council of governors - aintree university hospital · ref minute preliminary business cg15-16/031...

1/2

COUNCIL OF GOVERNORS 16 March 2016 5.30pm – 7pm

Board Room, Aintree Lodge

AGENDA

d = document v = verbal p = presentation

No Item Reference

Preliminary Business - Chairman

5.30 1. Apologies for Absence

To note the apologies

CG15-16/043 (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

CG15-16/044 (v)

3. Minutes from the last meeting (9 December 2015)

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

CG15-16/045 (d)

Where are we going as an Organisation?

5.35 4. Strategic Update

Chairman/Chief Executive

To note the update

CG15-16/046 (v)

How are we performing?

5.50 5. Finance & Performance – Key Issues & Assurance Received

Chair of the F&P Committee

CG15-16/047 (p)

How are we treating our patients?

6.00 6. Quality & Safety - Key Issues & Assurance Received

Chair of the Q&S Committee

CG15-16/048 (p)

How do we run ourselves? What do others think?

6.10 7. Report from Audit Committee

Chair of Audit Committee

CG15-16/049 (p)

6.20 8. Governor Activity

To note

CG15-16/050 (v)

6.35 9. Reports of Governor Committee Chairs:

Membership Committee (2 February 2016)

Quality of Care Committee (11 February 2016)

To discuss the key issues, approve any recommendations and note the reports

CG15-16/051 (d)

Cou

ncil

of G

over

nors

' Mee

ting

Age

nda

- 16

Mar

ch 2

016

of 31

Aintree University Hospital NHS Foundation Trust

Agenda: Council of Governors’ Meeting 16 March 2016 2/2

6.45 10. Terms of Reference for Governor Committee

Quality of Care Committee

To approve the terms of reference for the Committee

CG15-16/052 (d)

Other items for Governors to be aware of

6.50 11. Council of Governors’ Forward Plan 2016/17

To approve

CG15-16/053 (d)

Concluding Business

6.55 12. Any Other Business

Chairman

CG15-16/054 (v)

13. Date and Time of Next Meeting:

Wednesday 15 June 2016 at 12.30pm

Council of Governors – Objectives 2015/16

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

of 31

1/6

Council of Governors

Wednesday 9 December 2015 12.30pm

Board Room Aintree Lodge

DRAFT MINUTES

Present: Neil Goodwin - Chairman

Pamela Peel - Lead Governor

Sharon Bird - Public Governor

Mike Booth - Public Governor

Mike Bowker - 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

Lorraine Heaton - Staff Governor (AHPs)

Andrew Swift - Staff Governor (Medical)

John Wilding - Appointed Governor (University of Liverpool)

In Attendance: Steve Warburton - Acting Chief Executive

Joanne Clague - Non-Executive Director

Steve Evans - Medical Director

Nicola Firth - Director of Nursing & Quality

Michael Games - Corporate Governance Manager

Sue Green - Director of People and Corporate Affairs

Ian Jones - Acting 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: Tracey Barnes - Public Governor

Rose Milnes - Public Governor

Helen Frankland - Staff Governor (Nursing)

Paul Cummins - Appointed Governor (Sefton Council)

Barbara Hunter-Douglas - Appointed Governor (Edge Hill University)

Kerry McManus - Staff Governor (Other)

Juliet Herzog - Non-Executive Director

Tim Johnston - Non-Executive Director

Paul Fitzpatrick - Director of Estates & Facilities

3. C

G15

-16/

045

- M

inut

es o

f the

Las

t Mee

ting

(9 D

ecem

ber

2015

)

of 31


Minutes: Council of Governors Meeting 9 December 2015 2/6

Ref Minute

Preliminary Business

CG15-16/031 Apologies for Absence

The apologies were noted as above.

CG15-16/032 Declarations of Interest

There were no declarations of interest.

CG15-16/033 Minutes from the last meeting (14 October 2015)

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

The Chairman advised that the Council of Governors had met in Private Session prior to

the commencement of this meeting to approve the following recommendations of the

Nominations Committee:

The appointment of Steve Warburton as Chief Executive of the Trust

The re-appointment of Tim Johnston as a Non-Executive Director of the Trust for a

three year term of office with effect from 1 January 2016

The appointment of Joanne Clague as a Non-Executive Director the Trust with the

commencement of her three year term of office remaining as 1 April 2015.

Where are we going as an Organisation?

CG15-16/034 Strategic Update

The Chief Executive advised the meeting of the following matters:

Partnerships: A Board to Board meeting with the Royal Liverpool & Broadgreen

University Hospitals NHS Trust (RLBUHT) had taken place on 16 October 2015 at

which the clinicians of both Trusts presented the case for merger of acute adult

services across Liverpool. The Aintree Board considered the joint strategic options

appraisal (JSOA) that had been prepared by the Joint Clinical Advisory Group at its

Board meeting in October 2015 and fully endorsed the recommendations included in

the paper. The Trust issued a communication to its staff in this regard. The JSOA

was also considered by the RLBUHT Board in November 2015 and they issued a

communication to their staff. In addition, the Chief Executives of Aintree and

RLBUHT presented on joint working at the Mayor’s Health Summit which was well

received. A further meeting of the Joint Strategic Leadership Group was scheduled

for 11 December 2015 to agree next steps.

