public board of directors agenda - newcastle hospitals of... · a4 patient story sept 19.pdf (3...

Public Board of Directors

26 September 2019, 11:00 to 13:25Board Room, Culture Centre, RVI

Agenda1. Public Board of Directors' Meeting Agenda

1. A0 BoD Public Agenda 26 Sept 19.pdf (4 pages)

2. Business Items 28 minutes

2.1. Apologies for Absence and Declarations of InterestVerbal

Chairman

2.2. Minutes of the Meeting held on 27 June 2019 and Matters Arising

Attached

Chairman

A2 NuTH Public BoD Minutes 27 June 19 DRAFT.pdf (17 pages)

2.3. Meeting Action LogAttached

Chairman

A3 BoD Public Board Actions September 19.pdf (1 pages)

2.4. Patient StoryMr George Young, accompanied by Dr Melinda Firth (Senior ResolutionFacilitator) to attend at 11:02am to present this item

Presentation

Executive Chief Nurse

A4 Patient Story Sept 19.pdf (3 pages)

2.5. Chairman's ReportAttached

Chairman

A5 Chairman's Report September 2019.pdf (4 pages)

2.6. Chief Executive's ReportAttached

Chief Executive Officer (CEO)

A6 CEO board report - September 2019 Final.pdf (9 pages)

A6 Appendix 1 ICS MOU 16 Aug 2019.pdf (6 pages)

3. Strategy 7 minutes

3.1. Trust StrategyAttached

Interim Bus&Dev Director (IB&D) &

Assistant Chief Executive (ACE)

3.2. Global Digital Exemplar (GDE) UpdateAttached

Chief Information Officer (CIO)

A7(ii) Chief Information Officers Report September 2019.pdf (6 pages)

4. Quality & Patient Safety 44 minutes

4.1. Medical Director's ReportAttached

Medical Director (MD)

A8(i) - Medical Director's Report - September 2019.pdf (5 pages)

4.1.1. Consultant and Honorary Consultant Appointments

Board Reference Pack (BRP)

MD

4.1.2. Guardian of Safe Working Report

Attached

MD

A8(i)b Guardian of Safe Working quarterly report July 2019.pdf (9 pages)

4.1.3. EPRR Assurance

BRP

MD

4.2. Executive Chief Nurse ReportAttached

ECN

A8(ii) Executive Chief Nurse Report Sept 19.pdf (11 pages)

4.2.1. Freedom to Speak Up Guardian (F2SUG) Report

BRP

ECN

4.2.2. Q1 Patient Experience Report

BRP

ECN

4.2.3. Q1 Safeguarding Report

BRP

ECN

4.3. Maternity CNST Incentive Scheme Year 2 ReportAttached & BRP

ECN & Director of Quality &

Effectiveness (DQE)

A8(iii) Maternity CNST Incentive Scheme September 19.pdf (8 pages)

4.4. Healthcare Associated Infections (HCAI) Report from the Director of Infection, Prevention and Control (DIPC)

Julie Samuel, Deputy DIPC, to attend at 11:54am to present this item Attached & BRP

Deputy DIPC

A8(iv) Healthcare Associated Infections -DIPC Report.pdf (7 pages)

4.5. Children's Cardiac UpdateAttached

Chief Operating Officer (COO)

A8(v) Cardio board paper Sept 2019.pdf (5 pages)

4.6. Learning from DeathsAttached

MD & DQE

A8(vi) Board Learning from Deaths Sept 2019.pdf (10 pages)

5. Performance & Delivery 30 minutes

5.1. Integrated Quality, Performance, People & Finance Report

Attached

MD, ECN, COO, Director of HR (HRD)& Finance Director (FD)

A9 Integrated Quality and Performance Report Sept 2019.pdf (26 pages)

6. Engagement 10 minutes

6.1. People UpdateAttached

HRD

A10(i) 2019 09 People Board Paper FINAL.pdf (9 pages)

6.1.1. WRES Report & Action Plan

BRP

HRD

6.1.2. WDES Report & Action Plan

BRP

HRD

6.1.3. EDS & PSED Data

BRP

HRD

6.2. Flourish UpdateAttached & BRP

ACE & HRD

A10(ii) Flourish Update.pdf (7 pages)

7. Corporate Governance 14 minutes

7.1. Update from Committee ChairsVerbal

Committee Chairs

7.2. Corporate Governance UpdateAttached

Trust Secretary (TS)

A11(ii) Corporate Governance Update September 19.pdf (7 pages)

7.2.1. Policy Update

BRP

TS

7.2.2. Quarterly NHSI Declarations

BRP

TS

7.2.3. Modern Slavery Act Statement

BRP

TS

7.2.4. Committee Annual Reports

BRP

TS

7.3. Board Assurance Framework and Risk Management Report - Q1

Attached

ACE

A11(iii) Board Assurance Framework and Trust Risk Management Report Q1.pdf (14 pages)

A11(iii) Appendix 1.0 Executive Risk Oversight Register Q1.pdf (4 pages)

A11(iii) Appendix 2.0 NUTH BAFCRR 201920 Q1.pdf (16 pages)

8. Items to Approve 1 minutes

8.1. Trust ConstitutionAttached

TS

A12 Trust Constitution Update.pdf (3 pages)

A12 App A - Proposed Constitution - FINAL.pdf (74 pages)

9. Items to Receive 1 minutes

9.1. Date and Time of Next MeetingsAnnual Members' Meeting: 10am, Friday 27 September 2019, Clinical ResourceBuilding Education Centre, RVI

Public Board of Directors Meeting: Thursday 28 November 2019, Boardroom,Culture Centre, RVI

PUBLIC TRUST BOARD OF DIRECTORS’ MEETING

Thursday, 26th September 2019 in the Boardroom, Culture Centre, RVI

Start time 11.00am

Agenda

Item Lead Paper Estimated Timings

Page No

Business Items

A1 Apologies for Absence and Declarations of Interest

Chairman Verbal 11.00 – 11.02

A2 Minutes of the Meeting held on 27th June 2019 and Matters Arising

Chairman

Attached

10

A3 Meeting Action Log

Chairman Attached 27

A4 Patient Story [Mr George Young, accompanied by Dr Melinda Firth (Senior Resolution Facilitator), to attend at 11:02am to present this item]

ECN Attached

11.02 – 11.15

28

A5 Chairman’s Report

Chairman Attached 11.15 – 11.20

31

A6 Chief Executive’s Report

CEO

Attached 11.20 – 11.28

35

Strategy

A7(i) Trust Strategy IB&DD /

ACE To be tabled 11.28 –

11.30

A7(ii) GDE Update CIO Attached 11.30 – 11.35

50

Quality and Patient Safety

A8(i) Medical Director’s Report, including: a. Consultant & Honorary Consultant

Appointments b. Guardian of Safe Working Report c. EPRR Assurance

MD Attached & BRP

11.35 – 11.42

56 61

A8(ii) Executive Chief Nurse Report, including a. FTSUG Report b. Q1 Patient Experience Report c. Q1 Safeguarding Report

ECN

Attached & BRP

11.42 – 11.49

70

A8(iii) Maternity CNST Incentive Scheme Year 2 Report

ECN / DQ&E

Attached & BRP

11.49 – 11.54

81

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Page No

A8(iv) Healthcare Associated Infections (HCAI) Report from the Director of Infection, Prevention and Control (DIPC) [Julie Samuel, Deputy DIPC, to attend at 11:54am to present this item]

Deputy DIPC

Attached & BRP

11.54 – 12.04

89

A8(v) Children’s Cardiac Update COO Attached 12.04 – 12.14

96

A8(vi) Learning from Deaths MD / DQ&E Attached 12.14 – 12.19

101

Performance & Delivery A9 Integrated Quality, Performance, People

& Finance Report

MD, ECN, COO, HRD & FD

Attached

12.19 – 12.49

111

Engagement

A10(i) People Update, including: a. WRES Report & Action Plan b. WDES Report & Action Plan c. EDS & PSED Data

HRD Attached & BRP

12.49 – 12.54

137

A10(ii) Flourish Update ACE

Attached & BRP

12.54 – 12.59

146

Corporate Governance

A11(i) Update from Committee Chairs Committee Chairs

Verbal 12.59 – 13.09

A11(ii) Corporate Governance Update, including: a) Policy Update b) Quarterly NHSI Declarations c) Modern Slavery Act Statement d) Committee Annual Reports

TS Attached & BRP

13.09 – 13.11

153

A11(iii) Board Assurance Framework and Risk Management Report – Q1

ACE Attached 13.11 – 13.13

160

Item to Approve

A12 Trust Constitution

TS Attached 13.13 – 13.23

194

Items to Receive

A13(i) Date and Time of Next Meetings: AGM: 10am, Friday 27th of September 2019, New Education Centre, RVI Public Board meeting: Thursday 28th November 2019 in the Boardroom, Culture Centre, RVI

Chairman Verbal 13.23 – 13.25

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Page No

A13(ii) To resolve to exclude members of the press and public in accordance with the Health Services Act 2006 (Schedule 7 Section 18(E)) (as amended by the Health and Social Care Act 2012) and in view of publicity being prejudicial to the public interest.

Chairman Verbal

Key: BRP = document contained within a separate Board Reference Pack

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THIS PAGE IS INTENTIONALLY

BLANK

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Agenda item: A2

________________________________________________________________________________________________Minutes of the Trust Public Board Meeting – 27 June 2019Trust Public Board Meeting – 26 September 2019

DRAFT MINUTES OF THE BOARD OF DIRECTORS MEETING HELD ON27 JUNE 2019

Part A: Public Session

Present: Professor Sir John Burn ChairmanDame Jackie Daniel Chief Executive OfficerMr M Wilson Chief Operating OfficerMs M Cushlow Executive Chief NurseMrs A Dragone Finance DirectorMr A Welch Medical DirectorMr D Stout Non-Executive DirectorProfessor K McCourt Non-Executive DirectorMr K Godfrey Non-Executive DirectorMr S Morgan Non-Executive DirectorProfessor D Burn Non-Executive Director

In Attendance:

Mrs C Docking, Director of Communications & EngagementMr G King, Chief Information OfficerMrs D Fawcett, Director of Human Resources (HR)Ms N Bruce, Assistant Director for Business Strategy and PlanningMr R C Smith, Director of EstatesMrs K Jupp, Trust Secretary Mrs F Darville, Deputy Trust Secretary [Minutes]Mrs Barbara Goodfellow, Matron, Internal Medicine, Ms Alice Fitzpatrick, Physician Associate and Ms Pauline Morgan, Senior Sister, Internal Medicine [for agenda item 19/42 iv only] Dr L Pareja-Cebrian, Director of Infection Prevention and Control (DIPC) [for agenda item 19/43 v] only]Mr James Dixon, Head of Sustainability and Compliance [for agenda item 19/47 ii]

Observers:

Mrs R Hudson, Clinical Educator, Renal Services and Staff Governor Mr D Black, Member of the PublicMr G Davidson, Canon UKMr A Bailey, Outico LimitedMr D Stewart-David, Public GovernorMs N Lowthian, Member of StaffMs D Youssef, Member of StaffMs E Hughes, AbbottMr D Buckley, SiemensMr A Balmbra, Staff Governor

Note: The minutes of the meeting were written as per the order in which items were discussed.

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Agenda item: A2


19/42 BUSINESS ITEMS

i) Apologies for Absence and Declarations of Interest

Apologies were received Mrs Angela O’Brien, Director of Quality and Effectiveness, Mrs Kate Simpson, Interim Director of Business and Development (Ms Nicola Bruce, Assistant Director for Business Strategy and Planning deputising) and Non-Executive Directors Mr Jonathan Jowett and Mr Ewen Weir.

There were no additional declarations of interest made at this time.

ii) Minutes of the Meeting held on 25 April 2019 and Matters Arising

The minutes of the meeting were agreed to be an accurate representation, subject to an amendment required on page 16 to change the percentage increase to the Trust’s targeted reduction for Delayed Transfers of Care (DToCs) to 25%, rather than 15%.

There were no additional matters arising from the previous meeting.

It was resolved: to receive the minutes as an accurate record of the meeting, subject to the amendment outlined.

iii) Meeting Action Log

It was agreed that the actions presented on the log were in progress.

It was resolved: to (i) note the progress in the action log.

[Mrs Goodfellow (Matron, Internal Medicine), Ms Fitzpatrick (Physician Associate) and Ms Morgan (senior Sister, Internal Medicine) joined the meeting at 11:02am].

iv) Improving the Patient Experience Story

The Matron for Internal Medicine explained the work undertaken to implement the SAFER toolkit within the Trust’s Medicine Directorate. The approach included daily senior review, with a focus on early onward transfer of patients / early discharge through the use of the ‘big room’ approach to Board rounds, with better visual displays to agree estimated dates of discharge; and the development of patient owned goals.

Use of the toolkit had resulted in reduced length of stay for patients, with 33% of patient discharges occurring before midday, and improved patient flow for the Trust, ensuring that the right care was delivered to the patient in the right place. The average length of stay had improved overall and there had been an increase in the number of weekly discharges.

Significant focus had been placed on the ‘#reducingdaysawayfromhome’ campaign, recognising that every day a patient remains in hospital should deliver ‘added value’ to prevent the risk of a patient’s health deteriorating. Use of coloured wristband for patients who required physiotherapy intervention as a priority and the review of weekend transport were also assisting with a reduction in the number of days that patients were away from

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Agenda item: A2


home. To date the collaborative work had resulted in a reduction in the length of stay for patients by 1-2 days.

The next piece of work would be ‘#theresnoplacelikehome’.

[The Matron for Internal Medicine, the Physician Associate and Senior Sister for Internal Medicine left the meeting at 11:18am, accompanied by the Executive Chief Nurse].

It was resolved: to receive the improving the patient experience story.

v) Chairman’s Report

The Chairman presented his report, highlighting in particular the Trust’s ‘Outstanding’ Care Quality Commission (CQC) rating published in May 2019, commending the work of the loyal, dedicated and proud staff at Newcastle Hospitals; and the recent visit to the Trust by Lord Prior, chair of NHS England.

[The Executive Chief Nurse re-joined the meeting at 11:19am].

It was resolved: to receive the report.

vi) Chief Executive’s Report

[Mr Andrew Balmbra, Staff Governor, joined the meeting to observe at 11:20am].

The Chief Executive presented the report and highlighted the following points:

It was noted that the Chief Executive had been appointed as chair of the Shelford Group from 1 August 2019. In this role, the Trust would be able to both contribute and lead on the formulation and implementation of NHS policy.

The Interim People plan had been published which supported the Trust’s ambitious vision. It was noted that further work was required to identify the funding required from the spending review to deliver the plan.

A very successful Black, Asian and Minority Ethnic (BAME) recruitment event was held on Saturday 27th April when over 400 people from a whole range of different cultural backgrounds attended to learn about careers in the NHS. The event was supported by our fellow local NHS Trusts.

The Trust celebrated the eighth Equality, Diversity and Human Rights week from 13th – 17th May which enables organisations to promote the work they are doing to create more inclusivity for NHS patients and staff.

The ‘Flourish’ theme for June was ‘Let’s Celebrate’, with the Trust hosting the first ‘Celebrating Excellence’ awards at the Civic Centre. The awards were very well received by staff and thanks were extended to the Director of Communications and Engagement and her Communications team for the successful running of the event.

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Agenda item: A2


The results for the National Adult Inpatient Survey were received, which were positive for the Trust.

The Trust had appointed Dr Victoria McFarlane-Reid as Director of Enterprise and Business Development to commence the role from September 2019.

Dr Seamus O’Neill had been appointed as the Chief Executive Officer of the Northern Health Science Alliance and would commence in role from August 2019.

In regards to partnership working, the Trust was working closely with Newcastle University to review the operational arrangements for the Joint Research Office to align with the Trusts refreshed strategy. In addition, productive meetings had been held with Northumbria University to develop a Memorandum of Understanding for collaborative working in specific areas.


19/43 QUALITY AND PATIENT SAFETY

i) Medical Director’s Report

The Medical Director presented the report and highlighted the following areas to note:

The Medical Director group continues its active involvement in the ‘Flourish’ programme and would continue at pace in collaboration with other staff groups such as HR and the Chaplains.

Thanks and congratulations were extended to all staff groups for the achievement of the CQC ‘Outstanding’ rating, noting in particular the contributions of the Emergency Department, End of Life Care and Diagnostic Imaging who underwent intensive scrutiny with excellent outcomes.

The continued successful provision of Chimeric Antigen Receptor (CAR-T) cell therapy to patients at the Trust. Further, the Trust was at the forefront of immune effector cell therapy, which is an exciting development in the treatment of cancer.

The Medical Director commended the team involved in significantly improving the clinical outcomes for lung cancer patients as reported in the national publication.

The Trust’s Neuroendocrine Tumour Centre at Freeman Hospital had been in receipt of a prestigious European award to be certified as an ENETS (European Neuroendocrine Tumour Society) Centre of Excellence, with congratulations extended to the team.

Exemplary feedback was received following the Human Tissue Authority (HTA) inspection, which took place in May 2019.

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Agenda item: A2


It was advised that the Trust, along with South Tees Hospitals NHS Foundation Trust and others were involved in the newly established Acute Provider Regional Medical Director forum.

The influence of the Trust within the Northern Cancer Alliance was noted, with a particular focus on equitability of treatment.

Further detail regarding the Annual Organisational Audit for 2018/19 was included in the Board Reference Pack. The assessment results were approved by the Board.

It was resolved: to (i) receive the report and (ii) agree the assessment results contained within the Annual Organisational Audit.

a. Infection Prevention and Control Quarter 4 and 2018/19 Annual Report

The Medical Director advised that the Infection Prevention and Control Quarter 4 and 2018/19 Annual Report would be discussed in further detail under agenda item 19/43 v.


b. Consultant and Honorary Consultant Appointments

The Consultant and Honorary Consultant Appointments report was received for information.


ii) Executive Chief Nurse Report

The Executive Chief Nurse presented the report and noted the following areas for the Board’s attention:

In April 2019, the Chief Nursing Officer for England, Ruth May invited expressions of interest from all Trusts to increase capacity through access to infrastructure funding to increase clinical placement capacity for the 2019 intake. Funding of up to £50k will be made available to successful Trusts. A collective expression of interest has been submitted with local HEI’s, Northumbria Healthcare NHS Foundation Trust and Gateshead Health NHS Foundation Trust. The Trust received confirmation yesterday that the funding would be received.

Nurse staffing issues for escalation to Trust Board were noted on page 44, being those that had a Registered Nurse (RN) fill rate of less than 85% over a consecutive 3-month period.

There were currently 185wte Band 5 student nurses undergoing recruitment, with the majority expected to commence employment in the Trust through September and October 2019, which would assist in improving Trust vacancy fill rates in advance of winter pressures.

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Agenda item: A2


In relation to Midwifery Staffing, the Birthrate Plus (BR+) workforce tool continued to be utilised with data available for analysis from January 2019. Establishment levels continued to be reviewed. A staffing ratio of 1:1 is recommended in NICE Guidance and the Royal College of Midwives recommendation for midwife to births is 1:28 for hospital births. Currently the Trust maternity department achieves a ratio of 1:27 overall which is a safe ration for a complex tertiary maternity service. There were no occasions where one to one care could not be provided in the Newcastle Birthing Centre and only two occasions in the main delivery suite when one to one care could not be provided.

In relation to the Quarter 4 Safeguarding update, it was advised that the Trust had achieved the PREVENT training target of 85%. The Executive Chief Nurse paid tribute to the outgoing Head of Safeguarding for her dedication to this and her longstanding service to the Trust.

The Executive Chief Nurse advised that the International Dysphagia Diet Standardisation Initiative (IDDSI), a revised international framework for naming and describing foods and liquids, had been introduced safely into the Trust prior to full roll out.

Pertaining to Nurse Staffing on Ward 15 at the Freeman Hospital, Mr Godfrey queried what measures would be taken to address the issues that have arisen. The Executive Chief Nurse advised that further staff would be provided to ensure that beds would remain open.

The Chief Executive extended her congratulations to the Executive Chief Nurse and colleagues for the improving recruitment and retention of nursing staff position.

Professor McCourt advised that a plan would be required to ensure that a sufficient level of appropriately trained midwives would be maintained to which the Executive Chief Nurse noted that the work undertaken thus far to create additional placement capacity, and in the future with BR+, would highlight areas of risk, particularly around the age profile of Trust midwives.

It was resolved: to receive the Executive Chief Nurse report.

iii) Maternity CNST Incentive Scheme Report

The Executive Chief Nurse presented the report, with the following points to note:

In relation to Safety Action 3, the Board had received and reviewed the ATAIN action plan for returning admissions to Neonates.

In relation to Safety Action 4a, it was noted that according to the General Medical Council (GMC) national survey, the Trust’s Obstetrics and Gynaecology (O&G) departments were not identified as outliers for educational and training opportunities due to rota gaps. It was noted that 55% of O&G trainees at the Royal Victoria Infirmary (RVI) either disagreed or strongly disagreed with the statement: ‘In my current post, educational opportunities/training are rarely lost due to gaps in the rota’. However,

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Agenda item: A2


only 15% of the total trainees answered that they disagreed or strongly disagreed with the statement: ‘In my current post, gaps in the rota are dealt with appropriately to ensure my education and training are not affected’. However, it was further advised that there had been a robust recruitment drive, which saw the appointment of two Clinical Teaching Fellows, two Tier 2 Medical Trainees and two Trust doctors to mitigate any potential gaps that may arise as the year progresses. Regular meetings between Medical Director and Maternity team would continue.

In reference to Safety Action 4b, it was noted that the Trust was compliant with the three standards outlined (being ACSA standards 1.2.4.6, 2.6.5.1 and 2.6.5.6).

In reference to Safety Action 6, Board members noted that the Saving Babies Lives Bundle was considered at the Board of Directors meeting in April 2018 as part of the ‘CNST Incentive Scheme Maternity Safety Actions Saving Babies Lives’ paper which detailed compliance with the four outlined elements.

The Executive Chief Nurse commended the staff involved in the Trust’s achievement of the safety standards.

The Board of Directors approved the content of the self-assessment to date.

It was resolved: to receive the report and approve the self-assessment to date.

iv) CQC Report & Action Plan

The Medical Director presented the report and advised that although the Trust achieved an ‘Outstanding’ rating from the CQC, the report detailed a small number of areas for improvement. This included two ‘Must’ do actions relating to diagnostic and screening procedures. The actions outlined would be monitored on an ongoing basis with regular reporting to the Board regarding progress.


vi) Board Assurance Framework for 7 Day Hospital Services

The Medical Director presented the self-assessment for the Board’s consideration, highlighting the Trust’s performance against a number of clinical standards.

The Medical Director drew the Board’s particular attention to the action plan in place to address the one area where compliance was not currently achieved, being Clinical Standard 5.


[The Director for Infection Prevention and Control joined the meeting at 11:46am]

v) Healthcare Associated Infections (HCAI) DIPC Report

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Agenda item: A2


The Director for Infection Prevention and Control (DIPC) presented the report and highlighted the following points:

The Trust had not experienced any cases of MRSA for nine months. The DIPC paid tribute to the hard work of Trust frontline staff in achieving this position.

Occurrences of MSSA showed a slight reduction over the same period in 2018, however a peak in occurrences was observed in April 2019 whereby 12 MSSA bacteraemia cases occurred. Further, there were 9 cases in May 2019, compared to 15 in April and 10 cases in May last year.

The Infection Prevention and Control team continued to work on reducing cases of gram-negative bacteraemia and effective antibiotic management, with further updates to be provided to the Board of Directors in future reports.

In relation to deep cleaning, a concern regarding carbapenemase had arisen. Appropriate resources were being directed to resolve the matter.

Trends in flu had been observed in Australia, which historically informs the experience of flu in the UK for the following winter. It was advised that the strategy for the Trust’s flu campaign for 2019/20 had commenced.

In relation to flu, Mr Morgan queried the loss of bed days related to flu. The DIPC advised that cohorts of affected patients were isolated to prevent the spread of the virus, as well as advising those patients who had less severe flu symptoms to stay away from the hospital to avoid further exacerbation of symptoms.

The DIPC went on to reiterate the importance of staff vaccinations and noted in particular the benefit for early vaccination following the expected commencement of the flu ‘season’ in October. Further, the Executive Chief Nurse described the system approach undertaken by the Trust in the management of flu.

Mr Stout queried whether the vaccine would be tailored in response to the strains of flu in circulation in Australia, to which the DIPC advised that this was the case.

The Medical Director commended the work undertaken by the DIPC and the wider Infection Prevention and Control team.

A further update on the Trust Flu strategy would be provided in the Executive Chief Nurse report at the next meeting of the Board of Directors in September.


[The DIPC left the meeting at 11:57am]

19/44 PERFORMANCE AND DELIVERY

i) Integrated Quality, People, Finance & Performance Report

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Agenda item: A2


a. Quality

The Medical Director noted the following points:

Incident reporting continued to increase, demonstrating the positive patient safety culture within the organisation. It was acknowledged that reporting of incidents and ‘near misses’ aided future learning.

There were no Never Events (NEs) and 20 Serious Incidents (SIs) reported in the period.

Trust Mortality rates remain within the expected levels for the organisation’s size and case mix.

Summary-level Hospital Mortality Indicator (SHMI) for the Trust continues to be lower than the national average, despite a slight increase since the last quarter.

There had been one death that had been categorised as Hogan 5.

The Executive Chief Nurse provided the following additional points:

Two falls were observed in the period, which had been categorised as ‘major’ during the month of May, despite an overall decrease in falls. STEIS investigations into both incidents were ongoing.

Traction in the changes to Pressure Ulcer management had been observed, despite a slight increase in the monthly figures. This was contrary to the downward trajectory observed within the Trust since October 2018.

A national review of the Friends and Family Test was anticipated with further guidance from NHS Improvement (NHSI) expected.

b. Business Development & Performance

The Chief Operating Officer presented the Business Development and Performance element of the report and noted the following:

In relation to the performance within the Emergency Department (ED), the Trust performance was generally around the 95% mark for 4-hour waiting time. It was noted that the performance for April to June 2019 was slightly below the target at 94.8%; however, this was still a positive position when compared to national colleagues where the average was circa 85%. The Chief Operating Officer noted some of the influencing factors to the changing volume in the Emergency Department, including a reduction in the numbers of Walk In Centres. National work continued to improve access to GPs such as through making appointments to see an out of hours GP. Locally the Trust was working with its Alliance partners to alleviate the pressures in the ED.

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Agenda item: A2


In relation to Delayed Transfers of Care (DToCs), the Trust would roll out the SAFER toolkit (as demonstrated agenda item 19/42 iv) across the organisation and would focus on internal processes and its partnerships with local authorities.

In relation to the 18 week Referral to Treatment (RTT) target, the Trust was close to breaching the target at 92.3% of the 92% target. Capacity challenges were noted.

The Trust has been unable to meet the 6-week diagnostic target for a number of months, a matter that has been impacted by both workforce and demand pressures.

The achievement of Cancer performance remains a significant area of challenge for the Trust, despite the positive outcomes for patients. The Trust would focus on two areas, being i) information, process and tools; and ii) capacity, particularly in relation to lung and endoscopy.

Mr Morgan queried whether capacity constraints pertained to people or to space. The Chief Operating Officer advised that whilst the challenges predominately pertained to staffing, some spatial concerns were evident. The Chief Operating Officer went on to advise that in those areas where the Trust was experiencing challenges in recruitment, such as in Radiology, this was a national issue. The Chief Executive added that national guidance was expected regarding previously communicated requirements for reductions in the number of hospital beds.

The Board went on to discuss the Trust’s Cancer performance, with the Medical Director noting that although there was room for improvement in the organisation’s adherence of targets, the Trust was second in the country’s league tables for outcomes in relation to the 62 day target.

Mr Stout queried whether there were any areas of particular concern within the organisation’s cancer service portfolio. The Chief Operating Officer advised that there was room for improvement across a number of areas with performance measured and tracked at the weekly stand-up meetings.

Professor McCourt queried whether the emergency care metrics were influenced in part by ambulance diverts and the subsequent impact these could have on Trust performance. The Chief Operating Officer advised that this was not currently an area of concern and the Trust would continue to work closely with the North East Ambulance Service (NEAS).

The Chairman queried whether patients could be transferred between Emergency Departments and Walk In Centre facilities during times of high demand. The Chief Operating Officer advised that this could be explored if activity increased however improving education for patients to be seen in the most appropriate place in the first instance was preferable.

Professor Burn highlighted the use of the revised dementia risk assessment screening tool to which the Executive Chief Nurse explained that the tool had been simplified to improve ease of use with further improvements anticipated as part of the Paperlite project.

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Agenda item: A2


In relation to Complaints data, Mr Godfrey referred to the need to improve communication to patients. The Chief Operating Officer advised that following this the position should improve following the introduction of the centralised Appointment Booking Centre (ABC). Further, it was noted that since the introduction of the ABC to date, a number of improvements have been observed such as a 25% reduction in Did Not Attends (DNAs). The ABC would soon be rolled out to day cases and elective admissions, in addition to outpatients.

c. People

The Director of HR noted that:

Rates for mandatory training, appraisals and staff turnover continue to be positive.

The HR department continued to work in collaboration with Occupational Health colleagues in the management of sickness absence, a key challenge for the organisation. Page 124 demonstrated the Trust’s rates for sickness absence in comparison to the local Trusts.

Further opportunities are to be developed in relation to apprenticeships and the Executive Team were considering the best utilisation of the apprenticeship levy.

Flexible working was identified as an area for improvement within the staff survey results. A campaign would be launched in the next month to review flexible working arrangements within the Trust.

The Trust’s vacancy rate continues to be an area of focus. A number of recruitment methods were being utilised to improve the position such as through international recruitment.

Challenges in uptake of mandatory training were noted, with improvements in access required.

Professor McCourt requested further detail on the graph on page 127 detailing the top five reasons for staff leaving, particularly in relation to staff receiving their pensions and opting for flexi-retirement. The Director of HR advised that further detail would be provided during the next report to be presented at the Board meeting in September. Work was ongoing nationally due to changes to the Pension Tax regime with some staff opting to leave the Pension or review their job plans. The Chief Executive advised that discussions were ongoing within Shelford group meetings. Professor McCourt added that although this was a matter of debate at a recent British Medical Association (BMA) conference, the pension matter was not limited to clinical staff.

d. Finance

The Director of Finance advised of the following points from the report at the close of Month 2:

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Agenda item: A2


The Trust achieved the planned position for Income and Expenditure; however, this was assisted in part by the use of non-recurrent resources. The Finance and Investment Committee meeting scheduled for July would consider performance against the Cost Improvement Programme in detail.

The Trust had a cash balance of £119m, which would be used to fund the capital programme for this financial year and next financial year.

The Trust’s financial risk rating was ‘2’.

It was further noted that future iterations of the report would contain three areas – Quality, Finance and People. This would replicate the revised Board Committee structure.


19/45 ENGAGEMENT

i) People Update

The Director of HR presented the People Update, noting further information relating to the Interim People Plan was available in the Board Reference Pack (BRP). The following points were noted:

The Flourish programme continues to assist with enhancing the experience of staff working for the organisation and the Trust Personal Leadership Behaviours (PLBs) were in the process of being refreshed.

The organisation takes pride in its increasing diversity and will begin reporting on Workforce Race Equality Standard (WRES) compliance through the People Committee from August 2019. The first Black, Asian and Minority Ethnic conference would be hosted in the Trust in October 2019, with a Disability conference planned for later in the year.

The introductory handbook received by all new starters will be refreshed and supplemented by an online ‘First Day Kit’.

In conjunction with the Flourish agenda, a staff wellbeing workshop would be taking place, focussing on the importance of sleep, rest and healthy eating.

The Trust would continue to run awareness raising seminars for staff on pension taxation changes, a continuation to last year’s programme.

The North Regional Talent Board had recently been launched to provide a consistent approach to identifying emerging talent and capturing the necessary data with immediate focus on Workforce Directors and Nurse Directors.

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Agenda item: A2


The fill rate for Junior Doctors posts had improved and a resolution had been reached regarding the Junior Doctors contract.

The Trust was also undertaking a review of its education and training provision and a number of stakeholder events would be held.

Mr Stout queried whether there were any lessons to be learnt from the private sector regarding the pension’s changes. The Director of HR advised that the issue with NHS staff stems from the specific rules set out in the NHS pension scheme regarding defined benefits and the number of years of service.

Mr Godfrey commended the work ongoing to improve Junior Doctor facilities and queried the availability of national funding. The Director of Communications and Engagement advised that work would continue to agree proposals with the Junior Doctors forum for utilisation of the national funding issued.

It was resolved: to receive the update.

19/46 CORPORATE GOVERNANCE

i) Corporate Governance Update

The Trust Secretary presented the update for Board information and noted the requirement for the Board to agree a Non-Executive Director ‘buddy’ for the Insight Programme, a Gatenby Sanderson initiative for aspiring Non-Executive Directors.

It was resolved: to (i) receive the update and (ii) agree for Professor McCourt to provide Non-Executive Director support to the Insight Programme.

ii) Update from the Committee Chairs

The following updates were received.

Regarding the extraordinary Audit Committee meeting in May, Mr Stout advised that: The Committee was assured by progress made by Internal Audit to deliver the work

plan, particularly the significant progress made in the last month since the April Committee meeting.

External Audit provided an unqualified opinion on the Trust’s Final Accounts for 2018/19 and the Head of Internal Audit Opinion provided ‘good’ assurance.

The Committee discussed the potential financial impact to the Trust of changes to asset lives guidance from the Royal Institute of Chartered Surveyors (RICS). It was advised that the situation would be monitored by both the Audit Committee and the Finance and Investment Committee going forward.

Regarding the Finance and Investment Committee, Mr Morgan advised that: The Trust broke even in Month 2; however, the Trust financial position continued to

be challenging which would be monitored at the Committee going forward.

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Agenda item: A2


The Committee discussed the Cost Improvement Programme (CIP) at length, noting further emphasis required to realise plans.

It was agreed that the Trust’s Intellectual Property Policy would be updated to align it to the Newcastle University policy.

The Committee discussed recovery plans for the emerging pressures experienced by the Trust and the reinforcement of budgetary controls.

Regarding the Quality Committee, Professor McCourt advised that: Work continued to bring all elements of the Trust Quality groups together to ensure

that adequate assurance could be maintained. It was agreed that Dr Angus Vincent, Associate Medical Director for Patient Safety and

Quality, would join the Committee and that Professor Julia Newton, Associate Medical Director for Research, would regular attend meetings going forward.

The inaugural meeting discussed leadership walkabouts, space constraints with Neonates and health and safety matters.

Mr Godfrey advised that the first meeting of the revised Trust Charitable Funds Committee would be taking place the following day.

It was resolved: to receive the update from the Committee Chairs.

19/47 ITEMS TO APPROVE

i) Committee

a. Terms of Reference and Schedules of Businessb. Annual Reports

The Trust Secretary presented the Terms of Reference and the Schedule of Business for the revised Board Committee structure for Board approval. It was noted that the Terms of Reference would likely be refined and refreshed over the next 12 months.

It was noted that the Annual Reports would be presented to the next meeting of the Board due to Committee meeting scheduling.

It was resolved: to approve the Terms of Reference and Schedules of Business for the Board Committees.

ii) Proposal for Newcastle Hospitals to Declare a Climate Emergency

[The Head of Sustainability and Compliance joined the meeting at 12:50pm]

Mr James Dixon, Head of Sustainability and Compliance, provided a presentation to the Board with the following key areas to note:

In response to growing national and international awareness, organisations and members of the public are under pressure to reduce their impact on the environment.

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Agenda item: A2


To date, 85 UK councils and 2 universities have declared a climate emergency with a commitment to achieving carbon neutrality.

The Trust is keen to continue to collaborate with its local partner organisations. Newcastle City Council and Newcastle University have already declared their commitment to carbon neutrality.

The Trust energy centre contract was due for renewal in 2028 and significant technological advancements had occurred regarding renewable grid utilisation and decarbonising heat.

The Trust had the first environmentally sustainable analgesia fellow working on site.

The Trust has been working over the last decade to limit its impact on the environment, being the first Trust in Europe to utilise reusable sharps boxes and by sending 0% waste to land fill since 2011. Other initiatives, such as replacement of single use plastics in the Trust’s catering facilities and the introduction of electric buses soon to be in use, demonstrate this commitment further.

Despite this, further action is required by organisations and therefore, the Board was asked to agree to declare a ‘Climate Emergency’ (being the first NHS organisation to do so) and commit to the pledge for Newcastle Hospitals to become carbon neutral by 2040.

Mr Morgan queried the cost of the ambition of carbon neutrality. The Head of Sustainability and Compliance advised that although exact costings for meeting the pledge were currently unknown (due in part to technological advancements yet to come), it was widely acknowledged that taking the decision not to act would have a greater financial and moral detrimental effect to the organisation.

Mr Godfrey queried whether the pledge could be delivered by 2040. The Chief Executive advised of the importance of the Trust joining its civic partners in pledging to carbon neutrality and being a pioneer in the NHS. The Director of Estates noted that the pledge date of 2040 aligns the Trust with Newcastle University.

It was resolved: to (i) receive the report and (ii) support the Trust’s pledge to carbon neutrality by 2040 and agree to declare a climate emergency.

19/48 ITEMS TO RECEIVE

i) Date and Time of the Next Meeting in Public

The next scheduled meeting was agreed to be held on Thursday 26 September 2019, in the Board Room, Culture Centre, RVI.

The Annual General Meeting would be held on Friday 27 September 2019 with timing and location to be confirmed.

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Agenda item: A2


ii) Members of the press and public were excluded from the meeting in accordance with the Health Services Act 2006 (Schedule 7 Section 18(E)) (as amended by the Health and Social Care Act 2012) and in view of publicity being prejudicial to the public interest

The meeting closed at 13:06pm

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THIS PAGE IS INTENTIONALLY BLANK

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BOARD MEETINGS - ACTIONS Agenda item: A3

Log No. BOARD DATE PRIVATE /

PUBLIC

AGENDA ITEM ACTION ACTION BY Previous meeting

status

Current meeting

status

Notes

37 September 2018 Public 18/122 Corporate Governance and

Compliance

ii) Freedom to Speak Up Guardian

Mrs Parnell advised of a self-review tool for Boards in relation to the

Freedom to Speak Up Guardian. Mrs Parnell agreed to work with Mrs

Fawcett and Mr Godfrey regarding completion of the self-review tool

(ACTION08).

C Parnell/K

Godfrey

(NED)/Director of

HR

In progress Completed 19/10/18 - Meeting to be scheduled.

10/12/18 - Following the appointment of a new Freedom to Speak Up Guardian, this will

be picked up in the New Year with support from Mr Godfrey as NED link and Ms Cushlow,

Exec Link for the F2SUG.

24/01/19 - Trust Secretary and F2SUG to discuss further during meeting scheduled on the

4th of February. Update to be provided at a future Board meeting.

21/02/19 - Work underway in populating the self-assessment. Update to be provided

within the next F2SUG Board report due in April 2019.

15/04/19 - Update provided within the F2SUG report at April Board detailing that work on

self assessment to commence following awareness raising campaign later in the year.

Action on hold.

10/06/19 - The Executive Chief Nurse advised that this would be prepared for discussion

at the September 2019 meeting of the Board.

03/09/19 - Paper outlining current Freedom to Speak Up Guardian position included

under agenda item A8(ii)(a) for the September 2019 Board meeting.

68 April 2019 Public 19/27 Quality and Patient Safety

i) Medical Director's Report

d.Guardian of Safe Working Annual

Report on Junior Doctor Vacancies

Mr Godfrey requested future reports contain further information to

demonstrate the number of Junior Doctor vacant posts against the full

complement. The Medical Director agreed to ensure this was included

going forward [ACTION03].

Medical Director On hold Completed 11/06/19 - Detail requested from the GoSW for next report to be received by the Board.

16/08/19 - Included within July report to be presented to Trust Board in September 2019 -

the data has been included in the Private Board Reference Pack.

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Agenda item A4

TRUST BOARD

Date of meeting 26th September 2019

Title Patient Story

Report of Ms M Cushlow, Executive Chief Nurse

Prepared by Mrs Tracy Scott, Head of Patient ExperienceDr Melinda firth, Senior Resolution Facilitator

Public Private InternalStatus of Report

☒ ☐ ☐

For Decision For Assurance For InformationPurpose of Report

☐ ☐ ☒

Summary

The monthly patient story supplements the quarter 1 patient experience Board of Directors report and monthly complaints, friends and family data included within the Integrated Quality Report.

Recommendations The Board of Directors is asked to read, discuss and acknowledge the patient experience shared in this paper.

Links to Corporate Objectives

Put patients and carers first and plan services around them. Deliver a first class patient experience overall. In line with the Trust Patient Engagement Strategy continue to listen to and

learn from service user feedback as part of our broader strategy to improve patient experience.

Links to Strategy and Clinical Risks

Putting patients first and providing care of the highest standard focusing on safety and quality.

Tick yes or no as appropriate Yes No

Quality and Safety x

Legal x

Financial x

Human Resources x

Equality and Diversity x

Engagement and communication x

Sustainability x

Impact

Reports previously considered by

The patient story is a recurrent monthly report.

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Agenda item A4

____________________________________________________________________________________________________Patient StoryTrust Board – 26th September 2019

PATIENT STORY

1. EXPERIENCE OF MAKING A COMPLAINT

As shown in the quarter one Patient Experience report, the Trust received on average 56 new formal complaints per month; these complaints are a vital source of feedback and provide staff and the Trust with opportunities for learning and service improvement. However, we recognise that making a complaint can be a very stressful process for all who are involved with the process.

Mr Y and his family had concerns about the care delivered to their brother in law, who had a learning disability and other complex and life limiting health problems. Mr Y made a complaint on behalf of his brother in law who sadly passed away during the complaint process. This presentation is the story of Mr Y’s experience of making a complaint.

This presentation provides insight into the complaints process and the challenges facing complainants; the following issues are outlined:

What are the dilemmas facing patients or carers who have concerns about care/treatment or communication?

What challenges, worries and concerns do complainants have when making a complaint?

How difficult/stressful was it to make a complaint? How successful was the written response in addressing the concerns raised? How successful was the Local Resolution Meeting? What advice would Mr Y give to someone considering making a complaint? What advice would Mr Y give to the Trust regarding its complaints process?

Discussion

Patients or family members may have concerns or questions about care but may be unsure about raising their concerns or making a complaint. Concerns may arise at times of high stress when caring for someone who is very unwell or when bereaved, or indeed much later on following reflection or discussion. Making a complaint takes time and effort and can feel very challenging, stressful and daunting.

Considerable work has been done to try to improve how the Newcastle Upon Tyne Hospitals NHS Foundation Trust responds to complaints and this continues to be a key part of our work for 2019/2020. Feedback regarding the complaints process such as that received from Mr Y has been used in conjunction with our own internal review to inform service redesign. This redesign will begin with bespoke complaint training being delivered to senior staff and a one day workshop in which the Trust will review current complaint processes and evaluate capacity and demand with the overall aim to improve efficiencies and quality.

