to recruit members
from amongst people who are already committed to the Trust, and also to engage with them, hear
their ‘stories’ and recognise the contribution they make to the smooth running of the hospital
Helipad Consultation – A number of Governors attended the Stakeholder event and several of us
also dropped into two events held for the local residents.
External Activity
Fazakerley Health & Wellbeing Forum, 10 March – Care-at-the-Chemist presentation and wider
discussion about alternatives to going to AED. Lead Governor attended.
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Aintree University Hospital NHS Foundation Trust
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Healthy Liverpool event on Urgent & Emergency Care by Liverpool CCG, 17 March. Lead Governor
attended.
North West Coast Patient Safety Collaborative 8 March & 19 April – 2 Governors attended
MiAA Event on Mortality 5 May – 2 governors attended. The full note on the event is attached, but it
focussed on real people (rather than 'outcomes') and unexpected deaths, and getting all staff
involved in believing that they could make a difference to patient safety
Lead Governor Activity
Lead Governors conference call 26 April – nationally 12 Governors were involved. Feedback has
been provided to my colleagues and a follow-up virtual meeting via skype is scheduled later this
month
Meetings with Shadow Lead Governor of The Royal are ongoing though infrequent, most recent
meeting was 20 April
Meeting is scheduled later in June with Lead Governor of The Women’s Hospital.
Recommendation
The Council of Governors is asked to note the report.
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Aintree University Hospital NHS Foundation Trust
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Note on Nutrition and Hydration (N&H) Workstream
N&H is included in the quality account, as a priority for improvement for 2016/2017. Aintree is
working towards at least 95% delivery 7 days/week for completion of Nutrition and Hydration Risk
Assessments. I note it dropped from 95% in 2014 to 87% last year. I also note that it is not in
Monitors Risk framework which is disappointing because it is such a fundamental issue.
Reference to N&H was made in the AAA framework update paper given to the QoC Committee on
the 18th May [QC16-17/005] AAA Standard 6 refers to N&H and the tables on page 9, 16 and 17 of
the paper were disappointing reading for the wards and division of medicine compared to the division
of surgery.
N&H group meets quarterly but because the members of the collaborative are all front line staff, they
have not met since December because of pressures from winter and industrial action. I am very
impressed with the focus and commitment of the group but there appears to be problems in
consistent delivery on the wards.
Mike Booth 120616
Note on Integrated Clinical Network
Held on 8 June and chaired by Dr Julie Raj. Those present were representatives of South Sefton LIT; Knowsley CRG, Liverpool End of Life Strategic Group; Woodlands; Community District Nurses; Woodlands; Walton Centre and AUH Clinical Nurse Specialists.
AUH is providing excellent education palliative care support for all areas across the network. These include
Palliative Care Advanced Care Planning Amber Care Bundle Locality audit Unified Do Not Attempt Cardio Pulmonary Resuscitation (uDNACPR)
The introduction of the Amber Care has resulted in a low re- admission rate of 4% at AUH.
AUH's programmes of Advanced Care Planning and Amber Care Bundle has had national recognition that it is leading the way with these initiatives.
Sharon Bird 130616
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Aintree University Hospital NHS Foundation Trust
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Note on MiAA Event on Understanding Mortality There were 3 presentations: Dr Martin Farrier, Consultant Paediatrician and Corporate Clinical Director for Quality and Safety and Alison Unsworth, Coding Lead, Wrightington, Wigan and Leigh NHS FT. Alison introduced us to clinical coding and the key role this has in translating patient notes/ records into data codes that are used as the basis for payment, activity recording & performance management across the NHS. She explored the complexity of coding, the standards applied & the difficulties faced in translating notes. The accuracy of coding cannot be underestimated as it underpins all key decision making & payment mechanisms within the NHS. Martin shared his Trust’s story which started in 2007 when their HSMR was similar to Mid Staffs. He gave a number of examples using the following 4 step process which had achieved substantial change across the Trust. 1. Understanding data 2. Examining unexpected deaths 3. Engaging clinicians 4. Generating change The Trust has created about 200 Quality Champions all trained in the Institute for Health Improvements’ methodology. Martin referred to the often quoted figure that 3-5% of deaths that are believed to be preventable and the work of Helen Hogan under the Prism Programme to understand how these deaths can be avoided. Martin emphasised that it is important that each organisation understands and reviews the data and learns from that review process to consider what could have been done differently, so that changes and improvements are taken forward within each organisation. Paul Hawgood, Principal Business Intelligence Analyst at AQuA – his session ‘Mortality Insights & Myth busting’ took us through the 3 main methodologies to measure mortality: 1. SHMI or Summary Hospital Mortality Indicator 2. HSMR or Hospital Standardised Mortality Ratio 3. RAMI or Risk Adjusted Mortality Index. exploring the relative merits of each & busting some myths including whether adjustments should be made for deprivation, the impact of data coding accuracy, palliative care, auditing and learning lessons following every in hospital death and out of hospital deaths.
All presentations have been circulated to the Council of Governors.
Pamela Peel 120516
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Q4
15
-16
Q1
16
-17
(M
1 o
nly
)TR
END
OP
ERAT
ION
SC
AN
CEL
LED
OU
TPAT
IEN
TSC
AN
CEL
LED
STR
OK
EU
NIT
Page 20 of 43
WO
RK
FO
RC
E
TAR
GET
Q4
15
-16
Q1
16
-17
(M
1 o
nly
)TR
END
WO
RK
FOR
CE
-V
AC
AN
CIE
S2
35
20
6
-A
PP
RA
ISA
LS6
5.2
68
.6
-M
AN
DAT
OR
YTR
AIN
ING
24
.63
0.1
-AT
TEN
DA
NC
ER
ATE
95
.3%
96
.0%
6&7.
CG
16-1
7/00
6 &
007
- P
rese
ntat
ion
to C
ounc
il of
Gov
erno
rs
Page 21 of 43
Ke
y A
rea
s o
f A
ss
ura
nc
e
Fin
an
ce &
Perf
orm
an
ce
•D
ee
p D
ive
s/
Ke
y D
iscu
ssio
ns
–S
urg
ery
–C
ost
Imp
rove
me
nt
Pla
n D
eliv
ery
20
16
/17
(W
ork
sh
op
an
d
De
ep
Div
e)
–F
ina
ncia
l P
lan
Re
ve
nu
e &
Bu
dg
ets
20
16
/17
–E
me
rge
ncy &
Acu
te C
are
Pro
gra
mm
e
–T
ran
sfo
rma
tio
n T
ask &
Fin
ish
Gro
up
•O
bse
rva
tio
ns f
rom
Dire
cto
r W
alk
rou
nd
s&
Bo
ard
Co
nve
rsa
tio
ns
Page 22 of 43
Inte
rna
l S
ys
tem
of
Co
ntr
ol
Key Issu
es &
Assu
ran
ces
Ke
van
Ryan
, N
on
Execu
tive D
irecto
r
•B
oa
rd A
ssu
ran
ce
Fra
me
wo
rk
•In
form
atio
n G
ove
rna
nce B
rea
ch
(E
nd
osco
py)
•In
tern
al A
ud
it R
ep
ort
s
•A
nn
ua
l R
ep
ort
& A
cco
un
ts
•L
osse
s &
Co
mp
en
sa
tio
n
Ob
se
rva
tio
ns fro
m D
ire
cto
r W
alk
rou
nd
s&
Bo
ard
Co
nve
rsa
tio
ns
6&7.