Liverpool Health Community Services: it is understood that the Trust

Development Authority (TDA) was to lead on the tender process for community

services with Lots being issued for tender during December 2015 and January 2016.

The Trust would be giving consideration to bidding for the most appropriate services

that would complement its current service delivery either on a sole basis or in

conjunction with another health care provider.

Comprehensive Spending Review: NHS England had negotiated with the

Treasury for advanced funding into the NHS for 2016/17 but this would mean that

future years would see lower levels of growth. The reason for the advancement was

to bring about stability and redressing financial balance. In addition, there was

of 31



Ref Minute

acknowledgement that the 4% efficiency targets would be extremely difficult to meet

year on year and so it was anticipated that next year the efficiency target would be

reset at 2%.

The Council of Governors requested clarification on the following matters:

How will the discussions on joint working with RLBUHT continue to be

funded? Support has been provided on project costs by the Liverpool Clinical

Commissioning Group and it was hoped that this would continue to be the case going

forward.

Following the meeting of the JSLG on 11 December would there be a joint

statement issued? It was the intention to issue a joint statement once agreement

had been reached on the next steps and the formal wording of the communication

agreed by the two organisations.

The Council noted the update.

How are we performing?

CG15-16/035 Finance & Performance – Report on Key Issues & Assurance Received

David Fillingham (Non-Executive Director), Chair of the Finance & Performance

Committee, gave a presentation covering the key issues, challenges and achievements

for October/November 2015. Particular mention was made of the deteriorating

performance in A&E and the establishment of weekly conference calls to update the

Board on progress against actions identified. The scrutiny of the Trust’s challenging

financial position was also a major factor in the Committee’s deliberations with particular

emphasis on progress against the achievement of the Cost Improvement Programme.

The Committee had received presentations from the Medicine and Clinical Support

Services Divisions on the key challenges and actions in place to improve performance.

Clarification was sought on the position in relation to the closure of intermediate beds in

Sefton and it was explained that there was no intention by Sefton to replace these beds

and that they were spot purchasing beds where they were needed. The Trust was

further impacted by those patients remaining in hospital whilst the family liaise with the

local authority on finding an appropriate care home. The Trust had launched an initiative

to assess people within their homes where appropriate and established a step down

facility for medically optimised patients to alleviate the pressure within the hospital. The

Trust was doing all it could to improve its processes internally but it often required the

intervention and co-operation of other providers to complement the discharge process

undertaken by the Trust.

The Council noted the presentation.

How are we treating our patients?

CG15-16/036 Quality & Safety – Report on Key Issues & Assurance Received

Colin Maloney (Non-Executive Director), Member of the Quality & Safety Committee,

gave a presentation covering the purpose of the Committee, its key challenges and

specific items presented during October/November 2015. Specific mention was made of

3. C

G15

-16/

045

- M

inut

es o

f the

Las

t Mee

ting

(9 D

ecem

ber

2015

)

of 31



Ref Minute

the Committee’s review of 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 examination

of performance of the Trust’s infection prevention and control programme; examples of

emerging risks brought to the Committee’s attention (Ophthalmology and Results to

Action) and the monitoring of progress.

Clarification was sought on how governors can be assured that the information provided

to the Committee was correct. It was explained that it was the responsibility of the Non-

Executive Directors to challenge the data presented and triangulate it with other sources

to determine its accuracy. In addition, Director Walkrounds provided an opportunity to

validate the information provided in the reports. The point was made that the deep dives

and presentations from other staff members allowed the Committee the chance to

challenge and verify the content.

Reference was also made to the quality and safety of medical patients in surgical wards

and it was explained that some wards had mixed specialities because there were

patients with co-morbidities. A weekly meeting of harm reviews all incidents but there

had been no incidences relating to medical patients in surgical wards.


How do we run ourselves? What do others think?

CG15-16/037 Report from Audit Committee

Jo Clague (Non-Executive Director), Member of the Audit Committee, gave a

presentation covering the role of the Committee, its key items and challenges and the

progress and achievements/progress made. Reference was made to the deep dive

undertaken on the Board Assurance Framework (BAF) with particular mention made of

the praise received on the content, format and clarity of the BAF but with

acknowledgement that further work was required on its linkages to the operational risk

register and the management of all risks scoring above 15. The Committee also dealt

with the report from NHS Protect and the actions identified to improve compliance.

Reference was made to the Trust’s ‘satisfactory’ rating for Information Governance, the

improvement in compliance arising from ward spot checks and the positive rating

received by the Trust for its accurate annual reference cost returns following a national

audit.


CG15-16/038 Reports of Governor Committee Chairs

Membership Committee – 3 November 2015

Pam Peel, Chair of the Committee, referred to the report and advised that revisions had

been made to the content of the Governor Toolkit and it had been the intention to discuss

the matter at the Informal Governors’ meeting on 2 December but there was insufficient

time to do so. The Committee would continue to take the matter forward but would

require the support of the Communications Team to assist Governors.

of 31



Ref Minute

The Council noted the report.

Quality of Care Committee – 12 November 2015

Mike Booth, Chair of the Committee, referred to the report and advised that there had

been a healthy debate as part of the presentation on Outpatients on waiting in clinics and

how delays were communicated to patients. In addition, the Committee had welcomed

the changes being made to system in Pharmacy to improve service delivery. The

Committee had also been heartened by the improvements in mortality needs but

acknowledged that Governors may need further training in this area to enhance their

understanding.