Report of Ms Maurya CushlowExecutive Chief Nurse18th September 2019

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Agenda item A5

TRUST BOARD


Title Chairman’s Report

Report of Sir John Burn, Chairman

Prepared by Kelly Jupp, Trust Secretary


☒ ☐ ☐


☐ ☐ ☒

Summary

The content of this report outlines a summary of Chairman activity, including: Regional activities; Collaborative working arrangements and the Integrated Care System

developments; The Trust Climate Emergency Declaration; and Changes to the Governor Working Groups.

Recommendations The Trust Board are asked to note the contents of the report.



Maintaining sound financial management to ensure the ongoing development and success of our organisation.

Enhancing our reputation as one of the country’s top, first class teaching hospitals, promoting a culture of excellence in all that we do.

Links to Strategy and Clinical Risks NA

Tick yes or no as appropriate Yes NoQuality and Safety xLegal xFinancial xHuman Resources xEquality and Diversity xEngagement and communication xSustainability x

Impact

If yes, please give additional information: Provides an update on key matters.

Reports previously considered by Standing agenda item.

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Agenda item A5

____________________________________________________________________________________________________Chairman’s ReportTrust Board Meeting – 26th September 2019

CHAIRMAN’S REPORT

The first half of our financial year is now ending and it’s been a very successful period of time; being judged Outstanding again by the Care Quality Commission and having both our main sites listed in the Newsweek World Top 100 Hospitals endorsed our collective sense of Pride. Our hospital team were prominent in supporting the World Transplant Games, brought to Newcastle by the excellence of our longstanding transplant programme. The opening and closing ceremonies were spectacular and there was the bonus of our own Dr Nadia Stock being named Champion Female Athlete. The Great North Run was equally impressive with a host of fundraisers on the main run including our own Dame Jackie Daniel. An injury reduced me to the GNR 5K where I was able to sound the horn to set off our ‘‘Blue Wave’’ of 150 runners.

Our declaration of a Climate Emergency attracted national coverage and subsequent recognition in the Guardian that we are the first health organisation in the world to make such a declaration! As an invited speaker at the 35th Ernst Klenk Symposium in Cologne in September, this time devoted to treatment and prevention of rare diseases, I was able to report our continued status as a national centre of excellence for such things as children’s heart transplants, the revolutionary CAR-T cellular therapy for cancer and the exciting new gene therapy for a childhood genetic disease called Spinal Muscular Atrophy. My own research on use of aspirin to prevent hereditary cancer has now resulted in a new draft NICE guideline which will make England the first health service in the world to implement this low monetary value and effective means of cancer prevention. We were delighted to be informed that we had been made a finalist in the Health Services Journal national awards including the key category of ‘Acute or Specialist Trust of the Year’.

But there is no time to rest on our laurels. The inexorable growth in workload due to a mixture of rising expectations, an ageing population and stress elsewhere in our regional system mean we must continue to improve and find ways to better use our resources.

At a personal level, in addition to the ongoing programme of visits including meetings with the staff in paediatric medicine and the Institute of Transplantation, I have been working closely with the Chairs of other health organisations to integrate our attempts to provide a system of governance for the new Integrated Care System. I have attended our Wellbeing for Life Board in the city which brings together partners across the city including the community and voluntary sector. The recent report ‘Canaries in the Coalmine’ was discussed at the last meeting and highlighted the current position for the voluntary sector in the city. I would recommend this publication to the Board. The Wellbeing for Life Board is currently being reviewed to ensure it is fit for purpose in the context of our ongoing joint working across the City.

I was delighted to take part in the well-attended Pride Event on 20th July and have now joined the LGBTQ Allies group organised by our Chief Operating Officer, Martin Wilson. The LGBTQ Allies group has been established as part of one of our Trust Values “We are inclusive – Everyone is welcome here”, and is another visible way on top of the roll out of NHS Rainbow Badges and lanyards, of showing the leadership and support that we can all bring to making the Trust a great place to be a patient and to work.

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Agenda item A5

____________________________________________________________________________________________________Chairman’s ReportTrust Board Meeting – 26th September 2019

We have also agreed to participate in the Gatenby Sanderson Insight Programme which is aimed at increasing the pool of quality Non-Executive Director candidates from under-represented areas. We are looking forward to welcoming our first candidate, Theodora Adegbie, in joining us from October 2019.

Following discussions with our Council of Governors we have begun a review of their working groups to align them with the new Board Committees and we have amended the structure of the Nominations committee to make it more aligned with current guidance. This includes me taking the Chair with David Stewart David for the Governors moving to Deputy Chair, standing down executives and non-executives apart from the Senior Independent Director and increasing from four to six the total number of governors. These changes to governance are less dramatic but still important as they ensure we remain transparent in our work to live up to our new strapline:

Healthcare at its best: People at our heart

Report of Professor Sir John BurnChairman16th September 2019

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Agenda item A6

TRUST BOARD


Title Chief Executive’s Report

Report of Dame Jackie Daniel, Chief Executive Officer

Prepared by Caroline Docking, Assistant Chief ExecutiveAlison Greener, Executive PA to CEO


☒ ☐ ☐


☐ ☐ ☒

Summary This report sets out the key points and activities from the Chief Executive.

RecommendationsThe Board of Directors are asked to note the contents of this report and approve the Integrated Care System Memorandum of Understanding included in Appendix 1.


Put patients and carers first and plan services around them.Maintain a Finance and Use of Resources rating of 3.To deliver all CIP targets / operational efficiencies at all levels. Consistent achievement of all targets and continuing to deliver a first class patient experience.





Achievement of national performance targets – specifically the A&E 4 hour waiting time target.


Quality and Safety X

Legal X

Financial X

Human Resources X

Equality and Diversity X

Engagement and communication X

Impact

Sustainability X

Reports previously considered by Regular report.

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Agenda item A6

____________________________________________________________________________________________________Chief Executive ReportTrust Board – 26th September 2019

CHIEF EXECUTIVE’S REPORT

1. CEO OVERVIEW

It has been an incredibly busy summer for all of us in the Trust with many highlights and developments.

As a result of a £1.8bn boost for NHS hospitals, I’m delighted to report that we will receive £41.7 million to improve Paediatric Cardiac Services in the North East. This is fantastic news, which will enable us to progress with the relocation of these services to the Great North Children’s Hospital (GNCH). This announcement was warmly welcomed by our clinical teams in both the Cardio-thoracic directorate and at GNCH. A project board has been established to lead this work, and I’ve been pleased by the positive response from families and local charities who are keen to work with us to provide a truly state of the art environment. A detailed update is included under agenda item A8(v).

We pride ourselves on being an inclusive organisation and so I was keen to support our involvement in the Northern Pride Festival on 19th July. As a Trust we wholeheartedly supported the festival. I’m proud to say that for the first time we had a Newcastle Hospitals banner in the Stonewall Remembrance March thanks to our LGBT+ network. We also hosted a Pride NHS Breakfast at the RVI. This was a joyful event, supported by the Board of Directors, and attended by 100 gay and straight staff from across the Trust and wider NHS.

The UK is now one of the best countries in the world for gay equality and we have seen fantastic progress in public attitudes over the last 20 years, but there is still more that we can do. Reports highlight that LGBT people experience discrimination in healthcare settings and sadly one in seven reported avoiding healthcare for fear of discrimination from staff. (LGBT Health in Britain Report 2018, Stonewall). 41% of non-binary people said that they had harmed themselves in the last year and that one in four LGBT people said they had witnessed negative remarks by healthcare staff.

We all have an important role to play in making sure that everyone feels welcome in our organisation, and in our services. Events like Northern Pride are important because of the profile that they bring to these issues – but the care we give, and the approach we take towards our fellow citizens as we come into contact with them at work and in society, is just as important if we are to continue the drive towards equality. Equality is a fundamental part of our #Flourish approach, and I’m grateful for the hard work that members of all our staff networks put in throughout the year to encourage understanding and challenge stigma wherever it exists.

To support this, we have also become part of the NHS Rainbow badges approach. Everybody wearing a badge will have made a pledge to support inclusion. In just a few weeks over 5,000 staff have signed up and made a pledge.

Our inaugural Black, Asian and Minority Ethnic (BAME) conference will take place on 1st October and I am sure this will be an equally positive event.

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Agenda item A6


I also wanted to highlight our activity during the Great North Run weekend. Not only did we have 256 people running for our trust charities, we also celebrated the benefits of physical activity as we held the first NHS wave of the Great North 5k on 7th September at Newcastle Quayside. It was wonderful to see over 150 of our staff take part in this event. Physical activity is one of the best things we can all do to stay fit and healthy which is a key element of our #FlourishAtNewcastleHospitals approach. We hope to build on this success and strengthen our links with the Great North Run during their 40th anniversary next year.

On Friday 27th September, we will hold our Annual Members Meeting and review of the year, to which all are welcome. We will be taking this opportunity to launch our new Vision and Values for the Trust, which is the culmination of our work to develop a new Trust strategy. I am also using my weekly blogs to share the new vision, values, ambitions and strategic framework with our staff.

1.1 Other key headlines

Integrated Care Partnership/Integrated Care SystemAs an important NHS anchor organisation it is important that we continue working on a regional basis to support patient pathways and our wider NHS partners.

Following discussions at previous board meetings, all local NHS bodies will be considering the Integrated Care System (ICS) Memorandum of Understanding (MOU) at their September meetings. An updated version of the draft ICS MOU – is presented in Appendix 1 of this report for approval.

Shelford GroupSince taking over as Chair of the Shelford Group, I have chaired their annual event which took place on the 10th September. It provided an opportunity to review and refresh the strategic direction of the group as well as showcasing and sharing projects and learning from Chief Medical Officers, Chief Nursing Officers, Chief Financial Officers and Human Resources Directors groups.

Climate Emergency Our climate emergency declaration continues to attract national interest.

Following our announcement on 27th June, Channel 4 news ran a feature highlighting our declaration and also the actions we are taking to tackle the climate emergency.

I spoke at the NHS Assembly meeting on 5th July, and wrote an opinion piece for the Health Service Journal (HSJ) which was published on 8th August and is available here. (https://www.hsj.co.uk/efficiency/jackie-daniel-why-newcastle-ft-has-declared-a-climate-emergency/7025714.article )

I also joined NHS Chief Executive, Simon Stevens and Mayor of Greater Manchester, Andy Burnham at the Health and Care Innovation Expo, to highlight the steps we are taking. This is a crucial area for the NHS and our leadership position has been recognised and welcomed.

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https://www.hsj.co.uk/efficiency/jackie-daniel-why-newcastle-ft-has-declared-a-climate-emergency/7025714.article

https://www.hsj.co.uk/efficiency/jackie-daniel-why-newcastle-ft-has-declared-a-climate-emergency/7025714.article

Agenda item A6


The Guardian featured us as the first health organisation in the world to declare a climate emergency in their feature on 18th September and we continue to work with NHS Improvement/England (NHS I/E) to ensure that we can support the NHS further.

Paperlite and Digital Strategy I chaired the first Digital Strategy Group on the 23rd July. This will oversee our activities as a Global Digital Exemplar (GDE) to accelerate progress to full digital operation and to help take advantage of emerging digital capabilities. These meetings will be held on a quarterly basis.

Our Paperlite programme continues as we aim to roll out our digital patient record in October. Training for those staff who will use the new, enhanced patient electronic record began in August and over 8,000 staff had booked to complete their training. This is a significant change for the organisation and l would like to pay tribute to the many clinical, operational and IT staff who are working tirelessly to deliver this project.

Joint Working in NewcastleOur Newcastle Joint Executive Group held a workshop on 29th July which focussed on the development of a vision for global excellence. It was facilitated by PricewaterhouseCoopers (PwC) and looked at how moving to integrated health, care and wellbeing can put Newcastle at the forefront of cities across the world. This was a helpful session bringing together the range of public sector partners in the city.

World Transplant Games60 countries took part The World Transplant Games which were held in Newcastle / Gateshead from 17th to 23rd August. I had the pleasure of meeting the Chairman of the Organising Committee, Mr Graham Wylie OBE on 2nd July. Newcastle Hospitals were proud to be an important partner for this event, not least by providing clinical support. The event is an important opportunity to raise awareness of organ donation, to celebrate transplant patients regaining fitness and to encourage others to join the NHS Organ Donor Register. The Trust supported a number of local and national media opportunities.

Planning for a no deal departure from the EUOur planning arrangements in relation to this are in place and the trust will respond as and when required, led by our Medical Director, Mr Andy Welch. An update is included in agenda item A8(i).

1.2 Announcements

NHS Long Term Plan Implementation frameworkIn January, NHS I/E committed to publish an implementation framework for the NHS Long Term Plan, setting out further detail on how the commitments in that document will be delivered. This framework was published on 27th June. We are currently drafting our submission, the final version of which is required by November 2019.

NIHR Funding (Applied Research Collaboration)

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Agenda item A6


The Government announced £135 million investment in health research to equip the NHS for the future and will join up universities, innovators, local authorities and the NHS to help deliver commitments in the Long Term Plan. 15 partnerships across England have been awarded the funding through the National Institute for Health Research (NIHR). The NIHR Applied Research Collaboration North East and North Cumbria (ARC NENC) will be hosted by Northumberland, Tyne & Wear NHS Foundation Trust (NTW) together with Newcastle University priorities will include supporting children and families, multimorbidity, ageing and frailty and integrating physical, mental health and social care as well as others. I will be leading on prevention, early intervention and behaviour change.

1.3 Recruitment

I am delighted to confirm that Dr Victoria Macfarlane Reid commenced her role as Director of Enterprise and Business Development on Monday 23rd September 2019.

2. PERFORMANCE AND FINANCE

This month sees a refreshed performance report presented to the board which sets out all areas of quality, performance and people reporting (agenda item A9). This month’s headlines are:

2.1 Accident & Emergency (A&E)

A&E performance recovered in August to 95.3%, annual performance remains below standard at 94.9%. August saw a sharp decrease in Type 1 attendance from July of 695 patients; this is still 363 more than were seen in August the previous year.

2.2 Cancer

Cancer performance remains a major concern with pre-validation performance for July of:

62 Day Urgent – 77.4% 2 week wait (WW) Suspected Cancer – 82.9% 2 week wait (WW) Breast Symptomatic – 27.5%

A number of actions are being explored to increase diagnostic capacity and improve performance.

2.3 Referral to Treatment (RTT)

August performance not available due to timing.

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Agenda item A6


The overall RTT target was missed for the first time in July with achievement of 91.8% against the 92% standard, current indications from the volumes of activity performed are that August will not recover above 92%.

Activity recovery plans have been developed by directorates. Work remains ongoing to address the backlog of long wait patients.

2.4 Finance

The finance report included within the refreshed performance report covers financial performance – Income and Expenditure (I&E) and Balance Sheet - up to 31st August 2019. Our finance headlines are:

The Trust has an I&E surplus of £3.7 million including Provider Sustainability Funding (PSF) which is equal to plan.

The I&E position, along with other finance metrics, will mean the Trust will have a NHS improvement Financial Risk Rating of 2.

The Trust has overspent by £10.8 million due to cost pressures caused by slippage on Cost Improvement Programmes, drugs spend (matched by income), cost pressures within estates and the cost of waiting list initiatives.

The Trust has £11.8 million more income than in plan due mainly to additional healthcare contract income in July and income from highly specialised and overseas patients. This is predominantly matched by spend. Income also includes £4.1 million non-recurrent PFI income brought forward from 2018/19 – that is the maximum non-recurrent PFI funding available for the year.

The balance sheet remains strong with a cash balance of £128 million; £28.5 million above plan. That is a far higher cash balance than anticipated as it includes PSF funding and a number of other sums received in advance for GDE and Training and Education. All of the excess cash is committed within the forecast I & E positon.

Capital expenditure to 31st May was £14.1 million and was £1.9 million behind plan.

3. NETWORKING ACTIVITIES

I attended the second and third NHS Assembly meetings in London on 5th July and Manchester on 5th September. Topics included health and the environment and the EU exit.

The Chairman and I had the opportunity to tour the Centre for Life on 9th July and consider how we can support the upcoming 10th anniversary of the centre.

I met with Sir David Behan, Chair of Health Education England (HEE) on the 11th July 2019. It was an interesting discussion on the role of anchor institutions in co-ordinating research,

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Agenda item A6


innovation and specialised and general training and the role Shelford has in terms of life sciences and the research and innovation infrastructure. As a result, Sir David has been invited to meet with Shelford Chief Executives which will take place in December.

I met with Nick Brown, MP for Newcastle upon Tyne East on 5th August to discuss constituency matters.

I had the pleasure of welcoming Danny Mortimer, Chief Executive of NHS Employers on the 6th August. Danny met with our executive team and there was a valuable discussion around key workforce issues and opportunities which included the implementation of the people plan and how we can make and promote the NHS to be the best place to work. Danny met with some members of our Appointments and Remuneration Committee and also toured the Clinical Learning Centre and the Great North Children’s Hospital. The impact of the NHS pension rules have heavily featured through the summer and we are considering recent announcements carefully.

I welcomed North of Tyne Mayor Jamie Driscoll to the Trust on the 15th August. He took the opportunity to tour our cardiothoracic team as well as the Northern Centre for Cancer Care.

I visited the Radiology Department at the RVI on the 20th August where I met with a number of our radiologists who provide crucial diagnostic support across the trust. I look forward to returning to visit the nuclear medicine department shortly.

I opened the Appointment Booking Centre at Regent Point on the 22nd August. This service provides a single booking and call handling service for patients who need to attend any of our outpatient clinics across the Trust. Whilst I was there I took the opportunity to visit the IT Department and met these important ‘behind the scenes’ teams who keep our IT infrastructure in good order. I also spoke to the Paperlite project team, who are working hard to deliver our new electronic patient record in the Autumn.

4. AWARDS AND ACHIEVEMENTS

We have been shortlisted for five HSJ awards, including the prestigious ‘Acute or Specialist Trust of the Year’ with the ceremony taking place in London on Wednesday 6 November. Good luck to all our shortlisted teams. Other shortlisted teams are:

- ‘Acute or Specialist Service Redesign Initiative’ - A multidisciplinary team initiative to improve care for rib fracture patients.

- ‘Connecting Services and Information Award’ - In partnership with Clinithink’s CLiX ENRICH solution, which is used by our clinical research staff to transform how we identify patients for clinical trials.

- ‘Reservist Support Initiative Award’ - For our work in creating a forces friendly workplace including our active Armed Forces Staff Network.

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Agenda item A6


- ‘Acute or Specialist Service Redesign Initiative’ - Work by our Paediatric Asthma Team to improve asthma treatment for children and young people across the region.

We are also finalists in three categories of the Nursing Times Awards on 30 October which recognise those making nursing an innovative, patient-focused and inclusive profession:

- Senior nurses from the Trust and Newcastle/Gateshead CCG – ‘Continence Promotion and Care’ - for their UTI collaborative work on five wards in older people’s medicine to understand the causes, avoidance and earlier recognition of urinary tract infections.

- The palliative and end of life care team - ‘Patient Safety Improvement’- for developing a discharge pathway comprising of three routes (depending on the stage of a patient’s illness) with corresponding checklists which aspire to influence the safety and quality of discharges.

- Nurse Consultant in Tissue Viability, Fania Pagnamenta - ‘Innovation in Chronic Wound Management’ - for her work with staff in developing the skills required for them to apply compression bandages, improve care and maximise wound healing to patients with leg ulcers, who are admitted to hospital for unrelated conditions.

Nutrition Nurse Specialists Hayley Leyland, Jess McDonald and Stacey Vass at the Freeman Hospital won this year’s British Society of Gastroenterology Nurses Association (BSGNA) Nurse’s Award. The team received the award in recognition of their home parenteral nutrition (HPN) and intestinal failure service which offers the highest quality of care for patients from all over the North East and Cumbria.

The IT team were shortlisted for two awards at the national Public Sector Paperless Awards – the document store for Best Digital Document Management and Electric Observations for Paperlite Project of the Year. Graham King was also shortlisted for Chief Information Officer of the Year in the Digital Health Awards 2019 for his ‘selfless’ effort to run the regional procurement of a HIE (Health Information Exchange).

Consultant Respiratory Physician Hilary Tedd has been awarded the Emerging Women Leaders Programme Fellowship - a development programme commissioned specifically to address the under-representation of women in leadership roles within the RCP and the wider medical profession.

Report of Dame Jackie DanielChief Executive 19th September 2019

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1 Final version 16 August 2019

North East and North Cumbria Integrated Care System Memorandum of Understanding for NHS clinical commissioning groups and foundation trusts Introduction and Context 1. This Memorandum of Understanding (Memorandum) is an understanding between the North

East and North Cumbria NHS organisations within our ICS. It sets out the details of our commitment to work together to realise our shared ambitions to improve the health of the 3.1 million people who live in our area, and to improve the quality of their health and care services.

2. In working together as a system we will place the people we serve, and the communities in which they live, at the centre of our decision-making, alongside a commitment to clinical leadership at every level of our ICS, and to an appropriate balance between primary, community and acute care.

3. Our ICS is not a new organisation, but a new way of working to meet the diverse needs of our citizens and communities. It does not seek to introduce a hierarchical model; rather it provides a mutual accountability framework, based on principles of ICP subsidiarity, to ensure that we have collective ownership of the delivery of our shared priorities.

4. Although this MOU has a focus on collaboration between NHS organisations, the next stage of

our ICS development will be to engage with our partners, in local authorities and beyond, to develop shared priorities and the optimal governance arrangements to oversee their delivery.

5. The Memorandum is not a legal contract. It is not intended to be legally binding and no legal

obligations or legal rights shall arise between the Partners from this Memorandum.

A new approach to collaboration 6. Our approach to collaboration begins in each of our fourteen local authority areas which make

up the North East and North Cumbria. These places are the primary units for partnerships between Local authorities, NHS commissioners and providers, independent sector providers and the wider public and voluntary sector, working together with the public and patients to agree how to improve health and wellbeing and improve the quality of local health and care services.

7. In seeking to work together we will recognize the operational and financial pressures of our

Local Government and other partners, and work with them to optimise the use of our resources in the interests of the people we serve.

8. Place-based working, overseen by Health and Wellbeing Boards, is key to achieving the ambitious improvements in health outcomes that we all want to see. As an ICS we are clear that subsidiarity is vitally important and operated wherever appropriate. It is in our ‘places’ where the majority of services will continue to be commissioned, planned and delivered.

9. It is also intended to establish an ICS Partnership Assembly that will provide a strategic view on

issues where working at scale makes sense and adds value, with inclusive representation from NHS organisations (both non-executive and executive) and partners from each of our ICPs (see below). The ICS Partnership Assembly will help to shape and endorse our strategic priorities -

Agenda item: A6 - Appendix 1

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and make recommendations to statutory decision makers - so that local plans are complemented by a common vision and a shared plan for the North East and North Cumbria as a whole.

Working at scale as an Integrated Care System

10. Although we recognise that local relationships and place-based activity takes precedent, we

must also ensure strong connections through to the overall aims and objectives of the ICS. In addition, we must deliver the constitutional standards and deliver the best possible care for patients and the best possible experience for staff.

11. As one of the largest ICSs our operating model is different to other places, as we work across three broad levels of scale.

• Neighbourhood and Place – this is the main focus for partnership working between the NHS and local authorities in our cities, boroughs and counties, where primary care networks (serving populations of 30,000-50,000) operate within local authority/current CCG areas of between 150,000 to 500,000 people. Services commissioned and delivered at this level will be predominantly community based, with flexibility to adapt to local circumstances and need.

• Integrated care partnerships – will cover populations of around one million (with the exception of North Cumbria, which has unique geographical and demographic features). These are partnerships of neighbouring NHS providers and commissioners, working with their local authorities and other partners, to deliver safe and sustainable predominantly hospital-based health and care services for the people in their area.

• Integrated care system – covering a population of circa 3.1 million people, focussed on key strategic priorities for ‘at scale’ working allowing all NHS and partner organisations to: - Collectively prioritise based on a shared understanding of need and areas of

underperformance - Act with ‘one voice’ to represent the North East and North Cumbria and therefore be in

a better position to access resources that support our shared priorities. - Set stretching and consistent service standards – especially for vulnerable groups – and

ambitious targets to improve patient and staff experience - Manage risks and pressures better together as a system - Share and spread best practice - Reduce duplication and develop shared functions where appropriate

Our principles, values and behaviours as a collective senior leadership community: 12. To operate as an effective integrated health and care system we commit to working beyond

organisational boundaries. We will build our collective capacity to better manage the health of our population, striving to keep our people healthier for longer and reducing avoidable demand for health and care services. We will:

• Act collectively, demonstrating what can be achieved with strong system leadership

• Speak with one voice, where appropriate, in relation to matters relating to national health and care policy

• Maintain an unrelenting collective focus with our partners on improving health outcomes, based on the principle of prioritising patient first, then system and organisation

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• Recognise the continued strengths of each organisation and treat each other with respect, openness and trust, whilst also working as part of an ICS to identify shared priorities and where possible to collectively manage risk.

• Place innovation and best practice at the heart of our collaboration, ensuring that our learning benefits the whole population,

• Maximise opportunities for system-wide efficiencies

• Consider opportunities to manage our resources within a shared financial framework. ICS Planning in Progress 13. To tackle the challenges of continuous improvement, and to ensure the sustainability of our

services, NHS and other Partners are already developing six priority workstreams:-

I. Population Health and Prevention – making fast and tangible progress on improving population health through more effective screening and public awareness to better prevent, detect and manage the biggest causes of premature death in the North East and North Cumbria: cardiovascular disease, respiratory disease and cancer.

II. Optimising Health Services – setting clinical standards and coordinating initiatives

across the ICS to find sustainability solutions for those of our health services under the greatest pressure. This workstream will coordinate the work of our Clinical Networks, including the Cancer Alliance, Urgent Care Network and others, and manage the dependencies between the service improvement and reconfiguration proposals as they are developed by each ICP, and maintaining an oversight on quality across our patch.

III. Digital Care – Use digital technology to drive change, ensure our systems are inter-

operable, and improving how we use information technology to meet the needs of care providers, patients and the public, helping clinicians to share information and our patients to manage their healthcare.

IV. Workforce Transformation – building a future workforce for our ICS, with the right skills

and flexible support arrangements to enable them to work across multiple settings whilst working collectively to ensure we can recruit and retain staff in priority areas.

V. Mental Health - improving outcomes for people who experience periods of poor mental

health, particularly those with severe and enduring mental illness, and doing more improve the emotional wellbeing and mental health of children and young people, and breaking down the barriers between physical and mental health services.

VI. Learning Disabilities – transforming care for people with learning disabilities and autism

and improving the health and care services they receive so that more people can live in the community, with the right support, and close to home.

Our governance 14. We will always respect the principle of subsidiarity, and the ongoing responsibilities and

accountabilities of statutory CCGs and foundation trusts for services commissioned and delivered at ‘place’ level. The ICS cannot and will not replace or override the authority of ICS members’ boards, councils and governing bodies. Instead, the ICS’s governance has been designed to provide a strategic mechanism for collaborative action and common decision-making for issues which are best tackled on a wider scale.

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15. The proposed governance model for the ICS has two main features;

• The development of a strategy and shared priorities, through a Health Strategy Group and Partnership Assembly.

• The execution of these priorities through an ICS Management Group and then the ICPs themselves.

16. NB the development of our governance arrangements is an iterative process, and will be kept

regularly under review. Their chief purpose is to provide mechanisms to build consensus and ensure delivery of agreed priorities, but they do not over-ride the statutory authority of CCG governing bodies and trust boards.

Development of our ICS strategy

17. The ICS Health Strategy Group (HSG) will be a quarterly meeting, with membership

encompassing CEOs of each of our statutory NHS organisations, alongside clinical leaders and representation from our emerging primary care networks, the Association of Directors of Adults and Children’s Social Services, the Directors of Public Health Network, Public Health England, and the Academic Health Science Network.

18. In conjunction with the ICS Partnership Assembly (see below), and ensuring the principle of ICP subsidiarity, the role of the HSG will be to

• Agree an overall ICS strategy based on an understanding of both shared challenges, and the objectives in the Long Term Plan – and the priority workstreams that will deliver these priorities.

• Develop a single leadership architecture, including system rules, behaviours and leadership development.

• Share information and showcasing effective practice from across the ICS

19. The development of an ICS Partnership Assembly is now in discussion with our partners, but will have a key role in shaping our shared priorities for collaboration across health and care, and the wider determinants of health – including, for example, inclusive economic development, the environment, and climate change– that can drive improvements in population health. This Assembly will have an independent chair and vice-chair, and its membership is likely to comprise nominated representatives from each ICP, which could include Health and Wellbeing Board chairs as well as lay members and non-executive directors from NHS organisations. How this body is constituted will be subject to further discussions with our partners over the coming months.

Execution of priorities

20. The ICS Management Group will meet monthly, under the chairmanship of the ICS Executive Lead, with two CEO-level representatives from each of our ICPs (one NHS commissioner and one NHS provider), plus senior clinical leaders, representatives from tertiary acute and mental health providers, and NHS England/NHS Improvement.

21. The role of the Management Group will be to

• strengthen our system leadership capacity to tackle shared challenges

• oversee the delivery of the LTP and the ICS’s strategic priorities

• provide mutual support and accountability for the development of our ICPs

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• manage performance challenges and ensure robust oversight of emerging service quality issues

• jointly develop plans as a system to bridge financial gaps, and agree systems for prioritising, distributing and holding each other to account for transformation funding.

• Assess the recommendations emerging from our ICS workstreams, referring them on to ICPs for implementation if the proposals are supported

22. The ICS Management Group will have a symbiotic relationship with the governance

arrangements of each ICP. These arrangements are now under development in each of our ICPs, and will need to agree their own governance model, including the relationship between the ICP and their constituent statutory bodies, as well as the role of clinical leaders and non-executive and lay members.

23. The ICS Management Group will ensure mutual accountability by focusing on the delivery of strategic macro-level system work - with the ICPs taking forward a detailed work programme that fits the needs and requirement of their local populations.

24. It will be the responsibility of the ICP Leads to feedback from the Management Group and agree

locally how ICS workstream recommendations are best ratified and implemented in their ICPs. ICP leads will also escalate any local challenges to the ICS Management group for consideration of how best the wider system can provide support.

Mutual Financial Accountability

25. The ICS has a key role in supporting organisations and ICPs to collectively drive financial sustainability and improve productivity. As an ICS, we have agreed a set of principles for working together which include adopting a transparent, open-book approach to financial planning, in year reporting and a collective approach to financial risk management.

26. NHS organisations within our ICS are committed to working in collaboration to drive a system

response to the financial challenges we face and to take the necessary actions to achieve financial sustainability within the resources available. NHS organisations within our ICS have already committed to the delivery of the 19/20 ICS operational plan, which demonstrated full sign up to delivery of organisational control totals.

27. The ICS will also play a key role through relevant working groups, such as the ICS Finance

Leadership Group and Strategic Capital Working Groups, to provide guiding oversight and advice on ICS capital investment priorities and productivity and efficiency opportunities where this is appropriate to do so. This will include oversight of system level efficiency programmes informed by the Rightcare, Model Hospital and GIRFT programmes.

28. Working within our ICS, each ICP is now developing comprehensive 5 year financial plans in

support of the NHS Long Term Plan commitments to 2023/24. ICP plans, underpinned by common financial planning assumptions, but tailored to local priorities and circumstances will form the foundations upon which the overarching ICS system long term plan will be constructed.

29. Once plans are established, each ICP will need to engage in collective performance management

through open and transparent discussions, peer challenge and support. Local financial governance and accountability arrangements will be established within each ICP and principles associated with management of risk have been agreed. ICPs will take appropriate supportive

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action should individual organisations within the community be unable to deliver on agreed plans.

30. In the event that the ICP collective is unable to support delivery of agreed ICP plans, the ICS will

open discussions across the wider North East and North Cumbria NHS system to determine whether flexibility exists to offset deteriorating performance in one ICP against improving performance in another.

Conclusion 31. Through this Memorandum the NHS organisations in the North East and North Cumbria ICS

commit to - working together in partnership to realise our shared ambitions to improve the health of the

3.1 million people who live in our area - take a collaborative approach to improving population health, and to ensure the quality and

sustainability of their health and care services. Signed: Chief Executive …………………………………………………………………………….. Signed: Chair ……………………………………………………………………………. Date:

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Agenda item A7(ii)

TRUST BOARD

Date of meeting 26 September 2019

Title Chief Information Officer Report – Global Digital Exemplar (GDE) Update

Report of Graham King, Chief Information Officer

Prepared by Daniel Simms – Head of programme Delivery


☒ ☐ ☐


☐ ☒ ☐

Summary This report provides an update on key areas of progress across the infrastructure and GDE Programme deliverables.

Recommendations The Board of Directors is asked to receive and note the contents of the report.


Working in partnership to deliver fully integrated care and promoting healthy lifestyles to the people of Newcastle and beyond.Putting patients first and providing care of the highest standard focusing on safety and quality.Enhancing our reputation as one of the country’s top, first class teaching hospitals, promoting a culture of excellence in all that we do.





Legal

Financial X

Human Resources

Equality and Diversity

Engagement and communication

Sustainability

Impact

Operational efficiency and patient safety – yes.


Presentation to the Board of Directors at the Trust Board workshop held in July 2019.

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Agenda item A7(ii)

____________________________________________________________________________________________________Chief Information Officer Report – GDE UpdateTrust Board – 26th September 2019

CHIEF INFORMATION OFFICER UPDATE

1. INTRODUCTION

This report provides an update on key areas of progress for the Global Digital Exemplar (GDE) Programme. GDE programme – central funding. Delivery of regional “Great North Care Record” Health Information Exchange and

Patient Engagement Platform. Paperlite – progress to “go-live” 27th October 2019.

2. GDE PROGRAMME FUNDING

The programme continues, as a whole, to track to plan with all NHS Digital Funding Agreement Milestones having been met. The assurance documentation has been completed and a programme review has been undertaken by NHS Digital. The recommendation from this review is, for the full amount to be released however this is dependent upon final approval by the central programme. Confirmation is expected the first week in October.

The Trust is leading on two key regional initiatives to create the underpinning architecture and services to establish the Great North Care Record. Funding has been identified and secured for phase 1 build of the Patient Engagement Platform and the Health Information Exchange technology purchased.

3. PROGRAMME SUMMARY STATUS

The table below sets out the status of each project within the GDE Programme.Project Purpose StatusElectronic Document Management

Digital creation, signing and sending of Transfer of Care and Clinical documentation.

Complete

Digital Community Services

Configure digital platform for 32 community units.

Complete

Electronic Observations to 55 Adult Wards

Digital patient tracking boards and observations integrated to Cerner Electronic Patient Record (EPR)Additional components for:

- Paediatrics - Women’s Services

Complete

In progressComplete

Patient self-check in Trial of 6 kiosks to prove model for patient self-checking.

Complete

7 Day working Provide digital support for the 7-day working clinical standard.

Complete

Omnicell Drug Cabinets Digital drug cabinets to 14 high value areas – paused during winter period as planned.

Complete

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Agenda item A7(ii)


Project Purpose StatusDigital Image Store Provision of an “in patient” context capture

and view medical photography system integrated with Cerner EPR.

Complete

Enhanced EPR Uplift of clinical and nursing documentation to support paperlite processes:

• Medical• Nursing• Allied Health Professionals• Anaesthesia• Intensive Treatment Unit• Outpatient ordering• Patient Flow

October 19

Health Information Exchange

Regional sharing of Health and Care Records across the Integrated Care System (ICS) region.

Implementation

Patient Portal Multiple phase programme to enable multiple pathway digital services to patients.

Contract Award

2.1 Health Information Exchange

This initiative provides a capability for longitudinal record sharing for Direct Patient Care.Technical progress continues to track to meet a December 2019 go-live with functionality to replace the existing Medical Interoperability Gateway and connect the first Acute sites. Both Sunderland and Newcastle Foundation Trusts (FT) are in test with Northumberland Tyne and Wear FT having agreed the contract change with their system supplier to start work. There continues to be excellent regional engagement and collaboration.

2.2 Patient Portal / Engagement Platform

This initiative will create a single access point for patients to view and interact with their clinical record. The technology will be delivered in a series of phases starting with a web and app based service for patient to see all their appointments, clinical correspondence and record their preferences for the use of their data. The funding release has allowed contract signature with the selected supplier to proceed and the project to move forward.

2.3 Enhanced EPR paperlite Update

This section provides an update of progress towards implementation of the paperlite project scheduled for 27 October 2019.

2.3.1 System Quality - Test

Six cycles of functional testing have been executed to test the system functions as expected along with three cycles of User Acceptance Testing (UAT) to test that it meets the needs of the users. The diagram in Figure 1 describes an overview of the testing process.

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Agenda item A7(ii)


Figure 1

During each cycle the supplier has delivered fixes prioritised by an agreed severity rating. Severity ratings are decided based on formal criteria but can be summarised as Severity 1, 2 issues being critical issues that would prevent go live and Severity 5 being minor issues such as layout problems.

The programme is now in a period of weekly fix and test cycles to implement all change requests required for go live and severity 1 and 2 test issues. A full dress rehearsal of the ‘go live’ process will take place on Tuesday 8th October to test the technical and operational processes that will be followed during the weekend of transition to live operation.

A total of 888 defects have been raised during functional testing with only 44 remaining open of which 5 are considered material to the operation of the system. The 5 have been prioritised to be resolved prior to system implementation.

2.3.2 System Quality – Change Requests

During User Acceptance testing a number of changes have been raised to make adjustments to the system. These changes have been rated as Must, Should or Could changes to determine if they are required to be completed before go live. These priorities are assigned based on clinical risk and determined by the change board based on feedback from requestors.Based on the current resource and speed of delivery it is anticipated that all changes required for go live will be delivered by 27th September 19 ready for test.

2.3.3 Training

The programme has identified 11,324 members of staff that require training across clinical and non-clinical roles. Training progress is being measured daily and weekly reports of staff who have not booked onto required courses are being sent to Directorate Managers. As of 17th September 19, 78% of staff had booked onto the required training course.

Based on the current rate of bookings there still remains sufficient capacity to train staff. If bookings have not reached 90% by the end of September there will not be sufficient capacity to train to the ideal target, 95% of staff. Figure 4 shows the current training progress.

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Agenda item A7(ii)


Figure 4

Each attendee for training completes a feedback form and this is collated and reviewed daily. Feedback gathered has been used to improve courses, notably the clinician course, which now contains an overview of the process in outpatients and inpatients to assist understanding.

From the feedback received, 97% of attendees have stated that the training met their needs.

2.3.4 Access Devices

Additional hardware and upgrade requirements have been identified, working directly with clinical team leads. This work has been combined with the windows 10 project to prioritise the upgrade of computers in clinical areas to run windows 10. All hardware has been ordered with the majority delivered. The installation has focused on inpatient areas and as of 17th September 2019, 75% of inpatient wards at the RVI have been upgraded. It is planned to complete the installation of all equipment 2 weeks before go live.

3. RECOMMENDATION

The Board is requested to receive the report and note:

i) Progress of the paperlite Enhanced EPR and go-live date of 27th October.ii) The Trust’s engagement and leadership across the ICS digital landscape Report of Graham KingChief Information Officer26 September 2019

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Agenda item A8(i)

TRUST BOARD


Title Medical Director’s Report

Report of Andy Welch

Prepared by Andy Welch, Medical Director


☒ ☐ ☐


☐ ☒ ☐

Summary The report highlights issues the Medical Director wishes the Board to be made aware of.

Recommendations The Board of Directors is asked to note the contents.


Putting patients first and providing care of the highest standard focusing on safety and quality.Enhancing our reputation as one of the country’s top, first class teaching hospitals, promoting a culture of excellence in all that we do.


Putting patients first and providing care of the highest standard focussing on safety and quality.


Quality and Safety

Legal

Financial

Human Resources

Equality and Diversity

Engagement and communication

Sustainability

Impact

Quality and Safety considerations for CQC Well-Led Inspections.


This is a regular report to the Board. Previous similar reports have been submitted.

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Agenda item A8(i)

____________________________________________________________________________________________________Medical Director’s ReportTrust Board – 26th September 2019

MEDICAL DIRECTOR’S REPORTSEPTEMBER 2019

1. BREXIT PREPAREDNESS

Department of Health & Social Care (DH&SC) EU Exit Operational Readiness Guidance for a ‘no deal’ exit was received in December 2018. The Trust has undertaken planning as set out within that guidance:

Nominated a Senior Responsible Officer (SRO) for EU Exit Preparations - Medical Director.

Undertook risk assessment associated with EU Exit (January 2019). Continued business continuity planning (tested during Exercise Promethia, 20

February 2019). Convened EU Exit Planning Group, chaired by Trust SRO for EU Exit, attended by key

directorate leads that met bi-weekly until end March 2019, and has reconvened. Completed NHS England (NHSE) request for Strategic Assurance.

Since April 2019 and the announcement of the postponement of EU Exit until October 2019 the Trust has kept a watching brief over government level discussions around a possible “no deal” scenario. The state of readiness within the Trust has been maintained throughout this intervening period.

The Trust has attended/taken part in various EU Exit events/teleconferences during this intervening period to keep abreast of key areas:

The Trust EU Exit Planning Group has been reconvened and will meet fortnightly in the first instance. There has also been a national meeting to update Trusts.

1.1 Areas of Potential Concern

Parenteral Nutrition – there have been supply problems from Calea for some months due to manufacturing difficulties unrelated to the Brexit situation. It is possible that these may be exacerbated but currently the situation is controlled.

Insulin supplies – most insulin is manufactured in Europe. A supply problem is not envisaged but insulin from the USA is significantly more expensive. There are 12 weeks buffer stocks so no difficulties anticipated.

Directorates have been requested to ensure that business continuity plans are up to date.

There appear to be no significant procurement or supplies issues. Business Continuity team will continue to monitor latest operational guidance and

collaborate with Winter and EU Exit Teams. EU Nationals need to be educated around benefits of settlement scheme. Fuel – no significant expectation of any shortages. NHS and care Staff to get priority. If leave on no deal EU nationals visiting the UK will be chargeable for healthcare.

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Agenda item A8(i)


Flu vaccine supplies should be reliable with 80% of vaccine anticipated to be within UK by October.

Importance of effective Communications to staff.

2. RVI ROBOTICS

The RVI Da Vinci robot is now operational and will be used initially in Gynaecology, Upper GI and Lower GI cases. Access and training protocols have been established. The Trust commitment to robotic surgery, with well-established robotic facilities for Urology, Head and Neck and Thoracic Surgery at the Freeman Hospital, and associated training facilities, has ensured that this Trust is leading innovation in the robotic surgery field.

3. SUSTAINABILITY AND IMPROVEMENT GROUP (SIG)

The SIG Group continues to ensure progress towards achievement of the CIP target of £32m. To date, it is predicted that £26m will be achieved as full year effect with £16m in year. There are other initiatives under way, as yet not fully financially evaluated. A further workshop was recently successfully instituted at short notice to facilitate new innovative ideas.

4. HOSPITAL AQUIRED INFECTION

There have been no reported MRSA bacteraemias over the past 12 months. The incidence of MSSA also appears to be reducing significantly. Great credit is due to the Infection Control Team and Dr Lucia Pareja-Cebrian, AMD and Director of Infection Prevention and Control.

5. FATIGUE

An Association of Anaesthetists survey published in the scientific journal Anaesthesia reveals the extent and impact of fatigue on consultant anaesthetists and paediatric intensivists in the UK and Ireland.