CG
16-1
7/00
6 &
007
- P
rese
ntat
ion
to C
ounc
il of
Gov
erno
rs
Page 23 of 43
ww
w.p
wc.
co.u
k
Ain
tre
e U
niv
er
sit
y
Ho
sp
ita
l N
HS
Fo
un
da
tio
n
Tr
us
t Q
ua
lity
Rep
ort
20
15/1
6
Go
ver
nm
ent
an
d
Pu
bli
c S
ecto
r
Ma
y 2
016
8. E
xter
nal A
udito
rs R
epor
t on
the
Qua
lity
Acc
ount
Page 24 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
Co
nte
nts
Ba
ck
gr
ou
nd
an
d s
co
pe
1
Su
mm
ar
y o
f fi
nd
ing
s
3
De
tail
ed
fin
din
gs
7
Sc
op
e o
f th
is w
or
k
We
ha
ve
pe
rfo
rme
d t
his
wo
rk i
n a
cco
rda
nce
wit
h M
on
ito
r’s
Det
ail
ed g
uid
an
ce f
or
exte
rna
l a
ssu
ran
ce o
n q
ua
lity
rep
ort
s 2
015
/16
an
d
Mo
nit
or’
s D
eta
iled
req
uir
emen
ts f
or
qu
ali
ty r
epo
rts
20
15/1
6 w
hic
h w
ere
iss
ue
d i
n M
arc
h 2
016
an
d t
he
NH
S F
ou
nd
ati
on
Tru
st A
nn
ua
l R
ep
ort
ing
Ma
nu
al
20
15/1
6.
Re
po
rts
an
d l
ett
ers
pre
pa
red
by
ex
tern
al
au
dit
ors
an
d a
dd
ress
ed
to
go
ve
rno
rs,
dir
ect
ors
or
off
ice
rs a
re p
rep
are
d f
or
the
so
le u
se o
f th
e N
HS
F
ou
nd
ati
on
Tru
st,
an
d n
o r
esp
on
sib
ilit
y i
s ta
ken
by
au
dit
ors
to
an
y g
ov
ern
or,
dir
ect
or
or
off
ice
r in
th
eir
in
div
idu
al
cap
aci
ty,
or
to a
ny
th
ird
p
art
y.
Th
e m
att
ers
ra
ise
d i
n t
his
re
po
rt a
re o
nly
th
ose
wh
ich
ha
ve
co
me
to
ou
r a
tten
tio
n a
risi
ng
fro
m o
r re
lev
an
t to
ou
r w
ork
th
at
we
be
lie
ve
n
ee
d t
o b
e b
rou
gh
t to
yo
ur
att
en
tio
n.
Th
ey
are
no
t a
co
mp
reh
en
siv
e r
eco
rd o
f a
ll t
he
ma
tte
rs a
risi
ng
, a
nd
in
pa
rtic
ula
r w
e c
an
no
t b
e h
eld
re
spo
nsi
ble
fo
r re
po
rtin
g a
ll r
isk
s in
yo
ur
bu
sin
ess
or
all
in
tern
al
con
tro
l w
ea
kn
ess
es.
Th
is r
ep
ort
ha
s b
ee
n p
rep
are
d s
ole
ly f
or
yo
ur
use
in
a
cco
rda
nce
wit
h t
he
te
rms
of
ou
r e
ng
ag
em
en
t le
tte
r d
ate
d 1
9 A
pri
l 2
016
an
d f
or
no
oth
er
pu
rpo
se a
nd
sh
ou
ld n
ot
be
qu
ote
d i
n w
ho
le o
r in
p
art
wit
ho
ut
ou
r p
rio
r w
ritt
en
co
nse
nt.
No
re
spo
nsi
bil
ity
to
an
y t
hir
d p
art
y i
s a
cce
pte
d a
s th
e r
ep
ort
ha
s n
ot
be
en
pre
pa
red
fo
r, a
nd
is
no
t in
ten
de
d f
or,
an
y o
the
r p
urp
ose
.
Co
nte
nts
Page 25 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
1
Ba
ckg
rou
nd
N
HS
fo
un
da
tio
n t
rust
s a
re r
equ
ired
to
pre
pa
re a
nd
pu
bli
sh
a Q
ua
lity
Rep
ort
ea
ch y
ea
r.
Th
e Q
ua
lity
Rep
ort
ha
s to
be
pre
pa
red
in
acc
ord
an
ce w
ith
th
e N
HS
fo
un
da
tio
n t
rust
A
nn
ua
l R
epo
rtin
g M
an
ua
l (“
the
FT
AR
M”)
.
As
yo
ur
aud
ito
rs,
we
are
req
uir
ed t
o u
nd
erta
ke
wo
rk o
n y
ou
r Q
ua
lity
Rep
ort
un
der
Mo
nit
or’
s A
ud
it C
od
e a
nd
Mo
nit
or’
s ‘D
eta
iled
Gu
idan
ce f
or
Ex
tern
al
Ass
ura
nce
on
th
e Q
ua
lity
R
epo
rts
20
15/1
6’ (
‘th
e d
eta
iled
gu
ida
nce
’) w
hic
h w
as
pu
bli
shed
in
Ma
rch
20
16.
Th
e p
urp
ose
of
this
rep
ort
is
to p
rov
ide
the
Co
un
cil
of
Go
ver
no
rs o
f A
intr
ee U
niv
ersi
ty H
osp
ita
l N
HS
Fo
un
da
tio
n
Tru
st (
“th
e T
rust
”) w
ith
ou
r fi
nd
ing
s a
nd
rec
om
men
da
tio
ns
for
imp
rov
emen
ts,
in a
cco
rda
nce
wit
h M
on
ito
r’s
req
uir
emen
ts.
It i
s re
ferr
ed t
o b
y M
on
ito
r a
s th
e “G
ov
ern
ors
re
po
rt”.
Sco
pe
of
ou
r w
ork
W
e a
re r
equ
ired
by
Mo
nit
or
to r
evie
w t
he
con
ten
t o
f th
e
20
15/1
6
Qu
ali
ty R
epo
rt,
test
th
ree
per
form
an
ce i
nd
ica
tors
an
d p
rod
uce
tw
o r
epo
rts:
Lim
ited
ass
ura
nce
rep
ort
: T
his
rep
ort
is
a f
orm
al
do
cum
ent
tha
t re
qu
ires
us
to c
on
clu
de
wh
eth
er a
ny
thin
g
ha
s co
me
to o
ur
att
enti
on
th
at
wo
uld
lea
d u
s to
bel
iev
e
tha
t:
o
Th
e Q
ua
lity
Rep
ort
do
es n
ot
inco
rpo
rate
th
e m
att
ers
req
uir
ed t
o b
e re
po
rted
on
as
spec
ifie
d i
n A
nn
ex 2
to
C
ha
pte
r 7
of
the
FT
AR
M a
nd
Mo
nit
or’
s ‘D
eta
iled
re
qu
irem
ents
fo
r q
ua
lity
rep
ort
s 2
015
/16
’(“t
he
req
uir
emen
ts”)
;
o
Th
e Q
ua
lity
Rep
ort
is
con
sist
ent
in a
ll m
ate
ria
l a
spec
ts w
ith
so
urc
e d
ocu
men
ts s
pec
ifie
d b
y M
on
ito
r;
an
d
o
Th
e sp
ecif
ied
in
dic
ato
rs h
av
e n
ot
bee
n p
rep
are
d i
n a
ll
ma
teri
al
resp
ects
in
acc
ord
an
ce w
ith
th
e cr
iter
ia s
et
ou
t in
th
e d
eta
iled
gu
ida
nce
.
A l
imit
ed a
ssu
ran
ce e
ng
ag
emen
t is
les
s in
sco
pe
tha
n
a r
easo
na
ble
ass
ura
nce
en
ga
gem
ent
(su
ch a
s th
e ex
tern
al
au
dit
of
acc
ou
nts
). T
he
na
ture
, ti
min
g a
nd
ex
ten
t o
f p
roce
du
res
for
ga
ther
ing
su
ffic
ien
t a
pp
rop
ria
te e
vid
ence
are
del
iber
ate
ly l
imit
ed
com
pa
red
to
a r
easo
na
ble
ass
ura
nce
en
ga
gem
ent.
Go
ver
no
rs r
epo
rt:
A p
riv
ate
rep
ort
on
th
e o
utc
om
e o
f
ou
r w
ork
th
at
is m
ad
e a
va
ila
ble
to
th
e T
rust
’s G
ov
ern
ors
an
d t
o M
on
ito
r.
Ou
r li
mit
ed a
ssu
ran
ce r
epo
rt i
s re
stri
cted
, a
s re
qu
ired
by
Mo
nit
or,
to
th
e co
nte
nt
of
the
Qu
ali
ty R
epo
rt a
nd
tw
o
per
form
an
ce i
nd
ica
tors
on
ly.