The Council noted the report.

Nominations Committee – 7 December 2015

Neil Goodwin, Chair of the Committee advised that the recommendations from the

Committee had been approved by the Council in Private Session and reported at the

beginning of the this meeting.

CG15-16/039 Terms of Reference for Governor Committees

The Council of Governors reviewed the revised terms of reference for each of the

Governor Committees and approved them accordingly.

Other items for Governors to be aware of

CG15-16/040

Draft Minutes of the Annual Members’ Meeting – 30 September 2015

The draft minutes of the Annual Members’ Meeting held on 30 September 2015 were

noted by the Council.

CG15-16/041 Governor Activity

The Lead Governor advised that she had been honoured to attend the two Award

Ceremonies held in November 2015 and particularly mentioned the Trust’s recognition at

the HSJ Awards after being shortlisted in five categories. She also mentioned that she

had been in contact with the Fazakerley Health & Wellbeing Forum and planned to

attend a meeting in January 2016. She highlighted that this links with the membership

strategy in regard to forging links between Governors and the local community through

these types of bodies.

Mention was also made by other governors of their involvement in the Fracture Clinic,

Nutrition & Hydration Collaborative and the Leadership & Management event.

The Council noted the update.

Concluding Business

CG15-16/042 Any Other Business

The Associate Director of Corporate Governance/Board Secretary advised that a

3. C

G15

-16/

045

- M

inut

es o

f the

Las

t Mee

ting

(9 D

ecem

ber

2015

)

of 31



Ref Minute

process had been put in place for dealing with letters from members of the public in

regard to the Trust’s discussions with RLBUHT. Any letters received by the Trust or a

Governor would be forwarded to her and acknowledged and responded to by the Chief

Executive through Trust Communications to ensure there was a consistent message

being given. The Council noted the process.

The Lead Governor provided her congratulations on behalf of the Council to Steve

Warburton on his appointment as Chief Executive.

Date and Time of Next Meeting:

Wednesday 16 March 2016 in the Board Room Aintree Lodge at 5.30pm.

The meeting closed at 2.05pm Chair’s Signature: Date:

of 31

Fin

an

ce &

Pe

rfo

rman

ce (

F&

P)

Co

mm

itte

e

Ke

y Is

su

es,

Ch

all

en

ge

s &

Ac

hie

vem

en

ts

Mo

nth

8 t

o M

on

th 1

0

201

5/1

6

Da

vid

Fill

ingh

am

No

n-E

xe

cutive D

irecto

r/ D

ep

uty

Cha

irm

an

5. C

G15

-16/

047

- F

inan

ce &

Per

form

ance

- K

ey Is

sues

& A

ssur

ance

Rec

eive

d

of 31

Pro

gre

ss

/Ach

iev

em

en

ts

P

ati

en

t S

afe

ty T

he

rmo

me

ter

•C

on

sis

ten

tly a

bo

ve

th

e n

atio

na

l m

ed

ian

sco

re.

R

ed

uc

tio

n in

SH

MI

•F

urt

he

r im

pro

ve

me

nt; T

rust b

ette

r th

an

na

tio

na

l a

ve

rag

e.

P

ati

en

t E

xp

eri

en

ce

•O

ve

r 9

8%

of in

pa

tie

nts

wo

uld

re

co

mm

en

d A

intr

ee

.

R

efe

rra

l To

Tre

atm

en

t

•Ta

rge

t b

ein

g m

et o

n a

co

nsta

nt b

asis

.

R

ed

uc

tio

n in

Ou

tpa

tie

nt

Ca

nc

ella

tio

ns

•D

ow

nw

ard

tre

nd

in

ca

nce

llatio

n n

um

be

rs c

on

tin

ue

d.

C

-Dif

fic

ile p

erf

orm

an

ce

•C

ase

s w

ith

in c

on

tra

cte

d a

nd

in

tern

al tr

aje

cto

ry.

of 31

Ke

y C

ha

llen

ges

D

iag

no

sti

c A

ccess -

Q3 m

issed; Q

4 p

erf

orm

ance a

t risk

C

an

cer

62

-day –

Capacity issues (

Janua

ry)

caused p

erf

orm

ance d

ip. F

eb &

Marc

h

impro

vem

ent

not

enough t

o d

eliv

er

Q4 t

arg

et

S

tro

ke –

Perf

orm

ance n

ot

recovere

d a

s e

xpecte

d,

with f

low

issues h

avin

g n

egative

impact on d

irect ad

mis

sio

n o

f patients

to s

troke w

ard

C

QU

INs -

Perf

orm

ance p

ositiv

e; som

e r

isk o

n d

eliv

ery

of

sm

all

num

be

r of

targ

ets

M

RS

A –

1 c

ase r

eport

ed

D

ela

yed

Tra

nsfe

rs o

f C

are

/ R

ead

y f

or

Dis

ch

arg

e –

continuin

g incre

ase in n

um

ber

of patients

“re

ady f

or

dis

charg

e”

(once m

edic

ally

fit).

O

n-g

oin

g w

ork

with S

ocia

l

Serv

ices, C

om

munity T

rust

and C

om

mis

sio

ners

to a

ddre

ss.