A national survey of out-of-hours working and fatigue in 2,000 consultants in anaesthesia and paediatric intensive care in the United Kingdom and Ireland (2017) reveals that:

91% of consultant anaesthetists and paediatric intensivists experience work-related fatigue and 50% of them reported this had a moderate or severe negative impact on their health, wellbeing, work and home life.

45% of respondents admitted to either having a car accident or near miss when commuting when fatigued after a night shift.

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Agenda item A8(i)


Only a third (34%) said they have access to a private rest facility when on-call.Almost two thirds of respondents (62%) did not feel supported by their organisation to maintain their health and wellbeing.

In addition, only 15% always achieve 11 hours rest between finishing one shift and starting their next (the European Working Time Directive requires all doctors to have 11 hours of rest between clinical duties).

57% of trainee doctors had also experienced an accident or near miss when driving home after a night shift.

6. PROCTOR REQUIREMENTS FOR NEW PROCEDURES

A robot has been procured for use at the Royal Victoria Infirmary (RVI). The specialities involved will be Colorectal and Gynaecology in the first instance. This will facilitate more effective surgical access with reduced morbidity.

7. PAPERLITE

Paperlite is due to go live at the end of October. Preparation is well under way with all staff to undergo training before the go live date. Patient safety remains the overlying priority. Further detail is included within agenda item A7(ii).

8. RECOMMENDATION

The Board is asked to note the contents.

A R Welch FRCSMedical Director17th September 2019

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Agenda item A8(i)b

TRUST BOARD


Title Guardian of Safe Working Quarterly Report

Report of Dr Henrietta Dawson

Prepared by Dr Henrietta Dawson, Trust Guardian of Safe Working Hours


☒ ☐ ☐For Decision For Assurance For Information

Purpose of Report☐ ☐ ☒

Summary

The terms and conditions of service of the new junior doctor contract (2016) require the Guardian of Safe Working Hours to provide a quarterly report to the Trust Board to give assurance to the Board that the junior doctors’ hours are safe and compliant.The content of this report outlines the number and main causes of exception reports for the period 27th March to 26th June 2019.

Recommendations

The Board of Directors is asked to:(i) note the contents of this report.;(ii) confirm whether the information on rota gaps is required on a

quarterly basis; and(iii) agree that a suitable space be made available to make on call

room facilities available at the Freeman Hospital.


Maintaining compliance with all regulatory requirements Continue to recruit and retain the very best staff Deliver a first class patient experience




Impact

In order to maintain quality and safety, we must have a junior doctor workforce who can work within safe hours and receive excellent training.

Reports previously considered by Quarterly report of the Guardian of Safe Working Hours.

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Agenda item A8(i)(b)

____________________________________________________________________________________________________The Guardian of Safe Working Quarterly ReportTrust Board - 26th September 2019

THE GUARDIAN OF SAFE WORKING QUARTERLY REPORT

1. EXECUTIVE SUMMARY

This quarterly report to the Board covers the period 27th March to 26th June 2019.

There are now 488 trainees on the New Junior Doctor Contract (previously 499).

There were 47 exception reports in this period. This is a slight fall compared to last quarter. This quarter saw the first Guardian of Safe Working fines being imposed for breaches in hours worked. This is as a result of increased awareness in breaches of hours that incur a fine by junior doctors, and an increase in scrutiny of potential breaches highlighted by exception reports.

The main areas of exception reports are general medicine (RVI), general medicine (FRH) and general surgery (FRH).

The main cause of exception reports is when there is minimal staffing on the ward, and the workload is too heavy for the number of doctors allocated.

2. INTRODUCTION / BACKGROUND

The 2016 New Junior Doctor Contract came into effect on 3rd August 2016. Foundation year 1 (FY1) doctors commenced on the contract new Terms & Conditions (TCS) on 1st December 2016. The Trust has a ‘mixed economy’ of junior doctors as many still remain on 2002 contractual conditions. The 2016 Contract has recently been reviewed. The revised Terms and Conditions were published on 2nd September 2019.

The TCS on the new 2016 contract allows for exception reporting to raise reports on breaches of working hours and educational opportunities. These are ratified or rejected as appropriate by clinical supervisors and the process is overseen by the Guardian of Safe Working Hours.

Exception reports are reviewed to identify whether a breach has occurred which will be subject to a financial penalty (fine). Where such concerns are validated and shown to be correct in relation to: a. a breach of the 48-hour average working week (across the reference period agreed for that placement in the work schedule); or b. a breach of the maximum 72-hour limit in any seven days; or c. that the minimum 11 hours’ rest requirement between shifts has been reduced to fewer than eight hours; ord. breaks have been missed on at least 25% of occasions across a four week reference period the junior doctor will be paid for the additional hours at a penalty rate, and the Guardian of Safe Working Hours will levy a fine on the department employing the doctor for

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those additional hours worked. The money raised through fines must be used to benefit the education, training and working environment of trainees, and the allocation of funds decided through collaboration with the junior doctor forum.

The TCS require the Guardian of Safe Working Hours to provide a quarterly report to the Trust Board to give assurance to the Board that the junior doctors’ hours are safe and compliant.

This report is for the period 27th March to 26th June 2019.

3. HIGH LEVEL DATA (Q4 2018 data for comparison)

Number of Junior Doctors on New Contract 488 (499)Number of Exception reports 47 (68)Number of Exception reports for Hours Breaches 47 (68)Number of Exception reports for Educational Breaches 2 (1)Fines 3 (0)Number of Exception reports ‘Open’ / ‘Overdue’ 3/3 (5/4)Percentage of Exception reports agreed 98% (96%)

Admin Support for Role VariableJob Planned time for supervisors 0.125PA per trainee -

Variable

4. EXCEPTION REPORTS

4.1 Exception Report by Speciality (Top 5)

General Medicine 25General Surgery 12Renal Medicine 5Cardiology 3Accident and Emergency 1Otolaryngology 1

4.2 Exception Report by Rota (Top 5)

General Surgery F1 FRH 9General Medicine F1 RVI 8General Medicine CMT FRH 6COE/Gastro/Rheum CMT FRH 3COE/Gastro/Rheum F1 FRH 3

4.2 Exception Report by Grade

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Foundation Year 1 23CMT 24

4.3 Example Themes from Exception Reports

General Surgery (FRH F1 )This is a busy job, and when there are fewer people around to complete routine jobs, doctors end up staying late.

Medical staffing are currently reviewing the rotas and are in discussion with the department and junior doctors regarding a work schedule review.

General Medicine (RVI F1)When there are fewer doctors on the wards, and medical boarders to see on other wards the workload cannot always be completed in normal hours. This is exacerbated by the requirement to arrive and leave early on ‘handover days.’

The handover time has been changed so that doctors are no longer required to arrive early on these days.

General Medicine (FRH (various rotas))Excessive workload for the number of doctors available has been highlighted through exception reporting on certain wards. This is exacerbated by the requirement to complete discharge summaries in a timely manner. The consultants have been supportive.

Extra teaching fellows have been allocated to these wards from August 2019.

5. EXCEPTION REPORT OUTCOMES

5.1 Work Schedule Reviews

All work schedules are reviewed by medical staffing prior to commencement of new doctors commencing in post.

In addition, the general medicine work schedules have been reviewed to address issues highlighted through exception reports and fines. The general surgery work schedules are currently under review.

5.2 Fines

3 fines have been issued:1. General medicine F1 RVI: £980.61. Breach of 48 hour average working week.

This fine occurred in the previous quarter, but was only verified for reporting in this quarter.

2. General medicine F1 RVI: £463.17. Breach of 72 hour working in 7 days on 2 separate 7 day periods.

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3. General medicine F1 FRH: £241.08. Breach of 72 hour working in 7 days.

Actions TakenGeneral medicine work schedules have been reviewed to address potential breaches of the 72 hour rule.

The working pattern and workload on the ward where the 48 hour average working week breach occurred is being looked into by the clinical director, and has been discussed at departmental level. All exception reports arising from general medicine are being reviewed by the department on a monthly basis to address concerns early.

6. ISSUES ARISING

6.1 Workforce and Workload

The recurring theme as to when exception reports are raised is when there is a lack of trainees on the ward. Some wards have excessive workloads for the number of trainees allocated. When this is highlighted in exception reports, steps have been made to improve this.

6.2 Supervisor Engagement

Exception reports have in general been dealt with promptly, although not universally within the statutory 2 week time frame. Supervisor engagement is largely good. Where supervisors are not engaging this has been highlighted to their clinical director.

6.3 Administrative Support

The loss of both administrative supports has made this a challenging quarter. I am hopeful that this will improve with replacement personnel now settled in post, and the additional recent appointment of a further safe working administrator assistant.

7. ROTA GAPS

Specialties and rotas with gaps are outlined below. A full breakdown of rotas has been circulated privately to Trust Board members.

Site Specialty/Sub Specialty Grade Number required for

full complement

Vacancies as of June 2019

Neurosciences RVI Neurosurgery F2/ST1/ST2 6 1

Accident & Emergency Accident & Emergency F2 Missing data

RVI Accident & Emergency ACCS/CT1/ST1/ST2/ST3+ Missing data

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full complement


NCCC FH Oncology ST3+ 14 1 Haematology

FH Haematology ST3+ 9 2 Womens' Services

RVI Obstetrics & Gynaecology F2/ST1/ST2 12 1RVI Neonates ST3+ 8 1RVI Neonatal Transport ST3+ 4 1

Anaesthetics & Critical Care FH FH Anaesthetics – General and Cardiac CT1-2/ST3+ 26 1.2FH Critical Care F2/ST1-7 14 3 Anaesthetics & Critical Care RVI

RVI Anaesthetics ACCS/ST1-2/CT1-2/ST3+ 34 1RVI Critical Care (Ward 38) ST3+ 7 3.4RVI Critical Care (Ward 18) ST1/ST2 8 2.7RVI Critical Care (Ward 18) ST3+ 8 0.9

Plastic Surgery & Ophthalmology RVI Plastic Surgery F2/ST1/ST2 9 1RVI Plastic Surgery ST3+ 11 2

Chemical Pathology / Metabolic Medicine / Clinical Biochemistry

RVI Metabolic Medicine All grades 2 1 Cardiothoracic Services

FH Cardiothoracic Surgery F2/ST1/ST2 2 0.4FH Cardiothoracic Surgery ST3+ 4 2FH Cardiothoracic Anaesthesia ST3+ 14 1FH PICU ST3+ 9 1FH Paediatric Cardiology All grades 11 1FH Respiratory Medicine CMT/ST3+ 16 0.5 Musculoskeletal Services

FH Rheumatology CMT/ST1/ST2/ST3+ Missing Data General Surgery

FH General Surgery 2nd (CST) F2/ST1/ST2 Missing DataFH Vascular 1/6 ST3+ 7.5 3.5RVI General Surgery F2 Missing DataRVI General Surgery CT1-2/ST1ST2/ST3+ Missing Data

Childrens Services RVI Paediatrics 1st (now inc Paeds Surgery) F2/ST1/ST2 27 2.4RVI Paediatrics Surgery CST 2 1RVI Paediatric Oncology ST3+ 7.5 2RVI Paediatric ICU (PICU) ST3+ 8 3.4

Urology & Renal

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full complement


FH Renal Medicine ST3+ 8 4 General Internal Medicine

FH General Internal Medicine F2/GPVTS 8 3RVI Acute Medicine CMT 3 1RVI/FH General Internal Medicine – BOH & FOH F2/CMT 14 4RVI General Internal Medicine ST3+ 20 1FH Gastroenterology ST3+ Missing Data Foundation Year 1

FH General Internal Medicine - BOH F1 8 1

The data above has been included based on a previous feedback received from the Trust Board of Directors. The Board of Directors are asked to confirm whether the information on rota gaps is required on a quarterly basis.

7.1 Locum Spend

The total amount of internal locum spend is £511,006. No external agency locum spend.

8. RISKS AND MITIGATION

The main risk remains medical workforce coverage across a number of rotas. Many rotas are near the maximal safe working hours per week and when doctors are required to stay beyond their scheduled hours this can result in them exceeding their contractual safe working hours limit.

9 REVISION TO 2016 JUNIOR DOCTOR CONTRACT

The Junior Doctor contract has been revised, with the final draft being published on 2nd September 2019. It is likely that the revised contract will further reduce the hours spent by junior doctors on clinical tasks. The full impact of the revisions on working hours, rotas, pay and exception reporting is currently being assessed. The revised contract also increases the contractual requirements for hospitals to provide rest facilities and arrangements for safe travel to and from hospital, as well as on call facilities for non-resident doctors. Currently there are no on call facilities at the Freeman Hospital.

10. RECOMMENDATIONS

I recommend that we continue to be proactive at assessing the workforce/ workload balance, and continue to find local solutions to ensure that patient safety and excellent training are maintained.

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The lack of on call facilities, or an alternative solution for trainees at the Freeman Hospital must be rectified. Lack of suitable space is the main barrier to this. Estates have drafted potential plans, but these require vacation of offices which requires agreement. I recommend that approval of a suitable space to make on call room facilities available at the Freeman Hospital is agreed by the Board.

Report of Henrietta DawsonConsultant AnaesthetistTrust Guardian of Safe Working Hours12th July 2019

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TRUST BOARD

Date of meeting 26th September 2019Title Executive Chief NurseReport of Maurya Cushlow, Executive Chief NursePrepared by Elizabeth Harris, Deputy Chief Nurse




Summary

This paper has been prepared to inform the Board of Directors of key issues, challenges and information with regard to the Executive Chief Nurse areas of responsibility. The content of this report outlines:

Influenza campaign 2019/2020; Freedom to Speak Up Guardian (FTSUG); Nursing &Midwifery staffing; Patient Experience Q1; Patient Led Assessment of the Care Environment (PLACE); Safeguarding Q1; Band 5 forum; and Clinical Assurance Toolkit (CAT) summary.

RecommendationsThe Board of Directors is asked to:

i) Note and discuss the content of this report.ii) Note the actions taken.


Maintaining compliance with all regulatory requirements. Continue to recruit and retain the very best staff. Deliver a first class patient experience.



Working in partnership to deliver fully integrated care and promoting health lifestyles to the people of Newcastle and beyond.

Enhancing our reputation as one of the country’s top first class teaching hospitals, promoting a culture of excellence in all that we do.


Tick yes or no as appropriate Yes NoQuality and Safety Legal Financial Human Resources Equality and Diversity Engagement and communication Sustainability

Impact


The Executive Chief Nurse update is a regular detailed comprehensive paper bringing together a range of issues to the Trust Board.

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____________________________________________________________________________________________________Executive Chief Nurse ReportTrust Board – 26th September 2019

EXECUTIVE CHIEF NURSE UPDATE

1. INTRODUCTION/BACKGROUND

This paper aims to provide members of the Board of Directors with a summary of key issues, achievements and challenges within the Executive Chief Nurse portfolio of responsibility.

Last year 8,849 frontline staff were vaccinated out of a total of 11,982 which was a 74% uptake and an increase of 1,324 staff from the previous year’s campaign (8.5%). The Commissioning for Quality and Innovation (CQUIN) value for this year is £1million with an overall target uptake of 80% increasing the number of staff required to have vaccination by 763 to 9,585.

The Trust action planning process is tested and proven, and will benefit again this year from a very proactive leadership approach and direct involvement from the Executive Team. The weekly stand up meeting will be used to share progress and best practice and to challenge compliance and rates. Regular updates will also be provided to the Executive Team and Trust Board.

New for this year is a significant increase to time and clinic availability for the flu vaccine. Clinics will start at 07.30 and end at 17.00 each day at the Royal Victoria Infirmary (RVI) and Freeman Hospital (FH) sites as well as additional clinics at Regent Point. This year 4 weeks of ‘double' flu teams from 07.30-17.00 as well as peer vaccinators will launch the campaign. The weekend, evening and twilight clinics were well received last time and again will be in place but with increased numbers delivering vaccinations. There will also be a mobile flu team plan with addition of dedicated ‘flu Hotline’ for wards and departments to request a visit. In addition ‘Get a jab give a jab’ initiative will be in place again which was well received by staff and resulted in a donation of 11,500 tetanus vaccines last year through the World Health Organisation (WHO).

Public Health England are again recommending 2 types of flu vaccine this year, Quadrivalent and Trivalent with the latter recommended for individuals aged 65 and older. This is available from the Friday 11th October and will be delivered by booked appointment with Occupational Health or at a GP practice. The delay in availability for the Trivalent is due to national manufacturing issues outside of our control.

The Quadrivalent vaccine is available from Monday 23rd September 2019.

This change last year in guidance caused some challenge to the vaccination programme and accordingly changes have been made to this year’s programme. The Trust Patient Group

INFLUENZA CAMPAIGN (flu) 2019 – 2020Following a very successful staff influenza vaccine campaign in 2018/2019 we look forward to this year’s campaign launching Monday 23rd September 2019.

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Directive (PGD) now allows for administration of the quadrivalent vaccine to staff over 65 if they choose to take this option.

The Occupational Health Service (OHS) team are proactively contacting all staff aged 65 and over (approximately 200) to explain the options available in an attempt to improve communication and enhance both decision making and vaccination rates for this group of staff.

2. FREEDOM TO SPEAK UP GUARDIAN (FTSUG)

Since his appointment in January 2019, the Trust FTSUG has been working to actively promote this role and function. This work has resulted in an increase in the number of staff raising concerns. It should be highlighted that many of these concerns relate to historic issues which may have occurred up to 2 or 3 years previously, at a time when staff were less aware of support available.

During the period March – August 2019, 37 concerns were raised with the FTSUG which required intervention, equating to a 54% increase on the previous 6 month period. A further 42 concerns were raised which required only an initial conversation, support, advice or signposting to alternative, more appropriate service (an increase of 40%). Concerns were raised predominantly by admin and clerical staff; however, other staff groups including Senior Consultants, Managers, Scientists, Nurses, Radiologists and Domestic staff also raised concerns with the FTSUG. Many requested to remain anonymous throughout the process. The most common theme (85%) remains perceived bullying harassment or mismanagement of this issue.

The increase in activity reflects enhanced awareness of the FTSUG service across the workforce which was an obstacle to completing the ‘Freedom to Speak Up self-review tool’ published by NHS Improvement in May 2018. Since his appointment the FTSUG has actively worked to successfully address this gap and raise staff awareness of the role.

Regrettably, the current FTSUG has resigned from the position following his appointment to a senior operational management post within the Trust as this could have potentially hindered the relative independence of this role. The recruitment process for his replacement has begun and the current FTSUG will continue until his replacement has been appointed.

Despite such a short appointment, the FTSUG has made good progress raising awareness to support staff who may have concerns that they wish to discuss confidentially with someone independent of their own workplace. We anticipate this work will continue with his successor when appointed. It is recommended that the self-assessment should be undertaken by the new FTSUG on appointment to assess the status of the service and develop an action plan to address any outstanding development areas.

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The detailed FTSUG report is contained within the Board Reference Pack for consideration by Trust Board.

3. NURSING AND MIDWIFERY STAFFING

This is a regular Board review and analysis of staffing levels across the trust. This includes an update on recruitment, a summary of the revised spend analysis and progress towards safer staffing and clinical outcomes dashboard.

As previously reported, any ward demonstrating less than an 85% Registered Nurses (RN) day monthly fill rate is highlighted to the Executive Chief Nurse and summarised below for information.

In June 2019, 8 Wards reported a day RN fill rate of less than 85%, 11 in July 2019 and 18 in August 2019. The increase in August is due to the reduction in available bank staff and staff able to undertake overtime during the summer period. It is also noted that the vacancy rate is slightly higher as most of the new recruits are new registrants due to be deployed in September and October 2019.

The highest occurrence of fill rates below 85% was in Cancer Services and Medicine, and Older Peoples Medicine. The higher rate in Cancer Services is unusual due to a combination of maternity leave and awaiting new staff to be deployed into posts. Nearly all vacancies are filled but additional corporate support is being provided to the directorate in the short term. It is encouraging to note the recent improvement in the vacancy positon In Medicine and Older Peoples Medicine.

The following Wards were below 85% for all 3 months and the data cross-referenced with the Nursing Information Dashboard. Of note:

Ward June 2019

July 2019

August 2019

Nursing Information Dashboard

15 FRH (Older Peoples Medicine)

81.6% (CHPPD 6.3)

75.7% (CHPPD 5.9)

70% (CHPPD 6.1)

Ward reviewed at Staffing and Outcomes meeting. No concerns regarding Pressure Ulcer, Falls or IPC metrics. Responsive staff movements undertaken to support. Rostering KPI in-line with guidance. CHPPD maintained with reduced bed capacity. New staff starting in post in September 2019 and temporary staff moves undertaken in the short term.Recommendation – Ward under review by Associate Director of Nursing and Directorate team. Ward configuration currently under review to support additional staffing. Review of metrics at staffing and outcomes meeting on 16/09/19.

17 FRH(Older Peoples Medicine)

83.4% (CHPPD 6.1)

79.9% (CHPPD 6.2)

81.9%(CHPPD 5.8)

Although low fill rates are noted, the CHPPD continues to be maintained and match previous trends. No concerns regarding risk adjusted outcome measures and no concerns highlighted during review at Staffing and Outcomes meeting.

Recommendation - monitor outcome metrics and staffing. No concern regarding outcomes and no immediate response required.

41 RVI (Stroke Medicine)

74.2% (CHPPD 7.7)

74.7% (CHPPD 9.4)

71.0%(CHPPD 8.2)

Although fill rates remain low, CHPPD delivered to patients remains high and above national average. No concerns in relation to Falls, Pressure Ulcers, IPC indicators. Recommendation - monitor outcome metrics and staffing. No concern regarding outcomes and no immediate response above what is already in place.

AS RVI (Acute

74.2% (CHPPD

79.7% (CHPPD

81.1%(CHPPD

Recent recruitment has been successful and all established posts will be filled in September. Recent bed closures have been undertaken for estates

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Ward June 2019

July 2019

August 2019

Nursing Information Dashboard

Admissions) 7.7) 9.7) 9.0) work which is the reason for the high level of CHPPD despite the low fill rate. Recommendation - monitor outcome metrics and staffing. No concern regarding outcomes and no immediate response above what is already in place.

3.1 Trust Level Fill Rates

The Trust level fill rates for the previous 3 months are as follows:

Month RN day fill rate %

HCA Day fill rate %

RN Night fill rate %

HCA Night fill rate %

Trust fill rate %

Jun 2019 90.72% 102.44% 92.32% 112.01% 95.30%Jul 2019 92.29% 94.92% 93.12% 110.08% 94.74%Aug 2019 88.64% 93.09% 90.50% 105.52% 91.63%

The RN fill rates in August are broadly comparable to previous years, the monthly drop due to reasons previously highlighted.

The notable reduction in Healthcare Assistants (HCA) day and night fill rates is due to targeted work with wards regarding the utilisation of enhanced care, temporary staffing and the significant work undertaken to agree staffing numbers and demand templates. This has reduced the total trust fill rate but is actually an effective and efficient utilisation of the available workforce to meet patient need.

3.2 Recruitment and International Recruitment

There are currently 110wte Band 5 RN/Operation Department Practitioner (ODP)/Midwife vacancies in the Trust to be recruited. Work continues through social media campaigns and open days to improve this position and work toward filling all posts.

In addition to the figure above, there are currently 187wte external Band 5 who have been appointed, ie RN/ODP/students due to qualify currently in the recruitment process. The vast majority are due to be deployed in September and October 2019. Once deployed the Trust will be in an improved position to the same period last year.

There are currently 51wte Healthcare Assistants in the recruitment process with approximately 22wte residual posts to fill. Interviews are planned for October 2019 and it is expected that a large majority of these posts will be filled.

In August 2019, the Trust welcomed 9 International Nursing Recruits from the Philippines. The recruits are currently undertaking the Trust’s Objective Structured Clinical Examination (OSCE) preparation programme and are due to undertake the exam in the first week in October 2019.

At present, there are an additional 19 Filipino nursing recruits for deployment in October 2019 although we are awaiting final confirmation of numbers. It is expected that the recruits will undertake their OSCE prior to winter to maximise the winter workforce. All we be deployed as previously agreed in to Medicine/Older Peoples Medicine and theatre scrub vacancies.

The final 8 recruits will be deployed in February 2020. Three of the original cohort have failed to progress through the process.

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3.3 Nursing and Midwifery (N&M) spend and escalation

N&M staffing makes up a significant portion of the trusts pay spend. Whilst management responsibility and accountability sits at a directorate level, the Chief Nurse’s Team have the professional responsibility and indeed the expertise, to provide support, challenge and scrutiny of the directorate level safe staffing and spend position.

Managing, monitoring and assuring safe staffing is complex and detailed; patient safety is always the guiding principle. The advent of Safecare has offered the opportunity to review and reset all the nursing and midwifery staffing levels and budgets in the Trust; this has been successfully and collaboratively agreed with finance, Human Resources (HR) and the directorates. An ongoing monitoring process has been developed to identify if an over spend positon is a warranted or unwarranted variation and subsequently agreeing an action plan to recover where it is clinically safe to do so and maintain a high standard of patient care. This process is complementary to the trust’s financial escalation process and does not replace it.

In quarter 1, 5 directorates were asked to undertake an in-depth analysis using this process. All areas have had meetings with in line with the agreed process and agreed actions for implementation. The next Trust analysis will be after the close down of quarter 2 in October 2019. In the interim period, the Chief Nurse’s Team review monthly reports to map progress, variations in trends and the outputs of agreed actions.

3.4 Safer Staffing and Clinical Outcomes

As previously highlighted to the Board, the Chief Nurse’s Team are in the process of designing and implementing a monthly Safer Staffing and Nurse Sensitive Indicator dashboard. This is to replace the existing nursing information dashboard and will improve the process of highlighting wards of concern to proactively implement actions to reduce and mitigate risk. The dashboard has been created and the first phase of testing has been completed. Minor changes are required before further testing and full implementation. A visual representation of the data in the form of a heat map will be created to form part of the Chief Nurse’s report to Board moving forward. It is expected that the first view of this will be provided for review by the Board as part of the deep dive six monthly staffing report in November 2019.

A multi-professional group has been created and now meets on a monthly basis to review the dashboard and agree in-month actions. The first meeting of this group took place in August 2019 and will continue as the primary oversight and scrutiny group moving forward.

4. PATIENT EXPERIENCE QUARTER ONE (Q1)

The detailed Q1 patient experience report is contained within the Board Reference Pack for consideration by Trust Board.

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The Head of Patient Experience has been appointed substantively following a rigorous interview process. A service review is underway, supported by service improvement and workforce development, with the overall aim to improve efficiencies and quality in complaints management. The Trust has commissioned Moderngov to deliver bespoke complaint training to staff which will be initially targeted for directorate managers, clinical directors and matrons.

The Trust has received a total of 168 formal complaints in Q1, which is an increase on the 150 complaints logged in Q4. The Trust is receiving on average 56 new formal complaints per month, higher than the 45 per month average for the last full year.

The Trust received nine new referrals from the Parliamentary and Health Service Ombudsman (PHSO) during the first quarter compared to five in the same period last year. Four final reports have been received from the PHSO - one case was refused, two were not upheld and one was partially upheld.

The Trust continues to perform well in terms of the percentage of patients who would recommend the Trust to their family or friends if they needed similar care or treatment. Response rates continue to be a challenge in areas like the Emergency Department, Community Services, antenatal, postnatal and community services.

NHS England has been carrying out a review to improve some areas of the way in which the Family and Friends Test (FFT) works. This work started in June 2018 and was due to report the changes in April 2019. However, the findings were delayed and anticipated for publication September 2019; this will detail the changes for implementing the FFT from 1 April 2020.

The Care Quality Commission (CQC) results of the 2018 Adult Inpatient Survey were published in June 2019. 637 patients completed the survey which equated to a 53% response rate. The results were extremely positive, for example with ‘better than most trusts’ for 16 questions.

The next annual adult inpatient survey is due to take place in autumn 2019. The Trust has been approached by Ipsos Mori who is working with the CQC and agreed to participate in a pilot, to test a mixed method approach to the survey.

The results of the National Cancer Patient Experience Survey 2018 were published in September 2019. 1,176 patients completed the survey which equated to a 66% response rate.

In summary, our results show: The Trust results scored above the expected range than most trusts for 22 questions. The average rating of care overall was rated at 9.0 on a scale of zero (very poor) to 10

(very good).

5. PATIENT LED ASSESSMENT OF THE CARE ENVIRONMENT (PLACE)

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A new Team within NHS England and NHS Improvement undertook a review of the PLACE process. Following a number of pilots further recommended changes were implemented, which include new forms, questions and content. As a result of the review there is a delay in the 2019 PLACE assessments. Confirmation has now been received that the 2019 PLACE collection will open on Monday 16th September 2019 for a period of 10 weeks – closing on Friday 22nd November 2019.

A future update will be provided to the Trust Board in 2020 when the results become available.

6. SAFEGUARDING Quarter One (Q1)

This summary provides a Q1 update to inform the Board of Directors in relation to Safeguarding. Activity for Q1 evidences the following:

1299 “Cause for Concerns” (CFC) / referrals across the safeguarding teams; 197 Case discussions in the Multi-agency Safeguarding Hub by the Children’s Nurse

Advisors; 218 Deprivation of Liberty safeguards (DoLS) applications.

These figures capture the numerical activity of the team, although such a measure is unable to reflect the complexity of work, which in Q1 included involvement in Court of Protection Proceedings, a number of multidisciplinary team meetings to facilitate access to acute health care, ensuring the Mental Capacity Act (MCA) is incorporated into care and supporting children and young people who are at risk of criminal and sexual exploitation. The teams continue to provide support for Newcastle and out of area services users.

6.1 The Learning Disability Liaison Service

The Learning Disability Liaison service provides a lifelong service to individuals who have a Learning Disability and are accessing the acute health care services of the Trust. Review of the work of the team in 2018-2019 revealed that there are now 2766 electronic Learning Disability flags visible to Trust staff to prompt consideration of reasonable adjustments. The team also provided support and advice in relation to 1964 adults and children who have a Learning Disability, with 982 inpatient admissions within the last financial year.

6.2 Safeguarding Training

Safeguarding training remains a priority and is now incorporated at Trust Induction for all new staff as E-Learning. Safeguarding training is mandatory for all staff and allocated to roles as defined in the Training Needs Assessment (TNA). Training is provided in line with national requirements and objectives with additional bespoke safeguarding training on request. Ensuring Trust compliance with NHS England targets for Prevent training, both Basic Prevent Awareness Training (BPAT) and Workshop to raise Prevent Awareness (WRAP) continues to be a priority.

6.3 Changes to Legislation

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Changes to legislation nationally continue to shape practice from significant changes within the Mental Capacity Act (MCA) legislation to Learning from the Learning Disabilities Mortality Review (LeDer). The work of the safeguarding team continues to evolve in relation to case numbers and complexity, and with growing training expectations and the need for assurance; there are a number of risks they are working to mitigate.

The detailed Q1 safeguarding report is contained within the Board Reference Pack for consideration by Trust Board.

7. BAND 5 FORUM

Part of the commitment to defining and developing nursing@newcastle is to maximise frontline staff engagement opportunities. In August 2019, two forums were held specifically to engage with band 5 staff across the Trust. The invitations was for Band 5 nursing, midwifery and AHP staff, who make up more than 2,600 of our circa 5,000 workforce

The Forums were designed to ensure that as professional leads the senior nursing, midwifery and AHP team is connected and listening to staff, and of course to understand and capitalise the value of the band 5 roles and teams.

The events were informal with lively discussions and energy in the room. Focus group work centred upon 4 key questions:

In what ways can we engage Band 5 staff and what ideas do you have about this? How can we receive feedback from clinicians that represent the views of all? What would be helpful for you from us in terms of professional information and

leadership? We try very hard to work across professional boundaries delivering clinical care. Can

you think of any examples from your practice where this works really well?

The afternoon also included an overview, introduction and welcome from the Executive Chief Nurse and a group discussion about the 2020 strategy development to coincide with the ‘Year of the Nurse’. An evaluation questionnaire is being circulated to develop future communication and engagements and also to co-opt support for project and work streams.

8. CLINICAL ASSURANCE TOOLKIT (CAT)

This is a biannual review analysing trends in the results of the CAT survey and supports the Integrated Quality & Performance Report in which bi-monthly updates on CAT are given. CAT is a way for clinical staff to continuously self-assure standards of high quality care for patients and forms part of the overall Trust assurance.

The table below demonstrates the trends from the last 7 CAT reports and as can be seen, scores have been consistently above 91%. Staff Knowledge scores have remained above

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91% and the scores on Environmental Cleanliness continue to demonstrate high standards across the Trust. Formal Hand Hygiene Audits remain variable and are ongoing.

Less than 91%Between 91% and 97.9%98% or more

The scoring criteria are extremely rigorous, commensurate with the high standards in the Trust. Any area that has a red score (less than 91%) for the whole of the CAT or for Matrons cleanliness checks, over 2 consecutive sets of results will appear on the escalation report. Matrons are aware of their areas with lower scores and are encouraged to analyse results, act upon them and share with clinical teams. These numbers are very small and issues identified are acted upon immediately. Overall the small numbers of areas with lower scores gives reassurance that issues identified on CAT are being dealt with by the Directorates as they arise.

CAT has provided the Trust with a ward and department based audit tool owned by Clinical Leaders since 2011. The advent of electronic documentation will fundamentally change CAT and therefore the senior nursing team work plan this financial year includes an update and refresh of CAT. Future CAT reporting will be via the reviewed Quality Governance Structure and Patient Safety Committee.

Report of Maurya CushlowExecutive Chief Nurse18th September 2019

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____________________________________________________________________________________________________Maternity CNST Incentive Scheme Year 2 Report: Safety actions 1, 2 & 3Trust Board – 26th September 2019

TRUST BOARD


Title Maternity CNST Incentive Scheme Year 2 Report

Report of Angela O’Brien, Director of Quality and Effectiveness

Prepared by Jo Ledger, Head of Patient Safety and Louise Hall, Deputy Director of Quality & Safety


☒ ☐ ☐


☐ ☒ ☐

Summary

The NHS Resolution Clinical Negligence Scheme for Trusts (CNST) Maternity incentive scheme invites Trusts, in this Year 2 scheme, to provide evidence of their compliance using self-assessment against ten maternity safety actions. The scheme intends to reward those Trusts who have implemented all elements of the 10 Maternity Safety Actions.

The content of this report specifically addresses Maternity Safety Actions 1, 8 and 9 in order to report progress and ongoing compliance with the recommended standards and time-scales for these respective safety actions. The Trust is compliant with all other seven Maternity Safety Actions as outlined in previous reports.

The Board will receive further reports in November 2019 and January 2020 as required by the scheme.

Recommendations

The Board of Directors is asked to note the contents of this report and approve the self-assessment to date to enable the Trust to provide assurance that the required progress with the standards outlined in the ten maternity safety actions are being met.





Quality Strategy – Reducing avoidable harm.

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Tick yes or no as appropriate Yes NoQuality and Safety XLegal xFinancial XHuman Resources xEquality and Diversity xEngagement and communication xSustainability x

Impact

Failure to comply with the standards outlined could impact negatively on maternity safety, result in financial loss to the Trust from the incentive scheme and from potential claims.


This is the third report for Year 2 of this Maternity CNST incentive scheme.The first and second reports for Year 2 were presented to Board on 25th April and 27th June 2019 respectively.

Year 1 reports were previously presented to the Board for consideration on 26th April 2018 and 24th May 2018.

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____________________________________________________________________________________________________Maternity CNST Incentive Scheme Year 2 Report: Safety actions 1, 2 & 3Trust Board – 26th September 2019

MATERNITY CNST INCENTIVE SCHEME YEAR 2 REPORT: MATERNITY SAFETY ACTION COMPLIANCE

1. BACKGROUND TO CLINICAL NEGLIGENCE SCHEME FOR TRUSTS (CNST) MATERNITY INCENTIVE SCHEME – YEAR 2

Maternity safety is an important issue for Trusts nationally as obstetric claims represent the scheme’s biggest area of spend (£2,166.3 billion in 2017/18). Of the clinical negligence claims notified to NHS Resolution in 2017/18, obstetric claims represented 10% of the volume and 48% of the value.

NHS Resolution is operating a second year of the CNST maternity incentive scheme to continue to support the delivery of safer maternity care. The scheme incentivises ten maternity safety actions and invites acute trusts to provide evidence of their compliance against these.

The expectation by NHS Resolution is that implementation of these actions should improve Trusts’ performance on improving maternity safety and reduce incidents of harm that lead to clinical negligence claims.

This scheme intends to reward those Trusts who have implemented all elements of the 10 maternity safety actions by enabling trusts to recover the element of their contribution relating to the CNST incentive fund and by receiving a share of any unallocated funds. Failure to achieve compliance against the safety actions will result in the Trust not achieving the 10% reduction in maternity premium which NHS Resolution have identified.

The Trust was successful in Year 1 of this scheme in achieving all ten safety actions and was rewarded with £961,689 in recognition of achieving compliance with all 10 safety actions.

To be eligible for the incentive payment for this scheme, the Board must be satisfied there is comprehensive and robust evidence to demonstrate achievement of all of the standards outlined in each of the 10 safety actions.

The content of this report specifically addresses Maternity Safety Actions 1, 8 and 9 in order to report on progress and ongoing compliance with the standards and time-scales for these respective safety actions. The Trust is compliant with all other seven Maternity Safety Actions as outlined in previous reports.

A self-assessment was undertaken by the Women’s Services Directorate by reviewing the evidence available against all ten Maternity Safety Actions.

The Board will receive a further report for consideration in November 2019 and January 2020 as required by the scheme.

2. SAFETY ACTION 1: IS THE TRUST USING THE NATIONAL PERINATAL MORTALITY REVIEW TOOL (PMRT) TO REVIEW PERINATAL DEATHS TO THE REQUIRED STANDARD?

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____________________________________________________________________________________________________Maternity CNST Incentive Scheme Year 2 ReportTrust Board – 26th September 2019

The Trust currently produces a quarterly PMRT report; Quarter 3 data (01/10/2018 – 31/12/2018) and Quarter 4 data (01/01/2019 to 31/03/2019) were presented to the Board in April and June 2019 respectively. This report outlines data from PMRT Quarter 1 2019/20 (01/04/2019 - 30/06/2019).

The following standards are required to be compliant with Safety Action 1:

2.1 Standard A

A review of 95% of all deaths of babies suitable for review using the Perinatal Mortality Review Tool (PMRT) occurring from Wednesday 12 December 2018 have been started within four months of each death.

All deaths of babies in the Trust, who are suitable for review, are reviewed within four months of each death using the PMRT and this process pre-dates the date outlined in standard A (12/12/2018). This process is well underway, there are no concerns regarding ongoing compliance with this standard and cases either have a review in progress or a completed review. There is variation in PMRT data pulled month on month as this is dependent on the date of death of babies and the timing of Board report submission.

From 01/04/2019 - 30/06/2019 there were 12 baby deaths in the Trust (6 stillbirths & late fetal losses; 6 neonatal and post-neonatal deaths), see Board Reference Pack.

2.2 Standard B

At least 50% of all deaths of babies who were born and died in the Trust (including any home births where the baby died) from Wednesday 12 December 2018 will have been reviewed, by a multidisciplinary review team, with each review completed to the point that a draft report has been generated, within four months of each death.

We are confident in exceeding the 50% target outlined in this standard. The PMRT will only provide a completed (published) report after multidisciplinary case reviews have been fully completed. Where PMRT data set does not clearly generate accurate information, evidence of MDT involvement is available for each individual case review if needed.

There are likely to be challenges to achieving compliance with this standard in future submissions due to delays with completion of Post Mortems, which is outside the Trust’s control. This in turn leads to the subsequent delay in women being assigned their post-natal appointments.

2.3 Standard C

In 95% of all deaths of babies who were born and died in your Trust (including any home births where the baby died) from Wednesday 12 December 2018, the parents were told that a review of their baby’s death will take place and that their perspective and any concerns about their care and that of their baby have been sought.

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The Trust continues to be compliant with this standard. It is a routine part of the discussion with families after the death of a baby that a review will take place and their views are sought.

2.4 Standard D

Quarterly reports will be received by the Trust Board from 12th December 2018 until 15th August 2019 that include details of all deaths reviewed and consequent action plans.

We are confident of meeting this standard. The content of this report includes a summary of the deaths reported and reviewed for PMRT Quarter 1 2019/20. Two reviews have been completed in Quarter 1 and the reports published; these reviews have demonstrated the care was appropriate and consequent action plans were not required for any of these cases. The remaining cases are in draft and further information will be reported to the Board for consideration in November 2019 and January 2020 once completed.

3. SAFETY ACTION 8: CAN THE TRUST EVIDENCE THAT 90% OF EACH MATERNITY UNIT STAFF GROUP HAVE ATTENDED AN ‘IN-HOUSE MULTI-PROFESSIONAL MATERNITY EMERGENCIES TRAINING SESSION WITHIN THE LAST TRAINING YEAR?

The Trust has achieved the 90% target for each staff group as outlined in this standard. From training figures provided at the end of July 2019, all in house multi-professional staff groups have achieved 91 – 100% compliance with completion of emergency training sessions.

4. SAFETY ACTION 9: CAN THE TRUST DEMONSTRATE THAT THE SAFETY CHAMPIONS (OBSTETRICIAN AND MIDWIFE) ARE MEETING WITH BOARD LEVEL CHAMPIONS TO ESCALATE LOCALLY IDENTIFIED ISSUES?

The Trust is compliant with this safety action within the required deadline of 15/08/2109.

4.1 Standard A

The Executive Sponsor for the Maternal and Neonatal Health Safety Collaborative (MNHSC) is actively engaging with supporting quality and safety improvement activity within the trust and the Local Learning System (LLS).

The Trust remains compliant with this standard as outlined in the June paper to Board. The Director of Quality & Effectiveness is the Executive Sponsor and is fully engaged in quality improvement activities led by the Trust’s improvement Leads for the MNHSC and this pre-dates the date outlined in this standard (27/01/2019). The bi-monthly executive sponsor engagement meetings are used to escalate locally identified issue and minutes are available if needed. The Executive Sponsor has attended a National Learning Event on 20/06/2019 a Maternity National Learning Set on 19/07/2019 and will attend a local learning set on 27/09/2019.

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4.2 Standard B

The Board level safety champions have implemented a monthly feedback session for maternity and neonatal staff to raise concerns relating to relevant safety issues.

The Trust is compliant with this standard as was outlined in the June paper to Board. Staff feedback currently gathered in a number of ways; The Trust Executive Sponsor has actively engaged in monthly walkabouts to give staff the opportunity to raise any concerns.

4.3 Standard C

The Board level safety champions have taken steps to address named safety concerns and that progress with actioning these are visible to staff.

The Trust is compliant with the standard as outlined in the June 2019 paper to Board. A monthly ‘you said/we did’ framework is in-place to provide feedback to staff. The Trust has completed the Mat Neo SCORE survey and results are in progress currently, alongside other feedback mechanisms, for example Datix incident reviews, ‘Risky Business’ bulletins.