Th
e G
ov
ern
ors
rep
ort
co
ver
s
all
of
ou
r w
ork
an
d,
ther
efo
re,
the
thir
d l
oca
l in
dic
ato
r w
hic
h
is c
ho
sen
by
th
e G
ov
ern
ors
.
Ba
ck
gr
ou
nd
an
d s
co
pe
8. E
xter
nal A
udito
rs R
epor
t on
the
Qua
lity
Acc
ount
Page 26 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
2
Co
nte
nt
of
the
Qu
ali
ty R
epo
rt
We
are
req
uir
ed t
o i
ssu
e a
lim
ited
ass
ura
nce
re
po
rt i
n
rela
tio
n t
o t
he
con
ten
t o
f y
ou
r Q
ua
lity
Rep
ort
. T
his
in
vo
lves
:
Rev
iew
ing
th
e co
nte
nt
of
the
Qu
ali
ty R
epo
rt a
ga
inst
th
e re
qu
irem
ents
of
Mo
nit
or’
s p
ub
lish
ed g
uid
an
ce,
as
spec
ifie
d i
n A
nn
ex 2
to
Ch
ap
ter
7 o
f th
e F
T A
RM
an
d
Mo
nit
or’
s ‘D
eta
iled
req
uir
emen
ts f
or
qu
ali
ty r
epo
rts
20
15/1
6’;
an
d
Rev
iew
ing
th
e co
nte
nt
of
the
Qu
ali
ty R
epo
rt f
or
con
sist
ency
wit
h t
he
sou
rce
do
cum
ents
sp
ecif
ied
by
M
on
ito
r in
th
e d
eta
iled
gu
ida
nce
.
Per
form
an
ce i
nd
ica
tors
W
e a
re r
equ
ired
to
iss
ue
a l
imit
ed a
ssu
ran
ce r
epo
rt i
n r
esp
ect
of
two
ou
t o
f th
e th
ree
ind
ica
tors
sp
ecif
ied
by
Mo
nit
or.
Th
e in
dic
ato
rs f
or
the
yea
r en
ded
31
Ma
rch
20
16 s
ub
ject
to
li
mit
ed a
ssu
ran
ce (
the
“sp
ecif
ied
in
dic
ato
rs”)
; m
ark
ed w
ith
the
sym
bo
l
in
th
e Q
ua
lity
Rep
ort
, co
nsi
st o
f th
e fo
llo
win
g n
ati
on
al
pri
ori
ty i
nd
ica
tors
as
ma
nd
ate
d b
y
Mo
nit
or:
Sp
ec
ifie
d I
nd
ica
tor
s
Sp
ec
ifie
d i
nd
ica
tor
s
cr
ite
ria
(M
on
ito
r’s
D
eta
ile
d G
uid
an
ce
)
Per
cen
tag
e o
f in
com
ple
te
pa
thw
ays
wit
hin
18
wee
ks
for
pa
tien
ts o
n i
nco
mp
lete
p
ath
wa
ys a
t th
e en
d o
f th
e re
po
rtin
g p
erio
d
An
nex
C -
pa
ge
20
Per
cen
tag
e o
f p
ati
ents
wit
h
a t
ota
l ti
me
in A
&E
of
fou
r h
ou
rs o
r le
ss f
rom
arr
iva
l to
a
dm
issi
on
, tr
an
sfer
or
dis
cha
rge
An
nex
C –
pa
ge
21
Ou
r p
roce
du
res
incl
ud
ed:
ob
tain
ing
an
un
der
sta
nd
ing
of
the
des
ign
an
d o
per
ati
on
of
the
con
tro
ls i
n p
lace
in
rel
ati
on
to
th
e co
lla
tio
n a
nd
re
po
rtin
g o
f th
e sp
ecif
ied
in
dic
ato
rs,
incl
ud
ing
co
ntr
ols
o
ver
th
ird
pa
rty
in
form
ati
on
(if
ap
pli
cab
le)
an
d
per
form
ing
wa
lkth
rou
gh
s to
co
nfi
rm o
ur
un
der
sta
nd
ing
;
ba
sed
on
ou
r u
nd
erst
an
din
g,
ass
essi
ng
th
e ri
sks
tha
t th
e p
erfo
rma
nce
ag
ain
st t
he
spec
ifie
d i
nd
ica
tors
ma
y b
e m
ate
ria
lly
mis
sta
ted
an
d d
eter
min
ing
th
e n
atu
re,
tim
ing
a
nd
ex
ten
t o
f fu
rth
er p
roce
du
res;
ma
kin
g e
nq
uir
ies
of
rele
va
nt
ma
na
gem
en
t, p
ers
on
nel
a
nd
, w
her
e re
lev
an
t, t
hir
d p
art
ies;
con
sid
erin
g s
ign
ific
an
t ju
dg
men
ts m
ad
e b
y t
he
Tru
st i
n
pre
pa
rati
on
of
the
sp
ecif
ied
in
dic
ato
rs;
an
d
per
form
ing
lim
ited
tes
tin
g,
on
a s
elec
tiv
e b
asi
s o
f ev
iden
ce s
up
po
rtin
g t
he
rep
ort
ed p
erfo
rma
nce
in
dic
ato
rs,
an
d a
sses
sin
g t
he
rela
ted
dis
clo
sure
.
Lo
cal
ind
ica
tor
We
are
als
o r
equ
ired
to
un
der
tak
e su
bst
an
tiv
e sa
mp
le t
esti
ng
o
f o
ne
furt
her
lo
cal
ind
ica
tor.
Th
is i
nd
ica
tor
is n
ot
incl
ud
ed
in o
ur
lim
ited
ass
ura
nce
rep
ort
. In
stea
d,
we
are
req
uir
ed t
o
pro
vid
e a
det
ail
ed r
epo
rt o
n o
ur
fin
din
gs
an
d
reco
mm
end
ati
on
s fo
r im
pro
vem
ents
in
th
is,
ou
r G
ov
ern
ors
re
po
rt.
Th
e T
rust
’s G
ov
ern
ors
sel
ect
the
ind
icat
or
to b
e su
bje
ct t
o o
ur
sub
sta
nti
ve
sam
ple
tes
tin
g.
Th
e in
dic
ato
r se
lect
ed i
s em
erg
ency
rea
dm
issi
on
wit
hin
28
da
ys
of
dis
cha
rge
fro
m h
osp
ita
l.
Page 27 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
3
Co
nte
nt
of
the
Qu
ali
ty R
epo
rt
No
iss
ues
ha
ve
com
e to
ou
r a
tten
tio
n t
ha
t le
ad
us
to b
elie
ve
tha
t th
e Q
ua
lity
Rep
ort
do
es n
ot
inco
rpo
rate
th
e m
att
ers
req
uir
ed
to b
e re
po
rted
on
as
spec
ifie
d i
n A
nn
ex 2
to
Ch
ap
ter
7 o
f th
e F
T A
RM
an
d t
he
“Det
ail
ed r
equ
irem
ents
fo
r q
ua
lity
rep
ort
s 2
015
/16
.
Lim
ite
d A
ss
ur
an
ce
Re
po
rt
As
a r
es
ult
of
ou
r w
or
k,
we
are
ab
le t
o p
ro
vid
e a
n u
nq
ua
lifi
ed
lim
ite
d a
ss
ur
an
ce
re
po
rt
in r
es
pe
ct
of
the
c
on
ten
t o
f th
e Q
ua
lity
Re
po
rt.
Co
nsi
sten
cy w
ith
Oth
er I
nfo
rma
tio
n
No
iss
ues
ha
ve
com
e to
ou
r a
tten
tio
n t
ha
t le
ad
us
to b
elie
ve
tha
t th
e Q
ua
lity
Rep
ort
is
no
t co
nsi
sten
t w
ith
th
e o
ther
in
form
ati
on
so
urc
es d
efin
ed b
y M
on
ito
r’s
“Det
ail
ed r
equ
irem
ents
fo
r q
ua
lity
rep
ort
s 2
015
/16
”.