F

inan

cia

l p

erf

orm

an

ce:

•Im

pro

vem

ent

in d

eficit a

gain

st pla

n, but

continuin

g c

ost pre

ssure

s f

rom

medic

al and

nurs

e s

taffin

g,

(agency)

and d

eliv

ery

of

CIP

•In

com

e fro

m u

rgent

care

path

way r

ecovere

d,

but

applic

ation o

f P

bR

rule

s b

y

Com

mis

sio

ners

rem

ain

a c

halle

nge in p

ath

way r

edesig

n

•C

om

mis

sio

ners

to im

pose fin

es for

non

-deliv

ery

of A

ED

targ

ets

(4 h

rs a

nd a

mbula

nce

turn

aro

und),

despite im

pact

of

syste

m w

ide issues o

n t

arg

et

deliv

ery

.

5. C

G15

-16/

047

- F

inan

ce &

Per

form

ance

- K

ey Is

sues

& A

ssur

ance

Rec

eive

d

of 31

AE

D

A

&E

perf

orm

an

ce –

Continued p

oor

perf

orm

ance t

hro

ugh J

anuary

. Q

4 w

ill

not be m

et.

D

irect

dis

cussio

ns w

ith M

onitor

on im

pro

vem

ent

have t

aken

pla

ce.

Em

erg

en

cy &

Acu

te C

are

Pla

n:

•D

evelo

p s

et of princip

les a

s f

ram

ew

ork

for

imple

menta

tion t

o d

evelo

p

one v

isio

n/

model of care

for

the T

rust

•U

nderp

innin

g t

hese a

re c

lear

clin

ical path

wa

ys a

nd p

roto

cols

with

measura

ble

perf

orm

ance m

etr

ics

•E

arly S

enio

r R

evie

w a

cro

ss a

ll te

am

s

•Im

pro

ved c

om

munic

ation t

o facili

tate

co-o

rdin

ation (

board

huddle

s)

•O

ne ‘M

edic

al Take’ w

ith c

lear

role

s a

nd functions

•P

rote

cte

d A

ssessm

ent

Capacity in A

&E

and A

ssessm

ent

units

•C

lear

patient

flow

rule

s in a

nd o

ut

of hours

of 31

AE

D –

Go

ve

rnan

ce S

tru

ctu

re

5. C

G15

-16/

047

- F

inan

ce &

Per

form

ance

- K

ey Is

sues

& A

ssur

ance

Rec

eive

d

of 31

P

resen

tati

on

s f

rom

Div

isio

ns

•S

urg

ery

(M

8):

-U

nderp

erf

orm

ance o

n e

lective a

nd d

ay c

ase w

ork

(C

IP/p

roductivity p

lan)

-A

dm

in s

taffin

g o

vers

pend tackle

d thro

ugh c

hanges in w

ork

ing m

eth

ods

-A

nnu

al Leave P

olic

y s

till

a c

halle

nge (

adhere

nce to 6

week n

otice p

eriod)

-Im

ple

me

nta

tio

n o

f E

lectr

onic

Bo

okin

g T

oo

l fo

r T

he

atr

es (

eB

oT

) w

ith

in

sele

cte

d s

pecia

ltie

s p

roduced p

ositiv

e r

esults. O

n-g

oin

g w

ork

to r

oll

this

ou

t

•M

ed

icin

e (

M9):

-A

ED

perf

orm

ance -

inte

rim

support

appoin

ted t

o s

upport

form

ula

tion &

imple

menta

tion o

f com

pre

hensiv

e a

ction p

lan a

cro

ss the w

hole

syste

m

-Length

of sta

y incre

asin

g, dela

ys in d

ischarg

ing

medic

ally

fit a

key issue

-F

inancia

l positio

n d

ete

riora

ted.

CIP

pla

ns for

bed

clo

sure

s n

ot

imple

menta

ble

. M

edic

al agency s

pend t

o m

ain

tain

serv

ice d

eliv

ery

co

ntin

ue

d

•C

lin

ical S

up

po

rt S

erv

ice

s (

M10):

-F

inancia

l positio

n p

ositiv

e; expecte

d t

o c

om

e in a

t bala

nce for

the y

ear

-R

isk a

round r

adio

logis

t re

sig

natio

ns w

ith p

ote

ntial im

pact on p

erf

orm

ance.

Ke

y A

reas

Co

vere

d

of 31

2015/1

6 C

ap

ital

pro

gra

mm

e

P

rogre

ss r

eport

on t

he c

apital pro

gra

mm

e f

or

the y

ear.

Som

e s

lippage o

n the

pro

gra

mm

e,

princip

ally

rela

ting to t

he U

CA

T p

roje

ct.

1

2-H

ou

r B

reach

Rep

ort

C

onsid

er

reasons b

ehin

d the b

reach

and lessons learn

t.