Progress with actions in relation to safety concerns raised by staff are visible to staff and this was outlined in the June 2019 paper to Board. The three key areas of concern raised by staff are summarised below:

Sub-optimal Neonatal Intensive Care Unit (NICU) environment and estate; this is regularly discussed by the Executive Team and the Trust Board with the knowledge that the current estate doesn’t meet current building standards. Four additional cots have recently been commissioned by NHSE and there is estates works underway to create space through reconfiguration and to improve the existing environment. Re-provision of the Maternity and Neonatal Unit is included within the Estates Strategy.

Sub-optimal Maternity Assessment Unit (MAU) environment; lack of space and assessment rooms available for the increasing volume and complexity of the activity undertaken in the unit. Specific concerns are raised by staff in regards to the impact on patient’s privacy and dignity. A business case has been completed to enable short term modification of MAU to provide space for triage and to improve patient privacy as well as patient flow.

Midwifery staffing & skill mix concerns; there is a flexible approach across the directorate to locate staff in order to maintain safe skill mix.

Maternity & Neonatal Health Safety Collaborative initiative:A quality improvement plan, as part of the Trust’s work with the Maternity and Neonatal Health Safety Collaborative, outlines the key aim of ensuring 90% of maternity and neonatal records show evidence of a Maternity Early Warning Scores (MEWS) or Neonatal Early Warning Scores (NEWTT) charts being effectively used by June 2020. See Board Reference Paper. The Improvement approach launched in July 2019 includes staff engagement and delivery of education and training (in partnership with the Healthcare Academy) in the importance of using the charts effectively and escalating abnormal observations. This quality improvement work includes PDSA testing from early August 2019.

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5.0 RECOMMENDATIONS

To (i) note the content of this report, (ii) comment accordingly and (iii) approve the self-assessment to date.

Report of Angela O’BrienDirector of Quality & Effectiveness17/09/2019

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TRUST BOARD


Title Healthcare Associated Infections (HCAI) DIPC Report

Report of Maurya Cushlow, Executive Chief Nurse

Prepared by

Dr Lucia Pareja-Cebrian, AMD, Director of Infection Prevention & Control (DIPC), Consultant MicrobiologistMrs Elizabeth Harris, Deputy Chief NurseMrs Lisa Guthrie, Associate Director of Nursing, Clinical StandardsMrs Angela Cobb, Matron Infection Prevention & Control (IPC)


☒ ☐ ☐


☐ ☒ ☐

Summary

This paper is the bi-monthly report on Infection Prevention & Control (IPC). It complements the monthly Integrated Quality & Performance Report, summarises the current IPC position within the Trust at the end of August 2019. Trend data can be found in Appendix 1 (HCAI Report and Scorecard August 2019), enclosed in the Board Reference Pack, which details the performance at the start of the Financial Year and against targets where applicable.

Recommendations The Board of Directors is asked to (i) receive the briefing, note and approve the content and (ii) comment accordingly.


To put patients and carers at the centre of all we do and to provide care of the highest standard in terms of both safety and quality.

To continue to be recognised as a first-class teaching hospital, counted amongst the top 10 in the country, which promotes a culture of excellence, in all that we do.


Regulation 12 Safe Care and Treatment, Regulation 15 Premises and Equipment, and Regulation 20 Duty of Candour.

Listed below are Infection Related Risks rated 15 or above currently on the Risk Register:2142 Acquisition of HCAI is a risk to patient safety2521 Critical Care facilities are inadequate. Fail to meet existing standards for CC2925 Directorate capacity and environment in Women’s Services3558 Vertical Busbar Risers (NVW)3079 PFI Estate – increased risk of legionella and pseudomonas due to TMVs and flexi connections3591 Non-compliant heating and ventilation systems (RVI)3592 Non-compliant heating and ventilation systems (FH)

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____________________________________________________________________________________________________Healthcare Associated Infections (HCAI) – DIPC ReportTrust Board – 26th September 2019

The key IPC risks are recorded on the Trust’s Risk Register. Each of these risks are monitored and were reviewed in July by the Infection Prevention & Control Committee (IPCC).


Quality and Safety √

Legal √

Financial √

Human Resources √

Equality and Diversity √

Engagement and communication √

Sustainability √

Impact

Failure to effectively control infections may lead to patient harm, litigation against the Trust and loss of reputation.There are no specific equality and diversity implications from this paper.


This is a bimonthly update to the Board on Healthcare Associated Infections (HCAI).

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HEALTHCARE ASSOCIATED INFECTIONS (HCAI) – DIRECTOR OF INFECTION PREVENTION & CONTROL (DIPC) REPORT

1. INTRODUCTION / BACKGROUND

This paper provides bimonthly assurance to the Trust Board regarding HCAI incidents. It is an exception report and identifies actions and learning. An overview of HCAI rates is covered in the Integrated Quality & Performance Report and trend data can be found in Appendix 1 entitled HCAI Report and Scorecard August 2019 (located within the Board Reference Pack).

2. KEY POINTS FOR JUNE/AUGUST 2019

2.1 C. difficile Infections

NHS Improvement (NHSI) has changed C. difficile reporting from 2019/20 therefore the reported figures will not be comparable to previous years. The change includes reporting Community Onset Hospital Acquired (COHA) cases. These are patients who have been discharged within the previous 4 weeks. Additionally the time for cases referred to as hospital associated has been reduced by one day. At the end of August 2019 an additional 7 cases were assigned to the Trust as a result of these changes, which have had minimal impact upon the Trust trajectory. Overall, C. difficile infections are below trajectory with 38 cases and a total of 16 cases have been successfully appealed.

2.2 MRSA / MSSA Bacteraemias

At the end of August 2019, there have been no MRSA bacteraemia cases attributed to the Trust for one year; this is a very significant achievement and testament to the hard work and effort of everyone’s effort and commitment to reduce HCAIs.

There has been a reduction in MSSA bacteraemia cases in-comparison to this time last year. An internal reduction target of 10% has been set which is below last year’s total number of cases and current position is 2 cases above this point. Root cause analysis (RCA) continues to identify intravenous devices as the main source of infection. Work is ongoing to promote effective device management by the Infection Prevention and Control Team (IPCT) and IV Nurse Specialist. Device audits are regularly discussed with Matrons to enable clinical areas to self-monitor practice with the aim of reducing device related infections and education continues. Octenisan audits continue to assure monitoring and ensure standards of practice are maintained.

2.3 Gram Negative Bacteraemias (E. coli, Klebsiella, Pseudomonas)

There has been a reduction in E. coli bacteraemia cases in-comparison to this time last year. An internal reduction of 10% has been set and current position is 2 above trajectory. There is ongoing work incorporated within the Antimicrobial (AMR) framework aiming to prevent the most common causes of bacteraemias which are urinary tract, gastrointestinal and line

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related.

2.4 Outbreaks and Periods of Increased Incidence (PIIs)

There has been 1 outbreak declared in June 2019 due to diarrhoea and vomiting, no organism was detected and there was a total of 9 lost bed days.

There has been an increased incidence of C. difficile within the Directorate of Cancer Services and Clinical Haematology. This has been investigated through Periods of Increased Incidence (PII) meetings and ribotyping of cases has not demonstrated cross-infection of patients. However, environmental contamination has been identified and deep clean of the clinical area has been performed.

2.5 Sepsis

Compliance to sepsis screening is monitored by national standards and included in the standard contract. This change has had an impact on the methodology used for auditing our compliance with sepsis screening, as per the figures below:

59%

0% 0% 0%

Q1 Q2 Q3 Q40%

20%40%60%80%

100%

% Inpatient compliance

The data that is now gathered brings us additional intelligence on the areas that we need to strengthen to improve compliance. Enhanced education sessions are being promoted to all directorates to raise awareness on early recognition of sepsis. In addition to this, September is Sepsis awareness month, providing an opportunity for further education sessions.

An electronic alerting process within eRecord is being piloted and rolled out to ensure patient safety. This will lead to the development of a deteriorating patient/sepsis dashboard to highlight and identify at risk patients.

77%

0% 0% 0%

Q1 Q2 Q3 Q40%

50%

100%

% ED compliance

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2.6 Antimicrobials (AMR)

Antimicrobial Stewardship describes the different measures in place to ensureantimicrobials are used only when needed, to lessen the risk of antimicrobial resistance.The main focus areas are:

Reduction of overall antibiotic use: the Trust is aiming to achieve at least a 1% reduction. Last year this was a Commissioning for Quality and Innovation (CQUIN) scheme and it is now part of the Standard Contract. By the end of Quarter 1 2019/20 the Trust achieved a reduction of 1.08% in overall use. Changes in guidelines, education and daily review of antibiotics lead by Microbiologists and ID physicians are the main drivers for this reduction.

Improvement of UTI diagnosis and treatment in over 65 years. This is a CQUIN and it requires adherence to Public Health England (PHE) guidance on management of UTI in this age group. This is achieved by UTI care pathways, catheter care improvements and antibiotic prescribing. The drivers are education to both medical and nursing staff. Infection Prevention and Control Nursing (IPCN) team, microbiologists and Infectious Diseases (ID) physicians are involved in this process. Our reductions of UTI related Ecoli bacteraemias is a testament that the process is achieving results, however, data gathering to demonstrate our improvements is challenging. In addition to this, our IPCN team and continence nurses provide education to nursing and care homes in the community, however, the impact of this is very limited with the current resources.

Antibiotic prophilaxis for Colorectal surgery for elective procedures (in >18s) should be a single dose and prescribed in accordance to local antibiotic guidelines. This is another element of the Antimicrobial CQUIN. This is being led by microbiologist, ID physicians and surgeons, and the main challenges remain resources to gather the data required by the commissioners.

Anti-Fungal Stewardship CQUIN goals - Reduce inappropriate use of systemic anti-fungal agents and prevent the development of resistance to antifungals through the development of anti-fungal stewardship teams.

AMR is currently a priority for the NHS and it is likely that in the future there will continueto be CQUINs linked to performance in this area. The value for the current Antimicrobial CQUIN is £1million.

2.7 Water Safety

Following recommendations from the latest audit by the independent Authorising Engineer, there has been a review of the water safety structure. The Trust Water Safety Group is changing its governance framework so the Trust level group is more policy/governance driven and the site meetings are more operational therefore the Terms of Reference and membership have been reviewed and the Trust Water Safety plan is undergoing a significant refresh and review.

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2.8 Ventilation

The Ventilation Safety Group continues to monitor any issues arising from ventilation systems. The current challenges continue to be the aging ventilation structure. The Theatre refurbishment plan will be key to resolve some of those operational issues; however, this will inevitably cause disruptions.

Report of Maurya CushlowExecutive Chief Nurse18th September 2019

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TRUST BOARD

Date of meeting 26 September 2019

Title Cardiothoracic services – Congenital Heart Disease (CHD) update

Report of Martin Wilson, Chief Operating Officer

Prepared by Rachel Lonsdale, Directorate Manager Cardiothoracic services


☒ ☐ ☐


☐ ☐ ☒

Summary

The purpose of this paper is to update the Board on recent developments within the Congenital Heart Disease (CHD) Service, including:

- recent peer review of the trust’s services; and- the award of £41.7million of capital funding for the co-location of

children’s cardiac services with the Great North Children’s Hospital.Recommendations The Board of Directors is asked to note the contents of this report.


Enhancing our reputation as one of the country’s top, first class teaching hospitals, promoting a culture of excellence in all that we do


Capacity and demand pressures could result in the trust not achieving quality and operational standards.



Legal X

Financial X

Human Resources X



Sustainability X

Impact


Regular updates on these issues have been provided to the Board and Executive Team.

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____________________________________________________________________________________________________Congenital Heart Disease UpdateTrust Board – 26th September 2019

CARDIOTHORACIC SERVICES - CONGENITAL HEART DISEASE UPDATE

1. CONGENITAL HEART DISEASE SERVICES

The Trust provides high quality complex adult and paediatric congenital heart disease services from the Freeman Hospital and also hosts the Northern Congenital Heart Disease Network. The Trust has a strong reputation for these services, albeit with lower volumes of surgical procedures than in some other centres in the UK.

The configuration and service specification for congenital heart disease services has been a topic of significant public and commissioner interest over recent years. In 2016 NHS England (NHSE) released updated Congenital Heart Disease (CHD) Standards which outlined service specifications for adult CHD, paediatric CHD, and overarching local CHD provider networks. Together these contain 236 individual service standards.

The key standards for Newcastle Hospitals are:

• Minimum annual surgical activity: minimum of 4 surgeons for a sustainable oncall system and each consultant to perform a minimum of 125 surgical procedures per year to total 500 per annum by 2021; and

• Co-location of paediatric CHD services with paediatric surgery, nephrology and gastroenterology services (which are all based in GNCH on the RVI site) by April 2019 to ensure the 30 minute call to bedside standard is met.

In May 2018 the Trust Board agreed a three phased approach to moving towards meeting these NHS England service standards:

• Phase 1: Enhance staffing levels in order to ensure that the 375 activity standard is met and all other specialist service specifications are met (other than co-location).

• Phase 2: Co-locate paediatric services with Great North Children’s Hospital (GNCH) at the RVI.

• Phase 3: Move the remainder of the Cardiothoracic Directorate (the understanding of the Directorate that this means both adult CHD and all other Cardiology and Respiratory services) to the RVI.

2. CONGENITAL HEART DISEASE PEER REVIEW

In May 2019, NHS England undertook a peer review at Newcastle Hospitals of 38 of the above 236 service standards, as part of a scheduled national programme of peer reviews.

The outcome of the Northern Congenital Heart Disease Network Review is as follows;

• No immediate concerns. Two serious concerns. A number of areas for improvement were also suggested and many areas of good practice recognised.

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The outcome of the Adult and Paediatric Review is as follows;

• No immediate concerns. Four serious concerns. A number of areas for improvement were also suggested and many areas of good practice recognised.

Action plans to respond to the feedback have been developed, reviewed by NHS England, and are currently being implemented. Progress will be monitored through the Trust’s Quality Committee, via commissioner contract review mechanisms and the next cycle of peer review visits.

3. PATIENT FEEDBACK

In 2017, NHS England (NHSE) commissioned the development of a condition-specific, patient experience survey for congenital heart services which enabled the views of adults with CHD, children with CHD and their parents/carers to be heard in a consistent way across all centres providing level 1 CHD services.

On the 1st August 2019, the Trust received the first annual report of the NHSE CHD Patient Experience Survey for 2018/19. The headlines for Newcastle Hospitals were that 85% of patients reported a propensity to recommend the inpatient elements of the service and 87% for the outpatient service.

The rating of the quality of care for the Newcastle Hospitals CHD team is 2 percentage points above the overall total.

4. CAPITAL FUNDING TO SUPPORT CO-LOCATION OF CHILDREN’S CARDIOTHORACIC SERVICES AT THE GREAT NORTH CHILDREN’S HOSPITAL

On the 2nd August, the Trust learned that it had been awarded £41.7million of capital by the Department of Health and Social Care to enable the above phase 2 transfer and co-location of paediatric cardiothoracic services, including congenital heart disease, at the Great North Children’s Hospital at the RVI. This is a very welcome development and in line with the Trust’s vision and strategy.

A Project Board has been established which will meet every 6 weeks to progress the design, build, clinical transitions, workforce and revenue plans. The Project Board will also coordinate work to support the delivery of phase 3 and any double running implications for any temporary period when children’s and adults cardiothoracic services are not co-located on a single site. The Trust will work closely with commissioners with regard the service standards.

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5. RECOMMENDATIONS

The Board of Directors is asked to note the contents of this report.

Martin Wilson Mr Andy WelchChief Operating Officer Medical Director 17th April 2019

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TRUST BOARD


Title Learning From Deaths

Report of Mr Andy Welch, Medical Director

Prepared by Mrs Clare Casson, Quality and Assurance Lead


☒ ☐ ☐


☐ ☐ ☒

Summary

The content of this report outlines the process in place to provide the Board with assurance that unexpected deaths, including those deaths with potentially modifiable factors are reviewed, and that mechanisms are in place to ensure lessons are learned and shared.

RecommendationsThe Board of Directors is asked to (i) receive the report and (ii) note the actions taken to further develop the mechanism for sharing learning across the Trust.


Putting patients first and providing care of the highest standard focusing on safety and quality• Put patients and carers first and plan services around them• Maintaining our ‘Outstanding’ CQC rating

Links to Strategy and Clinical Risks Not applicable


Quality and Safety √

Legal √

Financial √

Human Resources √

Equality and Diversity √

Engagement and communication √

Sustainability √

Impact

Provision of assurance that patient outcomes are reviewed and lessons learned to include deaths of people with learning disabilities.

Reports previously considered by This is a recurrent report, provided quarterly.

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____________________________________________________________________________________________________Learning From DeathsTrust Board - 26th September 2019

LEARNING FROM DEATHS

1. INTRODUCTION

The objective of this report is to provide the Board with assurance that there is a robust process in place to review unexpected deaths, as well as those deaths with potentially modifiable factors, and that mechanisms are in place to ensure lessons are learned and shared.

For the purpose of this paper ‘modifiable factors’ are defined as factors identified that may have contributed to the death and which by means of locally or nationally achievable interventions could be modified to reduce the risk of future deaths.

2. BACKGROUND

The Care Quality Commission (CQC) report ‘Learning, candour and accountability’ published in December 2016 detailed concerns about the way NHS trusts investigate and learn from deaths of people in their care, and the extent to which families of the bereaved are involved in the investigation process.

The guidance released in March 2017 by the National Quality Board (NQB) set clear expectations for how trusts should engage meaningfully and compassionately with bereaved families and carers at all stages of responding to a death, and described trust boards’ responsibilities for ensuring effective implementation of this guidance. The Trust implemented the Learning from Deaths (LFD) guidance by the September 2017 deadline and has the required framework in place to facilitate learning from deaths within the Trust.

The NQB report ‘Learning from deaths: Guidance for NHS trusts on working with bereaved families and carers’, published in July 2018 consolidated the existing guidance and provided perspectives from family members who have experienced bereavement within the NHS. This additional guidance set out how organisations should support and engage families after a loved one’s death in their care but has been written with the intention of being a resource which families can also refer to. This guidance aims to align with the CQC’s new approach to assessing the ‘well-led’ domain which includes assessing how trusts have implemented the guidance published in 2017 by using appropriate Key Lines of Enquiry.

The introduction of medical examiners from April 2019 aims to ensure that all deaths not investigated through the coronial process are subject to independent scrutiny, with transparency and an opportunity for the bereaved to raise concerns.

The review of the first year of implementation published in March 2019 outlines the need for trusts to remind themselves of the key drivers to improving learning from deaths, to build on progress made and accelerate the changes required in culture to encourage openness and honesty.

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The review noted that where there were examples of good practice trusts had built on existing strengths, such as having an open culture within which the guidance could be integrated. Strong governance processes such as review groups and systems for learning from deaths were also factors.

3. MORTALITY REVIEW DATABASE – DATA SUMMARY

Current Morbidity and Mortality (M&M) meetings provide a robust forum for multidisciplinary discussion of each death. The mortality review database was launched in June 2017 and has improved the ease at which lessons identified within M&M meetings can be shared between Directorates. The database captures all mortality reviews and centralises the findings in one place for all level 2 deaths.

Level 1: The reviewer reviews the cause of death and discusses with the certifying doctor.Level 2: In addition, the reviewer also considers documents and health records associated with the death.

Since January 2019 this has included learning from Paediatric Mortality reviews as the Children’s Services Directorate has commenced use of the database to record all child death reviews. In addition, the Learning Disability Team (LDT) also uses the database to record their investigations.

The National Learning Disabilities Mortality Review (LeDeR) Programme was established as a response to the recommendations from the Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD 2013). CIPOLD reported that people with learning disabilities are three times more likely to die from causes of death that could have been avoided with good quality healthcare. In the past 12 months 13 patients died who were identified as having a learning disability and had reviews undertaken for each case according to the LeDeR guidelines.

A summary of the data inputted for the past 12 months is shown below:

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In Q1, 447 deaths were recorded within the Trust and to date, out of the 447 deaths, 294 patients have received a level 2 mortality review. These figures will continue to change due to ongoing M&M meetings over the forthcoming months. The figures will continue to be monitored and modified accordingly.

Within the Trust whenever a patient with a learning disability dies the death is reviewed by the clinical team supported by the LDT; there is further in depth review at the Learning Disability Mortality Review Panel and the death is also entered onto the LeDeR database for review. A report is provided from the Learning Disability Specialist Nurse to each Mortality Surveillance Group and lessons shared via various methods including Clinical Risk Group and Patient Safety Briefings.

All mortality data including (Standardised Hospital-level Mortality Indicator) SHMI, (Hospital Standardised Mortality Ratio) HSMR and (Variable Life Adjustment Displays) VLADS will continue to be closely monitored.

4. OUTCOME OF CASE REVIEWS – HOGAN SCORE 5

The Hogan score (below) was produced following a retrospective case record review, of 1000 adult deaths at 10 randomly selected acute hospitals across England in 2009. Case notes were reviewed estimating the life expectancy on admission and identified problems in care contributing to death. The Hogan scale, ranging from 1 (definitely not preventable) to 6 (definitely preventable), was used to determine if deaths were potentially avoidable, taking into account a patient's overall condition at the time.

1 Definitely not preventable 2 Slight evidence for preventability3 Possibly preventable, but not very likely, less than 50-50 but close call

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4 Probably preventable more than 50-50 but close call5 Strong evidence of preventability6 Definitely preventable

A score of 5 suggests ‘strong evidence of preventability’ and an investigation is initiated to determine if a serious incident is to be reported. The outcomes of cases reviewed in Q1 are summarised below:

273

14 3 2 2 0

Score 1 Score 2 Score 3 Score 4 Score 5 Score 60

100

200

300

Review by HOGAN in Q1

All HOGAN data is presented to the Mortality Surveillance Group and any patient death graded HOGAN >4 is presented on an individual basis.

Two patients received a HOGAN score of 5 during Q1. Both patient deaths are currently undergoing a Serious Incident (SI) investigation.

5. KEY LEARNING POINTS

The NQB recommendations state that providers should have systems for deriving learning from reviews and investigations and act on this learning. Learning should be shared with other services where it is perceived this will benefit future patients. Following a death, information gathered using case record review or an investigation should be used to inform robust clinical governance processes. The findings should be considered with other information and data including complaints, clinical audit information, and patient safety incident reports and outcomes measures. This information resource can then inform the Trust’s wider strategic plans and safety priorities.

The learning points identified in the last quarter (Q1) following M&M reviews are detailed in Appendix 1, together with how this information has been shared and what action has been taken.

6. OUTCOME OF INVESTIGATIONS LINKED TO SERIOUS INCIDENTS (SIs)

All unexpected deaths, or deaths with possible modifiable factors, are routinely escalated as potential SI via the Trust incident reporting system (Datix). Deaths of this nature are subject to a detailed review facilitated by a Clinical Director and usually involve members of the

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Agenda item A8(iv)


clinical team directly involved in the patients care. The review process includes an analysis of the care provided and determines whether any modifiable factors contributed to the death. Key learning points are identified and action plans generated. A summary of outcomes of investigations linked to SIs is shown below:

During April - June 2019 there were 26 SI reported to Commissioners via the Strategic Executive Information System (STEIS).

Of these 26, there were three patient deaths which were subject to a SI investigation. Two investigations are now complete and one investigation is ongoing.

The incidents and learning from the three deaths are summarised below:

2019/2981 – Unexpected Death This death was not preventable. No specific actions or learning identified.

2019/10407 – Unexpected Death; surgical complication Re-enforced the need for vigilance during surgical procedures shared locally.

2019/11841 – Missed referral Investigation in progress.

Q4 Investigation updateFollowing on from the previous report submitted to the Board in April 2019 the incident investigations from Q4 are summarised with learning points below:

2019/2317 – Delay in acting upon abnormal CT findingsInvestigation in progress.

2019/2642 - Sepsis due to MSSA bacteraemia An effective system to include escalation times as part of the Trusts GDE electronic

observation system. Agreed trust-wide processes to provide clear guidance to staff on referral

processes, treatment plans and pathways for follow-up by specialist teams.

2019/4047 - Fall on hospital premises Further risk reduction strategies implemented to mitigate the risk of reoccurrence.

2019/5019 - Extension of intracerebral haemorrhage following over anticoagulation Agreed standardisation of monitoring protocols. Training for staff strengthened in relation to local protocols. Agreed standardised labelling for laboratory requests to improve ordering process.

2019/5264 Fall – Fractured Neck of Femur as a result of a fall Care as expected, no specific actions or learning identified in this case.

2019/6897 – MI following a potential delay in cardiac interventions

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Agenda item A8(iv)


Agreed local procedure thresholds and escalation processes to ensure standardised approach

7. RECOMMENDATIONS

To (i) receive the report and (ii) note the actions taken to further develop the mechanism for sharing learning across the Trust.

Report of Mr Andy Welch Medical Director17th September 2019

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Appendix 1. Learning points identified in Q1

Directorate Speciality Date of Review

Learning Point Action to be taken

NCCC Oncology 11/04/2019 Explore the impact of rescinding a DNACPR - and the impact of the manner in which it was rescinded.

Discuss with Care of Dying team and clinical colleagues involved - culminating in M+M discussion.

Cardiothoracic Cardiology 16/04/2019 Consider other methods of obtaining medical attention when patients with active DNACPR deteriorate. Arrest call risks receipt of unwanted interventions which can be unduly distressing.

Review cardiac arrest call record. Ensure ward staff are mindful of other means of communication e.g. 'fast bleep'.

Cardiothoracic Cardiology 19/06/2019 Consider the risks of delaying PCI in severe LVSD and choice of side of Impella insertion.

Review with Cardiologists.

Cardiothoracic Cardio surgery 26/04/2019 Regularly review DNACPR decisions when a patients clinical condition changes

Review with Clinicians.

Cardiothoracic Adult Congenital 05/04/2019 Patients with raised CRP, temperature and previous cardiac surgery should have further work-up including BC & Echo.

Create document to record additional work-up required for patients with raised CRP, temperature and previous cardiac surgery.

Medicine Gastroenterology - FH

27/06/2019 TIPS should be counted as a procedure and include the cause of liver disease.

Feedback to all Foundation clinicians.

Medicine Emergency Department

01/04/2019 POCUS - in cardiac arrest the RV is often dilated. Findings need to be considered in context of history and embolism considered.

Raise for discussion in M&M Meetings.

Peri-op & CC Critical Care - FH 24/04/2019 The CCORT and ICCU reviews were appraised to determine if earlier admission to level 2 was appropriate. On review of NEWS and staff accounts it was agreed that care and timing of admission to level 2 was appropriate.

None identified.

Peri-op & CC Critical Care - RVI 03/04/2019 Input from Saturday interventional radiology service may have been beneficial.

Refer to stroke/INR service.

Learning Disability Team

Learning Disability 09/04/2019 Improve the quality of assessment documentation regarding the needs of patients with learning disability. Improve personalised care planning and recording of reasonable adjustments (particularly relating to nursing care on the wards).

Education and training to continue. Feedback from LeDeR Mortality Reviews to be shared with wards and departments and be included in the Safeguarding Communication Forums. Feedback to Trust Mortality Surveillance Group.

Children’s Services

Children’s Services 03/06/2019 Delivery in the local hospital and ex-utero transfer would have been preferable.

Feedback to North Tees. (Action completed).

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Children’s Services 03/04/2019 Ensure appropriate surgical representation at case review meetings.

Continue inviting surgical representation or request surgeons review cases outside the meeting and provide their findings for discussion.


Children’s Services 03/04/2019 Ensure clinicians can be identified in medical notes via appropriate record keeping.

All clinical notes should include signature, printed name, grade and GMC no. This will be raised via the Briefing in a minute process.


Children’s Services 26/06/2019 Where there has been a decision to give antibiotics these should be administered within an hour of the decision being made to prescribe.

1. Raise the importance of prompt antibiotic administration via department briefing in a minute process. 2. Posters within the department raising the awareness of the above need for prompt antibiotic admin. 3. Integrate antibiotic administration teaching. 4. Ensure that at morning handover (08.30) time critical jobs are handed over and are not left until after the ward round.


Children’s Services 05/05/2019 Placentas should be sent for histology following delivery of any unexpectedly unwell new-born infant.

Raise at Network board meeting and continue to reiterate on regional stabilisation course.


Children’s Services 29/04/2019 Where a decision is made to take a blood culture the rationale behind this and the treatment decisions should be documented.

Use briefing in a minute to disseminate to trainees the need to document rationale for taking a culture and subsequent treatment decisions.

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Integrated Board ReportQuality, Performance, People and Finance

September 2019

Agenda item A9

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Purpose

• This report provides an integrated overview of the Trust’s position across the domains of quality and performance, people and finance, in order that the Board can be appropriately assured that the organisation is, and will continue to be, an outstanding healthcare provider.

Format

• An executive summary of the position to the end of August 2019 is set out below. On the following pages are detailed sections covering each domain of quality and performance, people and finance.

Executive summary

• Staff across the Trust are working very hard to ensure the continued provision of high quality services in a context of increasing demand and capacity shortfalls for some clinical staff groups;

• At the end of August 2019, there have been no MRSA bacteraemia cases attributed to the Trust for one year, this is a significant achievement for the Trust;

• To the end of August, C. difficile infections are below Trust trajectory with a total of 38 cases, 16 cases have been successfully appealed;

• The Trust achieved the 95% A&E 4hr standard in August 2019, at 95.3% - the YTD achievement is 94.88% (11/09/19);

• The Trust failed to achieve the 92% 18 week standard for the second time in a row in August (90.6%) and has a total waiting list of 77,104, which is above the end of year trajectory of 72,960, and nearly 2,000 patients higher than last month’s reported waiting list. Performance continues to decline across a number of specialties, with 5 specialties below 92% during August;

• The Trust did not meet the 99% 6 week diagnostic standard in August for the ninth consecutive month at 95.2%;

• The Trust did not meet 7 of the 8 Cancer standards in July 2019; the Two Week Wait (2ww), Breast Symptomatic, 31 day first treatment, 31 day subsequent treatment (Drug), 31 day subsequent treatment (Surgery), 62 day Urgent and 62 day screening cancer standards; the 31 day subsequent treatment (Radiotherapy) cancer standard was the only standard achieved in July 2019.

Integrated Quality and Performance Report

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Contents: September 2019

Quality & Performance

People

Finance

• Healthcare Associated Infections• Harm Free Care• Incident Reporting• Serious Incidents & Never Events• Serious Incident Lessons Learned• Mortality• Friends and Family Test and Complaints• Health and Safety

• Monthly Performance Dashboard• A&E Access and Performance• Delayed Transfers of Care and Stranded Patients• 18 Weeks Referral to Treatment• Diagnostic Waits• Cancer Performance• Other Performance Standards

• Health and Wellbeing• Sustainable Workforce Planning

• Excellence in Training and Education

• Overall Financial Position• Financial Risk Rating

• Key issues

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Quality and Performance: Healthcare Associated InfectionsAt the end of August 2019, there have been no MRSA bacteraemia cases attributed to the Trust for one year; this is a significantachievement for the Trust.There has been an overall reduction in MSSA and E. coli bacteraemia cases in comparison to the same period last year.To the end of August C. difficile infections are below Trust trajectory with a total of 38 cases and a total of 16 cases have been successfully appealed.

0

10

20

30

40

MSSA per 100,000 bed days

-2

-1

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1

2

3MRSA per 100,000 bed days

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20

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40

C. difficile per 100,000 bed days

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40

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60E. coli per 100,000 bed days

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20

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40Klebsiella per 100,000 bed days

-5

0

5

10

15

20Pseudomonas per 100,000 bed days

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Quality and Performance: Harm Free CareThe Trust is currently demonstrating statistically significant reduction in Trust acquired pressure ulcers. There is a downward trend in incident and rate of Trust acquired pressure ulcers shown since February 2019 and a significant reduction shown between May and August 2019. This can be attributed to the work led by the Tissue Viability Team and Clinical Improvement Lead alongside ward teams to ensure improvement methodology is being used to drive change. There have been some excellent examples of reduction in pressure ulcers using Plan-Do-Study-Act cycles. The challenge now will be to sustain these improvements through the challenging Winter months.

In relation to inpatient falls, there was a statistically significant reduction in incidents between July and December 2018, however this has not been sustained this year. In June to August 2019 there has been a downward trend in incidents and rate of falls and currently this year the Trust have reported less falls resulting in serious harm than for the same period last year (currently 30% less than April to August 2018/19).

The incidents and rates of falls and PU are monitored closely and any serious incidents undergo a robust Root Cause Analysis (RCA) process which assists in the identification of quality improvement work streams which to date have been successful.

0

50

100

150Inpatient Acquired Pressure Ulcers

Pressure ulcers 18mth Ave. -2SD +2SD

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300

All Patient Falls

Falls 18mth Ave. -2SD +2SD

3

4

5

6

7Patient Falls per 1000 Bed Days

Falls per 1000 bed days 18mth Ave.-2 SD + 2SDTrust target National Target

0.0

0.5

1.0

1.5

2.0

2.5Pressure Ulcers per 1000 Bed Days

Pressure ulcers per 1000 bed days 18mth Ave. -2 SD + 2SD

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Quality and Performance: Incident Reporting

The percentage of incidents that resulted in severe harm or death reported in August 2019 is 0.4%. Nationally we report fewer incidents that result in severe harm or death than other similar providers.

This data is subject to change in future reports as severity grading is modified following investigation.

100011001200130014001500160017001800

Total Patient Incidents

Patient Incidents 18mth Ave. -2SD +2SD

25

30

35

40

Patient Incidents per 1000 Bed Days

Patient Incidents by 1000 Bed Days 18mth Ave. -2SD +2SD

0.0

0.1

0.2

0.3

0.4

0.5

0.6

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

% of Patient Safety Incidents Resulting in Severe Harm or Death

18/19 19/20

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Quality and Performance: Serious Incidents & Never EventsDuty of Candour (DoC) applies to patient safety incidents that occur when providing care and treatment that results in moderate harm, severeharm or death. It is a statutory requirement for the Trust to be open and transparent ensuring that patients/their families are informed about patient safety incidents that affect them, receive appropriate apologies, are kept informed of investigations and are supported to deal with the consequences.

In August there were 11 cases reported as Serious Incidents (SIs). The Duty of Candour (DoC) process has been initiated in all but one case to date.(An additional Pressure Ulcer case was initially reported as an SI in August but was subsequently de-registered as had been incorrectly graded).

GeneralOne delayed treatment - DoC to be initiatedTwo delayed diagnosis - DoC in progressOne **'Each Baby Counts' reportable case - DoC in progressOne incorrect pathology request - DoC in progressSix Pressure Ulcers ; four grade III & two grade IV - DoC in progress in five cases; clarifying next of kin details in one case.

** Incidents involving babies are reported as SIs in line with the agreement of a regional 'trigger list' within the Northern Maternity Clinical Networkgroup. This agreement is that all cases reported to the Royal College of Obstetrics & Gynaecology (RCOG) as fulfilling the criteria for the ‘Each Baby Counts’ national quality-improvement initiative should (by default) be notified as Serious Incidents. Since April 2019 all **'Each Baby Counts' reportable cases are now externally investigated by the Healthcare Safety Investigation Branch (HSIB) as part of their national programme. DoC is initiated by the Trust in conjunction with the HSIB for these cases.The trigger list includes the following:All babies at 37+0 weeks onwards withIntrapartum stillbirthEarly neonatal death (i.e. at days 0-6 from any cause other than congenital anomalies)Severe brain injury diagnosed in the first 7 days of life, when the babyWas diagnosed with grade III HIE, or was therapeutically cooledHas decreased ventral tone AND was comatose AND had seizures of any kind

0

5

10

15

20

25

Number of Serious Incidents Reported

Serious Incidents 18mth Ave. -2SD +2SD

0

1

0

2

1 1

0 0 0

1

0 00 0 0 0 00

1

2

3

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

Total Number of Never Events Reported

18/19 19/20

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Learning from SIs & NEs (April 2019 - June 2019)The following outlines key learning from completed SI investigations to date; any outstanding learning from Quarter 1 will be shared once investigationshave been completed. This data excludes information on falls, pressure ulcers and cases subsequently de-registered.

Complication of treatmentThere was no specific recommendations or learning identified.

Security incident effecting service deliveryReview of locking devices to ensure effective security is optimised.Local processes for senior on-call escalation have been strengthened.

Incorrect diagnosisLocal operating procedures and process checks strengthened to ensure optimum accuracy of reporting.

Unexpected deathCare was as expected, there were no specific recommendations or learning identified.

Unexpected death – surgical complicationRe-enforced need for vigilance during surgical procedures shared locally.

Learning from SIs & NE (January 2019 - March 2019)The following outlines the key learning from the SI investigations which were incomplete at the time of the July 2019 report.

Delayed diagnosisLocal processes strengthened to ensure more robust handover for patient transfers between organisations. An effective system to coordinate on-going surveillance to be developed as part of Trust-wide GDE development work.

Delay in follow-upStandard local processes for onward referral of patients have been strengthened.Delivery of additional staff training to re-inforce importance of safeguarding escalation of concern.

Delayed treatmentAgreed local procedures in place for standardised monitoring and escalation of concern.

Baby born in unexpected poor conditionCare was as expected, there were no specific recommendations or learning identified.

Complication of treatmentAwareness of the need for vigilance when using essential surgical devices, raised locally and nationally.

Complication of treatmentRe-enforced the standards for informed consent conversations.

Lost to follow-upAgreed standardised processes to strengthen the monitoring of patient surveillance.

Quality and Performance: Serious Incident Lessons Learned

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Quality and Performance: Mortality IndicatorsIn-hospital Deaths: In total there were 145 deaths reported in August 19 which is higher than the amount of deaths reported 12 months previously (n=128).Learning from Deaths: In August 2019, 145 deaths were recorded within the Trust and to date, out of the 145 deaths 14 patients have received a level 2 mortality review. These figures will continue to rise due to ongoing Mortality & Morbidity (M&M) meetings over the forthcoming months. The figures will continue to be monitored and modified accordingly.SHMI: The most recent published SHMI data shows the Trust has scored 96 from months April 18 - March 19, this continues to be lower than the national average and is within the "as expected" category.HSMR: The HSMR data shows a 12 month rolling HSMR score by quarter as well as monthly data. All scores are within expected limits, however, this number may rise slightly as the percentage of discharges coded increases.

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In-Hospital Deaths

In-hospital Deaths 18m Ave. -2 SD +2 SD

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40%

60%

80%

100%

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2

3

4

Learning from Deaths

Deaths with identified learning disability Deaths considered potentially avoidable

% Deaths reviewed

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80

100

120Monthly SHMI

SHMI 18m Ave -2SD +2SD National Average

60

80

100

120Monthly HSMR

HSMR 18m Ave -2SD +2SD National Average

80

100

120Quartlery HSMR

HSMR 18m Ave. -2SD +2SD National Average

85

95

105Quartlery SHMI

SHMI Average -2SD +2SD National Average

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Quality and Performance: FFT and Complaints

97% (96%) 1% (2%)

91% (86%) 7% (7%)

95% (94%) 2% (3%)

95% (95%) 0% (2%)

99% (97%) 0% (1%)

Friends and Family Test

There were 3,926 responses to the Friends and Family Test in June 2019.

The figures opposite show the proportion of people that would recommend or not recommend these services to a friend or family member if they needed similar care or treatment.

National results are shown in brackets.

Complaints

The Trust received a total of 168 formal complaints in Quarter One, which is quite an increase on the 150 complaints logged in Quarter 4. The Trust is receiving on average 56 new formal complaints per month, which is considerably higher than the 45 per month average for the last full year. This averages at approximately 14 complaints per week and is higher than last year’s figures, at just over 10 per week.

Taking into consideration the number of patients seen, the highest percentages of patients complaining up to the month of June are within Children’s Services with 0.06% (6 per 10,000 contacts) and the lowest is the Dental Hospital with 0.01%.

‘All aspects of clinical treatment’ remains the highest subject area of complaints at 56% of all the subjects Trust wide. ‘Communication’ and ‘Attitude of staff’ combined make the next largest subject area.

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Quality and Performance: Health and SafetyOverviewThere are currently 1087 health and safety incidents recorded on the Datix system from the 31st Aug 2018 to 1st Sept 2019, this represents an overall rate per 1000 staff of 72.8. Patient Services reported the highest number of health and safety incidents over this period (162) with Corporate Services (1) incidents. Directorate rates per 1000 staff for the highest reporting services are Dental Services (118.1), Peri-operative and Critical Care (96), Women's Services (91.1), Pharmacy (88), Directorate of Medicine (84.9) and Surgical Services (81).

Incidents of Aggression on StaffIn addition to the health and safety incidents, there are 668 incidents of physical and verbal aggression against staff by patients, visitors or relatives recorded on the Datix system from the 31st Aug 2018 to 1st Sept 2019; this represents an overall rate per 1000 staff of 44.7. Directorate rates per 1000 staff over this period for the highest reporting services of aggressive behaviour are Directorate of Medicine (183.5), Community (102.4), Musculoskeletal Services (85.5), Urology/Renal Services (81.8) and Neuroscience (81.1).

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30

40

50

Needlestick Injury or Sharps Incident

Needlestick injury or Sharps incident 12mth Ave. -2SD +2SD

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20

30

Slips, Trips and Falls

Slips, Trips, Falls 12mth Ave. -2SD +2SD

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2

3

4

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RIDDOR

RIDDORS 12mth Ave. -2SD +2SD

Sharps IncidentsThe average number of all sharps injuries monthly is 30.5 between Aug 18 and Aug 19 based on Datix reporting, with 13.3% of the reports relating to clean or non-medical sharps incidents. The average number of dirty sharps incidents over the period is 25.2.

Slips, Trips and FallsSlips on wet surface, fall on level ground and tripped over an object collectively account for 51.3 of falls between Aug 18 and Aug 19. Fall as a result of a faint, fit or other similar event, collision with an object and falls from a chair account for 17.2 of the incidents recorded. 19.3 % of the falls reported over the period relate to visitors/members of the public.

RIDDORThe most common reasons for reporting accidents and incidents to the HSE between Aug 18 and Aug 19 include slips and falls (7) and lifting and handling (2). These account for 39.1% of reportable accidents over the period.

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Quality and Performance: Monthly Performance Dashboard

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Quality and Performance: A&E Access and Performance• A&E performance in August 2019 was 95.3%, meaning the Trust met the monthly A&E 4hr standard. The month saw the lowest number of

monthly attendances in either 2018/19 or 2019/20 so far. The target was achieved despite staffing shortages which have contributed to a high number of closed beds since April, however this was partly counteracted by 0 bed days in the entire month being lost due to outbreaks.

• NuTH’s performance for August 2019 put it 5th in the whole of England out of 119 Trusts (NHSE August data excludes the 14 Trusts piloting the new A&E metrics). Despite the Trust achieving the 4hr target in August, September’s performance is currently 94.73% with an average of 32 breaches per day (as at 9th September), meaning the Trust can only have an average of 24 breaches per day to ensure it meets the 95% standard in September. This demonstrates that the sustainability of achieving the 4hr target remains fragile despite the success seen during 2018/19 and 2019/20 to date. Planning for winter is currently underway.