Lim
ite
d A
ss
ur
an
ce
Re
po
rt
As
a r
es
ult
of
ou
r w
or
k,
we
are
a
ble
to
pr
ov
ide
an
un
qu
ali
fie
d l
imit
ed
as
su
ra
nc
e r
ep
or
t in
re
sp
ec
t o
f th
e
co
ns
iste
nc
y o
f th
e Q
ua
lity
Re
po
rt
wit
h t
he
“D
eta
ile
d r
eq
uir
em
en
ts f
or
qu
ali
ty r
ep
or
ts 2
015
/16”
.
Su
mm
ar
y o
f fi
nd
ing
s
8. E
xter
nal A
udito
rs R
epor
t on
the
Qua
lity
Acc
ount
Page 28 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
4
Sel
ecte
d P
erfo
rma
nce
in
dic
ato
rs
Ou
r fi
nd
ing
s re
lati
ng
to
th
e p
erfo
rma
nce
in
dic
ato
rs a
re s
um
ma
rise
d a
s fo
llo
ws:
Pe
rfo
rm
an
ce
in
dic
ato
rs i
nc
lud
ed
in
ou
r
lim
ite
d a
ss
ura
nc
e r
ep
or
t F
ind
ing
s
Per
cen
tag
e o
f in
com
ple
te p
ath
wa
ys
wit
hin
18
wee
ks
for
pa
tien
ts o
n i
nco
mp
lete
pa
thw
ays
at
the
end
of
the
rep
ort
ing
per
iod
On
e is
sue
iden
tifi
ed.
Th
is h
as n
o i
mp
act
on
ou
r li
mit
ed a
ssu
ran
ce o
pin
ion
.
Per
cen
tag
e o
f p
ati
ents
wit
h a
to
tal
tim
e in
A&
E o
f fo
ur
ho
urs
or
less
fro
m a
rriv
al
to a
dm
issi
on
, tr
an
sfer
or
dis
cha
rge
Tw
o i
ssu
es i
den
tifi
ed.
Th
is h
as
no
im
pa
ct o
n o
ur
lim
ited
ass
ura
nce
op
inio
n.
Lim
ite
d A
ss
ur
an
ce
Re
po
rt
As
a r
es
ult
of
ou
r w
or
k,
we
are
ab
le t
o p
ro
vid
e a
n u
nq
ua
lifi
ed
lim
ite
d a
ss
ur
an
ce
re
po
rt
in r
es
pe
ct
of
the
m
an
da
ted
pe
rfo
rm
an
ce
in
dic
ato
rs
.
Pe
rfo
rm
an
ce
in
dic
ato
r n
ot
inc
lud
ed
wit
hin
o
ur
lim
ite
d a
ss
ur
an
ce
re
po
rt
Fin
din
gs
Em
erg
ency
re
-ad
mis
sio
ns
wit
hin
28
day
s o
f d
isch
arg
e fr
om
ho
spit
al’
N
o i
ssu
es i
den
tifi
ed.
An
nu
al
Go
ver
na
nce
Sta
tem
ent
We
iden
tifi
ed n
o i
ssu
es r
elev
an
t to
th
e Q
ua
lity
Rep
ort
.
Page 29 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
5
Rev
iew
ag
ain
st t
he
con
ten
t re
qu
irem
ents
W
e re
vie
wed
th
e co
nte
nt
of
the
Qu
ali
ty R
epo
rt a
ga
inst
th
e co
nte
nt
req
uir
emen
ts w
hic
h a
re s
pec
ifie
d i
n A
nn
ex 2
to
C
ha
pte
r 7
of
the
FT
AR
M a
nd
th
e re
qu
irem
ents
.
No
iss
ues
ca
me
to o
ur
att
enti
on
th
at
led
us
to b
elie
ve
tha
t th
e Q
ua
lity
Rep
ort
ha
s n
ot
bee
n p
rep
are
d i
n l
ine
wit
h t
he
FT
A
RM
or
the
req
uir
emen
ts.
Rev
iew
co
nsi
sten
cy a
ga
inst
sp
ecif
ied
so
urc
e d
ocu
men
ts
Ou
r w
ork
in
rel
ati
on
to
rev
iew
ing
th
e co
nte
nt
of
the
20
15/1
6
Qu
ali
ty R
epo
rt f
or
con
sist
ency
ag
ain
st t
he
foll
ow
ing
so
urc
e
do
cum
ents
sp
ecif
ied
by
Mo
nit
or
is c
om
ple
te:
Bo
ard
min
ute
s fo
r th
e fi
na
nci
al
yea
r, A
pri
l 2
015
to
Ma
rch
2
016
(th
e p
erio
d);
Pa
per
s re
lati
ng
to
qu
ali
ty r
epo
rt r
epo
rted
to
th
e B
oa
rd
ov
er t
he
per
iod
Ap
ril
20
15 t
o t
he
da
te o
f si
gn
ing
th
is
lim
ited
ass
ura
nce
rep
ort
;
Fee
db
ack
fro
m t
he
Co
mm
issi
on
ers
So
uth
Sef
ton
CC
G
rece
ived
;
Fee
db
ack
fro
m G
ov
ern
ors
;
Fee
db
ack
fro
m L
oca
l H
ealt
hw
atc
h o
rga
nis
ati
on
s (K
no
wsl
ey C
ou
nci
l’s
Hea
lth
Scr
uti
ny
Su
b-C
om
mit
tee
an
d
Hea
lth
wa
tch
Kn
ow
sley
(jo
int
resp
on
se)
rece
ived
, H
ealt
hw
atc
h L
iver
po
ol
an
d H
ealt
hw
atc
h S
efto
n
rece
ived
);
Th
e T
rust
’s c
om
pla
ints
rep
ort
pu
bli
shed
un
der
re
gu
lati
on
18
of
the
Lo
cal
Au
tho
rity
So
cia
l S
erv
ices
an
d
NH
S C
om
pla
ints
Reg
ula
tio
ns
20
09
;
Th
e 2
015
na
tio
na
l a
nd
lo
cal
pa
tien
t su
rvey
;
Th
e 2
015
na
tio
na
l a
nd
lo
cal
sta
ff s
urv
ey;
Ca
re Q
ua
lity
Co
mm
issi
on
In
tell
igen
t M
on
ito
rin
g R
epo
rts
Th
e H
ead
of
Inte
rna
l A
ud
it’s
an
nu
al
op
inio
n o
ver
th
e T
rust
’s c
on
tro
l en
vir
on
men
t.
No
iss
ues
ha
ve
ari
sen
fro
m t
he
wo
rk p
erfo
rme
d.
Per
form
an
ce i
nd
ica
tors
on
wh
ich
we
are
re
qu
ired
to
iss
ue
a l
imit
ed a
ssu
ran
ce
con
clu
sio
n
As
req
uir
ed b
y M
on
ito
r w
e h
av
e u
nd
erta
ken
sa
mp
le t
esti
ng
o
f tw
o p
erfo
rma
nce
in
dic
ato
rs o
n w
hic
h w
e is
sued
ou
r li
mit
ed a
ssu
ran
ce r
epo
rt:
1. p
erce
nta
ge
of
inco
mp
lete
pa
thw
ay
s w
ith
in 1
8 w
eek
s fo
r p
ati
ents
on
in
com
ple
te p
ath
wa
ys a
t th
e en
d o
f th
e re
po
rtin
g p
erio
d;
2.