F

inan

cia

l P

lan

nin

g U

pd

ate

an

d 2

016/1

7 B

ud

gets

- A

ppro

ved

Ke

y A

reas

Co

vere

d

£m

Incom

e

319.8

Expenditure

342.5

(22.7

)

CIP

7.0

Fin

an

cia

l g

ap

(1

5.7

)

ST

F a

llocation

9.5

Com

mis

sio

ner

support

required

7.4

Co

ntr

ol to

tal

1.2

5. C

G15

-16/

047

- F

inan

ce &

Per

form

ance

- K

ey Is

sues

& A

ssur

ance

Rec

eive

d

of 31

FIN

AN

CE

S &

AC

TIV

ITY

1. Im

pro

ve

me

nt in

co

sts

vs p

lan

re

fle

cts

no

n-r

ecu

rre

nt re

lea

se

fro

m r

ese

rve

s / b

ala

nce

sh

ee

t a

s m

itig

atio

n a

ga

inst C

IP

sh

ort

fall

an

d c

ost p

ressu

res. D

ete

rio

ratio

n in

in

co

me

po

sitio

n r

efle

cts

im

pa

ct o

f u

rge

nt ca

re f

low

issu

es o

n e

lective

ca

se

loa

d.

of 31

AC

CE

SS

TA

RG

ET

S

5. C

G15

-16/

047

- F

inan

ce &

Per

form

ance

- K

ey Is

sues

& A

ssur

ance

Rec

eive

d

of 31

CL

INIC

AL

IN

DIC

AT

OR

S

of 31

Qu

ality

& S

afe

ty C

om

mit

tee

Ke

y Is

su

es :

De

c-F

eb

201

5/1

6

Ju

liet H

erz

og

, N

on

-Executive

Dire

cto

r

6. C

G15

-16/

048

- Q

ualit

y &

Saf

ety

- K

ey Is

sues

& A

ssur

ance

Rec

eive

d

of 31

Ke

y C

ha

lle

ng

es

Serio

us Incid

ents

•A

ll in

cid

en

t re

po

rts r

evie

we

d,

hig

hlig

htin

g le

arn

ing

, th

em

es,

co

nce

rns

O

ph

tha

lmolo

gy R

isk r

epo

rt

•S

tan

din

g a

ge

nd

a ite

m a

nd

re

ma

ins o

n t

he

Tru

st

risk r

eg

iste

r

In

fectio

n P

reven

tio

n &

Co

ntr

ol

•E

xce

ptio

n r

ep

ort

s,

actio

n p

lan

s, p

rog

ress t

racke

d

•C

Difficile

be

low

na

tio

na

l tr

aje

cto

ry b

ut

ab

ove

in

tern

al str

etc

h

targ

et.

12

ca

se

s s

ucce

ssfu

lly a

pp

ea

led

, 5

ca

se

s p

en

din

g.

To

tal n

um

be

rs le

ss th

an

at

this

po

int

last ye

ar.

of 31

Sp

ec

ific

Ite

m P

res

en

tati

on

s

A

ss

au

lts

De

ep

Div

e

•F

ocus o

n t

rain

ing a

nd s

afe

ty.

Mo

nitori

ng in p

lace

C

om

pla

ints

Deep

Div

e (

Pati

en

t A

dvic

e &

Co

mp

lain

ts T

eam

– P

AC

T)

•F

ocus o

n k

ey p

oin

ts in d

ealin

g w

ith c

om

pla

ints

:

•p

utt

ing

th

ing

s r

igh

t

•access

•pro

cess

•re

sponse

L

ap

aro

tom

y A

ud

it

•P

rocess im

pro

vem

ent

pla

n

Q

uality

of

Pati

en

t C

are

in

AE

D

•O

ve

rvie

w o

f in

cid

en

ts b

y s

eve

rity

with

in t

he

A&

E D

ep

art

me

nt.

•D

espite p

oor

perf

orm

ance a

gain

st A

&E

4 h

our

access s

tand

ard

, evid

en

ce

sugge

sts

th

at

qualit

y o

f care

pro

vid

ed

to p

atients

has n

ot

suffere

d.

6. C

G15

-16/

048

- Q

ualit

y &

Saf

ety

- K

ey Is

sues

& A

ssur

ance

Rec

eive

d

of 31

Pro

gre

ss o

n Q

ua

lity

& S

afe

ty O

bje

cti

ve

s

T

he C

om

mitte

e r

egu

larly r

ece

ive

s r

epo

rts r

ela

ting

to

qua

lity &

safe

ty o

bje

ctives. In

this

tim

e p

eriod, th

e

follo

win

g w

ere

rece

ive

d:

•A

intr

ee

Qu

alit

y I

mp

rove

me

nt

Pro

gra

mm

e U

pd

ate

s

•C

orp

ora

te R

isk R

ep

ort

Q2

•P

ractice

, Im

pro

ve

me

nt

& L

esso

ns L

ea

rne

d Q

3

•Q

ua

lity S

tra

teg

y Y

ea

r 2

Q3

re

po

rt

•A

AA

Q3

re

po

rt

•W

ork

forc

e Q

3 r

ep

ort

•M

ort

alit

y r

ep

ort

•S

afe

Nu

rse

Sta

ffin

g r

ep

ort

of 31

Au

dit

Co

mm

itte

e

Ke

y Is

su

es,

Ch

all

en

ge

s &

Ac

hie

vem

en

ts

Mo

nth

8 t

o M

on

th 1

0

201

5/1

6

Tim

Joh

nsto

n, N

ED

Chair

7. C

G15

-16/

049

- R

epor

t fro

m A

udit

Com

mitt

ee

of 31

C

lin

ical A

ud

it P

erf

orm

an

ce R

evie

w

•aim

an

d d

efin

itio

n o

f clin

ica

l audits

•overv

iew

of

pla

nnin

g, pro

cess, re

port

ing a

nd m

onitoring u

ndert

aken

•2

01

4/1

5 p

erf

orm

an

ce

an

d p

erf

orm

an

ce

to d

ate

20

15

/16

, in

clu

din

g d

eta

ils o

f

cancelle

d a

nd

ab

an

do

ne

d p

roje

cts

du

rin

g 2

01

5/1

6

•overv

iew

of

NIC

E m

ain

tenance o

f com

plia

nce

•develo

pm

en

tal w

ork

bein

g u

ndert

aken inclu

din

g im

ple

menta

tion o

f a C

linic

al A

udit

Manag

em

ent

Syste

m (

CA

MS

)

Assura

nce

receiv

ed that

robust

govern

ance p

roce

ss in p

lace for

pro

ject

cancella

tion/a

bando

nm

ent w

ith e

scala

tion to C

linic

al S

tan

dard

s M

anag

er,

and to

Medic

al D

irecto

r fo

r appro

val if a

ppro

priate

, w

ith C

linic

al E

ffectiveness E

xecutive L

ed

Gro

up a

dvis

ed o

n 6

-month

ly b

asis

.

Ke

y A

rea

s C

ov

ere

d

of 31

Ke

y C

ha

lle

ng

es

In

form

ati

on

Go

vern

an

ce B

reach

Rep

ort

– E

nd

osco

py :

•in

cid

ent (r

eport

ed D

ecem

ber

2015)

arisin

g fro

m r

ecent

use o

f a s

yste

m p

urc

ha

sed

prior

to t

he T

rust’s r

evis

ed p

rocure

men

t pro

cesses b

ein

g in p

lace

•valid

ation identified 1

9 p

atient

record

s a

ffecte

d,

with 1

patient

requirin

g a

repeat

pro

ced

ure

•is

sue e

scala

ted im

media

tely

to T

rust

SIR

O,

pro

vid

ing a

ssura

nce

that

pro

cesses

were

bein

g a

dhere

d t

o

•re

vie

w o

f all

Tru

st

syste

ms u

nderw

ay w

ith a

ll depart

ments

required t

o c

onfirm

no

softw

are

in u

se that

was n

ot

recogn

ised o

r support

ed b

y t

he T

rust

•supplie

rs to

investigate

robustn

ess o

f syste

m.

Wid

er

revie

w t

o b

e c

om

ple

ted a

s p

art

of

the o

n-g

oin

g investigation to identify

oth

er

pote

ntial gaps o

r syste

m issues.

Revie

w o

f perf

orm

ance m

anag

em

ent

of

thir

d p

art

y s

upplie

rs to b

e a

dded t

o t

he

inte

rnal audit p

lan

. 7. C

G15

-16/

049

- R

epor

t fro

m A

udit

Com

mitt

ee

of 31

In

tern

al A

ud

it (

RS

M)

Pro

gre

ss R

ep

ort

•m

onitoring o

f C

ost

Impro

vem

ent

Schem

es

•IT

Dis

aste

r R

ecovery

•re

usable

Medic

al D

evic

es M

ain

tenance

•sic

kness A

bsence M

anag

em

ent

In

tern

al A

ud

it 2

016/1

7 S

trate

gy

Indic

ative

str

ate

gy

app

roved

a

nd

pro

vid

ed

to

Q

ualit

y

&

Safe

ty

Co

mm

itte

e

for

com

ment

L

ocal C

ou

nte

r F

rau

d S

erv

ice

Manag

em

ent

actions

from

N

HS

P

rote

ct

qualit

y

assessm

ent

report

ag

reed

w

ith

imple

menta

tion

follo

wed

up

un

de

r th

e 2

01

6/1

7 w

ork

pla

n

L

osses a

nd

Co

mp

en

sati

on

s R

ep

ort

•in

cre

ase in n

on

-clin

ical cla

ims

•susta

ined r

eduction in ‘sharp

s’ i

ncid

ents

Ke

y Ite

ms

of 31

1/1

Membership Committee Report

Report to Council of Governors

Date 16 March 2016

Committee Name Membership Committee

Date of Committee Meeting 2 February 2016

Chair’s Name & Title Pam Peel, Lead Governor

Summary of Meeting

The Committee received a presentation on the development of the new Trust website which provided

an overview of the progress made, the design, improved content and features to be made available.

The Committee discussed the proposed extranet feature and how this would work alongside existing

systems, being mindful of the need to maintain openness and transparency. The Committee was

advised that further engagement was to take place with stakeholders, including Governors, to

develop the proposed features.

The Committee received an update on the progress being made against the Membership Strategy

Implementation Plan and was advised that all actions remained on track. The Committee requested

that the Communications Team consider the objectives for year 2 and provide an update for the next

meeting.

The Committee reviewed the proposals for the Focus On events for 2016 and agreed that the topics

be Carers, Discharge/Leaving Hospital and Stroke.

A lengthy discussion took place on Governor involvement in membership engagement. Particular

emphasis was placed on the potential to hold a World Café style event so that Governors can

explore their role and expectations in engaging with members and what can be provided from the

Trust by way of support. Consideration was to be given to holding a World Café event for Governors

to be facilitated by Organisation & Development.