• Type 1 attendances at NuTH were significantly lower in August than in the first 7 months of 2019, however this seasonal drop corresponds with trends over the past few years, which show that Type 1 attendances are usually low in August. Overall in year A&E activity has seen a reduction of 3.11% against the same period last year (equating to circa 20 fewer patients per day). This overall drop is despite Type 1 and Type 2 attendances being higher than in 2018/19. The main driver for the overall decline is the large drop in the number of walk in centre attendances, with a significant proportion of this being seen at Ponteland Road. The 23.8% reduction in attendances is likely to be linked to the GP extended access initiative which began offering pre-bookable appointments in October 2018, and since April 2019 has offered over 100 pre-bookable appointments per day across all 3 sites.

• The Trust received 14 ambulance diverts during August 2019, with the majority of these diverts having NSECH or QE Gateshead as their original destinations. This places significant additional operational pressure on the Trust, which has already received more diverts in 2019/20 to date (65) than in the whole of 2018/19 (63).

• Due to NEAS still having difficulties with their information systems, no Trust has received ambulance arrival and handover figures since 1st April 2019.

91%

92%

93%

94%

95%

96%

97%A&E Performance Trend

2018/19 2019/20 Target

A&E ServiceApr – Aug

2018Apr – Aug

2019Percentage

VarianceVolume Variance

RVI Emergency Department 49,553 50,645 2.20% 1,092

GP Streaming 5,846 6,737 15.24% 891

Molineux Walk-in Centre 13,197 11,279 -14.53% -1,918

Westgate Rd Walk-in Centre 8,619 8,688 0.80% 69

Ponteland Rd Walk-in Centre 13,397 10,209 -23.80% -3,188

Eye Casualty 9,386 9,427 0.44% 41

Total 99,998 96,985 -3.11% -3,013

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Quality and Performance: Delayed Transfers of Care and Stranded Patients

• The number of bed days delayed due to Delayed Transfers of Care (DTOCs) increased significantly in August to 972, the highest level in the past 12 months. This was a particular contrast to the preceding 2 low months, with August showing a 64% increase on the number of bed days delayed in July.

• Over half of the delayed discharges were within Medicine and this corresponds with the number of discharges within the directorate falling during the second half of August. Factors which contributed to the increase in DTOCs include difficulties with NEAS capacity and greater identification of DTOCs due to an ongoing audit of patients with Length of Stay (LOS) of 21 days.

• Overall the 2019/20 YTD position has seen a reduction on previous years, with the first 5 months seeing 3,327 bed days delayed due to DTOCs – a 22% reduction on 2018/19 or 48% less than in 2017/18. August was the seventh successive month where there were no delayed discharges which were jointly attributable to the NHS and Social Care.

• During 2018/19, NuTH achieved a 21% reduction in the number of its super stranded patients (21 days+ LoS), with NHSE setting a target of a further 17% reduction during 2019/20, a trajectory against this target has been submitted. Progress will need to continue to be made throughout 2019/20 in order to meet NHSE’s target, particularly ahead of winter months.

• The number of stranded patients (7 days+ LoS) increased in August, contrasting with the progress shown in the first 4 months of 2019/20. The total rose from 601 at the start of August, the lowest level in the whole of 2019 so far, to 650 at the end of the month, with the higher number of DTOCs likely contributing to this. Correspondingly, the number of super stranded patients also increased from an average of 257 during July to 268 in August. Length of Stay remains an area of focus throughout the Trust, with a task and finish group having been established which is championing the new “There’s No Place Like Home” campaign. This campaign is particularly looking at patients who no longer require acute clinical care, with a LoS of 21-26 days.

• The Trust is committed to a holistic approach to patient flow encompassing but not limited to: patient discharge, bed capacity, DTOCs and cancelled operations. As such, part of the Trust’s ongoing improvement efforts focus on reducing the length of stay of patients who do not need ongoing medical care; plans are currently in place to review the care setting for patients receiving rehabilitation/therapy, the repatriation of patients to other local hospitals and a review of the Patient Choice directive.

05101520253035

0100200300400500600700800

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NuTH DTOC Bed Days

NHS Delays Social Care Joint Responsibility Daily Bed Delays

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Super-Stranded Patients

Number of Stranded Patients (>7) Number of Super Stranded Patients (>21)

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Quality and Performance: 18 Weeks Referral to Treatment

• The RTT Incompletes Performance in August was again non-compliant at 90.6% against the 92% standard. Therefore, 7,250 (9.4%) of the 77,104 patients on the Trust’s RTT waiting list were not treated within 18 weeks; this has deteriorated by over one thousand patients since last month (6,129 over 18 weeks waiting in July). This is a result of demand outstripping supply and the necessity to provide priority treatment for an increasing number of patients referred on a cancer treatment pathway. Waiting List Initiative activity and the capacity to treat elective patients has reduced due to national pension tax issues.

• There are some specialties where hitting the target is proving increasingly difficult and in August 5 specialties failed the RTT Incomplete standard with the associated financial penalty shown; Ophthalmology (£278.1k), Trauma & Orthopaedics(£117.9k, all from the spinal surgery sub-specialties), ENT (£144.3k), Urology (£30.9k) and Dermatology (£57.9k). The total penalties that would have been applicable if the Trust had not agreed a financial Control Total would be £629,100 for August, an increase of £227,700 from July. Increased demand and capacity constraints remain the concern; to note the specialties breaching are particularly high-volume services.

• The Trust closely monitors over 36 week waiters. In August 2019, 360 patients had not yet received their first treatment, waiting between 36 and 52 weeks since referral. This is an all time high. The majority of the >36 week waiters remain in Spinal Services (Orthopaedics), as below the table shows Specialties with more than 5 over 36 week waiters. There are an increasing number of patients who are waiting very close to 52 weeks particularly in Spinal deformity where capacity is limited and the risk of breaching this target is significant.

261221

134 162225 222 243 217 226 243

290360

0

100

200

300

400 RTT - Total Number of Over 36 Week Incompletes

>36 Weeks

76%

80%

84%

88%

92%

96%

50,000

60,000

70,000

80,000Trust RTT Incompetes Performance

Under 18 weeks Over 18 weeks

Compliancy % Compliancy % Target

RTT > 36 weeks 37 38 39 40 41 42 43 44 45 46 47 48 50 Total

108 - Spinal Surgery 14 19 14 8 21 8 6 5 1 4 8 2 124

101 - Urology 10 3 7 4 5 1 6 3 2 1 1 1 48

320 - Cardiology 5 6 3 4 5 4 4 2 1 39

107 - Vascular Surgery 6 3 3 6 5 1 1 27

130 - Ophthalmology 4 1 4 3 1 2 19

120 - ENT 2 5 3 2 3 1 17

330 - Dermatology 2 5 3 2 1 1 16

104 - Colorectal Surgery 2 3 1 2 1 1 1 13

502 - Gynaecology 1 1 4 1 8

160 - Plastic Surgery 1 1 1 1 1 1 8

110 - Trauma & Orthopaedics 4 1 1 7

100 - General Surgery 1 5

214 - Paediatric Trauma and Orthopaedics

2 1 1 1 5

RTT Incomplete Pathways18/19 Qtr

318/19 Qtr 4 19/20 Qtr 1 Jul-19 Aug-19

Total 212,777 214,096 218,347 75,051 77,140

> 18 weeks 13,785 15,380 17,082 6,129 7,250

Overall Compliance 93.5% 92.8% 93.2% 91.8% 90.6%

Incomplete Penalty £532.2k £606.6k £835.5k £401.4k £629.1k

Agreed Reinvestment £532.2k £606.6k £835.5k £401.4k £629.1k

15/26 120/265

Quality and Performance: Diagnostic Waits

• The Trust’s performance declined slightly in August 2019 to 95.2% against the 99% standard, bucking the 4 month trend of improving performance. August’s diagnostics performance remains one of the lowest performing months in the previous 4 years, and well below the level in August 2018 (98.4%). This is the ninth consecutive month where the Trust has failed this standard.

• Compliance against the diagnostics standard poses significant risk to NuTH’s nationally submitted trajectories; within the submitted trajectory for diagnostics NuTH is forecast to regain compliance during September 2019.

• As previously reported, there are long-standing workforce shortages in Radiology which significantly impact on diagnostic tests andreporting. The service are currently developing short, medium and long term plans which will undoubtedly require additional resource, whilst the service continues to outsource activity. Work is ongoing to review capacity and demand for both scanning and reporting with a new capacity and demand tool being trialled within the department.

• Additional recruitment has taken place within August with the successful addition of 15 radiographers from overseas; once these posts are filled and embedded it is hoped this will create additional capacity within the department. Further radiology recruitment is planned for September, with hope of recruiting of reporting radiologists within paediatrics and breast, as well as within general reporting.

• MRI breaches increased significantly with the total number > 6 weeks increasing from 45 to 153 and the total MRI waiting list increasing by nearly 1,000 from 1,551 to 2,424. The audiology position continues to improve with staffing levels normalising following additional shortages due to sickness and maternity, and the backlog cleared due to locum appointment. Sleep studies continue to have capacity issues and consequently this is the area with the greatest number of patients waiting >13 weeks (34).

• The Trust has a diagnostic action plan which is routinely shared with local and national commissioners.

92%93%94%95%96%97%98%99%

100%Diagnostic Waits (% under 6 weeks)

2018/19 2019/20 Target

DM01 Diagnostics Performance Apr-19 May-19 Jun-19 Jul-19 Aug-19

Number of Breaches 524 461 427 302 472

Number of ‘Excess’ Breaches 419 357 322 208 373

Performance (99% Standard) 95.0% 95.6% 95.9% 96.8% 95.2%

Penalty (£200 per breach) £83.8k £71.4k £64.4k £41.6k £74.6k

Total Waiting List 10,487 10,368 10,439 9,374 9,869

16/26 121/265

Quality and Performance: Cancer Performance (1/2)• The Suspected Cancer Two Week Wait (2WW) standard was not achieved for July. NuTH reported 82.9% against the 93% standard. Lower GI

performance was significantly under standard at only 15.2%, a further reduction from 32.7% in June, increased referrals and endoscopy capacity remain the core issues. Suspected Breast cancer performance increased significantly to 89.9% from 57.9%.

• The Breast symptomatic standard also failed with July performance reported at 27.5%, this is largely because appointment priority in Breast is being given to those with suspected cancer. Due to capacity issues within radiology, the service has had to reduce the numbers of clinic slots from previous levels earlier in the year, this is constantly being reviewed by the Directorates. The Breast Service across the region is fragile with a project manager to be appointed by the Cancer Alliance to work with Trusts across the region. Additional analysis on July patients has shown that of 118 Breast Symptomatic patients seen at NuTH, only 1 patient was identified as having cancer. Of all patients seen on a Breast pathway in July (243 suspected and 118 symptomatic), no patient identified with cancer waited more than 20 days for their first appointment.

• The 31 Day first treatment standard for July failed at 92.6% against the 96% standard. Significant concerns remain within Urology (77.9%) with theatre capacity issues cited as the main cause for breaches, as well as within Lung (86.9%) with Thoracic Surgery under capacity pressures due to a lack of adult ITU beds and theatre capacity.

• The 31 Day Subsequent Treatment standard for Radiotherapy (94%) was achieved at 97.9%, however the Subsequent Drug standard (98%) failed this month with 95.5% for July. Once again NuTH failed the 31 Day Subsequent Surgery standard reporting 87.3% for June against the 94% standard, this standard has became increasingly challenging mainly due to capacity (theatre and radiology) in a number of directorates.

Inter-Provider Transfer (IPT) rules have been applied to 62 Day performance:

• Overall 62 Day performance showed improvement from June (+6.6%) with July performance of 77.7% against the 85% standard. Challenges remain across a number of tumour groups, Urology at 56.6%, Gynae 53.3% and Lower GI 68.1%. Diagnostic and surgical/theatre capacity featured considerably as breach reasons across all tumour groups. The Trust also failed the 62 Day Screening Standard (90% threshold) at 85.7% with breaches predominantly within Breast.

• The improvement within 62 Day Performance was also seen within July for the most challenging tumour groups with improvements from June shown within Urology +18.3%, Gynae +16.9% and Lower GI +11.0%.

70%

75%

80%

85%

90%

95%

100%Cancer 2 week wait performance

2018/19 2019/20 Target

20%30%40%50%60%70%80%90%

100%Cancer Breast Symptomatic 2 week wait performance

2018/19 2019/20 Target

Please see additional charts on the next page

17/26 122/265

Quality and Performance: Cancer Performance (2/2)

86%

88%

90%

92%

94%

96%

98%

100%Cancer 31 Day First Treatments

2018/19 2019/20 Target

82%84%86%88%90%92%94%96%98%

100%Cancer 31 Day Subsequent Treatment Surgery

2018/19 2019/20 Target

30%

40%

50%

60%

70%

80%

90%

100%Cancer 62 Day Urgent Performance

2018/19 2019/20 Target

30%

40%

50%

60%

70%

80%

90%

100%Cancer 62 Day Screening Performance

2018/19 2019/20 Target

30%40%50%60%70%80%90%

100%Cancer 62 Day Urgent Performance by Tumour Group

June 2019 (%) July 2019 (%) Target

18/26 123/265

Quality and Performance: Other Performance Requirements• The Trust reported 63 ‘last minute’ cancelled operations in August 2019, with over 50% of these within Cardiothoracic (35), the most in an individual

directorate since the start of 2015/16. Across the Trust there have been 337 hospital cancellations in 2019/20 to date, a 34% increase on the corresponding period in 2018/19. Theatre lists overrunning and emergency surgery taking precedence were the most common reasons for cancellations in August, which corresponds with the trends seen throughout 2019/20 so far.

• The Trust reported 13 breaches in August against the standard to treat within 28 days following last minute cancellations, with no month having seen a higher level than this since the start of 2015/16. Consequently the Trust will not receive payment for these procedures. Breaches took place across numerous directorates – Surgery (3), MSU (3), Cardio (2), Renal (2), Dental (2) and Medicine (1).

• The introduction of the Trust’s outpatient DNA reminder service has successfully reduced DNA rates significantly to circa 5% in many areas. As a consequence of this the Trust has also seen an increase in the number of outpatient cancellations over the same time period.

• In relation to Dementia, the Trust continues to consistently perform below the national standard for 2 of the 3 metrics, but the referral metric has been met in each of the past 2 months. However, actions are being taken to improve compliance with the new screening tool having gone live during July and it is hoped the screening tool can be further amended to improve compliance following the rollout of Paperlite. This tool is being promoted throughout the Trust with the Trust’s Specialist Dementia Team targeting areas with the lowest compliance for further training.

• In August 2019 the ‘moving to recovery’ standard for IAPT was not met for the seventh month in a row, although performance did improve to its highest level of 2019/20 so far to 45.4% against the 50% standard. An audit of ‘unrecovered patients’ has been completed with a corresponding action plan focusing on patients nearly at recovery, offering patients the most appropriate intervention and the most appropriate outcome measures.

• The increased monthly target of 1.58% of people who have depression and/or anxiety receiving psychological therapies is still yet to be met in 2019/20, as August’s performance was 1.27%. Positively, the targets for seeing patients within both 6 and 18 weeks have been met consistently every month since September 2016, with 93.8% seen within 6 weeks in July. Notice has been served on this contract by commissioners and the Trust is due to cease delivery on 31/03/2020.

Reportable Cancelled Operations

18/19 Q3 18/19 Q4 Apr-19 May-19 Jun-19 Jul-19 Aug-19

Last minute cancelled operations

153 144 56 74 65 79 63

Number of 28 day breaches

8 23 1 5 9 3 13

Urgent operations cancelled for a 2nd or subsequent time

0 0 0 0 0 0 0

Penalty Amount £15,667 £70,041 * * * * *

Standards Target Jan-19 Feb-19Mar-

19Apr-19

May-19

Jun-19 Jul-19Aug-

19

% asked the dementia case finding question within 72 hours of admission.

90% 42% 42% 39% 34% 37% 45% 52% 50%

% reported as having had a dementia diagnostic assessment including investigations.

90% 87% 86% 81% 76% 88% 60% 44% 59%

% who are referred for further diagnostic advice in line with local pathways.

90% 32% 28% 36% 33% 46% 81% 100% 100%

19/26 124/265

People: Health and Wellbeing• Year to year comparison for sickness :

• Cost of absence £16.5m compared to £15.9m in August 2018

0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%

Community Services

Women's Services

Musculoskeletal Services

Clinical Research Facility

Peri-operative & Critical Care - FH

Internal Medicine - General

Cardiothoracic

Children's Services

Urology & Renal Services

Peri-operative & Critical Care - RVI

Estates

Patient Services

ENT, Plastics, Ophthalmology &…

Chief Operating Officer

Integrated Laboratory Medicine

Radiology

Cancer Services/ Clinical Haematology

Business & Development

Information Management & Technology

Neurosciences

Internal Medicine - Urgent Care

Dental Services

Surgical Services

Medical Physics

Human Resources

Supplies

Finance

Medical Director

Regional Drugs & Therapeutics

Pharmacy

Chief Executive

Sickness Absence (% Time Lost) by Directorate

3.50% 4.00% 4.50% 5.00%

Sickness Absence for Local Trusts for April 2019

Newcastle Upon Tyne Hospitals

Gateshead Health

Northumbria Health Care

South Tyneside & Sunderland

South Tees Hospitals

North Tees & Hartlepool

Tees, Esk and Wear Valleys

County Durham & Darlington

Northumberland, Tyne and Wear

0%

2%

4%

6%

8%

10%

010,00020,00030,00040,00050,00060,00070,00080,000

Sickness Absence by Staff Group

FTE Days Lost

% Time Lost

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

Sickness Absence (% Time Lost)

Long term Short term

12m Ave (total sickness) Target

20/26 125/265

People: Sustainable Workforce Planning

• Staff in post at August 2019 is 12,682 wte compared to 11,842 in August 2018.

• Staff turnover has fallen from 9.03% in August 2018 to 8.93% in August 2019, against a target of 8.5%.

• The total number of leavers in the period September 2018 to August 2019 was 1,408.

• Staff retention for staff over 1 year service stands at 86.2%, a decrease from 88.75% in August 2018.

369

199

187

111

97

71

0 50 100 150 200 250 300 350 400

Nursing & Midwifery Registered

Admin and Clerical

Scientific, Professional & Technical

Nursing & Midwifery Unregistered

Estates and Ancillary

Medical and Dental

Vacancies by Staff Group (wte)

4158

2269

2089

1188

997

744

623

572

0 1,000 2,000 3,000 4,000

Nursing & Midwifery Registered

Additional Clinical Services

Admin and Clerical

Medical and Dental

Estates and Ancillary

Allied Health Professionals

Healthcare Scientists

Scientific, Professional & Technical

Staff in Post (wte)

0%

2%

4%

6%

8%

10%

Turnover by Staff Group

Sep 18 -Aug19

0 50 100 150 200 250

Voluntary Resignation - Relocation

Retirement Age

Voluntary Resignation - Work Life Balance

Flexi Retirement

Voluntary Resignation - Promotion

Top Five Leaving Reasons

0% 20% 40% 60% 80% 100%

Over 1 year service

Less than 1 year service

Staff Retention

21/26 126/265

People: Sustainable Workforce Planning

• Comparing the periods September 2017 - August 2018 to September 2018 - August 2019), overall bank utilisation has fallen from 325 wte to 284 wte and agency from 158 wte to 149 wte.

• 9% Total Nursing vacancy rate as of Aug 1st 2019.

• 10% Band 5 Nursing Vacancy rate as of Aug 1st 2019.

0

50

100

150

200

Bank and Agency Utilisation by Staff Group

Bank (17-18) Bank (18-19) Agency (17-18) Agency (18-19)

0

5

10

15

20

25Internal Medical and Dental Bank Utilisation

Consultant Non-consultant Career Grade Trainee Grades

22/26 127/265

People: Excellence in Training and Education

• The 79% appraisal compliance at August 2019 not on target (81% at August 2018), against an end of year target of 90%.

• Mandatory training stands at 87% against a Q2 target of 85% and end of year target of 95%. August 2018 position was 84%.

0%10%20%30%40%50%60%70%80%90%

100%

Appraisals

Compliance

Target

0%10%20%30%40%50%60%70%80%90%

100%

Mandatory Training by Staff Group

Compliance

Target

0%10%20%30%40%50%60%70%80%90%

100%

Mandatory Training by Topic

Compliance

Target

53273

277

1047

0

200

400

600

800

1,000

1,200

1,400

19-20 Apprenticeship Starts (Progresstowards target in year)

Apprenticeship Starts Since 1 April 2017(Progress towards estimated 4 year target)

Apprenticeship starts

Achieved To Achieve

23/26 128/265

Finance: Overall Financial Position

This paper summarises the financial position of the Trust for the period ending 31st August 2019.

At Month 5, the Trust has delivered to the year to date and Income and Expenditure surplus of £3.7 million, including the

Provider Sustainability Funding (PSF) of £5.2 million. If the additional £1.154 million received as result of 2018/19 post accounts

PSF in 2019/20 is added, the surplus becomes £4.5 million.

Annual

Plan

Month 5

Budget

£'000

Month 5

Actual

Month 5

Variance

Income 1,100,358 454,540 466,366 11,796

Expenditure 1,083,454 451,032 461,806 10,774

I&E position (Control Total including PSF) 12,203 3,681 3,681 0

I&E position (exc impairment) 11,773 3,508 4,530 1,022

Closing Cash 92,059 99,469 127,961 28,492

Capital Programme 49,872 16,048 14,121 (1,927)

24/26 129/265

Finance: Financial Risk Rating

The NHS Improvement Use of Resources (UoR) metric considers five aspects of performance; liquidity and ability to service debt from revenue, underlying performance, variance from the Trust’s Plan and agency expenditure compared to Plan.

The metrics consolidate into a single Risk Rating which rates an organisation on a scale of 1 to 4, where ‘1’ reflects a low Financial Risk and ‘4’ reflects a Trust with high financial risk.

Based on these metrics the Trust would attain an overall Risk Rating of ‘2’which is a strong outcome. The profile is as follows:-

0 1 2 3 4

Liquidity

Debt Service Cover

I&E Surplus Margin

I & E Surplus Margin Achieved vs Plan

Agency Spend

Overall Risk Rating - Override

Financial Risk Rating

Actual Plan

25/26 130/265

Finance: Key issues

i) Operating income for the period ending 31st August 2019 is £466.4 million £11.8 million ahead of Plan. ii) Total operating expenditure for the period to Month 5 is £461.8 million, £10.8 million more than Plan.iii) The Trust reports an Income & Expenditure surplus of £3.7 million at Month 5, adjusted for £1.54m bringing the surplus to

£4.5 million. The Income & Expenditure profile as the year progresses can be seen in the chart.iv) To date the Trust realised £9 million of savings (Year to date £6.4 million) in relation to the Trust efficiency requirement. v) The Capital Expenditure to August was £14.1 million and is close to Plan.vi) The Cash balance is healthy and well above Plan.

-4

-2

0

2

4

6

8

10

12

14

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

£m

s

I&E Surplus 2019/20 (including PSF)

Plan Actual

26/26 131/265

Agenda item A10(i)

TRUST BOARD


Title ‘People’ Update

Report of Dee Fawcett, Director of HR

Prepared by Dee Fawcett, Director of HR


☒ ☐ ☐


☒ ☐ ☒

SummaryPurpose of the report is to provide an update to the Board regarding the Trust People agenda and seek approval to publish data and information relating to Equality and Diversity to meet requirements.

Recommendations The Board is asked to note the contents of this report.The Board is asked to confirm publication of the Equality data and information.

Links to Corporate Objectives Reputation as one of the country’s top first class teaching hospitals.

Links to Strategy and Clinical Risks Recruitment and retention; delivery of strategy.


Quality and Safety: Capable workforce – high quality care. X

Legal: Mitigate risks of ET issues. x

Financial: Effective use of people resources to manage cost. X

Human Resources: Outlined within report. X

Equality and Diversity: Employer of choice – high quality staff. X

Engagement and communication: Enhance reputation as an employer of choice. X

Sustainability: to delivery high quality care. X

Impact

Reports previously considered by N/A

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Agenda item A10(i)

____________________________________________________________________________________________________People UpdateTrust Board – 26th September 2019

TRUST BOARD PEOPLE UPDATE

1. BACKGROUND

The purpose of this report is to provide an update to the Board on key developments in support of the strategic objective: ‘to be the recognised employer and educator of choice, with a diverse, engaged and motivated workforce essential to the delivery of health and care services across the North East’.

2. TRUST STRATEGIC FRAMEWORK

The Trust People objective and 2019/20 breakthrough objectives are:

3. KEY PERFORMANCE INDICATORS

Performance against key workforce metrics is summarised in the integrated board report. Set out below is an update on what the Trust is currently doing and its actions plans to deliver its strategic priorities.

Staff Experience/#Flourish at Newcastle Hospitals

Current activity Ongoing/Next Steps2018 NHS Staff Survey – priority theme – ‘more flexible working’: Refreshed Flexible Working Policy. Implementation of Agile Working Policy Implementation of managers’ tool kit to

promote increased awareness of flexible working options across organisation.

Implementation of new technology (via mobile ‘phones/tablets’/PC’s) as additional alternative to hand scanning devices; increase choice for all non-medical staff to record working hours, book leave etc.

Trust-wide communications and engagement to update staff on range of flexible working options and to promote understanding and support.

Launch of 2019 NHS Staff Survey - opens 1/10/19 – 30/11/19 – target increase in response rate and improved staff engagement.

Support for Armed Forces Staff November 2019: Finalist for HSJ ‘Reservist Support Initiative Award’.

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Agenda item A10(i)


Delivery of new LCEA Scheme Local proposal developed consultation ongoing. Submit for consideration by Remuneration Committee - October 2019.

Health and Wellbeing October 2019: medical staff well-being workshop.

December 2019: Better Health at Work ‘Continuing Excellence’ interim assessment.

Workforce Diversity : Production and submission of Workforce Race

Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) data returns and action plans.

Production of Equality Delivery System (EDS2) assessment of grading against goal 3 and 4.

Production of Public Sector Equality Duty (PSED) workforce data.

September 2019: ACTION: approval of publication by Trust Board for WRES, WDES, EDS2 and PSED. Detailed information contained in Board Reference Pack (BRP).

1st October 2019; Trust inaugural BAME staff conference ‘Closing the Gap’ – open to all BAME staff and key systems partners.

September 2019 – Bi-Visibility Day. October 2019 – Black History Month. November 2019 – Trans Memorial Day. December 2019 – Disability Month.

‘A fair experience for all’ – NHS Interim People Plan to reduce the ethnicity gap of entry into formal disciplinary process.

The Trust currently sits within the NHS target range along with 24% of other Trusts.

Autumn 2019; Introduction of Cultural Ambassadors** as part of support available to BAME staff who are subject to disciplinary process.

‘Brexit’: Home Office has confirmed immigration

arrangements for EU citizens in the event of a ‘no deal’ exit.

Further clarity requested by NHS Employers regarding rights and entitlements of individuals coming to the UK from the EU or applying for voluntary exceptional leave to remain.

GMC registration – aim for ‘timely and streamlined’ registration process.

NHS Pension Scheme: 11/9/19; DHSC published new consultation

document regarding flexibilities to the NHS Pension Scheme applicable to clinicians.

September 2019: NHS Pensions Scheme Advisory Board recommendations on pension flexibility to the SOS expected.

October 2019: Trust ‘Pensions Information and Guidance Sessions’ x 15.

1 November 2019: DHSC consultation period ends.

Retirement/Older Workers December 2019; Launch NHS Retirement Fellowship ‘Newcastle Hospitals Branch’.

Flourish Activity Calendar 2019 September ‘Sleep Well’ October ‘Respect’ November ‘Men & Women’s Health’ December ‘Let’s Give’

** Cultural Ambassadors – 5 Trust BAME staff have been trained by the RCN. These staff are from a range of cultural backgrounds and variety of roles across the Trust.

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Agenda item A10(i)


2019/20 NHS England/Improvement ‘Single Oversight Framework’

The framework specifies 4 new ‘leadership and workforce metrics’ informed by staff survey data to assess organisational culture. These include bullying and harassment, team working and inclusion and BAME Staff Board representation. NHSE/I regional teams will ‘performance manage’ to determine where support is required.

Project Choice

2018 Internship completed. Of the eleven students, seven have secured employment, five within the Trust and two have joined employability programmes with the Prince’s Trust and Westgate College. The next intake commence their placements on 1st October.

Learning to improve our people practices

Following the tragic case of a manager at a London NHS Trust taking their own life following a disciplinary process, an independent inquiry was undertaken, resulting in a number of recommendations. The Chair of NHSI wrote to all Trusts earlier this year providing guidance on the management and oversight of investigation and disciplinary procedures to ensure that any formal procedures were underpinned by a concern to safeguard individual health and wellbeing, irrespective of the circumstances of a case. A review of the Trust practice has been undertaken and improvements are being implemented to better support staff involved in formal procedures.

Excellence in Education and Learning – including Professional and Leadership Development

Current activity Ongoing/Next Steps August 2019; Junior Doctor Induction and

on boarding aligned to NE streamlining of competences, utilisation of national e-learning modules to support transfer of learning; Implementation of ‘First Day Kit’ – e-welcome to support orientation into the Trust.

https://view.pagetiger.com/FirstDayKit/

2019 Spending Review; Additional CPD funding for Nurses, Midwives and AHP’s.

Clarity required regarding receipt of funds and distribution.

Preparation for Trust to inform ICS commissioning of CDP for the system

Leadership Development Place based ‘System Leadership’

programme well established. Trust Senior Leadership Development

programme for new and emerging leaders open to applicants

Trust participation in phase 1 of national ‘Talent Management Diagnostic’ pilot.

System leadership, cohort 2 commencing November; Proposal to continue to cohorts 3 and 4 in 2020 to be considered at JDG.

End October – selection process. Connecting with NCNE ICS lead to enable alignment

and sharing of best practice for Primary Care Network CD development.

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https://view.pagetiger.com/FirstDayKit/

Agenda item A10(i)


Application for Leadership Bursaries submitted to NELA for ‘system leadership’ including coaching and ‘coaching for inclusion’.

Further design developments to Newcastle Health and Care System Leadership Programme.

Postgraduate Leadership – Level 7 on line - Learning Platform to facilitate CPD via modular approach – partnership model with Newcastle University and NELA.

Launch December 2019 for use in Trust leadership development programme; marketing via University.

NHS GMTS 3 x trainees commenced in NuTH for 2 year placement – talent pipeline

‘Celebration of Learning’ – review and refresh of event

December 2019

Consultant Induction By December 2019 – revised programme in place.

Sustainable Workforce Planning

Current activity Ongoing/Next StepsApprenticeships: Move to national apprenticeship wage – aid

to recruitment and retention. Growth plans progressing, for example,

ILM 3 leadership for existing workforce Apprenticeship Delivery Team now

appointed to substantive employment contracts to enable growth plans to be realised.

Nurse Degree apprenticeships Established with Sunderland and Northumbria Universities, adult nurse and Nurse Associates.

Develop widening participation strategy. Ongoing collaboration with civic partners to pilot a

new ‘joint’ delivery model – maximising use of levy. Princes Trust – progress discussions to develop ‘pre-

employment programme’.

Workforce Information Systems: Allocate safe care: 10 out of 11 clinical

directorates now ‘live’ with SafeCare. Medi rota: ongoing implementation of

medical staff e-rostering – aim for all medical staff rostered by end March 2020.

E Job-Planning: 2019/20 consultant e-job planning round ongoing using SARD.

October 2019 – Safecare ‘go live’ in Medicine.

Medi rota – requirement for ESR and e-payroll interfacing still in development.

E-Job Planning - scoping work underway to identify potential solutions for e-job planning for all clinical staff groups (Nurse Specialists/Clinical Pharmacists/AHP’s).

o By March 2021: Aim to achieve Level 1 of national NHSE/I ‘Levels of Attainment’ for e-job planning.

NHSI Developing Workforce Safeguards Finalise analysis of recommendations and complete action plan to ensure compliance with this and National Quality Board guidance on safe, productive staffing.

Recruitment & Retention: Increased volume of activity; impact on By end October 2019:

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Agenda item A10(i)


‘time to appoint’. Further international recruitment to

appoint Radiographers. Trust considered ‘exemplar’ in approach to

international recruitment and sharing best practice at external conferences.

Steady reduction in receipt of EEA applicants to medical posts in the Trust.

o Orientation of 16 new Portuguese radiographers by end October.

o Additional 19 Philippine nurses commence employment.

October 2019: participation in NHSE/I National Nurse Retention programme cohort 5 – ‘best performing national Trusts’.

Volunteer Workforce: 49 Helpforce Volunteer pledges received.

Progressing ‘on boarding’.

October 2019: Implementation of new Volunteer Service infrastructure to support growth.

Pears Foundation – develop funding proposal to support Young Persons Volunteer Programme to cultivate skills for learning and success.

Careers/Work Experience 2020 events planning: March and October. 2020 Workforce Planning: Increased in Clinical Radiology Trainee

programme supporting national expansion of radiology training.

Participation in strategic regional planning workshops, adopting an integrated approach with a focus on population health.

Trust workforce planning event for DMs and senior leaders planned for November 2019

Development (partnership with North Tyneside CCG and Northumbria FT) of primary care practitioner role.

Medical Associate Professions (MAPs) proposal to be considered at new ‘Workforce Panning, Design and Transformation Group’.

Placement capacity: support national expansion of nurse placements in partnership with Northumbria and Gateshead FT’s.

Transformation and Change

Current activity Ongoing/Next StepsImplementation of Robotic Process Automation (RPA) and use of AI: RPA software now fully installed into

workforce information team.

End November 2019: Continue feasibility assessments to identify and operationalise ‘high return’ automated HR processes.

Advanced Clinical Practice: Participation in HEE Advanced Practice Survey.

Strategy paper for consideration at Trust Workforce Design Group.

October 2019; participation in national Advanced Clinical Practice Conference.

Physician Associates Recruitment for HEE PA Preceptorship Trainee hosted by Trust in partnership with local Health Centre

Nursing Associates December 2019 - recruitment of additional small cohort.

April 2020: 22 due to qualify. June 2021: 28 due to qualify.

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Agenda item A10(i)


5. SYSTEM WORKING

North East and North Cumbria ICS have begun development of an ICS workforce strategy. A Workforce Programme has been established comprising three workforce delivery groups: Getting Education and Supply Right – led by HEE NE:

o Funding has been achieved to establish a Workforce Transformation Hub to include support for primary care workforce, and to establish a faculty of advanced practice to support development of the current workforce to undertake advance practice roles.

Becoming a Great Place to Work – led by Human Resource Directors:o Continuation and maximising value of North East Streamlining Programme –

recruitment and retention/statutory and mandatory training compliance/occupational health.

o Working collaboratively to develop an ‘improved offer’ for everyone working in the NHS – focus on Health and Wellbeing/Equality, Diversity, Inclusion/Flexibility of Employment. Developing a region-wide approach and development of a 3-5 year plan to

incorporate standard KPI’s, mental health, self-care mental health guide, musculoskeletal issues and menopause.

Valuing and Supporting Leadership at all Levels – predominantly led by NELA.o Funding has been secured to facilitate system leadership for clinical leaders,

population health management and collaborative leadership in systems.

6. HEE WORKFORCE DEVELOPMENT FUNDS

£500K has been allocated by HEE to the ICS Workforce Transformation and Strategy Board. An invitation for proposals for these monies has been extended to all organisations and proposals will be considered and determined by that Board. All proposals are expected to be aligned to the overarching principles of (i) supporting or enabling health prevention or population health focused workforce development (ii) fit with the ambition and priorities of ICS work streams (iii) not duplicate projects already underway. Deadline for submission 2nd October 2019.

7. EDUCATION, TRAINING AND WORKFORCE DEVELOPMENT REVIEW

There has been a very broad spectrum of engagement both internally and externally with key stakeholders and partners. This process has been overseen by a small Advisory Group. The formal review will be concluded by end September and a report and recommendations will be submitted to the Trust. It is anticipated these will be discussed by the Executive Team and any recommendations, supported by an appropriate action plan will be submitted for consideration by the People Committee in October.

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Agenda item A10(i)


8. RECOMMENDATIONS

The Board is asked to note the content of this report. The Board is asked to approve publication on the Trust website of the Workforce Race and Workforce Disability Equality Standard data and action plan, the Equality Delivery System assessment and the Public Sector Equality Duty workforce data.

Report of Dee FawcettDirector of HR

18 September 2019

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Agenda item A10(ii)

TRUST BOARD


Title #FlourishAtNewcastleHospitals update and progress report

Report of Caroline Docking, Assistant Chief Executive

Prepared by Caroline Docking, Assistant Chief Executive


☒ ☐ ☐


☐ ☐ ☒

Summary This paper outlines the progress taken to develop and deliver the trusts #FlourishAtNewcastleHospitals approach

Recommendations The Board of Directors is asked to note progress and support the approach going forward.





Legal x

Financial x

Human Resources x



Sustainability x

Impact


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Agenda item A10(ii)

____________________________________________________________________________________________________Flourish UpdateTrust Board – 26th September 2019

FLOURISH AT NEWCASTLE HOSPITALS UPDATE AND PROGRESS REPORT

1. BACKGROUND

Flourish at Newcastle Hospitals is our approach to supporting our staff to liberate their potential.

It was launched by Dame Jackie very shortly after her arrival at Newcastle Hospitals, with an initial event on 17th July 2018. Through that event, three themes were agreed to articulate the approach that we would take. Focus groups were held in relation to each theme which set out areas for action.

The themes agreed by and with staff are:

a) Well workforceThis encompasses both physical and mental health, and wellbeing for staff.

b) Reward and recognitionEnsuring that staff are recognised and rewarded for their efforts, and that they feel valued.

c) Values and behavioursThe values we hold and the behaviours we experience and exhibit came up frequently at events as an important factor to impact upon staff experience.

As our #FlourishAtNewcastleHospitals (Flourish) approach has progressed and developed, this initial engagement work has been firmly at the centre of planning.

However, Flourish is not something that can be completely planned and managed. It’s a social movement, and its success will be in changing the culture of the organisation from one which was perceived to be overly bureaucratic and inflexible to one which enables every member of staff to bring their whole selves to work and liberate their potential. Importantly, through the influence of this approach, we also want to become the most flexible employer in our NHS peer group, an area where we currently underperform.

Executive Leads for Flourish are Caroline Docking, Assistant Chief Executive and Dee Fawcett, Director of Human Resources. A Flourish Steering Group exists to support and engage a wider group of stakeholders. However, Flourish should not be a ‘top down’ approach with activity imposed from the Executive Team. Instead we have attempted to create opportunities for people to take their own action and to use their own initiative. We have actively followed the lead of staff from different parts of the organisation who have come forward with ideas.

2. MEASURING THE IMPACT

Measuring the impact of a social movement and culture change is difficult, particularly in a short space of time.

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The staff survey is a good benchmark to take the temperature of our staff group over time, and we have now incorporated the staff survey into our flourish approach and branding to make the clear link to longer term cultural change rather than short term action plans. We are also undertaking specific campaigns to tackle issues raised through the staff survey within the Flourish branding and approach – a good example of this being the current flexible working campaign.

Where measures for particular activities exist (for example web and social media activity), these are set out in the paper.

3. FLOURISH ACTIVITIES

Since the first Flourish event in July 2018, a number of other events have been held. These are:

Date Topic2nd October 2018 Flourish event: branding and feedback from focus groups.

How can we help people to unlock their potential?16th October 2018 Leadership Congress – Leadership in Newcastle. 13th December 2018 Flourish event: Our Values and behaviours – developing

the Trust values. Agreeing monthly programme of flourish activities.

5th March 2018 Leadership Congress: Hospitals at the Heart of Innovation.4th April 2019 Flourish Event: Staff Survey results and action planning.21st June 2019 Celebrating Excellence Event.20th July 2019 Pride Breakfast. 7th September 2019 Great North 5k.16th and 23rd September 2019 Project Menopause meetings. 24th October 2019 (planned) Flourish stocktake and review, and Living our Values.27th November 2019 (planned) Leadership Congress: safety theme.

The Flourish events and Leadership Congress’ are a major undertaking bringing together over 100 staff to each event.

The staff awards are worthy of note, as this was a very clear request from staff during the initial Flourish engagement. This brought together almost 400 staff for a gala evening to celebrate success and achievement and was very warmly welcomed by staff who attended.

Alongside these major events, we agreed a programme of monthly activities which were promoted through the channels below. The intention was to provide a theme and a focus for each month and encourage individuals and teams in the organisation to get involved as they saw appropriate and where they were particularly interested. The monthly themes were agreed following discussion at the Flourish event in December 2018 and discussion with the Better Health at Work (Health and Wellbeing) Champions.

This approach of ‘enabling, not organising’ is an important part of developing an empowering culture. The first monthly activity was ‘Let’s Give’ a campaign to support the local foodbank which was initiated directly by staff members. It took place over the

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Christmas period and was very successful. From January 2019 the activities were promoted through the dedicated website.

The monthly activities were:

Theme Web visits Other activityJanuary – Let’s move (pedometer challenge)

1634 67,711 miles recorded (135,421,793 steps) 73 teams made up of 762 people.141 downloads of let’s move poster

February – Let’s Talk (Time to Talk day)

616 37 downloads of let’s talk poster. Numerous team talk events and tea and chat shared on twitter

March – Lets work better 1164 353 downloads of Taking Time poster329 downloads of email etiquette posterAdditional 1,029 Full Toolkits downloaded for Let’s Work Better

Pledge it, Plan it 1860 178 downloads of Pledge it Plan it resourcesMindful May 3268 198 downloads of going home checklistLet’s Celebrate 2234 Not web based activityWork Perks 2852 782 sign ups to view the work perks offersLet’s be sustainable 3198 Activity was via contact with the

Sustainability teamSleepwell 4852 565 views of the sleepy shift worker video

211 downloads of Working at night poster141 downloads of Sleeping problems guide

There have been 21,408 total web visits since the launch of the website.

It is also good to see directorates and other groups building their own activity to support Flourish. For example, Lucia Pareja-Cebrian, Trust Director of Infection Prevention and Control, is leading work focussing on clinicians views to engage them more effectively in the programme. There is also an emerging admin and clerical group to engage this often difficult to reach group in the approach more fully.

4. MARKETING

There are 4 key marketing elements to the Flourish approach,

1. Embedding in trust activity – Flourish is now a routine part of our operational activity and every opportunity will be taken to ensure brand consistency across the organisation. This will be supported by the new trust branding standards and style guide.

2. Social media – The Trust social media accounts are a key channel for flourish, particularly the trust Twitter and Instagram accounts which have a large proportion of followers who are members of staff. (For examples of social media activity, please see Appendix 1).

3. Website – the flourish website was established in January 2019 to provide a focus for Flourish activity and a central point for information given the limitations of the current

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intranet and trust website. This has been a hugely successful approach, ensuring that there is easy access to information for staff – both at work and at home.

4. Dame Jackie’s Blog – The fortnightly Blog routinely highlights flourish activity, providing a summary of recent events, promoting upcoming events and opportunities and ‘setting the tone’.

5. NEXT STEPS

Flourish has been identified as our cornerstone programme to support our ‘People’ strategic objective.

The planned Flourish event on 24th October will give staff an opportunity to review the progress so far and share their views and ideas about the next steps for the #FlourishAtNewcastleHospitals approach. This will enable us to consider it alongside our new values and ensure alignment.

The embedding of Flourish within the strategy also provides a framework to ensure that it is a key element of strategic development in every part of the organisation.