per
cen
tag
e o
f p
ati
ents
wit
h a
to
tal
tim
e in
A&
E o
f fo
ur
ho
urs
or
less
fro
m a
rriv
al
to a
dm
issi
on
, tr
an
sfer
o
r d
isch
arg
e
We
are
req
uir
ed t
o o
bta
in a
n u
nd
erst
an
din
g o
f th
e k
ey
pro
cess
es a
nd
co
ntr
ols
fo
r m
an
ag
ing
an
d r
epo
rtin
g t
he
in
dic
ato
rs a
nd
sa
mp
le t
est
the
da
ta u
sed
to
ca
lcu
late
th
e in
dic
ato
r b
ack
to
su
pp
ort
ing
do
cum
enta
tio
n. O
ur
wo
rk i
s p
erfo
rmed
in
acc
ord
an
ce w
ith
th
e d
eta
iled
gu
ida
nce
an
d
incl
ud
ed:
Iden
tifi
cati
on
of
the
crit
eria
use
d b
y t
he
Tru
st f
or
mea
suri
ng
th
e in
dic
ato
r;
Co
nfi
rma
tio
n t
ha
t th
e T
rust
ha
d p
rese
nte
d t
he
crit
eria
id
enti
fied
ab
ov
e in
th
e Q
ua
lity
rep
ort
in
su
ffic
ien
t d
eta
il
tha
t th
e cr
iter
ia a
re r
ead
ily
un
der
sta
nd
ab
le t
o u
sers
of
the
Qu
ali
ty R
epo
rt;
De
tail
ed
fin
din
gs
8. E
xter
nal A
udito
rs R
epor
t on
the
Qua
lity
Acc
ount
Page 30 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
6
Ob
tain
ing
an
un
der
sta
nd
ing
of
the
key
pro
cess
es a
nd
co
ntr
ols
fo
r m
an
ag
ing
an
d r
epo
rtin
g t
he
ind
ica
tor
thro
ugh
ma
kin
g e
nq
uir
ies
of
Tru
st s
taff
an
d t
hro
ug
h
per
form
ing
a w
alk
thro
ug
h;
Ch
eck
ing
Tru
st’s
rec
on
cili
ati
on
of
the
rep
ort
ed
per
form
an
ce i
n t
he
Qu
ali
ty R
epo
rt t
o t
he
da
ta u
sed
to
ca
lcu
late
th
e in
dic
ato
r fr
om
th
e T
rust
’s u
nd
erly
ing
sy
stem
s;
Tes
tin
g a
sa
mp
le o
f re
lev
an
t d
ata
use
d t
o c
alc
ula
te t
he
ind
ica
tor
ba
ck t
o s
up
po
rtin
g d
ocu
men
tati
on
; a
nd
Ob
tain
ing
rep
rese
nta
tio
ns
tha
t th
e d
ata
use
d t
o c
alc
ula
te
the
ind
ica
tor
is a
ccu
rate
ly c
ap
ture
d a
t so
urc
e a
nd
th
at
no
so
urc
es o
f in
form
ati
on
/da
ta r
elev
an
t to
th
e in
dic
ato
r
per
form
an
ce h
av
e b
een
ex
clu
ded
.
We
on
ly t
este
d a
sa
mp
le o
f d
ata
, a
s st
ate
d a
bo
ve,
to
su
pp
ort
ing
do
cum
enta
tio
n.
Th
eref
ore
, th
e er
rors
rep
ort
ed
bel
ow
are
lim
ited
to
th
is s
am
ple
. W
e h
av
e a
lso
no
t te
sted
th
e u
nd
erly
ing
sys
tem
s, f
or
exa
mp
le
the
pa
tien
t a
dm
inis
tra
tio
n s
yst
em a
nd
th
e d
ata
ex
tra
ctio
n
an
d r
eco
rdin
g s
yst
ems.
O
ur
fin
din
gs
are
set
ou
t b
elo
w.
Pe
rc
en
tag
e o
f in
co
mp
lete
pa
thw
ay
s w
ith
in 1
8 w
ee
ks
fo
r p
ati
en
ts o
n i
nc
om
ple
te p
ath
wa
ys
Re
po
rte
d p
er
for
ma
nc
e:
20
15/1
6 T
hre
sho
ld:
92
%
20
15/1
6 A
ctu
al:
95
.7%
Cr
ite
ria
id
en
tifi
ed
:
We
con
firm
ed t
he
Tru
st u
ses
the
foll
ow
ing
cri
teri
a f
or
mea
suri
ng
th
e in
dic
ato
r fo
r in
clu
sio
n i
n t
he
Qu
ali
ty R
epo
rt:
Th
e in
dic
ato
r is
ex
pre
ssed
as
a p
erce
nta
ge
of
inco
mp
lete
pa
thw
ays
wit
hin
18
wee
ks
for
pa
tien
ts o
n i
nco
mp
lete
p
ath
wa
ys a
t th
e en
d o
f th
e p
erio
d;
Th
e in
dic
ato
r is
ca
lcu
late
d a
s th
e a
rith
met
ic a
ver
ag
e fo
r th
e m
on
thly
rep
ort
ed p
erfo
rma
nce
in
dic
ato
rs f
or
Ap
ril
20
15
to M
arc
h 2
016
;
Th
e cl
ock
sta
rt d
ate
is
def
ined
as
the
da
te t
ha
t th
e re
ferr
al
is r
ecei
ved
by
th
e F
ou
nd
ati
on
Tru
st,
mee
tin
g t
he
crit
eria
se
t o
ut
by
th
e D
epa
rtm
ent
of
Hea
lth
gu
ida
nce
; a
nd
Th
e in
dic
ato
r in
clu
des
on
ly r
efer
rals
fo
r co
nsu
lta
nt-
led
ser
vic
e, a
nd
mee
tin
g t
he
def
init
ion
of
the
serv
ice
wh
ereb
y a
co
nsu
lta
nt
reta
ins
ov
era
ll c
lin
ica
l re
spo
nsi
bil
ity
fo
r th
e se
rvic
e, t
eam
or
tre
atm
ent.
Iss
ue
s i
de
nti
fie
d t
hr
ou
gh
wo
rk
pe
rfo
rm
ed
:
No
. Is
su
e
Imp
ac
t o
n l
imit
ed
as
su
ra
nc
e r
ep
or
t
1.
Fo
r o
ne
pa
tien
t w
ith
in o
ur
sam
ple
we
no
ted
th
at
the
clo
ck s
tart
da
te r
eco
rded
wa
s N
o i
mp
act
on
ou
r li
mit
ed a
ssu
ran
ce r
epo
rt.
Page 31 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
7
dif
fere
nt
fro
m t
he
da
te o
n t
he
refe
rra
l le
tte
r.
Ho
wev
er,
this
did
no
t h
av
e a
n i
mp
act
on
th
e a
ctu
al
per
form
an
ce a
s th
e p
ati
ent
wa
s st
ill
rep
ort
ed i
n t
he
corr
ect
mo
nth
.
Ov
er
all
Co
nc
lus
ion
:
Ou
r su
bst
an
tiv
e te
stin
g o
f th
e in
dic
ato
r id
enti
fied
on
e is
sue.
No
im
pa
ct o
n o
ur
lim
ited
ass
ura
nce
rep
ort
res
ult
ing
in
an
u
nm
od
ifie
d r
epo
rt i
n r
esp
ect
of
this
in
dic
ato
r.
Pe
rc
en
tag
e o
f p
ati
en
ts w
ith
a t
ota
l ti
me
in
A&
E o
f fo
ur
ho
ur
s o
r l
es
s f
ro
m a
rriv
al
to a
dm
iss
ion
, tr
an
sfe
r
or
dis
ch
ar
ge
Re
po
rte
d p
er
for
ma
nc
e:
20
15/1
6 T
arg
et:
at
lea
st 9
5%
ea
ch q
ua
rter
2
015
/16
Act
ua
l: 9
0.7
%
Cr
ite
ria
id
en
tifi
ed
:
We
con
firm
ed t
he
Tru
st u
ses
the
foll
ow
ing
cri
teri
a f
or
mea
suri
ng
th
e in
dic
ato
r fo
r in
clu
sio
n i
n t
he
Qu
ali
ty R
epo
rt:
Per
cen
tag
e o
f A
&E
att
end
an
ces
wh
ere
the
pa
tien
t sp
ent
4 h
ou
rs o
r le
ss i
n A
&E
fro
m a
rriv
al
to t
ran
sfer
, a
dm
issi
on
or
dis
cha
rge.
Th
e cl
ock
sta
rts
fro
m t
he
tim
e th
at
the
pa
tien
t a
rriv
es i
n A
&E
an
d s
top
s w
hen
th
e p
ati
ent
lea
ves
th
e d
epa
rtm
ent
on
a
dm
issi
on
, tr
an
sfer
fro
m t
he
ho
spit
al
or
dis
cha
rge
.