The Committee approved the revised FT Membership Form

Recommendation

The Council of Governors is asked to note the report.

9. C

G15

-16/

051

- R

epor

ts o

f Gov

erno

r C

omm

ittee

Cha

irs -

Mem

bers

hip

Com

mitt

ee 2

Feb

ruar

y 20

16

of 31

1/1

Quality of Care Committee Report

Report to Council of Governors

Date 16 March 2016

Committee Name Quality of Care Committee

Date of Committee Meeting 11 February 2016

Chair’s Name& Title Mike Booth

Summary of Meeting

A presentation was provided on Patient Experience – current position and future plans which

included an overview of the key priorities of the Quality Strategy 2014/17 with particular emphasis on

care providing a positive experience. Details were also provided of the results of the National

Inpatient Survey 2014 and the improvements made during 2015 together with an overview of the

outputs from the Friends & Family Test (FFT) and details of where feedback is received from. The

Committee was informed that the patient experience team had submitted an application for the

Patient Experience Network National Awards (PENNA) and had been shortlisted for the awards

ceremony on 2 March 2016. In addition, application had been made for the NHS England Friends

and Family Test awards but details of shortlisting were still awaited. The presentation also provided

an overview of the shared improvements dashboard established within the Trust to track progress.

Work was also being undertaken on the flexible visiting project with two wards identified as pilots and

the development of a Visitors Charter to set out expectations of visitors and staff. An overview was

also provided of the key priorities for 2016/17.

The Committee was presented with the report on the Aintree Assessment and Accreditation

Framework Q3 2015/16 and advised that the framework had been in place for over a year and

provided management with a tool for assessing nursing and ward standards against detailed criteria.

An overview was provided of the ward assessments undertaken in Q3 with nine being undertaken of

which two wards had received Aintree Champions Excellence (ACE), three wards were rated Green,

two Amber and two Red. It was explained that the two Red rated wards had been assessed under

the framework for the first time and robust action plans had been put in place although nothing

significant had come to light during the assessments. The Committee was further advised that it was

the intention to roll out the assessment to outpatients during Q4 and that the criteria was being

updated to improve the standards.

The Committee also discussed the Trust 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 had reduced further to its lowest position of 99.9,

consolidating the Trust’s position and ensuring the Trust was no longer considered an outlier. It was

also highlighted that the HSMR remained below expected and that the Trust’s crude mortality rate

continued to show a downward trend.

The Committee reviewed its Forward Plan 2016/17 and noted that the quality priorities would be

determined once the review of the Quality Strategy objectives for 2016/17 had been concluded.

The Committee undertook its annual review of its terms of reference and noted the proposed

revisions to the attendees to include Deputies. It was agreed to recommend their approval to the

Council of Governors.

Recommendation

The Council of Governors is asked to note the report.

9. C

G15

-16/

051

- R

epor

ts o

f Gov

erno

r C

omm

ittee

Cha

irs -

Qua

lity

of C

are

Com

mitt

ee 1

1 F

ebru

ary

2016

Page 28 of 31

Quality of Care Committee: Terms of Reference February 2016 1/2

Quality of Care Committee

TERMS OF REFERENCE

Authority

1. The Quality of Care (QoC) Committee is authorised by the Council of Governors (CoG) and will

be Governor-led.

Purpose

2. To act as a focal point for work involving the care and safety of patients and to enable Governors

to become better informed on issues of concern to members and the public.

Membership

3. The QoC will be comprised of seven Governors.

4. The Chair of the Committee will be elected by the QoC Committee on an annual basis.

5. The Director of Nursing & Quality and the Medical Director or their respective deputies will be in

attendance. Other members of the Executive Team will be asked to attend as appropriate

6. Membership of the Committee will be reviewed annually at the first meeting of the Council of

Governors after the Annual Members Meeting. Governors will be invited to express an interest in

membership of the Committee prior to that meeting of the Council of Governors.

7. Vacancies will be filled by open self nomination and election by the Council of Governors if

necessary for the appropriate term.

8. All Governors will be welcome to attend meetings of the Committee although voting rights will be

restricted to the seven formal Governor members.

Quorum

9. A quorum shall be four members of the Committee.

10. Any decisions reached at an inquorate meeting shall be referred to the next quorate meeting for

approval.

Requirements of Membership

11. It is essential that all members participate in the meetings and punctuality must be observed.

12. The Chair will ensure that the key issues identified are highlighted as appropriate to the HMB

and/or lead executive director/manager as required.

10. C

G15

-16/

052

- T

erm

s of

Ref

eren

ce fo

r G

over

nor

Com

mitt

ee -

Qua

lity

of C

are

Com

mitt

ee

Page 29 of 31


Quality of Care Committee: Terms of Reference February 2016 2/2

Duties

13. In order to fulfil its role, the duties of the Committee will be:

To understand, support and be engaged with the Trust’s Quality Strategy

To receive reports on progress towards achieving the quality priorities, namely:

o care that is safe

o care that is clinically effective

o care that provides a positive experience for patients and their families

To receive and comment on indicators on safety, clinical effectiveness and patient

experience, in line with the national direction on quality. At present, these include:

Healthcare Associated Infections (HCAI), Mortality, Cleanliness and Patient Satisfaction. As

further indicators are developed or more detailed work is necessary, Governors may be

asked to contribute to additional working groups.