The next leadership Congress is planned for 27th November and a programme of events for 2020 is being developed.

6. RECOMMENDATIONS

The Board is asked to note the contents of this report and support future activity.

Report of Caroline DockingAssistant Chief ExecutiveSeptember 2019

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Social media activity Appendix 1

The #FlourishAtNewcastleHospitals hashtag has been adopted widely on Twitter, Linked in and Instagram.

Our top tweets include:

Top Tweet (Sept) NHS5k earned 12.4K impressionsThanks to everyone who supported the #NHSWave this morning - great day for it! #GNR5K @Great_Run #FlourishAtNewcastleHospitals pic.twitter.com/OazfFUr3n2

Top Tweet (July) earned 10.6K impressions“We’re very proud to be launching the NHS Rainbow badge at Newcastle Hospitals” @gordonuk73 introduces the @RainbowNHSBadge @NewcastleHosps Find out how you can pledge your support for LGBT+ staff patients & visitors on the Intranet before wearing your 🌈 badge with #Pride pic.twitter.com/ZN3ufb0BM9

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https://twitter.com/hashtag/NHSWave?src=hash

https://twitter.com/hashtag/GNR5K?src=hash

https://twitter.com/Great_Run

https://twitter.com/hashtag/FlourishAtNewcastleHospitals?src=hash

https://t.co/OazfFUr3n2

https://twitter.com/gordonuk73

https://twitter.com/RainbowNHSBadge

https://twitter.com/NewcastleHosps

https://twitter.com/hashtag/Pride?src=hash

https://t.co/ZN3ufb0BM9


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Agenda item A11(ii)

TRUST BOARD

Date of meeting 26 September 2019Title Corporate Governance UpdateReport of Dame Jackie Daniel, Chief ExecutivePrepared by Kelly Jupp, Trust Secretary, and Fay Darville, Deputy Trust Secretary




Summary

The report includes an update on the following areas: Revised Board Committee Structure Update Implementation of AdminControl The Archivist Project Trust Constitution Update Corporate Risk Update Insight Programme Senior Information Risk Owner (SIRO)/ Information Governance (IG) Update Data Warehouse development Fit and Proper Persons Requirements [FPPR] Modern Slavery Act Declaration NHSI Quarterly Declarations Policy Update

Recommendations

The Board of Directors are asked to (i) receive the update; (ii) note the contents; (iii) endorse the Modern Slavery Act Statement for 2019/20 included in the Board Reference Pack item A11(ii)(c); and (iv) approve the quarterly NHS Improvement declarations.


Maintaining compliance with all regulatory requirements. Deliver a first class patient experience.



Working in partnership to deliver fully integrated care and promoting healthy lifestyles to the people of Newcastle and beyond.



Impact

Impacts on those highlighted at a strategic and reputational level. Reports previously considered by Standing agenda item.

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Agenda item A11(ii)

____________________________________________________________________________________________________Corporate Governance Update Trust Board – 26 September 2019

CORPORATE GOVERNANCE UPDATE

1. INTRODUCTION

Board members will recall that the Trust implemented a revised Corporate Governance structure in April 2019, following consultation with the Good Governance Institute (GGI) during the latter half of 2018 and early 2019.

The revision has allowed for the Board of Directors to maintain adequate oversight and assurance of Trust activity through its streamlined Board Committee structure of six committees (Quality, Audit, People, Finance and Investment, Charitable Funds and Appointments and Remuneration).

This report provides an update on the ongoing work in relation to the governance arrangements within the Trust to date.

2. REVISED BOARD COMMITTEE STRUCTURE UPDATE

Meetings of the six Board Committees continue to take place in accordance with the approved Terms of Reference (ToR) of each Committee.

During the course of the initial Committee meetings under the new structure, the ToR and meeting agendas have continued to be reviewed and refined to ensure that adequate assurance is provided without duplication, as well as identifying any potential gaps in assurance.

Over the summer, work has also continued to refine those structures beneath the Board Committee level, the Management Groups, to ensure that they were fit for purpose. This has included the formulation of new groups where gaps in assurance have been identified, combining groups or removing groups which are no longer required. This work continues.

3. IMPLEMENTATION OF ADMINCONTROL

Board members will recall that following a procurement process, the Trust procured the AdminControl software to assist with the management, collation and issuing of Board and Committee papers.

Following the last meeting of the Board of Directors, AdminControl have provided training on site to over 25 of the Trust’s Board and Committee members.

A ‘soft’ launch of the solution was undertaken using the Executive Team meeting papers in August 2019, which were issued utilising the software. This identified that some further requirements were necessary to ensure consistency of access to meeting papers. It is anticipated that these requirements will be completed during September 2019.

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Agenda item A11(ii)


4. THE ARCHIVIST PROJECT

Board members will recall that the Trust procured the services of a trained Archivist from the Tyne and Wear Archives (TWA), based at the Discovery Museum, on a temporary basis to assist with ensuring that the Trust remains complaint with the Public Records Act 1958.

As part of the work undertaken, the Archivist has identified a number of records which required transfer to the Local Place of Deposit, being the TWA, under the legislation. These records are deemed to be in the public interest and therefore transfer will allow access for research and other purposes.

Work continues to ensure that the Trust maintains compliant and a transfer agreement, which stipulates the Trust’s ongoing obligation, is being finalised.

The Archivist, in collaboration with Corporate Services, has identified departments that may benefit from further training to ensure that the necessary records are stored correctly and then subsequently offered to archive when required.

A meeting to discuss lessons learnt during the course of the project is scheduled for early October, with a full report to be provided to the Audit Committee later that month.

5. TRUST CONSTITUTION UPDATE

Since the last meeting of the Board of Directors, the Trust’s work in collaboration with DAC Beachcroft to review the Trust’s Constitution has progressed to ensure that it is in line with both current legislation and best practice.

Representatives from DAC Beachcroft (DACB) attended the Council of Governor Workshop on 18 July 2019 and provided a presentation on:i) the role of a Governor, specifically in relation to Constitution amendments;ii) the nature of a Trust Constitution; iii) the key elements which all Constitutions should be clear on; and iv) the related aspects of the Foundation Trust Code of Governance.

Following this, DACB hosted a workshop on 8 August 2019 for the Trust Secretary and a working group of Trust Governors to review the initial table of findings setting out the proposed changes.

A revised constitution was subsequently drafted by DACB and at the Council of Governors meeting on 19 September, the Council were asked to consider and approve the proposed changes to the Trust Constitution. Governors considered and agreed the proposed amendments. Further it was agreed that a Governor working group be established to consider the creation of a ‘Patient Constituency’.

The proposed amendment Trust Constitution is included under agenda item A12 for the Trust Board of Directors consideration and approval.

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Agenda item A11(ii)


In addition to the work undertaken with the Trust Constitution, DACB also produced a Code of Conduct for Trust Governors.

6. CORPORATE RISK UPDATE

During the last quarter, work has progressed to refresh the Trust Risk Management Policy. The Corporate Risk & Assurance Manager has been working alongside our governance partners, the Good Governance Institute, to ensure the risk management policy effectively supports the Trust’s risk management approach. The risk management policy is in the final stages of completion and implementation is planned for October 2019.

As part of the Risk Management Policy review, the Corporate Risk & Assurance Manager has been working with the Clinical Governance and Risk Team and the Training and Development Team to facilitate the development of Risk Management E-learning modules which will provide a more flexible approach for staff to complete risk management training.

Further the Corporate Risk & Assurance Manager has been engaging with other NHS Trusts and Healthcare providers to learn, share and develop healthcare risk management and attends a Healthcare Risk Special Interest Group chaired by the Head of Corporate Risk for NHS Digital. The Trust will be hosting the next meeting of the Healthcare Risk Specialist Interest Group in October 2019 which will see representatives from UK healthcare providers attend to learn, share and develop new risk management ideas and approaches.

The Board Assurance Framework, Executive Risk Oversight Register and Quarter 1 Risk Management Report is included under agenda item A11(iii).

7. THE NON-EXECUTIVE DIRECTOR INSIGHT PROGRAMME

As highlighted in the last Corporate Governance Update, the Trust has agreed to participate in the North East cohort of the Insight Programme, originally launched by Gatenby Sanderson in 2016. This programme aims to assist in increasing the pool of quality Non-Executive Director (NED) candidates from under-represented areas.

The central induction event took place on 24 July 2019 at the Freeman Hospital to introduce the NHS to the candidates and was attended by the Trust Chairman and Professor Kath McCourt, Non-Executive Director, the nominated ‘buddy’ from the Non-Executive Directors.

An update is included within the Chairman’s Report, agenda item A5.

8. SENIOR INFORMATION RISK OWNER (SIRO) AND INFORMATION GOVERNANCE UPDATE

As reported to the Trust Board in June 2019, the Data Security and Protection Toolkit (DPST) for 2018/19 was submitted in March 2019 as ‘standards not fully met - plan agreed’ due to four non-mandatory assertions not being completed in full at the time of the submission.

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Agenda item A11(ii)


Work has continued to address the remaining four assertions, with two of which now being complete before the required deadline of 30th September 2019.

Progress on the remaining two assertions was reported to the newly established Data Security Advisory Group (‘DSAG’, formerly the Information Governance Committee) who met for the first time on 16th September 2019. Despite significant effort and actions taken, it is likely that the two remaining assertions will not be completed in full by the end of the September deadline – one assertion involves the procurement and installation of an IT solution and the other relates to mandatory training compliance levels. Therefore the Trust will liaise directly with NHS Digital to consider next steps.

As discussed at the recent DSAG meeting, a working group is being established to consider the requirements of the National Data Opt Out implementation. The national data opt-out applies to the disclosure of confidential patient information for purposes beyond individual care across the health and adult social care system in England. All health organisations who use or supply health data for secondary purposes other than direct health care have to be compliant with the opt out requirements by 31st March 2020.

The DSAG also received an update on the Trusts progress in relation to cyber and data security standards.

9. FIT AND PROPER PERSONS REQUIREMENTS

Work is underway as part of the annual fit and proper persons process for the Trust. The outcome of the work will be reported to the Trust Board in November.

10. POLICY UPDATE

The Trust continues to remain abreast of developments on the national stage, in both the health and social care arena and beyond. As such, a Policy Update is produced on a routine basis.

Please see agenda item A11(ii)a in the Board Reference Pack (BRP).

11. QUARTERLY NHSI DECLARATIONS

Board members will recall that as a Foundation Trust, Quarterly NHS Improvement (NHSI) declarations must be completed which require Trust Board approval, being:i) A declaration required by General condition 6 and Continuity of Service condition 7 of

the NHS provider licence. ii) A Corporate Governance Statement declaration (‘FT4 declaration’).

Due to the change in Board meeting dates from monthly to every two months, the quarterly declarations will be submitted to the next available Trust Board meeting for approval.

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Agenda item A11(ii)


Please see agenda item A11(ii)b in the BRP.

12. MODERN SLAVERY DECLARATIONS

Following agreement at the Audit Committee in July 2019, the Board is required to endorse the contents of the Modern Slavery Act Annual Declaration for 2019/2020 prior to sign off by the Chief Executive.

Please see agenda item A11(ii)c in the BRP.

13. COMMITTEE ANNUAL REPORTS

The Annual Committee reports are included within the BRP under item A11(ii)(d).

14. OTHER MATTERS

At the Audit Committee meeting on 23rd July it was agreed that the Schedule of Business for the Committee be amended to receive the Board Assurance Framework four times a year rather than twice a year.

15. UPCOMING DATES

Please note the following dates:

27 September – Review of the Year and Annual Members’ Meeting, Clinical Resource Building Education Centre, Royal Victoria Infirmary.

31 October – Board Development Session.

16. RECOMMENDATIONS

The Board of Directors are asked to (i) receive the update; (ii) note the contents; (iii) endorse the Modern Slavery Act Statement for 2019/20 included in the BRP (item A11(ii)(c)) and (iv) approve the quarterly NHS Improvement declarations.

Report of Kelly JuppTrust Secretary16 September 2019

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Agenda item A11(iii)

BOARD OF DIRECTORS MEETING


Title Board Assurance Framework and Trust Risk Management Report Q1

Report of Caroline Docking, Assistant Chief ExecutiveKelly Jupp, Trust Secretary

Prepared by Natalie Yeowart, Corporate Risk and Assurance Manager


☒ ☐ ☐


☐ ☐ ☒

SummaryThe purpose of this report is to detail the Board Assurance Framework, Executive Oversight Register and Trust Risk Management Quarter 1 (Q1) position.

Recommendations The Board of Directors are asked to note the Q1 risk position.


Put patients and carers first and plan services around them.Maintain compliance with all regulatory requirements.





Legal x

Financial x

Human Resources x



Sustainability x

Impact

Identifying, understanding, monitoring and addressing current and future risks throughout the Trust together with the proactive management, mitigation and (where possible) elimination of these risks is essential for efficient and effective delivery of safe, sustainable and high quality services.

Reports previously considered by Board Assurance Framework (BAF) and Trust Risk Register quarterly report.

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____________________________________________________________________________________________________Board Assurance Framework and Trust Risk Register Report Q1 ReportBoard Of Directors – 26th September 2019

BOARD ASSURANCE FRAMEWORK AND TRUST RISK MANAGEMENT REPORT

1. INTRODUCTION

Corporate risk management is an essential activity for healthcare organisations. Identifying, understanding and managing the uncertainties on objectives are critical to achieving success.

Risk Management is more than taking or avoiding risk. An important element of risk management is the development of a clear understanding of the risks pertinent to the organisation and ensuring principals of effective governance are in place to support a consistent and integrated approach to risk management.

The purpose of this report is to provide a quarter 1 update on the management of the Board Assurance Framework, Oversight Register and risk held on Trust-wide risk registers (Operational). Please refer to the Oversight Register (Appendix 1.0) and Board Assurance Framework (Appendix 2.0) documents included in the Board Reference Pack.

2. BOARD ASSURANCE FRAMEWORK (BAF) 2019– 2020 Q1

Each Committee of the Board has a responsibility to review, assess and gain assurance on the effectiveness of mitigations and action plans as set out in the Board Assurance Framework specific to the Committee purpose and function. On a quartely basis each Committee of the Board receives a report detailing the quartely Executive Lead review and any recommendations for risks held on the Board Assurance Framework aligned to that Committee. Please note that the People Committee are yet to receive their first assurance report due to the scheduling of the meetings and this will be reported in the August meeting.

The table below details the Executive Lead risk review, the assurance gained from the Committee and any comments/feedback received. The full Board Assurance Framework document can be found in Appendix 2.0.

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Risk Ref

Risk Description Current Score

Executive Risk Review Committee discussion/assurance received

Finance and Investment Committee S05.1 The 2019/20 Trust

Plan includes large cost improvement targets; there is a risk to delivering the national cost efficiency targets without compromising on quality.

4x4 (16)

Risk SO5.1 was populated by the Corporate Risk and Assurance Manager and content reviewed by the Deputy Director of Finance. All controls, assurances and further actions have been added in this quarter. Substantial Assurance has been received and added for four areas relating to finance; financial reporting, budgetary control, financial ledger and treasury and cash flow.

Following discussion with the Director of Finance a decision to reduce the current risk score from 5x3(20) to 4x4(16) has been agreed. Given the longevity of this risk, all actions are ongoing and will be under regular review throughout the year.

Committee members discussed the current scoring of 4x4(16) and questioned whether the score should increase as the risk of not achieving the cost efficiency target was high. It was agreed to feedback to the Corporate Risk and Assurance Manager for further discussion with the risk owner.

Further discussion around this risk has taken place and given the longevity of the cost improvement plan the risk owner is comfortable that the current scoring is appropriate. The current score will be monitored and adjusted in line with quarterly financial analysis.

SO1.1 Capacity and demand pressures could result in the Trust not achieving quality and operational standards.

5x3(15) SO1.1 has been reviewed consistently on a quarterly basis by the Chief Operating Officer. In March, minor amendments were made to the wording of control no 5 and no 7. One action relating to completion of the winter pressure plan is now complete and has been added to the controls and assurance section.

New actions (7, 8 and 9) have been added in the quarter with regard to delivery of the sustainability and improvement plan, development of a cancer strategy and development of system wide health and social care joint capacity and demand plan. Risk scores remain unchanged at 5x3(15).

Committee assured on the effective management of this risk.

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Risk Ref

Risk Description Current Risk Score


Finance and Investment Committee S01.7 Increasing costs to

defend against cyber security threats and the requirements to meet cyber security regulations could impact on the Trust's ability to deliver IT quality improvements and efficiency plans.

4x3(12) SO1.7 has been populated by the Head of IT and Corporate Risk and Assurance Manager. Final approval received by Chief Information Officer.

All controls, assurances, risk scoring and further actions have been added in this quarter. Risk actions to mitigate/reduce risk are expected to be completed in stages with an estimated completion time of 18 months.

The Chief Information Officer detailed the controls in place to monitor and manage this risk as well as the ongoing work regarding Cyber Essentials. The committee discussed the current scoring and whether this needed to be higher.

Committee members discussed similar cyber security incidents at external organisations. The Chief Information Officer agreed to contact an external organisation to gain information and learning from their cyber incident.

Following review of current scores, the Chief Information Officer is comfortable that the current risk score of 4x3(12) is an accurate score.

SO1.6 That we do not comply with health and safety through failing to maintain Trust estates and environments.

N/A N/A The Committee have asked that further consideration around the description and articulation of this risk is carried out by the Director of Estates to be reported in the next assurance report to Finance and Investment Committee.

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Risk Ref



Quality Committee SO1.2 Failure to achieve

required CQC standards could impact on the Trust's ability to remain "Outstanding"

4x3 (12)

SO1.2 is currently exceeding the Trust Risk Appetite. The risk has been reviewed by the risk owner in a timely manner. There is only one action remaining relating to the outcome of CQC Well Led Review. It is believed that following the completion of the remaining action this risk score will reduce.

Committee assured on the effective management of this risk.

SO1.4 That we fail to deliver safe, appropriate person centred care for our patients including the provision of safe environments and equipment.

4x2(8) SO1.4 was reviewed by the Director of Quality & Effectiveness. SO1.4 is currently within the Trust’s risk appetite. Risks within the Trust’s risk appetite should be considered for de-escalation to be managed at lower level in the Organisation.

Further consideration is needed with regard the articulation of the assurances in this risk to ensure measurable sources of assurance are included. However, if the assurances are reworded and can demonstrate that they are measurable; this would demonstrate a good level of control over this risk with reporting mechanisms in place to provide assurance to Board.

Committee note the need for further articulation of risk assurances and measurable content.

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Risk Ref



SO1.5 Due to the complexity of patient conditions, there is a risk of HCAI whilst in the care of the Trust which could result in harm, serious illness and affect the Trust's ability to achieve IPC standards of Care.

5x3(15) SO1.5 was reviewed by the Deputy Chief Nurse. Risk scores have reduced in the Quarter from 5x4 (20) to 5x3 (15). This risk is managed effectively and in a timely manner. Controls and assurances are documented and demonstrate robust assurance for the management and reporting of this risk through the governance structure.

Discussions between the Executive Chief Nurse, Deputy Chief Nurse and the Corporate Risk and Assurance Manager have taken place and all are in agreement that this risk should reduce to 15.

Discussion took place around the appropriate level to manage this risk. The Committee agree the reduction in the risk score from 20 to 15 is appropriate however feel this risk should remain on the BAF given the profile and significance of risk; and further that despite a number of actions having been taken, the numbers of HCAIs have not reduced significantly as yet to demonstrate that the actions taken have been fully effective.

Controls and actions are in place however the Committee noted further work is needed to effectively manage this risk.

S03.1 Uncertainty regarding local/Regional issues could affect the sustainability of NUTH services.

4x2(8) S03.1 was reviewed by Caroline Docking, Martin Wilson. It was felt that Trust is in a very favourable position in terms of the influence, membership and collaboration in local and regional issues. It was felt appropriate to reduce the risk score from 4x3(12) to 4x2(8)

Discussion took place with the Trust Chief Executive in relation to this risk and it was agreed that this risk is effectively managed and it was appropriate to reduce the risk score from 4x3 to 4x2.

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BOARD ASSURANCE FRAMEWORK Q1 POSITION

There have been no new risks added to the Board Assurance Framework in Q1. As at July 2019, there are currently 9 risks held on the Board Assurance Framework.

55

9 9 9

January 2019

March 2019

April 2019 July 2019 0

10

20

30

40

50

60

Number of Risks

The Number Of Risks Held On Board Assurance Framework 2019 -2020

The table below shows the 9 live risks broken down by risk type.

1

3

3

1

1

Compliance/Regulatory

Quality Outcomes - Safety

Quality Outcomes- Effectiveness

Finance/VfM

Reputation

Board Assurance Framework Risks by Risk Type

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RISK ESCALATION

There have been no escalations of risk to the Board Assurance Framework in the quarter (April-July 2019).

RISK CLOSURES

There have been no risk closures on the Board Assurance Framework in the Quarter.

3. EXECUTIVE OVERSIGHT

Following a review of compliance with the existing corporate risk register reporting the Executive Risk Group have agreed to move to an Executive Oversight approach. This approach allows the Trust to manage risk at the most appropriate level in the organisation whist maintaining Executive level oversight of risks which:

Risk owners have communicated the need for additional support; The risk is exceeding a risk appetite tolerance (currently 15+); and The risk indicates a significant/increased risk and/or shows weaknesses in management.

A risk which falls into the criteria will be initially discussed with the risk owner to explore risk in further detail.

Following review with the risk owner, the risk will be considered for addition to the Executive Oversight Register by the Executive Lead pertaining to the risk area of focus. The Executive Lead will be responsible for providing the Executive Risk Group with assurance that actions to address gaps in control or assurance are in place and being managed effectively supported by the Corporate Risk and Assurance Manager.

An Executive oversight report will be produced detailing risks which have been discussed with the risk owner and agreed by the relevant Executive Lead. This report will be submitted to the Executive Risk Group on a monthly basis for review and discussion. Following review by the Executive Risk Group the Executive Oversight Report will be circulated to all directorates for information. A flow chart to show this process is shown below.

EXECUTIVE OVERSIGHT PROCESS

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3.1. EXECUTIVE OVERSIGHT REGISTER There have been 4 risks added to the oversight register in June 2019. These risks are shown in the table below.

ID Directorate Risk Description Current Score3634 Medicine Excessive wait for mental health review in ED. 163679 Neurosciences Neuroradiology reporting delay and backlog. 153670 Musculoskelet

al Spinal – delay in investigations and surgery due to long waiting times.

16

2845 Urology and Renal

Insufficient ST level medical staff to deliver safe renal medical care.

20

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As at July 2019 there are 15 risks monitored via the Executive Oversight register. The table below shows the impact classification of the 15 risks on the Executive Oversight register. All risks have been reported and reviewed at Executive Risk Group.

4

5

3

3

Quality Outcomes - Safety

Quality Outcomes - Effectiveness

Compliance/Regulatory

Finance/VFM

The table below gives a summary of the movement of the 15 risks monitored on the oversight register.

Four risks have been added to the oversight register in June. Of these risks two risks are new risks opened in May requiring oversight (3679, 3670) and two risks are existing risks added to the oversight in June. (3634, 2845) There have been no risks removed from the Executive Oversight Register in the quarter.

Risk Ref

Risk Description Initial Current Target Movement in Quarter

2488 Breast service delivery affected by radiologist shortages.

8 20 4

2263 Contracting and Data Challenge. 16 16 4

3634 Excessive wait for mental health review in ED.

16 16 4

3165 Inability to provide blood transfusion services due to staffing shortages.

20 15 10

3591 Non-compliant with ventilation systems. 15 15 5

3676 Neuroradiology reporting delay and backlog 20 15 9 New risk May 19

Risk Ref

Risk Description Initial Current Target Movement in Quarter

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4. OPERATIONAL RISK

There are currently 457 risks held on the Datix Risk Register Module. This is a reduction of 52 risks which have been closed since April 2019.

Operational Risk Profile

The Estates Department continue to identify the largest number of risks (69) as well as the largest risk exposure compared to other Directorates/Departments.

In the quarter there has been an significant increase in risks in the total number of risks held by Childrens services, Cardiothoracic and peri-operative care. A review of themes in these areas have not highlighted any new themes or emerging risks. Work is underway to understand the increase in these areas and support staff to effectively manage risks at Directorate level.

3670 Spinal – delay in investigations and surgery due to long waiting times.

20 16 8 New riskMay 19

3525 Non-compliant passive fire protection 20 20 5

3593 Non-compliance with Control of Asbestos Regulations 2012.

15 20 5

3105 McKesson Cardiology IT System 15 20 4

3509 Reduction in Deprivation of Liberty Safeguards (DoLS) Applications.

15 15 3

3359 Inadequate UPS systems on both RVI and FH sites causing a risk of failure to take over the power supply which may result in a total power failure throughout the affected Trust sites.

15 15 5

2845 Insufficient ST level medical staff to deliver safe renal medical care.

10 20 6

2881 New Models - Work is moving on a pace to introduce new, system-based governance models in Northumberland. This could result in capped funding in future.

16 16 12

3323 CCG VBC Policy 20 20 16

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The table below shows the total number of open risks by each Directorate broken down by risk level.

Directorate/Department Low Medium

Risk HighVery High Risk

Extreme Risk Total

Estates 1 5 32 19 2 61Children's Services 2 9 30 8 0 49Cardiothoracic Services 1 5 22 2 1 31Peri-operative and Critical Care 0 4 23 2 0 29Directorate of Medicine 0 6 12 9 0 27Integrated Laboratory Medicine 1 4 14 7 0 26Patient Services 0 2 19 3 0 24Neurosciences 0 1 15 1 0 17Surgical Services 1 2 14 0 0 17Urology and Renal Services 0 1 10 4 1 16Information Technology 0 8 6 1 0 15Musculoskeletal Services 0 6 7 1 0 14Northern Medical Physics 0 1 7 5 0 13Community 0 1 8 3 0 12Radiology 0 0 10 1 1 12Women's Services 1 1 3 7 0 12Business and Development 0 2 7 1 1 11EPOD 0 0 6 3 1 10Medical Director's Directorate 1 6 3 0 0 10NCCC & Specialist Haematology 1 1 7 0 0 9Finance 0 4 2 2 0 8Pharmacy 0 0 6 1 0 7Dental Services 0 0 5 1 0 6Supplies and Procurement 2 0 4 0 0 6Institute of Transplantation 1 2 0 2 0 5Human Resources 0 1 2 0 0 3Regional Drugs and Therapeutics 2 1 0 0 0 3Research 1 0 2 0 0 3Chief Operating Officer 0 0 1 0 0 1Total 15 73 277 83 7 457

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Risk types are selected for each risk on the Datix risk system. The table below shows the top 5 risk categories with the highest number of risks as at July 2019. The risk type with the highest number of risks was Safety of patients, public or staff with a total of 188 risks.

188

69

50

2718

Safety of patients, staff or public

Service / business interruption

Quality / Complaints / Audit

Finance including claims

Human resources / organisational development

0

20

40

60

80

100

120

140

160

180

200

Total Number of Risks

Total Number Open Risks by Risk Type as at July 2019

5. RECOMMENDATIONS

The Board of Directors are asked to:

Receive the report for the Q1 period. Provide any comments or feedback.

Natalie Yeowart Corporate Risk & Assurance Manager 19th September 2019

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ID Opened Directorate Title Description Rating (initial)

Rating (current)

Rating (Target)

Controls in place Actions Manager

2488 26.11.2013 Radiology Breast Service Delivery Affected

by Radiologist Shortages

Many senior members of the breast unit are about to or have recently retired. Breast radiologists are in short supply nationally so recruitment is proving to be difficult. Additionally there are on going issues with providing breast imaging in Carlisle that compounds the problem. Increased demands on the service through patients lost to screening and need to offer them additional appointments is also challenging.

8 20 4 1. Looking to support registrars with breast interest. 2. Radiologist with interest in breast and paediatric radiology has moved more to breast radiology to help with demand.3. Have trained consultant radiographers in breast imaging. 4. Additional evening and weekend clinics are running.5. 2 appointments made for additional Consultant mammographers.

1. Escalation of risk to symptomatic and screening breast services. 2. Resolve carlisle issues. 3. Aim to recruit new consultant.

Mr Gordon Kirkup

2263 02.08.2012 Finance Contracting and Data Challenge

There is a risk of significant finance ail loss to the Trust due to data challenges.

Commissioners have a implemented a process of data challenge involving the identification of any data they feel is incorrect and the threat not to pay for that activity.

16 16 1 1. The risk of challenges is monitored monthly and included in the finance report to the Board and Finance and Investment Committee.2. Internal PbR Group in place to ensure that all activity delivered in the Trust is appropriately classified and coded. The group will work out how the Trust will be paid for new types of activity.3. Activity and income is reconciled quarterly in the cash-up process.4. Active chasing of all outstanding debtors to secure payment by Commissioners.

1. Monitor process 2. investigate the feasibility of monthly cash up. 3. Communication to clinical directorates. 3. Education sessions. 4. Monitor the quartely loss throughout 2019/20 for trend.

Angela Dragone

3634 14.02.2019 Medicine Excessive wait for mental health review in ED

There is a risk that patients who present to ED with mental health issues may spend excessive periods of time in the ED awaiting mental health review. This is due to long waits for assessment by appropriate mental health services, lack of suitable mental health treatment options and shortage of mental health beds. This results in a poor patient experience negative impact on patient health. Criteria used to establish rating = requiring time off work for >14 days/major injury leading to long term disability/incapacity, Mismanagement of patient care with long-term effects. Non-compliance with national standards with significant risks to patients if unresolved. We have records of this happening regularly. e.g. A patient with a known psychiatric history was brought into the Emergency Department intoxicated and suicidal. He absconded and jumped from a bridge whilst waiting to be transferred to a bed in Northumberland Tyne and Wear Mental Health Trust (NTW), sustaining multiple major injuries.

16 16 4 1. Early identification of high risk patients so they can be moved into a mental health appropriate room within ED when available.2. Working with estates to explore changes that would allow a second mental health room to be provided.3. Multiagency forum with NTW to open conversation around mental health patients presenting to ED and what improvements can be made. This is part of the national CQUIN which aims to reduce attendances to the ED in partnership with NEAS, NTW and commissioners.4. Increase in care plans being put on place and easy to access for front line staff

Dawn Youssef

3165 18.01.2017 Integrated Labs Inability to provide blood transfusion

services due to staffing shortages

There is a risk that the blood transfusion service cannot be provided 24/7. This is due staff retention problems within Blood Sciences. This issue is particularly acute within Haematology and Blood Transfusion whereby the current out of hours staffing complement of 1:8 has compromised our ability to maintain a Blood Transfusion Service on the Freeman site on two separate occasions. Although our business continuity plan would involve cross site transfer of specimens, the acute nature of the clinical work undertaken at Freeman, including transplant patients requires on-site Blood Transfusion to maintain patient safety. It must also be noted that due to the nature of the work undertaken in Blood Transfusion staff must receive ongoing training and competence assessment on a site specific basis. As a result it is extremely difficult to utilize any form of short term Bank staff or locum support if we encounter a significant staff shortfall.

20 15 10 1. Recruit trainee staff on very regular basis. Staff are internally trained and developed.2. Rota patterns are being reviewed to make them more appealing.3. Financial bonding in place for newly appointed trainees. 4. Due to start training new cohort of staff soon.

Christopher Shaw

Executive Risk Oversight Register - June 2019


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Rating (current)

Rating (Target)


3591 07.12.2018 Estates Non compliant Ventilation

Systems

Ventilation systems are non compliant with HTM 03-01Cause: Ageing infrastructure and lack of suitable investment through lifecycle maintenance. Consequence: Risk of patient harm due to outbreak of Air Borne Disease - MRSA and Clostridium difficile, Tuberculosis / Legionella etc, potential non compliance with statutory regulation (including CQC), with potential prosecution, financial penalties and adverse publicity.

15 15 5 1. Management and maintenance of Heating and Ventilation systems are reviewed and monitored by the Trust Ventilation Safety Group. 2. A full review of planned maintenance has been undertaken and a robust maintenance schedule is now in place. 3. A collaborative risk assessment has been undertaken with Infection Prevention and Control to prioritise replacement of identified air handling units (AHU).

1. Replace priority AHU Andy Fairless

3679 23.05.2019 Neuro sciences

Neuroradiology reporting delay

and backlog

Current waiting times for routine scans is at 60 days. KPI is 14 days. This is due to Impact of pension changes staff have reduced PA back to 10 resulting in loss of reporting sessions. Staff are less willing to do WLI which has been the main vehicle to managing demand in the past. Also push to uncouple INR and DNR rota faster to allow delivery of MT servcie

20 15 9 1. Demand and Capacity modeling is being carried out.2. Increased non medical reporting.

1. Seek approval of funds from Execs. 2. Exploring outsourcing options mirroring Radiology

Christopher Wright

3670 09.05.2019 MSK SPINAL - delay in investigations and

surgery due to long wait times

Demand exceeds capacity and there are long waiting times for outpatient appointments and surgery for degenerative and deformity spinal patients. High risk of 52 week breaches. Current failure to meet RTT target. High number of patient complaints.

20 16 8 1. Weekly review of waiting list. 2. theatre and outpatient capacity and liaising with clinical team for prioritization.

1. Demand and capacity review. 2. Weekly review of waiting list

Robert Willers

3525 13.09.2018 Estates Non-Compliant Passive Fire Protection

Increased risk of fire and smoke spread due to non-compliant passive fire protection throughout the Royal Victoria Infirmary Site. Full extent of deficiency is unknown.Cause: Compartmentation breaches within fire walls, floors and ceilings. Significant defects and lack of information associated with Fire Door sets and Dampers.Consequence: Risk to life, smoke inhalation, excess loss of premises/assets in the event of fire spread. Non-compliance with Regulatory Reform (Fire Safety Order) which would lead to legal proceedings, prosecution, financial penalties and damage to the Trust’s reputation. Inability to rely on compartmentation can impact current evacuation procedures (Progressive horizontal) which can lead to unnecessary service disruption.

Catastrophic - Incident leading to death, Multiple permanent injuries or irreversible health effects, an event which impacts a large number of patients (there are many more catastrophic outcomes).

20 20 5 1. All areas are covered by an up to date fire risk assessment. 2. Amendments to local evacuation procedures to ensure they are suitable and sufficient where deficiencies are known. 3. A Q Mark accredited maintenance regime for fire doors has been implemented across the Trust. 4. Standardised schedules that have been agreed with the Trust Fire Safety team.

1. Embed fire permits.2. Passive fire protection survey - compartmentation. 3. Passive fire protection survey - fire/smoking dampers.4. Passive fire protection surveys - fire doors.

Rob Smith

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Rating (current)

Rating (Target)


3593 07.12.2018 Estates Non Compliance with Control of

Asbestos Regulations 2012

Non compliance with Control of Asbestos Regulations 2012, Regulation 4 'Duty to Manage' which requires duty holders to identify the location and condition of asbestos in non-domestic premises and manage the risk to prevent harm. Cause: Lack of robust information as existing surveys are deemed inadequate in line with current standards. Consequence: Risk of exposure to Asbestos by Trust staff and contractors , non-compliance with CAR 2012 which could lead to prosecution and financial penalties with a negative impact on the Trust’s reputation.

15 20 5 1. Revised policy 2. Implementation of an Asbestos Management Plan. 3. Trust wide Asbestos Management Group 4. Qualified and competent staff in post with specific responsibilities to manage asbestos. 5. Existing surveys in place although these are out of date and need to be updated.

1. Management surveys trust-wide.2. Communications procedure for staff and contractors. 3. Develop comprehensive asbestos register.

Stephen Lynch

3105 28.09.2016 Cardio McKesson Cardiology IT

System dated and requires upgrade

There is a risk of loss of patient information and disruption of services due to the current McKesson echo reporting system requiring an upgrade/refresh. It poses a significant risk due to the age of the hardware as well as the operating system (Windows XP) which reached the end of its life in 2015. This has been unsupported since 2017 posing a potential security risk for the network.

15 20 4 Business case submitted and IT are now in exclusive discussions with McKesson to seek a quote for a replacement system. Update 17/1/19: IT currently in discussion with McKesson about implementation.6/2/19: Paper submitted to CMG for procurement and installation costs. 7/2/19: Presentation at CMG delayed by Exec Team. Daily concerns now around efficiently of system. Decision made by Directorate Management to increase likelihood to 'likely to occur on many occasions'. Evidence in place to support this.

1. Business case/capital request being drafted.2. IT to liaise with McKesson to cost up replacement. 3. Update regarding implementation.

Rachel Lonsdale

3509 14.08.2018 Patient Services Reduction in Deprivation of

Liberty Safeguards (DoLS) Applications

The number of DoLS applications across the Trust have reduced since April 2017 when the process change and responsibility fell to ward staff to complete the applications. Patients may be illegally detained without an appropriate legislative framework. Patients who should be deprived of their liberty under the MCA/DoLS framework may be at high risk if they are allowed to leave Trust services. The CQC are likely to focus on the application of the MCA & DoLS in future inspections, so there is a regulatory impact.

15 15 3 There is a DoLS action plan in place that includes:1) Audit process to monitor implementation/compliance across the Trust2) additional training specific to MCA / DoLS3) Escalation process to DM's & CD's & to Safeguarding Committee

1. continue to implement and monitor action plans. Jo Gamble

3359 08.11.17 Estates Inadequate UPS and IPS systems (Mains power

issues)

Mains power outage with a risk of failure of the backup system and also inadequate IPS system. Cause: Inadequate UPS systems on both RVI and FH sites causing a risk of failure to take over the power supply which may result in a total power failure throughout the affected Trust sites. IPS system may potentially cause local ‘nuisance’ power cuts through equipment tripping. Consequences: Risk of serious patient harm or death in the event of a total power failure through the loss of essential electrical equipment. Risk to Trust reputation, prosecution, financial penalties, media interest etc.

15 15 5 1. Standby generators in place and run on load. 2. Electrical transformer and switchgear maintenance undertaken. 3. Regular routine maintenance and electrical testing within theatres and areas without UPS.

1. Install UPS and IPS systems at RVI and Freeman. Andy Fairless

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Rating (current)

Rating (Target)


2845 09.09.2015 Urology and Renal Insufficient ST Level Medical staff

to deliver safe Renal medical care

There is a risk to patient safety and staff wellbeing on the Renal unit. This is due to the reduction in number of specialist trainees (ST) available to Freeman Hospital for multiple reasons, which has resulted in lack of Junior Doctor cover for key services. The consequences of this are: Compromised patient safety, Poor patient experience, Increased workload on existing junior doctor team and impact on their wellbeing, Poor training experience for juniors, Poor GMC survey results and reputational damage with impact on recruitment and risk of loss of training posts from NUTH to other regional centres, Impact of unmet demand on nursing staff, Increased workload on consultants especially the on call consultant with reduced availability for training and associated stress, Reduction in OP activity due to reduced trainee availability and corresponding increase in waiting times, particularly for review appointments, Risk of both junior rotas (tier 1 and tier 2) having coinciding gaps in the on-call rota, Risk of non-compliant rota breaching the new contract.

10 20 6 1. Proposal for HD Nurse Practitioner to be developed. 2. Review of medical staff to be undertaken, including consideration of move to increase in consultant delivered services. 12/4/16 - 2 x temp junior doctors in place acting as CMT 12/7/16 - all junior doc posts recruited in to next rotation - so risk downgrade by directorate clinical governance comm01/05/17 - MTI recruited and in post 4/9/17 - reduced trainee commitment to OPD and HD until 21/5/18 - second MTI in post. Ideally all posts would be fully recruited regionally with FT Specialist Trainees, or appropriate numbers of LTFT Trainees.Aug 18: Risk downgraded due to recent improvements in rota cover and elimination of gaps. The Director of Medical Education is liaising with the service Clinical Lead regarding future-proofing of staffing.Second MTI in post. Use of locums to cover vacant on-call shifts.Prioritisation of workload to maintain patient safety.

1. Junior Doctor recruitment. 2. Respond to GMC Survey. 3. Submit proposal for additional nurse practitioners. 4. Education Leads request that HR seek locum cover for identified gaps. 5. Education leads seek cover personally from network of colleagues. 6. Advice and guidance to be introduced asap to reduce ST workload when on call, fielding GP calls about non urgent matters. 7. Referral management systems to be introduced (under discussion with Dr Plummer) to limit phone calls to STs when on call.

Dr Katrin Jones

2881 05/11/2019 Business & Development

New models of care in surrounding

localities

Work is moving on a pace to introduce new, system-based governance models in Northumberland. This could result in capped funding in future with a neighbouring FT provider having control over resources for services currently provided by this Trust, with consequent risk around future income streams and developments.North Tyneside has established a Future Care Programme Board to look at establishing an MCP in North Tyneside and Primary Care Homes in each of its localities.Gateshead has established a Gateshead Health and Care Partnership and are evaluating the merits of a potential ICP.

16 16 12 1. Executive engagement in Northumberland System Transformation Board, Future Care Programme Board for North Tyneside and the Gateshead Health and Care Partnership.2. Decision-making around engagement and risks discussed on a monthly basis atthe Trust Board3. Legal advice shared with another FT

1. Trust away day 2. Engagement on developments

Helen Byworth

3323 19.09.17 Business & Development

Financial risk due to CCG Value Based

Commissioning Policy

Risk of financial losses due to CCG mandated prior approval scheme for 'procedures of limited clinical value’ (tonsillectomies, bunions and the like). Services have to seek prior approval (obtain a ‘PAT’ ticket) and CCGs will not pay for activity that proceeded without one from 1st August 2017.

20 20 16 Trust is in continual negotiations with commissioners. The Trust has communicated all recognised concerns, and negotiated a few exceptions to the process. The contract has dispute mechanisms in place and the contracting team has ensured all communication places the Trust in a strong position should it escalate to dispute resolution. A year-end agreement for 2017/18 protected some Trust income in the short-term.

1. Seek legal advice.2. Clear audit trail and engagement at senior level. 3. Engagement with other FT's. 4. Process for minimising commissioner challenge to be better embedded with clinical directorates.

Helen Byworth

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BOARD ASSURANCE FRAMEWORK

Q1 2019/2020

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Strategic Objective: 1Putting patients first and providing care of the highest standard focusing on safety and quality.Strategic Risk Description: Capacity and demand pressures could result in the Trust not achieving quality and operational standards.

Risk Rating: Impact Likelihood Score Rating Risk Appetite: Key Element: Quality Outcomes

Inherent Risk (risk on identification) 5 4 20 High Risk Appetite: Low Residual Risk (current risk)5 3 15 Moderate Risk Appetite Score: 6-10 (5x5) Target Risk: 5 2 10 Low

Controls & Mitigation Assurances/Evidence Gaps in Control/Actions Timescale

1. Monthly performance monitoring and reporting.1. Reporting via Operational Policy Group, 1. National Waiting List Reduction Initiative.2. Weekly performance monitoring. sub committees and BoD. 2. Review of radiologist staffing shortages. 3. Operational Plan 18/19. 2. Weekly reporting to Exec Team. 3. Delivery of Operational Plan 19/20.4. Contract and performance metric data. 3. Operational Plan reviewed by NHSI. 4. NICU staffing and opening of additional 5. Monitoring of operational performance dashboard. 4. Regular collection and analysis of data beds. 6. Operational Policy Group Meeting. reported via Integrated report. 7. Delivery of sustainability and improvement 7. Performance Improvement plans. 5. Integrated report via BoD. plan. 8. Nurse staffing escalation plan. 6. Minutes of Operational Policy Group 8. Development of cancer strategy. 9. Winter pressure plan 18/19.Meeting. 9. Development of system wide Health and

7. Performance improvement plans. social care joint capacity and demand plan. monitored at Operational Policy Group. 8. Nurse staffing escalation plan. 9. Winter pressure plan document.