Pa
tien
ts s
ho
uld
be
cou
nte
d w
her
e th
eir
tota
l ti
me
in A
&E
is
04
:00
:01
ho
urs
or
gre
ate
r. P
ati
ents
wit
h a
to
tal
tim
e o
f 0
4:0
0:0
0 h
ou
rs o
r lo
wer
sh
ou
ld n
ot
be
cou
nte
d.
A&
E,
mea
ns
a T
ype
1, T
yp
e 2
or
Ty
pe
3 A
&E
dep
art
men
t.
Iss
ue
s i
de
nti
fie
d t
hr
ou
gh
wo
rk
pe
rfo
rm
ed
:
No
. Is
su
e
Imp
ac
t o
n l
imit
ed
as
su
ra
nc
e r
ep
or
t
1.
Fo
r tw
o p
ati
ents
wit
hin
ou
r sa
mp
le t
he
tim
e
per
th
e su
pp
ort
ing
do
cum
enta
tio
n v
iew
ed
wa
s d
iffe
ren
t to
th
e ti
me
reco
rded
in
th
e sy
stem
. H
ow
ever
th
is d
id n
ot
ha
ve
an
im
pa
ct
on
act
ua
l p
erfo
rma
nce
as
the
pa
tien
ts w
ere
stil
l re
po
rted
as
a b
rea
ch o
r n
on
bre
ach
co
rrec
tly
.
No
im
pa
ct o
n o
ur
lim
ited
ass
ura
nce
rep
ort
.
8. E
xter
nal A
udito
rs R
epor
t on
the
Qua
lity
Acc
ount
Page 32 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
8
Co
nc
lus
ion
:
Ou
r su
bst
an
tiv
e te
stin
g o
f th
e in
dic
ato
r id
enti
fied
tw
o i
ssu
es.
No
ne
imp
act
on
ou
r li
mit
ed a
ssu
ran
ce r
epo
rt r
esu
ltin
g i
n
an
un
mo
dif
ied
rep
ort
in
res
pec
t o
f th
is i
nd
ica
tor.
Per
form
an
ce i
nd
ica
tors
no
t in
clu
ded
wit
hin
ou
r li
mit
ed a
ssu
ran
ce r
epo
rt
Mo
nit
or
als
o r
equ
ires
us
to u
nd
erta
ke
sub
sta
nti
ve
sam
ple
tes
tin
g o
f a
lo
cal
ind
ica
tor
sele
cted
by
th
e G
ov
ern
ors
, th
e re
sult
s o
f w
hic
h a
re n
ot
incl
ud
ed w
ith
in o
ur
lim
ited
ass
ura
nce
rep
ort
.
We
ob
tain
an
un
der
sta
nd
ing
of
the
key
pro
cess
es a
nd
co
ntr
ols
fo
r m
an
ag
ing
an
d r
epo
rtin
g t
he
ind
ica
tor
an
d s
am
ple
tes
t th
e d
ata
use
d t
o c
alc
ula
te t
he
ind
ica
tor
ba
ck t
o s
up
po
rtin
g d
ocu
men
tati
on
.
We
test
ed o
nly
a s
am
ple
, a
s st
ate
d a
bo
ve.
Ou
r re
po
rted
err
ors
be
low
are
lim
ited
to
th
is s
am
ple
.
Ou
r fi
nd
ing
s a
re d
eta
iled
as
foll
ow
s:
Em
er
ge
nc
y r
e-a
dm
iss
ion
s w
ith
in 2
8 d
ay
s o
f d
isc
ha
rg
e f
ro
m h
os
pit
al
Re
po
rte
d p
er
for
ma
nc
e:
20
15/1
6 T
arg
et:
n/a
– n
o t
arg
et d
efin
ed
20
15/1
6 A
ctu
al:
8%
Cr
ite
ria
id
en
tifi
ed
:
We
con
firm
ed t
he
Tru
st u
ses
the
foll
ow
ing
cri
teri
a f
or
mea
suri
ng
th
e in
dic
ato
r fo
r in
clu
sio
n i
n t
he
Qu
ali
ty R
epo
rt:
Th
e in
dic
ato
r is
ex
pre
ssed
as
the
per
cen
tag
e o
f em
erg
ency
ad
mis
sio
ns
to t
he
Tru
st o
ccu
rrin
g w
ith
in 2
8 d
ays
of
the
last
, p
rev
iou
s d
isch
arg
e fr
om
ho
spit
al;
Th
e n
um
era
tor
incl
ud
es f
inis
hed
an
d u
nfi
nis
hed
in
pa
tien
t sp
ells
, in
clu
din
g w
her
e th
e p
ati
ent
die
s;
Th
e n
um
era
tor
excl
ud
es p
ati
ents
wit
h a
ma
in s
pec
iali
ty u
po
n r
ead
mis
sio
n c
od
ed u
nd
er o
bst
etri
c; a
nd
th
ose
wh
ere
the
rea
dm
itti
ng
sp
ell
ha
s a
dia
gn
osi
s o
f ca
nce
r (o
ther
th
an
ben
ign
or
in s
itu
) o
r ch
emo
ther
ap
y f
or
can
cer
cod
ed
an
yw
her
e in
th
e sp
ell;
Th
e d
eno
min
ato
r in
clu
des
all
fin
ish
ed c
on
tin
uo
us
inp
ati
ent
spel
ls w
ith
in s
elec
ted
med
ica
l a
nd
su
rgic
al
spec
iali
ties
, w
ith
a d
isch
arg
e d
ate
up
to
31
Ma
rch
;
Page 33 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
9
An
nu
al
Go
ver
na
nce
Sta
tem
ent
In t
he
req
uir
emen
ts
Mo
nit
or
ask
s F
ou
nd
ati
on
Tru
sts
to i
ncl
ud
e a
bri
ef d
escr
ipti
on
of
the
key
co
ntr
ols
in
pla
ce t
o p
rep
are
an
d
pu
bli
sh a
Qu
ali
ty R
epo
rt a
s p
art
of
the
An
nu
al
Go
ver
na
nce
Sta
tem
ent
in t
he
20
15/1
6 p
ub
lish
ed a
cco
un
ts.
Th
e A
nn
ua
l G
ov
ern
an
ce S
tate
men
t, w
ith
in t
he
Fo
un
da
tio
n T
rust
’s 2
015
/16
A
nn
ua
l R
epo
rt,
incl
ud
es t
he
foll
ow
ing
sta
tem
ent
spec
ific
to
th
e Q
ua
lity
Rep
ort
:
Th
e d
ire
cto
rs
are
re
qu
ire
d u
nd
er
th
e H
ea
lth
Ac
t 2
00
9 a
nd
th
e N
ati
on
al
He
alt
h S
er
vic
e (
Qu
ali
ty A
cc
ou
nts
)
Re
gu
lati
on
s 2
010
(a
s a
me
nd
ed
) to
pre
pa
re
Qu
ali
ty A
cc
ou
nts
fo
r e
ac
h f
ina
nc
ial
ye
ar
. M
on
ito
r h
as
is
su
ed
gu
ida
nc
e t
o N
HS
fo
un
da
tio
n t
ru
st
bo
ar
ds
on
th
e f
or
m a
nd
co
nte
nt
of
an
nu
al
Qu
ali
ty R
ep
or
ts w
hic
h
inc
orp
or
ate
th
e a
bo
ve
le
ga
l r
eq
uir
em
en
ts i
n t
he
NH
S F
ou
nd
ati
on
Tr
us
t A
nn
ua
l R
ep
or
tin
g M
an
ua
l.
Th
e T
rust
ha
s ef
fect
ive
syst
ems,
pro
cess
es a
nd
mec
ha
nis
ms
in p
lace
to
pro
du
ce t
he
Qu
ali
ty A
cco
un
t a
nd
to
en
sure
th
at
it
is a
gen
era
l a
nd
ba
lan
ced
vie
w a
nd
th
at
ap
pro
pri
ate
co
ntr
ols
are
in
pla
ce t
o e
nsu
re t
he
acc
ura
cy o
f th
e d
ata
. A
na
tio
na
l
rep
ort
on
th
e re
vie
w o
f th
e T
rust
’s R
efer
ral t
o T
rea
tmen
t (R
TT
) p
rov
ided
po
siti
ve
rein
forc
emen
t o
f th
e q
ua
lity
an
d a
ccu
racy
of
the
da
ta f
or
elec
tiv
e w
ait
ing
tim
es.