To review the results of patient satisfaction surveys, both national and local and to

understand the impact on patient care

To comment on the Trust’s declaration(s) to the Care Quality Commission on compliance with

its registration on behalf of the Council of Governors

Reporting

14. The Chair of the Committee will report on the proceedings of each meeting to the next meeting of

the Council of Governors.

15. Minutes of the Committee meetings will be provided to the Council of Governors on request.

Administration of Meetings

16. The Committee/Group will meet quarterly. The duration of each meeting shall be approximately

1.5 hours with the schedule of meetings agreed at the initial CoG meeting following the Annual

Members’ meeting.

17. The FT Secretary will make arrangements to ensure that the Committee is supported

administratively. Duties in this respect will include preparation of agendas and taking minutes of

the meeting.

18. Agendas and papers will be circulated at least 4 working days (or 3 working days plus a

weekend) in advance of the meeting.

19. Minutes will be circulated to Group members as soon as is reasonably practicable.

Review

20. The Terms of Reference shall be reviewed annually (next review date: February 2017) and

submitted to the Council of Governors for approval following a review by the QoC of its

performance against the terms of reference.

Page 30 of 31

Co

G F

OR

WA

RD

PL

AN

(2016/1

7)

Me

eti

ng

Da

teL

ea

d D

ir/

Off

icer

09

.03

.16

16

.03

.16

Ma

y S

es

sio

n0

9.0

6.1

61

5.0

6.1

62

8.0

9.1

60

6.1

0.1

61

3.1

0.1

6N

ov S

es

sio

n0

1.1

2.1

60

8.1

2.1

6F

eb

Se

ss

ion

09

.03

.17

15

.03

.17

Ap

po

intm

en

t o

f N

on

-Exe

cu

tive

Dir

ecto

rN

G

Info

rmal M

eeti

ng

s

XX

X

XX

Ch

air

ma

n/ C

hie

f E

xe

cu

tive

’s S

tra

teg

ic

Up

da

teN

G/S

WX

XX

XX

An

nu

al R

ep

ort

& A

cco

un

ts 2

01

5/1

6T

JX

Str

ate

gic

Dir

ectio

n o

f T

rave

lN

G/S

WX

Qu

alit

y A

cco

un

t P

rio

ritie

sN

FX

Bu

sin

ess P

lan

nin

g P

roce

ss/P

rio

ritie

s

SW

XX

Fin

an

ce

& P

erf

orm

an

ce

- K

ey Issu

es &

Assu

ran

ce

Re

ce

ive

dD

F/I

JX

XX

XX

Qu

alit

y &

Sa

fety

- K

ey Issu

es &

Assu

ran

ce

Re

ce

ive

dJH

/NF

XX

XX

X

Re

po

rt f

rom

Au

dit C

om

mitte

eT

J/I

JX

XX

XX

Pw

C L

on

g F

orm

Re

po

rt (

Exte

rna

l

Assu

ran

ce

on

QA

)S

W/C

KX

Au

dito

rs L

ette

r (d

ate

tb

c)

SW

X

Co

G S

elf A

sse

ssm

en

tC

KX

Co

G D

raft

Ob

jective

s 2

01

5/1

6C

K/N

GX

Co

G F

orw

ard

Pla

n 2

01

5/1

6C

KX

Skill

s A

ud

itC

KX

An

nu

al R

ep

ort

on

Me

mb

ers

hip

Str

ate

gy

CK

X

Qu

alit

y o

f C

are

Co

mm

itte

e T

oR

NF

X

No

min

atio

ns C

om

mitte

e T

oR

CK

X

Me

mb

ers

hip

Co

mm

itte

e T

oR

CK

X

Org

an

& T

issu

e D

on

atio

n A

nn

ua

l R

ep

ort

SE

X

Co

mm

itte

e R

ep

ort

s:

M

em

be

rsh

ip C

om

mitte

e

Q

ua

lity o

f C

are

Co

mm

itte

e

N

om

ina

tio

ns C

om

mitte

e

Go

ve

rno

r A

ctivity

XX

XX

X

Bu

dg

et &

An

nu

al P

lan

SW

X

20

15

/16

An

nu

al R

isk R

atin

g / F

ee

db

ack o

n

An

nu

al P

lan

20

16

/17

IJX

X

Ho

w D

o w

e R

un

Ou

rselv

es?

W

hat

Do

Oth

ers

Th

ink?

Ho

w A

re W

e T

reati

ng

Ou

r P

ati

en

ts

Wh

ere

Are

We G

oin

g A

s A

n O

rgan

isati

on

Sett

ing

th

e C

on

text

Ho

w A

re W

e P

erf

orm

ing

?

Item

s f

or

Info

rmati

on

Ind

ivid

ual It

em

s Id

en

tifi

ed

in

Year

An

nu

al M

em

bers

Meeti

ng

Go

vern

or

Sessio

ns

XX

XX

X

11. C

G15

-16/

054

- C

ounc

il of

Gov

erno

rs' F

orw

ard

Pla

n 20

16/1

7

Page 31 of 31

council of governors - aintree university hospital · ref minute preliminary business cg15-16/031...

Documents