Ref: SO1.1Review Comments: minor amendments to the wording of control no5 and no7. Gap in control/action re: development of e-referral process removed. Amendment to the wording of action no3 from radiology to radiologist. Action no4 complete and moved to controls. Gap in control/actions added (no7,8,9)Executive Lead: Board Sub Committee: Updated/Review Date:

Chief Operating Officer Finance and Investment May 2019

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Strategic Objective: 1Putting patients first and providing care of the highest standard focusing on safety andquality.Strategic Risk Description: Failure to achieve required CQC standards could impact on the Trust's ability to remain "Outstanding"

Risk Rating: Impact Likelihood Score Rating Risk Appetite: Key Element: Reputation

Inherent Risk (risk on identification) 4 4 16 Moderate Risk Appetite: Low Residual Risk (current risk)4 3 12 Moderate Risk Appetite Score:6-10 (5x5) Target Risk: 4 1 4 Very Low


1. CQC Quarterly report. 1. Quarterly report to BoD. 1. Await outcomes of CQC. 01.05.20192. Insight presentation to Board. 2. No outliners identified through Insight3. CQC 2016 must and should action plan. 3. CQC 2016 must and should completed4. CQC engagement with staff. action plan. 5. CQC task and finish Group. 4. CQC engagement plan delivered to staff.6. Peer Review Process.4. CQC handbook. 7. IRMER Action Plan 4. CQC resources page Internet.

5. CQC Task and Finish Group minutes and meeting minutes. 6. Peer Review Process outcomes/resultsreported via Integrated report to BoD. 7. Completed IRMER action plan.

Ref: SO1.2Review Comments: Risk Reviewed by CEO.Executive Lead: Board Sub Committee: Updated/Review Date:

Chief Executive Officer Quality Committee June 2019

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Strategic Objective: 1Putting patients first and providing care of the highest standard focusing on safety and quality.Strategic Risk Description: That we fail to deliver safe, appropriate person centred care for our patients including the provision of safe environments and equipment.Risk Rating: Impact Likelihood Score Rating Risk Appetite:

Key Element: Quality Outcomes Inherent Risk (risk on identification) 4 4 16 Moderate Risk Appetite: Low Residual Risk (current risk)4 3 12 Low Risk Appetite Score:6-10Target Risk: 4 1 4 Very Low

Controls & Mitigation Assurances/Evidence Gaps in Control/Actions Timescale1. Application of NHS Core Standards for EPRR.1. Compliance with core standards 1. Delivery of the Quality Strategy 01.04.20202. Adherence to CQC Fundamental standards monitored via EPRR steerring group. 2. CQC inspection 2019 31.06.20193. Clinical standards, policies and guidelines.2. Quality and clinical governance infrastructure, including audit 3. Develop system to capture CQC Assurance 31.07.20194. Evidence-based practice3. Clinical audit programmes, internal and external reviews5. Records Management Governance 4. Monitoring of clinical outcomes 6. Incident reporting and management process5. NUTH 1819 32 Records Management7. Safeguarding strategy and governance arrangementssubstantial assurance. 8. Patient safety and quality review 6. CGARD monitoring and analysis of 9. Medicines Management Governance structure patient safety incidents reported to BoD10. Clinical Quality Governance arrangementsvia Integrated report. 11. CQC inspection 2016 7. Monitoring compliance with safeguarding strategy and policy12. Robust HR/recruitment processes8. Patient safety reviews 6 monthly and

annually -reported to Quality Governance Group 9. Reporting to Quality Committee 10. Internal and external peer review process11. CQC inspection rating 'Outstanding'12. Review of compliance against policy

Ref: SO1.4Review Comments: Risk reviewed by Director of HR, Associate Director of Nursing and Deputy Chief Nurse, controls, assurances and actions added. Scoresreviewed and remain the same.Executive Lead: Board Sub Committee: Updated/Review Date:

Medical Director/Executive Chief Nurse Quality Committee June 2019

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Strategic Objective: 1Putting patients first and providing care of the highest standard focusing on safety andquality.Strategic Risk Description: Due to the complexity of patient conditions, there is a risk of HCAI whilst in the care of the Trust which could result in harm, seriousillness and affect the Trust's ability to achieve IPC standards of Care.Risk Rating: Impact Likelihood Score Rating Risk Appetite:

Key Element: Quality Outcomes Inherent Risk (risk on identification) 5 5 25 High Risk Appetite: Low Residual Risk (current risk)5 3 15 Moderate Risk Appetite Score:(6-10)Target Risk: 5 2 10 Low


1. Monthly Quality & DIPC report 1. Bimonthly Report via Trust Governance Structure 1. Consider ways to improve individual 2. Directorate SIRM & HCAI Action Plans (Quality and Board of Directors) compliance 3. Trust focus and education for IPC including 2. Monitoring of Action Plans at Directorate SIRMGood Antimicrobial Stewardship3. IPC Training, education and compliance monitoring4. IPC policy and Procedure 4. Annual policy compliance and review 5. IPCC delegated sub groups 5. Minutes of IPCC delegated sub groups 6. Environmental/cleanliness monitoring6. Monitoring and Review at IPCC Meeting 7. Performance Reporting 7. Integrated Quality & Performance Report/Executive Chief8. Audit programme Nurse Report to Board of Directors9. SSI surveillance8. Robust audit programme in place monitored at IPCC 10. National reporting 9. SSI mandatory surveillance reviewed at IPCC11. IPC Operational Plan 10. National mandatory reporting benchmarking reviewed

at IPCC 11. Monitoring of Operational Plan via IPCC Meetings.

Ref: SO1.5Review Comments: Executive Lead: Board Sub Committee: Updated/Review Date:

Executive Chief Nurse Quality Committee July 2019

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Strategic Objective: 1Putting patients first and providing care of the highest standard focusing on safety and quality.Strategic Risk Description: If we fail to maintain Trust estates and environments there is a risk to the safety of patients, staff and visitors which could impact on the quality ofcare and reputation of the Organisation.Risk Rating: Impact Likelihood Score Rating Risk Appetite:

Key Element: Inherent Risk (risk on identification) 0 0 0 Very Low Risk Appetite: Residual Risk (current risk)0 0 0 Very Low Risk Appetite Score:Target Risk: 0 0 0 Very Low


Ref: SO1.6Review Comments: Further consideration around the description and articulation of this risk is required by the Director of Estates and will be reported into the next meeting of the Finance and Investment Committee. Executive Lead: Board Sub Committee: Updated/Review Date:

Director of Estates Finance and Investment

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Strategic Objective: 1Putting patients first and providing care of the highest standard focusing on safety and quality.Strategic Risk Description: Increasing costs to defend against cyber security threats and the requirements to meet cyber security regulations could impact on the Trust'sability to deliver IT quality improvements and efficiency plans.Risk Rating: Impact Likelihood Score Rating Risk Appetite:

Key Element: Quality Outcomes Inherent Risk (risk on identification) 4 5 20 High Risk Appetite: Low Residual Risk (current risk)4 3 12 Moderate Risk Appetite Score: 6-10Target Risk: 4 1 4 Very Low


1. Improvement to antivirus and firewall software1. Activity captured and analysed by IT Dept 1. Implement vunerable management Estimated 2. Cyber alerts 2. Procedure in place to alert to Cyber incidents 2. Develop exception reporting from system to be staged 3. Website filtering 3. Software in place to monitor access to suspcious website log. over 18 4. Annual external review of security 4. Asssurance report received from External Review 3. implement access control to control months 5. Penetration testing 5. Internal reporting of Penetration Test 3rd party support software 6. Cyber Security Training 6. Training package delivered to staff 4. Implement enhanced password security 7. IT Hints and Tips communications 7. Circulated monthly to all staff 5. seek approval of Cyber essentials business 8. Windows security patches 8. Compliant with all windows security patches Case 10. Cyber essentials standard 10. Certification of achievement of standardRef: SO1.7Review Comments: All controls, assurances, risk scoring and further actions have been added in this quarter. All controls, assurances, risk scoring and further actions have been added in this quarter. Risk actions to mitigate/reduce risk are expected to be completed in stages with an estimated completion time of 18 months. Executive Lead: Board Sub Committee: Updated/Review Date:

Chief Information Officer Finance and Investment Committee July 2019

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Strategic Objective: 3Working in partnership to deliver fully integrated care and promoting healthy lifestylesto the people of Newcastle and beyond.Strategic Risk Description: Uncertainty regarding local/Regional issues could affect the sustainability of NUTH services.

Risk Rating: Impact Likelihood Score Rating Risk Appetite: Key Element: Quality Outcomes

Inherent Risk (risk on identification) 4 4 16 Moderate Risk Appetite: LowResidual Risk (current risk)4 2 8 Low Risk Appetite Score:6-10Target Risk: 4 1 4 Very Low


1. Current engagement and discussions at regional and 1. Updates via Chief Executives Report 1. Delivery of Acute Hospital collaboration Ongoing national meetings. 2. Updates at Executive Team Meeting workplan2. Active member of Shelford Group, NHS Provider and 3. Working closely with national leaders to influence 2. Delivery of JDG workplan. NHS Confed. NHS policy. 3. Chief Executive Chair of Shelford Group. 4. Regular updates via B&D report and CEO report to Board. 4. Chief Executive role in STP workstreams. 5. Minutes of ICS and ICP meetings 5. Active invovement in ICP and ICS. 6. Minutes of Meeting and updates via BoD and Exec Team6. Member of ICS Health Strategy Group. 7. Updates to Exec Team and Board 7. Chief Executive member of JEG and JDG.8. Regular attendance and alliance working with group. 8. Alliance working with Newcastle GP,NEAS9/10/11/12. Active contributor in regional systems and on urgent care models. collaborations9. Active engagement in Gateshead Health and Care system. 10. Active engagement in North Tyneside Future Care. 11. Member of Northumberland System TransformationBoard 12. Member of Acute Hospital Collaboration. Ref: SO3.1Review Comments: S03.1 was reviewed by Caroling Docking, Martin Wilson and discussed with Dame Jackie Daniel. . It was felt that Trust is in a very favourable position in terms of the influence, membership and collaboration in regional issues. It was felt appropirate to reduce the risk score from 4x3(12) to 4x2(8) Executive Lead: Board Sub Committee: Updated/Review Date:

Chief Executive N/A June 2019

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Strategic Objective: 4Enhancing our reputation as one of the Country's top, first class teaching hospitals, promoting aculture of excellence in all we do.Strategic Risk Description: Inability to recruit and retain staff including qualified nurses, specialist staff and medics could result in the inability to provide safe, effective, highclass services.Risk Rating: Impact Likelihood Score Rating Risk Appetite:

Key Element: Quality Outcomes Inherent Risk (risk on identification) 4 4 16 Moderate Risk Appetite: Low Residual Risk (current risk) 4 3 12 Moderate Risk Appetite Score:6-10Target Risk: 4 1 4 Very Low


1. Trust Nursing & Midwifery staffing guidelines 1. Gap analysis demonstrating high level of compliance 1. Completion of NMRRG action plans and 01.04.20202. International recruitment with national staffing guidance workstreams to improve recruitment and 3. Safe Staffing performance 1. Compliance with national guidance (NQB and NHSI) retention. 4. Acuity and dependancy tool 2. International recruitment plan in place 2. Delivery of Trust Equality Action Plan. 5. Nursing and Midwifery Recruitment retention3. Safe Staffing Metrics monitored and reported in 3. Delivery of Trust-wide workforce strategy Group Chief Nurse report to Board including any areas of concern 4. Teaching fellow/surgical rota scheme 6. Trustwide Workforce Strategy 4. Regular monitoring of staffing requirements using 5. Delivery of bespoke recruitment campaign7. oversees recruitment campaign accuity and dependancy tool 6. review of utilisation of apprenticeship scheme 8. B5 Development Programme 5. Minutes of Nursing and Midwifery retention group9. Member of Cavendish Group 6. Strategy Document/action plan 10. Benefits everyone package in place 7. IQ&P Report via Board of Directors 12. Florish at work campaign 8. Programme in place, workforce data reviewed by 13. Trust Equality objectivesDirector of HR and Team, retention of staff successful.

9. Enhanced local involvement 10. Attractive benefit scheme in place for staff. 12. Ongoing health and wellbeing programme 13. Action plan in place.

Ref: SO4.1Review Comments: N=Nursing, SS=specialist staffing, M=medical staffing Executive Lead: Board Sub Committee: Updated/Review Date:

Director of HR People Committee June 2019

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Strategic Objective: 5Maintaining sound financial management to ensure the ongoing development and success of ourorganisation.Strategic Risk Description: The 2019/20 Trust Plan includes large cost improvement targets, there is a risk to delivering the national cost efficiency targets withoutcompromising on quality.Risk Rating: Impact Likelihood Score Rating Risk Appetite:

Key Element: Financial Inherent Risk (risk on identification) 5 5 25 High Risk Appetite: Moderate Residual Risk (current risk)4 4 16 Moderate Risk Appetite Score: 12-16Target Risk: 4 1 4 Very Low


1. Directorate action plan in place 1. Clear targets allocated to Directorates. 1. Ongoing monitoring of CIP Ongoing 2. Annual Plan in Place. 2. Monitored via Finance and Investiment Committee. 2. Support Directorates and Corporate 3. Performance Monitoring 3. Monitoring of Finance at Finance and Investment Managers to deliver CIP 01.04.20204. Transformation workstreams with assigned Executive Committee meeting via Finance Report. 3. Engage with all Directorates to deliver Team lead 3. Finance Director Report to BoD monthly Board Approved Sustainability Transformation 5. Directorate Performance Reviews 3. Integrated Performance Report to BoD monthly Plan in partnership with Mckinsey 01.04.20206. Finance Policy and Procedures 4. Updates and monitoring Sustainability, Improvement7. Finance and Investment Committee Newcastle Group8. Mckinsey appointed as sutainability partners. 5. Review documentation and Action plans. 9. Sustainability Improvement Newcastle Group6. Annual review of Financial policy and procedure.

6. Compliance with Regulatory requirements6. NUTH 1819 12 Financial Reporting - Substantial Assurance6. NUTH 1819 13 Bugetary Control - Substantial Assurance6. NUTH 1819 17 Treasury & Cashflow - Substantial Assurance 6. NUTH 1819 11 Finance Ledger - Substantial Assurance 7/9. Minutes of Meeting. 8. Board sustainability plan.

Ref: SO5.1Review Comments: Executive Lead: Board Sub Committee: Updated/Review Date:

Director of Finance Finance & Investment July 2019

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Internal Audit Plan

Audit Review Area2018/2019

Q1 Q2 Q3 Q4Final Issue

Date Audit Ref BAF RefAssuranceReceived

Assuranceto BAF

Management of Projects ·External Reviews ·Hosted Services - LCRN · 12.12.2018 NUTH 1819 08 B1.1 n/aStandards of Business Conduct Policy · 23.04.2019 NUTH1819 09 ¤ Substantial Risk Management · 21.08.2018 NUTH 1819 09 A2.1 GoodFinancial Ledger · 07.12.2018 NUTH 1819 11 ¤ SubstantialFinancial Reporting · 19.09.2018 NUTH 1819 12 ¤ SubstantialBudgetary Control · 23.11.2018 NUTH 1819 13 E1.1 Substantial Accounts Payable · 01.02.2019 NUTH1819 14 E1.1 Substantial Accounts Receivable ·Payroll Controls · 02.05.2019 NUTH1819 16 ¤ Substantial Treasurery/Cash flow management · 12.11.2018 NUTH 1819 17 E1.1 Substantial Income Source - Private Patients ·Income Source - Private patients Embassy Staff · 27.09.2018 NUTH 1819 19 ¤ Good Income Source - Overseas visitors ·E-procurement ·Ordering and receipt of goods and services · 17.07.2018 NUTH 1819 22 ¤ Limited Charitable funds · 16.01.2019 NUTH 1819 23 ¤ SubstantialCentral cashier · 12.09.2018 NUTH 1819 24 ¤ Good Patient money and property ·Cost Improvement Programme ·NHS Improvement ·Monitoring care quality commission/NICE · 30.08.2018 NUTH 1819 28 A2.1 GoodPerformance Monitoring/Management · · ·Sustainable Development/CRC Scheme · 16.07.2018 NUTH 1819 33 ¤ SubstantialRecords Management · 31.10.2018 NUTH 1819 32 A2.1 Substantial PFI Contract Monitoring ·Insurance arrangements · 12.09.2018 NUTH 1819 35 ¤ Reasonable Recruitment - Temporary Staffing ·Recruitment - Medical Staffing ·Time and attendance systems ·Management of Volunteers · 02.10.2018 NUTH 1819 39 D2.1 Limited Occupational Health · 27.09.2018 NUTH 1819 40 ¤ Substantial Absence Management - Consultants ·Bank and Agency ·Medical Staffing - payroll controls · 20.12.2018 NUTH 1819 70 ¤ ReasonablePayroll - Very Senior Management/LPA ·Estates Governance · 17.08.2018 NUTH1819 45 Good

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Estates Procurement ·Asbestos Management · 13.02.2018 NUTH1819 47 A2.5k Good PREM Assurance Model ·Portable Appliance Testing ·Waste Management · 12.12.2018 NUTH 1819 50 A2.5 Reasonable Estates/FM Replacement System ·Transport ·Decontamination · 07.01.2019 NUTH1819 53 A2.5 GoodPharmacy Prescribing ·Medicines Management ·Safeguarding Adult and Children ·WinPak · 18.01.2019 NUTH 1819 57 2.5d Reasonable Consulting Job PlanningIG Toolkit ·GDPR · 03.05.2019 NUTH 1819 60 ¤ SubstantialNetwork Continuous Testing · ·Network Device Security Monitoring ·Telephony/VoIP ·Data Centre Physical/Environment Controls ·Key system controls · ·IT Service Management/Incidents & Problem ·IM&T Programme Management Framework ·System Development Controls · 23.11.2018 NUTH 1819 61a ¤ GoodBusiness Cases ·Raising Concerns · 06.02.2019 NUTH1819 04 ¤ Reasonable Fire Safety Culture Review · 07.03.2019 NUTH1819 80 ¤ n/aCRN Minimal Controls · 12.03.2019 NUTH1819 72 ¤ n/aJAC Pharmacy System IT General Controls · 01.05.2019 NUTH1819 68 ¤ n/aSentinel SpaceLabs ( Cardiology System) IT Controls · 12.04.2019 NUTH1819 69 ¤ Good

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Key Elements Risk Level Risk Appetite Risk Tolerance Statement

Quality/Outcomes

1 (Minimal) Low 6-10

The quality of our services, measured by clinical outcomes, patient safety and patientexperience is paramount. We will provide high quality and safe services to our patients and willrarely accept risks that could limit our ability to fulfil this objective.

We are strongly averse to risks that could result in poor quality care or unacceptable clinicalrisk, non-compliance with standards or poor clinical or professional practice.

Financial/ VFM 2 (Cautious) Moderate 12-16

We will strive to deliver our services within the budgets modelled in our financial plans and willonly consider exceeding these constraints if a financial response is required to mitigate risksassociated with patient safety or quality of care. All such financial responses will be undertakenensuring optimal value for money in the utilisation of public funds.

Compliance/regulatory

2 (Cautious) Moderate 12-16The Trust sees regulatory compliance as important in optimising quality and financialsustainability. The Trust Board is willing to take a cautious approach to risks in this area.

Innovation 4 (Seek) Significant (High) 20-25

We will continue to encourage a culture of innovation within the Trust. We are willing to acceptrisks associated with innovation, research and development to enable the integration of care,development of new models of care and improvements in clinical practice that could supportthe delivery of our person and patient centred values and approach.

Commercial 2 (Cautious) Moderate 12-16We will consider commercial opportunities as they arise noting that the Board’s tolerance forrisks relating to its commercial factors is limited to those events where there is little or nochance of impacting on the Trusts core purpose – to deliver health services to those in need.

Reputation 1 (Minimal) Low 6-10

We will maintain high standards of conduct, ethics and professionalism.

The Board’s tolerance for risks relating to its reputation is limited to those events where thereis little or no chance of significant repercussion for the organisation.

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Newcastle upon Tyne Foundation Trust HospitalsStrategic Objective

1. Putting patients first and providing care of the highest standard focusing on safety and quality.

2. Being a nationally and internationally respected leader in Research and Development underpinningour pioneering services.

3. Working in partnership to deliver fully integrated care and promoting healthy lifestyles to the peopleof Newcastle and beyond.

4. Enhancing our reputation as one of the country’s top, first class teaching hospitals, promoting aculture of excellence in all that we do.

5. Maintaining sound financial management to ensure the ongoing development and success of ourorganisation.

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BAF 5x5 Risk Scoring Matrix

IMPACTLIKELIHOOD 1. Insignificant 2. Minor 3. Moderate1 – Rare 1 2 3Not expected tooccur Very Low Very Low Very Low

2 – Unlikely 2 4 6

Occurs infrequently Very Low Very Low Low

3 – Possible 3 6 9

Once or twice a year Very Low Low Low

4 – Likely

Hazard will occur butis not persistent. 4 8 12

Very Low Low Moderate5 –Almost Certain

Constant threat iscustom and practice 5 10 15

Very Low Low Moderate

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4. Major 5.Catastrophic4 5

Very Low Very Low

8 10

Low Low

12 15

Moderate Moderate

16 20

Moderate High

20 25

High High

IMPACT

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Agenda Item A12

TRUST BOARD

Date of meeting 26 September 2019Title Trust Constitution Update

Report of Kelly Jupp, Trust Secretary

Prepared by Kelly Jupp, Trust Secretary



Purpose of Report☒ ☐ ☐

Summary The content of this report outlines a summary of the work undertaken in reviewing the Trust Constitution.

RecommendationsThe Trust Board are asked to consider and approve the proposed changes to the Trust Constitution as attached in Appendix A, noting that the changes were agreed by the Council of Governors on 19th September 2019.


Maintaining compliance with all regulatory requirements. Deliver a first class patient experience.

Links to Strategy and Clinical Risks No direct risk identified.



Legal X

Financial X

Human Resources X



Sustainability X

Impact

If yes, please give additional information: The Trust Constitution is a legal document and any changes must be approved by the Trust Council of Governors and Trust Board, prior to final approval at the Trust Annual Members Meeting.


The Trust Constitution has been a matter of discussion for the Council of Governors following identification of review. This report highlights the culmination of the initial review process in collaboration with DACB.

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Agenda item A12

____________________________________________________________________________________________________Trust Constitution Trust Board – 26th September 2019

TRUST CONSTITUTION UPDATE

1. INTRODUCTION

The Trust Constitution was first produced in May 2006 and specific sections have been reviewed and updated since that time; however, a full review of the Constitution was deemed timely given the change in the governance structure arrangements.

DAC Beachcroft LLP (“DACB”) were commissioned to undertake a wholescale review of the Trust Constitution and make recommendations in order to update, clarify and simplify it.

As part of this exercise, DACB have prepared a table of amendments highlighting elements of the Trust’s Constitution which required updating to comply with law as well as updates which would reflect best practice. This table formed the basis of discussions with a Council of Governors (“CoG”) working group at a meeting on 8 August 2019.

Following the working group meeting, DACB have produced a paper to highlight the key proposed amendments to the Trust’s Constitution which will require approval by both the Council of Governors and the Trust Board of Directors in accordance with the NHS Act 2006. This paper has been circulated privately to Trust Governors and Board members and the proposed amended Constitution is attached in Appendix A of this document.

2. WORKING GROUP MEETING – 8 AUGUST 2019

The Working Group met and considered a number of matters including:1. The current age limit for members – with a proposal to reduce the age limit for

members from 18 to 16 years old;2. The Constituency composition – including whether a new ‘Patient Constituency’

should be created, minimum membership levels and renaming/redefining the Public Constituencies and associated classes;

3. Legislative updates and consequential updates to definitions;4. The tenure of Governors and Non-Executive Directors – with a proposed amendments

to add clarity over tenure; 5. Appointed Non-Executive Directors (NED) – including exploring the creation of

Associate NED posts; and6. Clarity over the definition of ‘significant transactions’.

3. RECOMMENDATIONS AND NEXT STEPS

The Board of Directors are asked to consider and approve the proposed changes to the Trust Constitution as attached in Appendix A.

The Council of Governors agreed the proposed amendments and subject to approval from the Board of Directors, the updated Constitution would require final approval at the Trust Annual Members Meeting on 27th September 2019.

Report of Kelly Jupp, Trust Secretary20th September 2019

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i

Agenda item 12 - Appendix A

NHS FOUNDATION TRUST

CONSTITUTION

[September 2019]

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Table of contentsClause heading and number Page number

1. INTERPRETATION AND DEFINITIONS ....................................................................................4

2. NAME .........................................................................................................................................5

3. PRINCIPAL PURPOSE ..............................................................................................................5

4. POWERS....................................................................................................................................6

5. FRAMEWORK ............................................................................................................................6

6. MEMBERSHIP AND CONSTITUENCIES ..................................................................................6

7. APPLICATION FOR MEMBERSHIP ..........................................................................................6

8. RESTRICTION ON MEMBERSHIP............................................................................................8

9. ANNUAL MEMBERS’ MEETING................................................................................................8

10. COUNCIL OF GOVERNORS – COMPOSITION........................................................................8

11. COUNCIL OF GOVERNORS – ELECTION OF GOVERNORS.................................................8

12. COUNCIL OF GOVERNORS – TENURE ..................................................................................9

13. COUNCIL OF GOVERNORS – DISQUALIFICATION AND REMOVAL ....................................9

14. COUNCIL OF GOVERNORS – DUTIES OF GOVERNORS......................................................9

15. COUNCIL OF GOVERNORS – MEETINGS OF GOVERNORS..............................................10

16. COUNCIL OF GOVERNORS – STANDING ORDERS ............................................................10

17. COUNCIL OF GOVERNORS – CONFLICTS OF INTEREST OF GOVERNORS....................10

18. COUNCIL OF GOVERNORS – EXPENSES............................................................................10

19. COUNCIL OF GOVERNORS – FURTHER PROVISIONS.......................................................11

20. BOARD OF DIRECTORS – COMPOSITION ...........................................................................11

21. BOARD OF DIRECTORS – GENERAL DUTY.........................................................................11

22. BOARD OF DIRECTORS – QUALIFICATION FOR APPOINTMENT AS A NON-EXECUTIVE DIRECTOR.......................................................................................................................11

23. BOARD OF DIRECTORS – APPOINTMENT AND REMOVAL OF CHAIR AND OTHER NON-EXECUTIVE DIRECTORS...........................................................................................................11

24. BOARD OF DIRECTORS – APPOINTMENT OF SENIOR INDEPENDENT DIRECTOR .......12

25. BOARD OF DIRECTORS – APPOINTMENT OF DEPUTY CHAIR .........................................12

26. BOARD OF DIRECTORS – APPOINTMENT AND REMOVAL OF THE CHIEF EXECUTIVE AND OTHER EXECUTIVE DIRECTORS.........................................................................12

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27. BOARD OF DIRECTORS – DISQUALIFICATION ...................................................................12

28. BOARD OF DIRECTORS – MEETINGS ..................................................................................13

29. BOARD OF DIRECTORS – STANDING ORDERS..................................................................13

30. BOARD OF DIRECTORS – CONFLICTS OF INTEREST OF DIRECTORS............................13

31. BOARD OF DIRECTORS – REMUNERATION AND TERMS OF OFFICE .............................14

32. REGISTERS.............................................................................................................................14

33. REGISTERS – INSPECTION AND COPIES............................................................................14

34. DOCUMENTS AVAILABLE FOR PUBLIC INSPECTION.........................................................15

35. AUDITOR..................................................................................................................................16

36. AUDIT COMMITTEE.................................................................................................................16

37. ACCOUNTS..............................................................................................................................16

38. ANNUAL REPORTS AND FORWARD PLANS........................................................................17

39. PRESENTATION OF THE ANNUAL ACCOUNTS AND REPORTS TO THE GOVERNORS AND MEMBERS............................................................................................................18

40. INSTRUMENTS........................................................................................................................18

41. AMENDMENTS OF THE CONSTITUTION ..............................................................................18

42. MERGERS ETC. AND SIGNIFICANT TRANSACTIONS.........................................................19

ANNEX 1 – PUBLIC CONSTITUENCY.................................................................................................21

ANNEX 2 – STAFF CONSTITUENCY...................................................................................................22

ANNEX 3 – COMPOSITION OF COUNCIL OF GOVERNORS ............................................................25

ANNEX 4 – MODEL ELECTION RULES 2014......................................................................................26

ANNEX 5 – ADDITIONAL PROVISIONS – COUNCIL OF GOVERNORS............................................68

ANNEX 6 – ADDITIONAL PROVISIONS – BOARD OF DIRECTORS .................................................73

ANNEX 7 – FURTHER PROVISIONS – MEMBERS.............................................................................75

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4

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

(A PUBLIC BENEFIT CORPORATION)

Unless the contrary intention appears or the context otherwise requires, words or expressions contained in this constitution bear the same meaning as in the 2006 Act. References in this constitution to legislation include all amendments, replacements, or re-enactments made.

References to legislation include all regulations, statutory guidance or directions. Headings are for ease of reference only and are not to affect interpretation.

Words importing the masculine gender only shall include the feminine gender; words importing the singular shall include the plural and vice-versa.

1. INTERPRETATION AND DEFINITIONS

1.1 In this constitution:-

“2006 Act” means the National Health Service Act 2006;

“2012 Act” means the Health and Social Care Act 2012;

“Accounting Officer” means the person who from time to time discharges the functions specified in paragraph 25(5) of Schedule 7 to the 2006 Act;

“Annual” Members’ Meeting’”

has the meaning set out in paragraph 9;

“Board of Directors” means the Board of Directors as constituted in accordance with this Constitution and the 2006 Act;

“Chair” means the person appointed by the Council of Governors under Schedule 7 paragraph 17(1) of the 2006 Act to be the Chair of the Trust;

“Class” means the division of a Membership Constituency by reference to the description of individuals eligible to be Members of it;

“Council of Governors”

means the Council of Governors as constituted in accordance with this Constitution;

“Deputy Chair” means the Non-Executive Director appointed by the Council of Governors to exercise the Chair’s functions if the Chair is absent for any reason;

"Director" means a director on the Board of Directors;

“Financial Year” means any period of twelve months beginning on 1st April;

“Governor” Means an individual who has been elected to the position of governor in accordance with the provisions of this Constitution;

“Governor Code of Conduct”

means the code of conduct for Governors as adopted by the Trust from time to time;

“Health Service Body” has the meaning given in Section 9(4) of the 2006 Act;

“Lead Governor” means the Governor elected by the Council of Governors as Lead Governor in accordance with paragraph 3 of Annex 5;

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“Local Authority Governor”

means a member of the Council of Governors appointed by one or more local authorities whose area includes the whole or part of an area specified in Annex 1 as an area for a public constituency;

"Member" means a Member of the Trust;

“Membership Constituency(ies)”

means (1) the Public Constituency; and/or (2) the Staff Constituency;

“Monitor” or the “regulator”

means the corporate body known as Monitor, as provided by Section 61 of the 2012 Act, which as of 1 April 2017 is part of NHS Improvement;

“NHS Foundation Trust Code of Governance”

means the code of governance for NHS Foundation Trusts published by Monitor;

“Public Constituency” means the constituency of the Trust constituted in accordance with paragraph 7.1;

“Public Governor” means a member of the Council of Governors elected by the members of the Public Constituency;

"Secretary" means the Secretary of the Trust or any other person appointed to perform the duties of the Secretary of the Trust, including a Joint, Assistant or Deputy Secretary under this Constitution;

“Senior Independent Director”

shall have the meaning ascribed in the NHS Foundation Trust Code of Governance;

“Significant Transaction”

has the meaning ascribed in paragraph 42;

“Staff Constituency” means the constituency of the Trust constituted in accordance with paragraph 7.2;

“Staff Governor” means a member of the Council of Governors elected by the members of the Staff Constituency;

“Trust” means The Newcastle upon Tyne Hospitals NHS Foundation Trust;

“University Governor” means a member of the Council of Governors appointed by a university providing a medical or dental school to a hospital of the Trust or in relation to nursing provision.

2. NAME

2.1 The name of this Trust is “The Newcastle upon Tyne Hospitals NHS Foundation Trust”.

3. PRINCIPAL PURPOSE

3.1 The principal purpose of the Trust is the provision of goods and services for the purposes of the health service in England.

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3.2 The Trust does not fulfil its principal purpose unless, in each Financial Year, its total income from the provision of goods and services for the purposes of the health service in England is greater than its total income from the provision of goods and services for any other purposes.

3.3 The Trust may provide goods and services for any purposes related to:

3.3.1 the provision of services provided to individuals for or in connection with the prevention, diagnosis or treatment of illness; and

3.3.2 the promotion and protection of public health.

3.4 The Trust may also carry on activities other than those mentioned in the above paragraph for the purpose of making additional income available in order better to carry on its principal purpose.

4. POWERS

4.1 The Trust is to have all the powers of an NHS Foundation Trust set out in the 2006 Act.

4.2 All the powers of the Trust shall be exercised by the Board of Directors on behalf of the Trust.

4.3 Any of these powers may be delegated to a committee of Directors or to an Executive Director.

5. FRAMEWORK

5.1 The Trust shall have two (2) Membership Constituencies, a Council of Governors and a Board of Directors. The Board of Directors will exercise the powers of the Trust. The Membership Constituencies will elect certain of their Members to the Council of Governors in accordance with this Constitution and other Governors will be appointed by various bodies which are also set out in this Constitution. The Council of Governors will fulfil those functions imposed on it by the 2006 Act and by this Constitution.

6. MEMBERSHIP AND CONSTITUENCIES

6.1 The Trust is to have two (2) Membership Constituencies:

6.1.1 the Public Constituency constituted in accordance with paragraph 7.1; and

6.1.2 the Staff Constituency constituted in accordance with paragraph 7.2;

6.2 An individual may become a Member by application to the Trust using the process advertised by the Trust.

7. APPLICATION FOR MEMBERSHIP

7.1 Public Constituency

7.1.1 Members of the Trust who are members of a Public Constituency listed in column 1 of Annex 1 are to be individuals:

(a) who live in the area specified for the relevant Class in the corresponding entry in column 2 of Annex 1;

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(b) who are not eligible to become a member of the Staff Constituency and are not members of any other Membership Constituency; and

(c) are not disqualified from membership under paragraph 8.

7.1.2 The minimum number of members in each Class of the Public Constituency is specified in Annex 1.

7.2 Staff Constituency

7.2.1 An individual who is employed by the Trust under a contract of employment with the Trust may become or continue as a Member provided:

(a) that they:

(i) are employed by the Trust under a contract of employment which has no fixed term or has a fixed term of at least 12 months;

(ii) have been continuously employed under a contract of employment with the Trust for at least 12 months; or

(iii) work on behalf of a voluntary organisation within the meaning of the 2006 Act or are registered volunteers at the Trust and in either case have continuously exercised functions for the Trust for at least 12 months and whose place of work is at the Trust and who are acknowledged in writing by the Trust as being eligible for Membership in accordance with this paragraph 7.2; and

(b) that they are not disqualified from Membership pursuant to paragraph 8; and

(c) that they have made an application to the Trust for Membership of the appropriate Class within the Staff Constituency.

7.2.2 For the purposes of this paragraph 7, Chapter 1 of Part XIV of the Employment Rights Act 1996 (Continuous Employment) shall apply when determining whether an individual has been continuously employed by the Trust or has continuously exercised functions for the Trust.

7.2.3 The Staff Constituency shall be divided into the following Classes:

(a) the Medical and Dental Staff Class;

(b) the Nursing and Midwifery and related Staff Class;

(c) the Health Professionals Council and related Staff Class;

(d) the Administrative & Clerical, Management and Hospital Chaplains Staff Class;

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(e) the Ancillary and Estates Staff Class; and

(f) the Volunteers Staff Class.

each description of individuals being specified within Annex 2 and being referred to as a Class within the Staff Constituency.

7.2.4 A person who is eligible to be a member of the Staff Constituency in accordance with this Constitution may not become or continue as a member of any other Constituency.

7.2.5 The minimum number of members in each Class of the Staff Constituency is specified in Annex 2.

8. RESTRICTION ON MEMBERSHIP

8.1 An individual who is a member of a Constituency, or of a Class within a Constituency, may not while Membership of that Constituency or Class continues, be a member of any other Constituency or Class.

8.2 An individual who satisfies the criteria for Membership of the Staff Constituency may not become or continue as a member of any Constituency other than the Staff Constituency.

8.3 An individual must be at least 16 years old to become a Member.

8.4 Further provisions as to the circumstances in which an individual may not become or continue as a Member are set out in Annex 7.

9. ANNUAL MEMBERS’ MEETING

9.1 The Trust shall hold an annual meeting of its members (“Annual Members’ Meeting”). The Annual Members’ Meeting shall be open to members of the public.

10. COUNCIL OF GOVERNORS – COMPOSITION

10.1 The Trust is to have a Council of Governors, which shall comprise both Elected and Appointed Governors.

10.2 The composition of the Council of Governors is specified in Annex 3.

10.3 The members of the Council of Governors, other than the Appointed members, shall be chosen by election by their Constituency or, where there are Classes within a Constituency, by their Class within that Constituency. The number of Governors to be elected by each Constituency, or, where appropriate, by each Class of each Constituency, is specified in Annex 3.

11. COUNCIL OF GOVERNORS – ELECTION OF GOVERNORS

11.1 Elections for elected members of the Council of Governors shall be conducted in accordance with the Model Election Rules.

11.2 The Model Election Rules, as published from time to time by NHS Providers, form part of this Constitution. The Model Election Rules current at the date of this Constitution are attached at Annex .

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11.3 A subsequent variation of the Model Election Rules shall not constitute a variation of the terms of this Constitution for the purposes of paragraph 41 of this Constitution (Amendment of the Constitution).

11.4 An election, if contested, shall be by secret ballot.

12. COUNCIL OF GOVERNORS – TENURE

12.1 Elected Governors

12.1.1 An Elected Governor may hold office for a term of up to 3 years.

12.1.2 An Elected Governor shall cease to hold office if they cease to be a Member of the Constituency or Class by which they were elected.

12.1.3 An Elected Governor shall be eligible for re-election at the end of their term provided that no governor shall hold office for more than a period of 9 years in aggregate.

12.2 Appointed Governors

12.2.1 An Appointed Governor may hold office for a term of up to 3 years.

12.2.2 An Appointed Governor shall cease to hold office if the appointing organisation withdraws its sponsorship of them.

12.2.3 An Appointed Governor shall be eligible for re-appointment at the end of their term provided that no Governor shall hold office for more than a period of 9 years in aggregate.

13. COUNCIL OF GOVERNORS – DISQUALIFICATION AND REMOVAL

13.1 The following may not become or continue as a member of the Council of Governors:

13.1.1 a person who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged;

13.1.2 a person in relation to whom a moratorium period under a debt relief order applies (under Part 7A of the Insolvency Act 1986);

13.1.3 a person who has made a composition or arrangement with, or granted a trust deed for, his creditors and has not been discharged in respect of it; or

13.1.4 a person who within the preceding five years has been convicted in the British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on them.

13.2 Governors must be at least 16 years of age at the date that their term of office commences.

13.3 Further provisions as to the circumstances in which an individual may not become or continue as a member of the Council of Governors are set out in Annex 5.

14. COUNCIL OF GOVERNORS – DUTIES OF GOVERNORS

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14.1 The general duties of the Council of Governors are:

14.1.1 to hold the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors, and

14.1.2 to represent the interests of the Members as a whole and the interests of the public.

14.2 The Trust must take steps to secure that the Governors are equipped with the skills and knowledge they require in their capacity as such.

15. COUNCIL OF GOVERNORS – MEETINGS OF GOVERNORS

15.1 The Chair of the Trust (i.e. the Chair of the Board of Directors, appointed in accordance with the provisions of paragraph 23 below) or, in their absence the Senior Independent Director, shall preside at meetings of the Council of Governors.

15.2 Meetings of the Council of Governors shall be open to members of the public. Members of the public may be excluded from a meeting for special reasons.

15.3 Further provisions as to the exclusion of members of the public are set out in the Council of Governors Standing Orders.

15.4 The provisions of this paragraph shall be without prejudice to the power of the Council of Governors, as exercised by the Chair or other Governors, to exclude, suppress or prevent disorderly conduct or other misconduct at a meeting.

15.5 For the purposes of obtaining information about the Trust’s performance of its functions or the Directors’ performance of their duties, the Council of Governors may require one or more of the Directors to attend a meeting.

16. COUNCIL OF GOVERNORS – STANDING ORDERS

16.1 The Council of Governors, in consultation with the Board of Directors, shall adopt Standing Orders.

16.2 The Standing Orders shall specify the arrangements for excluding Governors from discussion or consideration of any contract, proposed contract or other matter, as appropriate.

17. COUNCIL OF GOVERNORS – CONFLICTS OF INTEREST OF GOVERNORS

17.1 If a Governor has a pecuniary, personal or family interest, whether that interest is actual or potential and whether that interest is direct or indirect, in any proposed contract or other matter which is under consideration or is to be considered by the Council of Governors, the Governor shall disclose that interest to the members of the Council of Governors as soon as he becomes aware of it. The Standing Orders for the Council of Governors shall make provision for the disclosure of interests and arrangements for the exclusion of a Governor declaring any interest from any discussion or consideration of the matter in respect of which an interest has been disclosed.

18. COUNCIL OF GOVERNORS – EXPENSES

18.1 The Trust may pay travelling and other reasonable expenses to members of the Council of Governors at rates determined by the Trust.

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19. COUNCIL OF GOVERNORS – FURTHER PROVISIONS

19.1 Further provisions with respect to the Council of Governors are set out in Annex 5.

20. BOARD OF DIRECTORS – COMPOSITION

20.1 The Trust is to have a Board of Directors, which shall comprise both Executive and Non-Executive Directors.

20.2 The Board of Directors is to comprise:

20.2.1 a Non-Executive Chair

20.2.2 a minimum of 7 to a maximum of 9 other Non-Executive Directors; and

20.2.3 6 Executive Directors.

20.3 One of the Executive Directors shall be the Chief Executive (who shall also be the Accounting Officer).

20.4 One of the Executive Directors shall be the Finance Director.

20.5 One of the Executive Directors is to be a registered medical practitioner or a registered dentist (within the meaning of the Dentists Act 1984).

20.6 One of the Executive Directors is to be a registered nurse or a registered midwife.

21. BOARD OF DIRECTORS – GENERAL DUTY

21.1 The general duty of the Board of Directors and of each Director individually is to act with a view to promoting the success of the Trust so as to maximise the benefits for the Members of the Trust as a whole and for the public.

21.2 In exercising their duties, the Board of Directors shall have due regard to the NHS Foundation Trust Code of Governance.