A n
um
ber
of
imp
rov
emen
ts w
ere
iden
tifi
ed a
nd
th
ese
ha
ve
bee
n t
ak
en f
orw
ard
fo
r
imp
lem
enta
tio
n b
y t
he
Tru
st.
Th
is r
epo
rt w
as
rece
ived
by
th
e A
ud
it C
om
mit
tee.
Th
e E
xec
uti
ve
lea
d f
or
the
Qu
ali
ty A
cco
un
t
is t
he
Dir
ecto
r o
f N
urs
ing
& Q
ua
lity
. T
he
con
ten
t o
f th
e Q
ua
lity
rep
ort
ref
lect
s th
e T
rust
’s o
vera
ll Q
ua
lity
Str
ate
gy
an
d t
he
pri
ori
ties
in
clu
ded
in
th
is d
ocu
men
t.
Th
e d
eno
min
ato
r ex
clu
des
da
y c
ase
s, s
pel
ls w
ith
a d
isch
arg
e co
ded
as
dea
th,
ma
tern
ity
sp
ells
(b
ase
d o
n s
pec
ialt
y,
epis
od
e ty
pe,
dia
gn
osi
s),
an
d t
ho
se w
ith
men
tio
n o
f a
dia
gn
osi
s o
f ca
nce
r o
r ch
emo
ther
ap
y f
or
can
cer
an
yw
her
e in
th
e sp
ell;
an
d
Pa
tien
ts w
ith
men
tio
n o
f a
dia
gn
osi
s o
f ca
nce
r o
r ch
emo
ther
ap
y f
or
can
cer
an
yw
her
e in
th
e 3
65
da
ys
pri
or
to
ad
mis
sio
n a
re e
xcl
ud
ed f
rom
th
e d
eno
min
ato
r.
Iss
ue
s i
de
nti
fie
d t
hr
ou
gh
wo
rk
pe
rfo
rm
ed
:
No
. Is
su
e
Imp
ac
t o
n l
imit
ed
as
su
ra
nc
e r
ep
or
t
1.
No
iss
ues
no
ted
. N
o i
mp
act
on
ou
r li
mit
ed a
ssu
ran
ce r
epo
rt.
Co
nc
lus
ion
:
Ou
r su
bst
an
tiv
e te
stin
g o
f th
e in
dic
ato
r id
enti
fied
no
iss
ues
. T
her
efo
re,
ther
e w
ou
ld h
av
e b
een
no
im
pa
ct o
n o
ur
lim
ited
a
ssu
ran
ce r
epo
rt h
ad
it
bee
n r
epo
rted
up
on
.
8. E
xter
nal A
udito
rs R
epor
t on
the
Qua
lity
Acc
ount
Page 34 of 43
Ain
tre
e U
niv
ers
ity H
osp
ita
l N
HS
Fo
und
ation
Tru
st
Pw
C
10
Th
e G
ov
ern
ors
, sta
ff a
nd
ex
tern
al
org
an
isa
tio
ns
such
as
the
Cli
nic
al
Co
mm
issi
on
ing
Gro
up
s, t
he
Lo
cal
Au
tho
rity
Ov
erv
iew
an
d S
cru
tin
y C
om
mit
tees
, th
e th
ree
Hea
lth
wa
tch
an
d t
he
Co
un
cil o
f G
ov
ern
ors
wer
e co
nsu
lted
on
th
e p
rio
riti
es f
or
20
15/1
6
in d
eter
min
ing
wh
ich
of
the
loca
l in
dic
ato
rs w
as
to b
e re
vie
wed
by
ex
tern
al
au
dit
.
As
pa
rt o
f o
ur
rep
ort
on
th
e fi
na
nci
al
sta
tem
ents
we
wer
e re
qu
ired
to
:
Rev
iew
wh
eth
er t
he
An
nu
al
Go
ver
na
nce
Sta
tem
ent
refl
ects
co
mp
lia
nce
wit
h M
on
ito
r’s
gu
ida
nce
; a
nd
Rep
ort
if
it d
oes
no
t m
eet
the
req
uir
emen
ts s
pec
ifie
d b
y M
on
ito
r o
r if
th
e st
ate
men
t is
mis
lea
din
g o
r in
con
sist
ent
wit
h
oth
er i
nfo
rma
tio
n w
e a
re a
wa
re o
f fr
om
ou
r a
ud
it o
f th
e fi
nan
cia
l st
ate
men
ts.
Th
e w
ork
we
un
der
too
k o
n t
he
An
nu
al
Go
ver
na
nce
Sta
tem
ent
as
pa
rt o
f o
ur
wo
rk o
n t
he
fin
an
cia
l st
ate
men
ts i
den
tifi
ed n
o
issu
es r
elev
an
t to
th
e Q
ua
lity
Rep
ort
.
Page 35 of 43
In t
he
even
t th
at,
pu
rsu
an
t to
a r
equ
est
wh
ich
Ain
tree
Un
iver
sity
Ho
spit
al
NH
S F
ou
nd
atio
n T
rust
ha
s re
ceiv
ed u
nd
er t
he
Fre
edo
m o
f In
form
atio
n A
ct 2
00
0,
it i
s re
qu
ired
to
dis
clo
se a
ny
in
form
ati
on
co
nta
ined
in
th
is r
epo
rt,
it w
ill
no
tify
Pw
C p
rom
ptl
y a
nd
co
nsu
lt w
ith
Pw
C p
rio
r to
dis
clo
sin
g su
ch r
epo
rt.
Ain
tree
NH
S F
ou
nd
atio
n T
rust
ag
rees
to
pay
du
e re
gar
d t
o a
ny
rep
rese
nta
tio
ns
wh
ich
Pw
C m
ay m
ak
e in
co
nn
ecti
on
wit
h s
uch
dis
clo
sure
an
d
Ain
tree
Un
iver
sity
Ho
spit
al N
HS
Fo
un
dat
ion
Tru
st s
hal
l a
pp
ly a
ny
rel
eva
nt
exem
pti
on
s w
hic
h m
ay
exis
t u
nd
er t
he
Act
to
su
ch r
epo
rt.
If,
fo
llo
win
g c
on
sult
atio
n w
ith
Pw
C,
Ain
tree
Un
iver
sity
Ho
spit
al
NH
S F
ou
nd
ati
on
Tru
st d
iscl
ose
s th
is r
epo
rt o
r a
ny
pa
rt t
her
eof,
it
sha
ll e
nsu
re t
hat
an
y
dis
cla
imer
wh
ich
Pw
C h
as
incl
ud
ed o
r m
ay s
ub
seq
uen
tly
wis
h t
o i
ncl
ud
e in
th
e in
form
atio
n i
s re
pro
du
ced
in
fu
ll i
n a
ny
cop
ies
dis
clo
sed
.
Th
is d
ocu
men
t h
as
bee
n p
rep
ared
fo
r th
e in
ten
ded
rec
ipie
nts
on
ly.
To
th
e ex
ten
t p
erm
itte
d b
y l
aw,
Pri
cew
ate
rho
use
Co
op
ers
LL
P d
oes
no
t a
ccep
t o
r a
ssu
me
an
y l
iab
ilit
y,
resp
on
sib
ilit
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Page 36 of 43
1/1
Membership Committee Report
Report to Council of Governors
Date 15 June 2016
Committee Name Membership Committee
Date of Committee Meeting 3 May 2016
Chair’s Name & Title Pam Peel, Lead Governor
Summary of Meeting
In reviewing the action from the previous meeting, the Committee considered the content of the
Aintree News and put forward some suggestions about the role of Governors for inclusion in the
forthcoming and future editions of the newsletter. This would help in promoting Governors and assist
in their engagement with members.
The meeting predominately reviewed the proposed programme for a World Café style event for
Governors on engagement. The Committee was provided with an overview of the objectives of the
session and the proposed questions to be issued in advance to aid discussion and debate at the
workshop.
In reviewing the questions, the Committee provided feedback and some suggested alterations to the
wording for consideration. The Committee was advised that the purpose of the preparatory
questions was to check that there was a common understanding of engagement amongst governors
and obtain a baseline for moving forward. The action plan arising from the workshop discussions
would effectively be owned by the Governors with an opportunity to pledge their commitment to
member engagement. It was acknowledged that there would be varying degrees amongst
Governors on the time they spend in this regard.
The Committee also considered the options in regard to the date for holding the workshop and
agreed that the afternoon of Wednesday15 June 2016, following the formal Council of Governors’
meeting, would be the most appropriate. It was agreed that a ‘Save the Date’ email was to be issued
to Governors to ensure that as many as possible were able to attend.
Recommendation
The Council of Governors is asked to note the report.
9.1
Mem
bers
hip
Com
mitt
ees
03 M
ay 2
016
Page 37 of 43
1/2
Quality of Care Committee Report
Report to Council of Governors
Date 15 June 2016
Committee Name Quality of Care Committee
Date of Committee Meeting 18 May 2016
Chair’s Name& Title Mike Booth
Summary of Meeting
A presentation was provided on the National Inpatient Survey Results 2015 which included details
of the process undertaken, the Trust’s previous yearly rankings. Detail was also provided on the
results of the survey with particular emphasis on the areas where the Trust had improved or
worsened compared to other Trusts. The Committee was advised that it had scored significantly
better than average on 11 questions and significantly worse than average in 0 questions. The Trust
had been ranked 16th out of 81 participating Trusts, with nine of the first 15 organisations classified
as specialist trusts. An overview was also provided on the key priorities for 2016/17 with specific
emphasis on flexible visiting, improving experiences on the use of the Bereavement service and
commence training in patient ‘shadowing’. The Committee welcomed the excellent results received
by the Trust and the improvements made to enhance patient experience within the Trust.
The Committee was presented with the report on the Aintree Assessment and Accreditation
Framework Q4 2015/16 and advised that there had been seven Aintree Champions Excellence
(ACE) rated wards during the year and that there were no Red rated wards at the year end. The
Committee was provided with an overview of the process undertaken for the assessment and how
wards were beginning to work together to learn best practice. The Committee noted that the
framework had been rolled out to Theatres, Critical Care and A&E and it was the intention to adapt
the framework for roll out in 2016/17 to Outpatients. Furthermore, the standards had been reviewed
with some amendments made to certain standards which had been communicated to the wards in
advance on the assessments for 2016/17. The Committee sought and received clarification the
reasons for red ratings in safeguarding noting that this predominately related to releasing staff to
undertake the necessary training. The Committee noted the report.
The Committee also discussed the Trust’s current mortality rates using the Standard Hospital
Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) methodologies.
The Committee was advised that the Trust’s SHMI was ranked 7th lowest of all 22 North West peers
which had been a vast improvement on the Trust’s position from two years ago. It was also
highlighted that the HSMR remained below expected and that the Trust’s crude mortality rate
continued to show a downward trend, particularly in regard to the winter months.
The Committee also received a report on the Quality Strategy Year 2 Improvement position and
noted that whilst not all the objectives had been achieved, there had been marked improvement in
the majority of quality goals set.
The Quality Strategy Year 3 Delivery Plan was also provided to the Committee and was advised that
the one of the key projects would be on the reduction of MSSA cases. Furthermore, the
collaborative work originally scheduled for 2015/16 would be progressed with more vigour during
2016/17.
9.2
Qua
lity
of C
are
Com
mitt
ee 1
8 M
ay 2
016
Page 38 of 43
Aintree University Hospital NHS Foundation Trust
Quality of Care Committee Report – 18 May 2016: Council of Governors 15 June 2016 2/2
Recommendation
The Council of Governors is asked to note the report.
Page 39 of 43
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Page 40 of 43
1/3
Agenda Item (Ref) CG15-16/011 Date of Meeting: 15 June 2016
Report to Council of Governors
Report Title Lead Governor and Deputy Lead Governor
Lead Neil Goodwin, Chairman
Lead Officer Caroline Keating, Associate Director of Corporate Governance/ Board
Secretary
Action Required Approval
Report purpose To inform the Council of Governors of the process undertaken to
source a Lead Governor and Deputy Lead Governor and seek approval
of the appointments.
Strategic Objective (s)
this work supports Deliver outstanding care
Achieve best patient outcomes
Promote research and education
Deliver sustainable healthcare to meet people’s needs
Provide strong system leadership
Be a well-governed and clinically-led organisation
Related Board
Assurance Framework
(BAF) risk
SR6 – Well-Led - governance
Business Priority N/A
Equality Impact
Assessment required?
No
Next Steps
REPORT HISTORY
Committee / Group Name
Agenda Ref
Report Title Date of submission
Brief summary of outcome
11. L
ead
Gov
erno
r an
d D
eput
y Le
ad G
over
nor
Page 41 of 43
Aintree University Hospital NHS Foundation Trust
Lead & Deputy Lead Governor Nominations: Council of Governors – 15 June 2016 2/3
Executive Summary
1. The report provides the Council of Governors with a brief overview of the process undertaken to
source a new Lead Governor and Deputy Lead Governor of the Trust
2. It confirms the proposed re-appointment of Pamela Peel as Lead Governor for a term of office of
12 months. In addition, an election is to be held at the Council of Governors’ meeting on 15 June
2016 for the appointment to the position of Deputy Lead Governor for a term of office of 12 months
with Lorraine Heaton and John Johnson putting their names forward for consideration by the
Council.
Background
Regulatory Requirements and the Trust Constitution
3. The NHS Foundation Trust Code of Governance, published by Monitor (now NHS Improvement),
contains a section relating to the role of the nominated lead governor which highlights that the role
is largely to facilitate direct communication between NHS Improvement and the Trust’s council of
governors.
4. Annex 5 of the Trust’s Constitution states the following:
The Council of Governors shall appoint one of the Governors to be Lead Governor of the
Council of Governors. The Lead Governor may be a Public Governor, an Appointed
Governor or a Staff Governor.
The term of office of the Lead Governor shall be 12 months. A Governor may be re-
appointed as the Lead Governor by the Council of Governors at the end of that term. Only
in exceptional circumstances would a Lead Governor serve for more than 2 years.
Key Issues / Proposals
5. In June 2015, the Council of Governors approved the appointment of Pamela Peel as Lead
Governor and Lorraine Heaton as Deputy Lead Governor for a term of 12 months. It has,
therefore, been necessary to source nominations from the current Council of Governors for the
positions of Lead Governor and Deputy Lead Governor for a 12 month term of office. To that end,
the Board Secretary wrote to the Council of Governors on 27 May 2016 seeking expressions of
interest for both roles and the following nominations were received:
Lead Governor – Pamela Peel (Public)
Deputy Lead Governor – Lorraine Heaton (Staff) and John Johnson (Public)
6. As only one nomination was received for the Lead Governor role, it is proposed that the Council of
Governors re-appoints Pamela Peel.
7. In respect of the appointment of Deputy Lead Governor, an election will be held which will be
undertaken at the formal Council of Governors’ meeting on 15 June 2016.
8. In terms of the process, each Governor will be provided with a ballot slip containing the names of
both candidates and will be asked to place an X against their preferred candidate only and put their
ballot slip into the box provided. The votes will be counted by the Board Secretary (acting as
Page 42 of 43
Aintree University Hospital NHS Foundation Trust
Lead & Deputy Lead Governor Nominations: Council of Governors – 15 June 2016 3/3
Returning Officer) and the result provided at the meeting. The candidate receiving the highest
number of votes will be declared appointed as the Deputy Lead Governor.
Recommendation
9. Council of Governors to approve the re-appointment of Pamela Peel as Lead Governor for a term
of 12 months.
10. The candidate receiving the highest number of votes to be appointed as Deputy Lead Governor
also for a term of 12 months.
Author: Michael Games, Corporate Governance Manager
Date: 9 June 2016
11. L
ead
Gov
erno
r an
d D
eput
y Le
ad G
over
nor
Page 43 of 43