22. BOARD OF DIRECTORS – QUALIFICATION FOR APPOINTMENT AS A NON-EXECUTIVE DIRECTOR

22.1 A person may be appointed as a Non-Executive Director only if:

22.1.1 they are a member of the Public Constituency; or

22.1.2 where any of the Trust’s hospitals includes a medical or dental school provided by a university, they exercise functions for the purposes of that university; and

22.1.3 they are not disqualified by virtue of paragraph 27 below or Annex 6.

23. BOARD OF DIRECTORS – APPOINTMENT AND REMOVAL OF CHAIR AND OTHER NON-EXECUTIVE DIRECTORS

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23.1 The Council of Governors at a general meeting of the Council of Governors shall appoint or remove the Chair of the Trust and the other Non-Executive Directors.

23.2 Removal of the Chair or another Non-Executive Director shall require the approval of three-quarters of the members of the Council of Governors.

23.3 Non-Executive Directors shall be appointed by a duly authorised Nominations Committee.

23.4 The maximum tenure for any Non-Executive Director (including the Chair) shall be 9 years in aggregate.

24. BOARD OF DIRECTORS – APPOINTMENT OF SENIOR INDEPENDENT DIRECTOR

24.1 The Board of Directors shall appoint one of the independent Non-Executive Directors to be the Senior Independent Director in consultation with the Council of Governors, for such a period not exceeding the remainder of their term as a Non-Executive Director, as they may specify on appointing them.

24.2 The Senior Independent Director will be available to Governors if they have concerns that the Chair is unable to resolve.

25. BOARD OF DIRECTORS – APPOINTMENT OF DEPUTY CHAIR

25.1 The Council of Governors at a general meeting of the Council of Governors shall appoint one of the Non-Executive Directors as a Deputy Chair.

25.2 Any Director so appointed may at any time resign from the office of Deputy Chair by giving notice in writing to the Chair. The Council of Governors may thereupon appoint another Non-Executive Director as Deputy Chair in accordance with this Constitution.

26. BOARD OF DIRECTORS – APPOINTMENT AND REMOVAL OF THE CHIEF EXECUTIVE AND OTHER EXECUTIVE DIRECTORS

26.1 The Non-Executive Directors shall appoint or remove the Chief Executive.

26.2 The appointment of the Chief Executive shall require the approval of the Council of Governors.

26.3 A committee consisting of the Chair, the Chief Executive and the other Non-Executive Directors shall appoint or remove the other Executive Directors.

27. BOARD OF DIRECTORS – DISQUALIFICATION

27.1 The following may not become or continue as a member of the Board of Directors:

27.1.1 a person who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged;

27.1.2 a person in relation to whom a moratorium period under a debt relief order applied (under Part 7A of the Insolvency Act 1986);

27.1.3 a person who has made a composition or arrangement with, or granted a trust deed for, his creditors and has not been discharged in respect of it; or

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27.1.4 a person who within the preceding five years has been convicted in the British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on them.

27.2 Further provisions as to the circumstances in which a person may not become or continue as a member of the Board of Directors are set out in Annex 6.

28. BOARD OF DIRECTORS – MEETINGS

28.1 Meetings of the Board of Directors shall be open to members of the public. Members of the public may be excluded from a meeting for special reasons.

28.2 Before holding a meeting, the Board of Directors must send a copy of the agenda of the meeting to the Council of Governors. As soon as practicable after holding a meeting, the Board of Directors must send a copy of the minutes of the meeting to the Council of Governors.

29. BOARD OF DIRECTORS – STANDING ORDERS

29.1 The Board of Directors shall adopt Standing Orders for the practice and procedure of the Board of Directors.

29.2 The Standing Orders shall specify the arrangements for excluding Directors from discussion or consideration of any contract, proposed contract or other matter, as appropriate.

30. BOARD OF DIRECTORS – CONFLICTS OF INTEREST OF DIRECTORS

30.1 The duties that a Director of the Trust has by virtue of being a Director include in particular:

30.1.1 a duty to avoid a situation in which the Director has (or can have) a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the Trust.

30.1.2 a duty not to accept a benefit from a third party by reason of being a Director or doing (or not doing) anything in that capacity.

30.2 The duty referred to in paragraph 30.1.1 is not infringed if:

30.2.1 the situation cannot reasonably be regarded as likely to give rise to a conflict of interest, or

30.2.2 the matter has been authorised in accordance with this Constitution.

30.3 The duty referred to in paragraph 30.1.2 is not infringed if acceptance of the benefit cannot reasonably be regarded as likely to give rise to a conflict of interest.

30.4 In paragraph 30.1.2, “third party” means a person other than:

30.4.1 the Trust, or

30.4.2 a person acting on its behalf.

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30.5 If a Director of the Trust has in any way a direct or indirect interest in a proposed transaction or arrangement with the Trust, the Director must declare the nature and extend of that interest to the other Directors.

30.6 If a declaration under this paragraph proves to be, or becomes, inaccurate or incomplete, a further declaration must be made.

30.7 Any declaration required by this paragraph must be made before the Trust enters into the transaction or arrangement.

30.8 This paragraph does not require a declaration of an interest of which the Director is not aware or where the Director is not aware of the transaction or arrangement in question.

30.9 A Director need not declare an interest:

30.9.1 if it cannot reasonably be regarded as likely to give rise to a conflict of interest;

30.9.2 if, or to the extent that, the Directors are already aware of it;

30.9.3 if, or to the extent that, it concerns terms of the Director’s appointment that have been or are to be considered:

(a) by a meeting of the Board of Directors; or

(b) by a committee of the Directors appointed for the purpose under this Constitution.

31. BOARD OF DIRECTORS – REMUNERATION AND TERMS OF OFFICE

31.1 The Council of Governors at a general meeting of the Council of Governors shall decide the remuneration and allowances, and the other terms and conditions of office, of the Chair and the other Non-Executive Directors.

31.2 The Trust shall establish a committee of Non-Executive Directors to decide the remuneration and allowances, and the other terms and conditions of office, of the Chief Executive and other Executive Directors.

32. REGISTERS

32.1 The Trust shall have:

32.1.1 a Register of Members showing, in respect of each Member, the Constituency to which they belong and, where there are Classes within it, the Class to which they belong;

32.1.2 a Register of Members of the Council of Governors;

32.1.3 a Register of Interests of Governors;

32.1.4 a Register of Directors; and

32.1.5 a Register of Interests of the Directors.

33. REGISTERS – INSPECTION AND COPIES

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33.1 The Trust shall make the registers specified in paragraph 32 available for inspection by members of the public, except in the circumstances set out below or as otherwise prescribed by regulations.

33.2 The Trust shall not make any part of its registers available for inspection by members of the public which shows details of any Member, if they so request.

33.3 So far as the registers are required to be made available:

33.3.1 they are to be available for inspection free of charge at all reasonable times; and

33.3.2 a person who requests a copy of or extract from the registers is to be provided with a copy or extract.

33.4 If the person requesting a copy or extract is not a Member, the Trust may impose a reasonable charge for doing so.

34. DOCUMENTS AVAILABLE FOR PUBLIC INSPECTION

34.1 The Trust shall make the following documents available for inspection by members of the public free of charge at all reasonable times:

34.1.1 a copy of the current constitution;

34.1.2 a copy of the latest annual accounts and of any report of the auditor on them; and

34.1.3 a copy of the latest annual report;

34.2 The Trust shall also make the following documents relating to a special administration of the Trust available for inspection by members of the public free of charge at all reasonable times:

34.2.1 a copy of any order made under section 65D (appointment of trust special administrator), 65J (power to extend time), 65KC (action following Secretary of State’s rejection of final report), 65L (trusts coming out of administration) or 65LA (trusts to be dissolved) of the 2006 Act;

34.2.2 a copy of any report laid under section 65D (appointment of trust special administrator) of the 2006 Act;

34.2.3 a copy of any information published under section 65D (appointment of Trust special administrator) of the 2006 Act;

34.2.4 a copy of any draft report published under section 65F (administrator’s draft report) of the 2006 Act;

34.2.5 a copy of any statement provided under section 65F (administrator’s draft report) of the 2006 Act;

34.2.6 a copy of any notice published under section 65F (administrator’s draft report), 65G (consultation plan), 65H (consultation requirements), 65J (power to extend time), 65KA Monitor’s decision), 65KB (Secretary of State’s response to Monitor’s decision), 65KC (action following Secretary of State’s rejection of final report) or 65KD

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(Secretary of State’s response to re-submitted final report) of the 2006 Act;

34.2.7 a copy of any statement published or provided under section 65G (consultation plan) of the 2006 Act;

34.2.8 a copy of any final report published under section 65I (administrator’s final report);

34.2.9 a copy of any statement published under section 65J (power to extend time) or 65KC (action following Secretary of State’s rejection of final report) of the 2006 Act; and

34.2.10 a copy of any information published under section 65M (replacement of trust special administrator) of the 2006 Act.

34.3 Any person who requests a copy of or extract from any of the above documents is to be provided with a copy.

34.4 If the person requesting a copy or extract is not a Member, the Trust may impose a reasonable charge for doing so.

35. AUDITOR

35.1 The Trust shall have an auditor.

35.2 The Council of Governors shall appoint or remove the auditor at a general meeting of the Council of Governors.

35.3 A person may only be appointed as the auditor if they (or, in the case of a firm, each of its members) are a member of one or more of the bodies referred to in paragraph 23(4) of Schedule 7 to the 2006 Act.

35.4 The auditor is to carry out their duties in accordance with Schedule 10 to the 2006 Act.

36. AUDIT COMMITTEE

36.1 The Trust shall establish a committee of Non-Executive Directors as an Audit Committee to perform such monitoring, reviewing and other functions as are appropriate.

37. ACCOUNTS

37.1 The Trust must keep proper accounts and proper records in relation to the accounts.

37.2 The accounts are to be audited by the Trust’s auditor.

37.3 The Trust shall prepare in respect of each financial year annual accounts in such form as Monitor may with the approval of the Secretary of State direct.

37.4 The functions of the Trust with respect to the preparation of the annual accounts shall be delegated to the Accounting Officer.

37.5 In preparing its annual accounts, the Accounting Officer shall cause the Trust to comply with any directions given by Monitor with the approval of the Secretary of State as to:

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37.5.1 the methods and principles according to which the accounts are to be prepared;

37.5.2 the content and form of the accounts,

and shall be responsible for the functions of the Trust as set out in paragraph 25 of Schedule 7 to the 2006 Act.

37.6 The Accounting Officer shall cause the Trust to:

37.6.1 lay a copy of the annual accounts, and any report of the auditor on them, before Parliament; and

37.6.2 once it has done so, send copies of those documents to Monitor within such a period as Monitor may direct.

37.7 The following documents will be made available to the Comptroller and Auditor General for examination at their request:

37.7.1 the accounts;

37.7.2 any records relating to them; and

37.7.3 any report of the auditor on them.

38. ANNUAL REPORTS AND FORWARD PLANS

38.1 The Trust shall prepare an Annual Report and send it to Monitor.

38.2 The annual reports are to give:

38.2.1 information on any steps taken by the Trust to secure that (taken as a whole) the actual membership of the Public Constituency and of the Classes of the Staff Constituency is representative of those eligible for such Membership; and

38.2.2 any other information which Monitor requires.

38.3 The document containing the information with respect to forward planning (referred to above) shall be prepared by the Directors.

38.4 In preparing the document, the Directors shall have regard to the views of the Council of Governors.

38.5 Each forward plan must include information about:

38.5.1 the activities other than the provision of goods and services for the purpose of the health service in England that the Trust proposes to carry on; and

38.5.2 the income it expects to receive from doing so.

38.6 Where a forward plan contains a proposal that the Trust carry on an activity of a kind mentioned in paragraph 38.5.1 the Council of Governors must:

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38.6.1 determine whether it is satisfied that the carrying on of the activity will not to any significant extent interfere with the fulfilment by the Trust of its principal purpose or the performance of its functions; and

38.6.2 notify the Directors of the Trust and its determination.

38.7 A Trust which proposes to increase by 5% or more the proportion of its total income in any Financial Year attributable to activities other than the provision of goods and services for the purpose of the health service in England may implement the proposal only if more than half of the members of the Council of Governors of the Trust voting approve its implementation.

39. PRESENTATION OF THE ANNUAL ACCOUNTS AND REPORTS TO THE GOVERNORS AND MEMBERS

39.1 The following documents are to be presented to the Council of Governors at a general meeting of the Council of Governors:

39.1.1 the annual accounts;

39.1.2 any report of the auditor on them; and

39.1.3 the annual report.

39.2 The documents shall also be presented to the Members of the Trust at the Annual Members’ Meeting by at least one member of the Board of Directors in attendance.

39.3 The Trust may combine a meeting of the Council of Governors convened for the purpose of paragraph 39.2 with the Annual Members’ Meeting.

40. INSTRUMENTS

40.1 The Trust shall have a seal.

40.2 The seal shall not be affixed except under the authority of the Board of Directors.

40.3 A document purporting to be duly executed under the Trust’s seal or to be signed on its behalf is to be received in evidence and, unless the contrary is proved, taken to be so executed or signed.

41. AMENDMENTS OF THE CONSTITUTION

41.1 The Trust may make amendments to this Constitution only if:

41.1.1 more than half of the members of the Council of Governors voting approve the amendments, and

41.1.2 more than half of the members of the Board of Directors voting approve the amendments.

41.2 Amendments made under paragraph 41.1 take effect as soon as the conditions in that paragraph are satisfied, but the amendment has no effect in so far as this Constitution would, as a result of the amendment, not accord with Schedule 7 of the 2006 Act.

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41.3 Where an amendment is made to this Constitution in relation the powers or duties of the Council of Governors (or otherwise with respect to the role that the Council of Governors has as part of the Trust):

41.3.1 at least one member of the Council of Governors must attend the next Annual Members’ Meeting and present the amendment; and

41.3.2 the Trust must give the members an opportunity to vote on whether they approve the amendment.

41.4 If more than half of the members voting approve the amendment, the amendment continues to have effect; otherwise, it ceases to have effect and the Trust must take such steps as are necessary as a result.

41.5 Amendments by the Trust to this Constitution are to be notified to Monitor. For the avoidance of doubt, Monitor’s functions do not include a power or duty to determine whether or not the constitution, as a result of the amendments, accords with Schedule 7 of the 2006 Act.

42. MERGERS ETC. AND SIGNIFICANT TRANSACTIONS

42.1 The Trust may only apply for a merger, acquisition, separation or dissolution with the approval of more than half of the members of the Council of Governors.

42.2 The Trust may enter into a Significant Transaction only if more than half of the members of the Council of Governors voting approve entering into the transaction.

42.3 In paragraph, the following words have the following meanings:

42.3.1 “Significant Transaction” means a transaction which meets any one of the tests below:

(a) the total asset test; or

(b) the total income test; or

(c) the capital test (relating to acquisitions or divestments); or

(d) the subsidiary test.

42.3.2 The total asset test is met if the assets which are the subject of the transaction exceed 25% of the total assets of the Trust.

42.3.3 The total income test is met if, following the completion of the relevant transaction, the total income of the Trust will increase or decrease by more than 25%.

42.3.4 The capital test is met if the gross capital of the company or business being acquired or divested represents more than 25% of the capital of the trust following completion (where “gross capital” is the market value of the relevant company or business’s shares and debt securities, plus the excess of current liabilities over current assets, and the Trust’s total taxpayers’ equity).

42.3.5 The subsidiary test is met if the Trust is required to report the formation of, or material change to, a subsidiary of the Trust to NHS Improvement. To avoid doubt, the Trust is not required to engage

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with the Council of Governors with respect to material changes to its subsidiaries until such time as such changes become reportable to NHS Improvement.

The term “subsidiary” shall have the meaning ascribed by NHS Improvement, which is as follows: “subsidiary” means a separate, distinct legal entity for the purposes of taxation, regulation and liability owned or partly owned by a provider. “Subsidiary” includes companies limited by shares or companies limited by guarantee, limited liability partnerships and community interest companies. For clarity, ‘subsidiary’ includes joint ventures falling within the definition above.

42.3.6 For the purposes of calculating the tests in this paragraph 42.3 figures used for the Trust assets, total income and taxpayers’ equity must be the figures shown in the latest published audited consolidated accounts.

42.4 A transaction:

42.4.1 excludes a transaction in the ordinary course of business (including the renewal, extension or entering into an agreement in respect of healthcare services carried out by the Trust);

42.4.2 excludes any agreement or changes to healthcare services carried out by the Trust following a reconfiguration of services led by the commissioners of such services;

42.4.3 excludes any grant of public dividend capital or the entering into of a working capital facility or other loan, which does not involve the acquisition or disposal of any fixed asset of the Trust.

42.5 The Trust may enter into Material Transactions provided that it has sought the views of the Council of Governors. A “Material Transaction” for the purposes of this paragraph 42.5 shall mean a transaction which meets one of the following tests:

42.5.1 the total asset test; or

42.5.2 the total income test; or

42.5.3 the capital test (relating to acquisitions or divestments).

where the definitions set out in paragraph 42.3 will apply, except that instead of the threshold being 25% it shall be “greater than 10%”.

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Annex 1

Public Constituency

The Public Constituency shall be divided into the following Classes:

Name Areas Governors

Minimum Number of members

Newcastle upon Tyne All electoral areas within the Newcastle upon Tyne area

9 820

Northumberland and Tyne and Wear excluding Newcastle upon Tyne

All electoral areas within Northumberland and Tyne and Wear area excluding those areas within Newcastle upon Tyne

11 910

North East All electoral areas within County Durham, Cumbria, Darlington, Tees Valley and Sunderland, and the rest of England

4 270

Total 24 2,000

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Annex 2

Staff Constituency

The Staff Constituency shall be divided into the following Classes:

Name Eligibility Governors

Minimum Number of members

Medical and Dental As set out below. 1 50

Nursing and Midwifery As set out below. 2 100

Health Professionals Council

As set out below. 1 50

Administrative & Clerical, Management and Hospital Chaplains

As set out below. 1 50

Ancillary and Estates As set out below. 1 50

Volunteers As set out below. 1 30

Total 7 330

1. The members of the Medical and Dental Staff Class are fully registered medical practitioners within the meaning of the Medical Act 1983 or dentists within the meaning of the Dentists Act 1984 and who are otherwise fully authorised and licensed to practise in England and Wales or who are otherwise designated by the Trust from time to time as eligible to be members of this Staff Class, having regard to the usual definitions applicable at that time for persons carrying on the professions of medical practitioner or dentist, and who are employed by the Trust in that capacity at the date of their application and who at all times remain employed by the Trust in that capacity. Such individuals are not eligible for Membership of any other Staff Class.

2. The members of the Nursing and Midwifery and related Staff Class are individuals who are registered under the Nurses, Midwives and Health Visitors Act 1997 and who are otherwise fully authorised and licensed to practise in England and Wales or are otherwise designated by the Trust from time to time as eligible to be members of this Staff Class, having regard to the usual definitions applicable at that time for persons carrying on the profession of registered nurse or registered midwife, and who are employed by the Trust in that capacity at the date of their application and who at all times remain employed by the Trust in that capacity. Such individuals are not eligible for Membership of any other Staff Class.

3. The members of the Health Professionals Council and related Staff Class are individuals who are members of the Staff Constituency who are not fully registered persons within the meaning of the Medicines Act 1956, but whose regulatory body falls within the remit of the Council for the Regulation of Health Care Professions established by section 25 of the NHS Reform and Health Care Professionals Act 2002 and who are not registered with the Nursing and Midwifery Council, and who are employed by the Trust in that capacity at the date of their application, and who at all times remain employed by the Trust in that capacity. Such individuals are not eligible for Membership of any other Staff Class. Also included within this group are non-professionally registered staff groups.

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4. The members of the Administrative & Clerical, Management and Hospital Chaplains Staff Class are individuals who are members of the Staff Constituency who do not come within sections 1, 2 or 3 of this Annex 2 and are designated by the Trust as administrative & clerical, management staff or hospital chaplains, and who at all times remain employed by the Trust in that capacity. Such individuals are not eligible for Membership of any other Staff Class.

5. The members of the Ancillary and Estates Staff Class are individuals who are who are members of the Staff Constituency and are designated by Trust as ancillary and estates staff, and who at all times remain employed by the Trust in that capacity. Such individuals are not eligible for Membership of any other Staff Class.

6. The members of the Volunteers Staff Class are individuals who are who are members of the Staff Constituency who are eligible for Membership pursuant to paragraph 7.2.1(a)(iii) of this Constitution.

7. The minimum number of members required for the Staff Constituency is to be 1,730.

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Annex 3Composition of Council of Governors

ConstituencyNumber of seats on the Council of Governors

Elected Governors

Public constituency 24Newcastle upon Tyne 9Northumberland and Tyne and Wear excluding Newcastle upon Tyne

11

North East 4

Staff constituency 7Medical and Dental 1Nursing and Midwifery 2Health Professionals Council 1Administrative & Clerical, Management and Hospital Chaplains 1Ancillary and Estates 1Volunteers 1

Appointed GovernorsNewcastle City Council 1Newcastle University 1Northumbria University 1Advising on the Patient Experience (APEX) 1Community/Charity 1

Total 34

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Annex 4Model Election Rules 2014

PART 1: INTERPRETATION 1. Interpretation

PART 2: TIMETABLE FOR ELECTION2. Timetable3. Computation of time

PART 3: RETURNING OFFICER4. Returning officer5. Staff6. Expenditure7. Duty of co-operation

PART 4: STAGES COMMON TO CONTESTED AND UNCONTESTED ELECTIONS8. Notice of election9. Nomination of candidates10. Candidate’s particulars11. Declaration of interests12. Declaration of eligibility13. Signature of candidate14. Decisions as to validity of nomination forms15. Publication of statement of nominated candidates16. Inspection of statement of nominated candidates and nomination forms17. Withdrawal of candidates18. Method of election

PART 5: CONTESTED ELECTIONS19. Poll to be taken by ballot20. The ballot paper21. The declaration of identity (public and patient constituencies)

Action to be taken before the poll22. List of eligible voters23. Notice of poll24. Issue of voting information by returning officer25. Ballot paper envelope and covering envelope26. E-voting systems

The poll27. Eligibility to vote28. Voting by persons who require assistance29. Spoilt ballot papers and spoilt text message votes30. Lost voting information31. Issue of replacement voting information32. ID declaration form for replacement ballot papers (public and patient

constituencies)33 Procedure for remote voting by internet

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34. Procedure for remote voting by telephone35. Procedure for remote voting by text message

Procedure for receipt of envelopes, internet votes, telephone vote and text message votes36. Receipt of voting documents37. Validity of votes38. Declaration of identity but no ballot (public and patient constituency)39. De-duplication of votes40. Sealing of packets

PART 6: COUNTING THE VOTES41. Interpretation of Part 642. Arrangements for counting of the votes43. The count44. Rejected ballot papers and rejected text voting records45. First stage46. The quota47. Transfer of votes48. Supplementary provisions on transfer49. Exclusion of candidates50. Filling of last vacancies51. Order of election of candidates

PART 7: FINAL PROCEEDINGS IN CONTESTED AND UNCONTESTED ELECTIONS52. Declaration of result for contested elections53. Declaration of result for uncontested elections

PART 8: DISPOSAL OF DOCUMENTS54. Sealing up of documents relating to the poll55. Delivery of documents56. Forwarding of documents received after close of the poll57. Retention and public inspection of documents58. Application for inspection of certain documents relating to election

PART 9: DEATH OF A CANDIDATE DURING A CONTESTED ELECTION59. Countermand or abandonment of poll on death of candidate

PART 10: ELECTION EXPENSES AND PUBLICITY

Expenses60. Election expenses61. Expenses and payments by candidates62. Expenses incurred by other persons

Publicity63. Publicity about election by the corporation64. Information about candidates for inclusion with voting information65. Meaning of “for the purposes of an election”

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PART 11: QUESTIONING ELECTIONS AND IRREGULARITIES66. Application to question an election

PART 12: MISCELLANEOUS67. Secrecy68. Prohibition of disclosure of vote69. Disqualification70. Delay in postal service through industrial action or unforeseen event

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PART 1: INTERPRETATION

1. Interpretation

1.1 In these rules, unless the context otherwise requires:

“2006 Act” means the National Health Service Act 2006;

“corporation” means the public benefit corporation subject to this constitution;

“Council of Governors”

means the Council of Governors of the corporation;

“declaration of identity”

has the meaning set out in rule 21.1;

“election” means an election by a constituency, or by a class within a constituency, to fill a vacancy among one or more posts on the Council of Governors;

“e-voting” means voting using either the internet, telephone or text message;

“e-voting information” has the meaning set out in rule 24.2;

“ID declaration form” has the meaning set out in Rule 21.1; “internet voting record” has the meaning set out in rule 26.4(d);

“internet voting system”

means such computer hardware and software, data other equipment and services as may be provided by the returning officer for the purpose of enabling voters to cast their votes using the internet;

“lead Governor” means the Governor nominated by the Council of Governors to fulfil the role described in Appendix B to The NHS Foundation Trust Code of Governance Monitor, December 2013) or any later version of such code.

“list of eligible voters” means the list referred to in rule 22.1, containing the information in rule 22.2;

“method of polling” means a method of casting a vote in a poll, which may be by post, internet, text message or telephone;

“Monitor” means the corporate body known as Monitor as provided by section 61 of the 2012 Act;

“numerical voting code”

has the meaning set out in rule 64.2(b)

“polling website” has the meaning set out in rule 26.1;

“postal voting information”


“telephone short code”

means a short telephone number used for the purposes of submitting a vote by text message;

“telephone voting facility”


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“telephone voting record”

has the meaning set out in rule 26.5 (d);

“text message voting facility”


“text voting record” has the meaning set out in rule 26.6 (d);

“the telephone voting system”

means such telephone voting facility as may be provided by the returning officer for the purpose of enabling voters to cast their votes by telephone

“the text message voting system”

means such text messaging voting facility as may be provided by the returning officer for the purpose of enabling voters to cast their votes by text message;

“voter ID number” means a unique, randomly generated numeric identifier allocated to each voter by the Returning Officer for the purpose of e-voting,

“voting information” means postal voting information and/or e-voting information

1.2 Other expressions used in these rules and in Schedule 7 to the NHS Act 2006 have the same meaning in these rules as in that Schedule.

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PART 2: TIMETABLE FOR ELECTIONS

2. Timetable

2.1 The proceedings at an election shall be conducted in accordance with the following timetable:

Proceeding Time

Publication of notice of election Not later than the fortieth day before the day of the close of the poll.

Final day for delivery of nomination forms to returning officer

Not later than the twenty eighth day before the day of the close of the poll.

Publication of statement of nominated candidates

Not later than the twenty seventh day before the day of the close of the poll.

Final day for delivery of notices of withdrawals by candidates from election

Not later than twenty fifth day before the day of the close of the poll.

Notice of the poll Not later than the fifteenth day before the day of the close of the poll.

Close of the poll By 5.00pm on the final day of the election.

3. Computation of time

3.1 In computing any period of time for the purposes of the timetable:

(a) a Saturday or Sunday;

(b) Christmas day, Good Friday, or a bank holiday, or

(c) a day appointed for public thanksgiving or mourning,

shall be disregarded, and any such day shall not be treated as a day for the purpose of any proceedings up to the completion of the poll, nor shall the returning officer be obliged to proceed with the counting of votes on such a day.

3.2 In this rule, “bank holiday” means a day which is a bank holiday under the Banking and Financial Dealings Act 1971 in England and Wales.

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PART 3: RETURNING OFFICER

4. Returning officer

4.1 Subject to rule 69, the returning officer for an election is to be appointed by the corporation.

4.2 Where two or more elections are to be held concurrently, the same returning officer may be appointed for all those elections.

5. Staff

5.1 Subject to rule 69, the returning officer may appoint and pay such staff, including such technical advisers, as he or she considers necessary for the purposes of the election.

6. Expenditure

6.1 The corporation is to pay the returning officer:

(a) any expenses incurred by that officer in the exercise of his or her functions under these rules,

(b) such remuneration and other expenses as the corporation may determine.

7. Duty of co-operation

7.1 The corporation is to co-operate with the returning officer in the exercise of his or her functions under these rules.

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PART 4: STAGES COMMON TO CONTESTED AND UNCONTESTED ELECTIONS

8. Notice of election

8.1 The returning officer is to publish a notice of the election stating:

(a) the constituency, or class within a constituency, for which the election is being held,

(b) the number of members of the Council of Governors to be elected from that constituency, or class within that constituency,

(c) the details of any nomination committee that has been established by the corporation,

(d) the address and times at which nomination forms may be obtained;

(e) the address for return of nomination forms (including, where the return of nomination forms in an electronic format will be permitted, the e-mail address for such return) and the date and time by which they must be received by the returning officer,

(f) the date and time by which any notice of withdrawal must be received by the returning officer

(g) the contact details of the returning officer

(h) the date and time of the close of the poll in the event of a contest.

9. Nomination of candidates

9.1 Subject to rule 9.2, each candidate must nominate themselves on a single nomination form.

9.2 The returning officer:

(a) is to supply any member of the corporation with a nomination form, and

(b) is to prepare a nomination form for signature at the request of any member of the corporation,

but it is not necessary for a nomination to be on a form supplied by the returning officer and a nomination can, subject to rule 13, be in an electronic format.

10. Candidate’s particulars

10.1 The nomination form must state the candidate’s:

(a) full name,

(b) contact address in full (which should be a postal address although an e-mail address may also be provided for the purposes of electronic communication), and

(c) constituency, or class within a constituency, of which the candidate is a member.

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11. Declaration of interests

11.1 The nomination form must state any financial interest that the candidate has in the corporation. If the candidate has no such interests, the paper must include a statement to that effect.

12. Declaration of eligibility

12.1 The nomination form must include a declaration made by the candidate:

(a) that he or she is not prevented from being a member of the Council of Governors by paragraph 8 of Schedule 7 of the 2006 Act or by any provision of the constitution; and,

(b) for a member of the public or patient constituency, of the particulars of his or her qualification to vote as a member of that constituency, or class within that constituency, for which the election is being held.

13. Signature of candidate

13.1 The nomination form must be signed and dated by the candidate, in a manner prescribed by the returning officer, indicating that:

(a) they wish to stand as a candidate,

(b) their declaration of interests as required under rule 11, is true and correct, and

(c) their declaration of eligibility, as required under rule 12, is true and correct.

13.2 Where the return of nomination forms in an electronic format is permitted, the returning officer shall specify the particular signature formalities (if any) that will need to be complied with by the candidate.

14. Decisions as to the validity of nomination

14.1 Where a nomination form is received by the returning officer in accordance with these rules, the candidate is deemed to stand for election unless and until the returning officer:

(a) decides that the candidate is not eligible to stand,

(b) decides that the nomination form is invalid,

(c) receives satisfactory proof that the candidate has died, or

(d) receives a written request by the candidate of their withdrawal from candidacy.

14.2 The returning officer is entitled to decide that a nomination form is invalid only on one of the following grounds:

(a) that the form is not received on or before the final time and date for return of nomination forms, as specified in the notice of the election,

(b) that the form does not contain the candidate’s particulars, as required by rule 10;

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(c) that the form does not contain a declaration of the interests of the candidate, as required by rule 11,

(d) that the form does not include a declaration of eligibility as required by rule 12, or

(e) that the form is not signed and dated by the candidate, if required by rule 13.

14.3 The returning officer is to examine each nomination form as soon as is practicable after he or she has received it, and decide whether the candidate has been validly nominated.

14.4 Where the returning officer decides that a nomination is invalid, the returning officer must endorse this on the nomination form, stating the reasons for their decision.

14.5 The returning officer is to send notice of the decision as to whether a nomination is valid or invalid to the candidate at the contact address given in the candidate’s nomination form. If an e-mail address has been given in the candidate’s nomination form (in addition to the candidate’s postal address), the returning officer may send notice of the decision to that address.

15. Publication of statement of candidates

15.1 The returning officer is to prepare and publish a statement showing the candidates who are standing for election.

15.2 The statement must show:

(a) the name, contact address (which shall be the candidate’s postal address), and constituency or class within a constituency of each candidate standing, and

(b) the declared interests of each candidate standing,

as given in their nomination form.

15.3 The statement must list the candidates standing for election in alphabetical order by surname.

15.4 The returning officer must send a copy of the statement of candidates and copies of the nomination forms to the corporation as soon as is practicable after publishing the statement.

16. Inspection of statement of nominated candidates and nomination forms

16.1 The corporation is to make the statement of the candidates and the nomination forms supplied by the returning officer under rule 15.4 available for inspection by members of the corporation free of charge at all reasonable times.

16.2 If a member of the corporation requests a copy or extract of the statement of candidates or their nomination forms, the corporation is to provide that member with the copy or extract free of charge.

17. Withdrawal of candidates

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17.1 A candidate may withdraw from election on or before the date and time for withdrawal by candidates, by providing to the returning officer a written notice of withdrawal which is signed by the candidate and attested by a witness.

18. Method of election

18.1 If the number of candidates remaining validly nominated for an election after any withdrawals under these rules is greater than the number of members to be elected to the Council of Governors, a poll is to be taken in accordance with Parts 5 and 6 of these rules.

18.2 If the number of candidates remaining validly nominated for an election after any withdrawals under these rules is equal to the number of members to be elected to the Council of Governors, those candidates are to be declared elected in accordance with Part 7 of these rules.

18.3 If the number of candidates remaining validly nominated for an election after any withdrawals under these rules is less than the number of members to be elected to be Council of Governors, then:

(a) the candidates who remain validly nominated are to be declared elected in accordance with Part 7 of these rules, and

(b) the returning officer is to order a new election to fill any vacancy which remains unfilled, on a day appointed by him or her in consultation with the corporation.

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PART 5: CONTESTED ELECTIONS

19. Poll to be taken by ballot

19.1 The votes at the poll must be given by secret ballot.

19.2 The votes are to be counted and the result of the poll determined in accordance with Part 6 of these rules.

19.3 The corporation may decide that voters within a constituency or class within a constituency, may, subject to rule 19.4, cast their votes at the poll using such different methods of polling in any combination as the corporation may determine.

19.4 The corporation may decide that voters within a constituency or class within a constituency for whom an e-mail address is included in the list of eligible voters may only cast their votes at the poll using an e-voting method of polling.

19.5 Before the corporation decides, in accordance with rule 19.3 that one or more e-voting methods of polling will be made available for the purposes of the poll, the corporation must satisfy itself that:

(a) if internet voting is to be a method of polling, the internet voting system to be used for the purpose of the election is:

(i) configured in accordance with these rules; and

(ii) will create an accurate internet voting record in respect of any voter who casts his or her vote using the internet voting system;

(b) if telephone voting to be a method of polling, the telephone voting system to be used for the purpose of the election is:


(ii) will create an accurate telephone voting record in respect of any voter who casts his or her vote using the telephone voting system;

(c) if text message voting is to be a method of polling, the text message voting system to be used for the purpose of the election is:


(ii) will create an accurate text voting record in respect of any voter who casts his or her vote using the text message voting system.

20. The ballot paper

20.1 The ballot of each voter (other than a voter who casts his or her ballot by an e-voting method of polling) is to consist of a ballot paper with the persons remaining validly nominated for an election after any withdrawals under these rules, and no others, inserted in the paper.

20.2 Every ballot paper must specify:

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(a) the name of the corporation,

(b) the constituency, or class within a constituency, for which the election is being held,

(c) the number of members of the Council of Governors to be elected from that constituency, or class within that constituency,

(d) the names and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates,

(e) instructions on how to vote by all available methods of polling, including the relevant voter’s voter ID number if one or more e-voting methods of polling are available,

(f) if the ballot paper is to be returned by post, the address for its return and the date and time of the close of the poll, and

(g) the contact details of the returning officer.

20.3 Each ballot paper must have a unique identifier.

20.4 Each ballot paper must have features incorporated into it to prevent it from being reproduced.

21. The declaration of identity (public and patient constituencies)

21.1 The corporation shall require each voter who participates in an election for a public or patient constituency to make a declaration confirming:

(a) that the voter is the person:

(i) to whom the ballot paper was addressed, and/or

(ii) to whom the voter ID number contained within the e-voting information was allocated,

(b) that he or she has not marked or returned any other voting information in the election, and

(c) the particulars of his or her qualification to vote as a member of the constituency or class within the constituency for which the election is being held,

(“declaration of identity”)

and the corporation shall make such arrangements as it considers appropriate to facilitate the making and the return of a declaration of identity by each voter, whether by the completion of a paper form (“ID declaration form”) or the use of an electronic method.

21.2 The voter must be required to return his or her declaration of identity with his or her ballot.

21.3 The voting information shall caution the voter that if the declaration of identity is not duly returned or is returned without having been made correctly, any vote cast by the voter may be declared invalid.

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Action to be taken before the poll

22. List of eligible voters

22.1 The corporation is to provide the returning officer with a list of the members of the constituency or class within a constituency for which the election is being held who are eligible to vote by virtue of rule 27 as soon as is reasonably practicable after the final date for the delivery of notices of withdrawals by candidates from an election.

22.2 The list is to include, for each member:

(a) a postal address; and,

(b) the member’s e-mail address, if this has been provided

to which his or her voting information may, subject to rule 22.3, be sent.

22.3 The corporation may decide that the e-voting information is to be sent only by e-mail to those members in the list of eligible voters for whom an e-mail address is included in that list.

23. Notice of poll

23.1 The returning officer is to publish a notice of the poll stating:

(a) the name of the corporation,

(b) the constituency, or class within a constituency, for which the election is being held,

(c) the number of members of the Council of Governors to be elected from that constituency, or class with that constituency,

(d) the names, contact addresses, and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates,

(e) that the ballot papers for the election are to be issued and returned, if appropriate, by post,

(f) the methods of polling by which votes may be cast at the election by voters in a constituency or class within a constituency, as determined by the corporation in accordance with rule 19.3,

(g) the address for return of the ballot papers,

(h) the uniform resource locator (url) where, if internet voting is a method of polling, the polling website is located;

(i) the telephone number where, if telephone voting is a method of polling, the telephone voting facility is located,

(j) the telephone number or telephone short code where, if text message voting is a method of polling, the text message voting facility is located,

(k) the date and time of the close of the poll,

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(l) the address and final dates for applications for replacement voting information, and

(m) the contact details of the returning officer.

24. Issue of voting information by returning officer

24.1 Subject to rule 24.3, as soon as is reasonably practicable on or after the publication of the notice of the poll, the returning officer is to send the following information by post to each member of the corporation named in the list of eligible voters:

(a) a ballot paper and ballot paper envelope,

(b) the ID declaration form (if required),

(c) information about each candidate standing for election, pursuant to rule 61 of these rules, and

(d) a covering envelope;

(“postal voting information”).

24.2 Subject to rules 24.3 and 24.4, as soon as is reasonably practicable on or after the publication of the notice of the poll, the returning officer is to send the following information by e-mail and/ or by post to each member of the corporation named in the list of eligible voters whom the corporation determines in accordance with rule 19.3 and/ or rule 19.4 may cast his or her vote by an e-voting method of polling:

(a) instructions on how to vote and how to make a declaration of identity (if required),

(b) the voter’s voter ID number,

(c) information about each candidate standing for election, pursuant to rule 64 of these rules, or details of where this information is readily available on the internet or available in such other formats as the Returning Officer thinks appropriate,

(d) contact details of the returning officer,

(“e-voting information”).

24.3 The corporation may determine that any member of the corporation shall:

(a) only be sent postal voting information; or

(b) only be sent e-voting information; or

(c) be sent both postal voting information and e-voting information;

for the purposes of the poll.

24.4 If the corporation determines, in accordance with rule 22.3, that the e-voting information is to be sent only by e-mail to those members in the list of eligible voters for whom an e-mail address is included in that list, then the returning officer shall only send that information by e-mail.

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24.5 The voting information is to be sent to the postal address and/ or e-mail address for each member, as specified in the list of eligible voters.

25. Ballot paper envelope and covering envelope

25.1 The ballot paper envelope must have clear instructions to the voter printed on it, instructing the voter to seal the ballot paper inside the envelope once the ballot paper has been marked.

25.2 The covering envelope is to have:

(a) the address for return of the ballot paper printed on it, and

(b) pre-paid postage for return to that address.

25.3 There should be clear instructions, either printed on the covering envelope or elsewhere, instructing the voter to seal the following documents inside the covering envelope and return it to the returning officer:

(a) the completed ID declaration form if required, and

(b) the ballot paper envelope, with the ballot paper sealed inside it.

26. E-voting systems

26.1 If internet voting is a method of polling for the relevant election then the returning officer must provide a website for the purpose of voting over the internet (in these rules referred to as "the polling website").

26.2 If telephone voting is a method of polling for the relevant election then the returning officer must provide an automated telephone system for the purpose of voting by the use of a touch-tone telephone (in these rules referred to as “the telephone voting facility”).

26.3 If text message voting is a method of polling for the relevant election then the returning officer must provide an automated text messaging system for the purpose of voting by text message (in these rules referred to as “the text message voting facility”).

26.4 The returning officer shall ensure that the polling website and internet voting system provided will:

(a) require a voter to:

(i) enter his or her voter ID number; and

(ii) where the election is for a public or patient constituency, make a declaration of identity;

in order to be able to cast his or her vote;

(b) specify:

(i) the name of the corporation,

(ii) the constituency, or class within a constituency, for which the election is being held,

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(iii) the number of members of the Council of Governors to be elected from that constituency, or class within that constituency,

(iv) the names and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates,

(v) instructions on how to vote and how to make a declaration of identity,

(vi) the date and time of the close of the poll, and

(vii) the contact details of the returning officer;

(c) prevent a voter from voting for more candidates than he or she is entitled to at the election;

(d) create a record ("internet voting record") that is stored in the internet voting system in respect of each vote cast by a voter using the internet that comprises of:

(i) the voter’s voter ID number;

(ii) the voter’s declaration of identity (where required);

(iii) the candidate or candidates for whom the voter has voted; and

(iv) the date and time of the voter’s vote,

(e) if the voter’s vote has been duly cast and recorded, provide the voter with confirmation of this; and

(f) prevent any voter from voting after the close of poll.

26.5 The returning officer shall ensure that the telephone voting facility and telephone voting system provided will:

(a) require a voter to

(i) enter his or her voter ID number in order to be able to cast his or her vote; and


(b) specify:

(i) the name of the corporation,

(ii) the constituency, or class within a constituency, for which the election is being held,

(iii) the number of members of the Council of Governors to be elected from that constituency, or class within that constituency,

(iv) instructions on how to vote and how to make a declaration of identity,

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(v) the date and time of the close of the poll, and

(vi) the contact details of the returning officer;

(c) prevent a voter from voting for more candidates than he or she is entitled to at the election;

(d) create a record ("telephone voting record") that is stored in the telephone voting system in respect of each vote cast by a voter using the telephone that comprises of:




(iv) the date and time of the voter’s vote

(e) if the voter’s vote has been duly cast and recorded, provide the voter with confirmation of this;

(f) prevent any voter from voting after the close of poll.

26.6 The returning officer shall ensure that the text message voting facility and text messaging voting system provided will:

(a) require a voter to:

(i) provide his or her voter ID number; and


in order to be able to cast his or her vote;

(b) prevent a voter from voting for more candidates than he or she is entitled to at the election;

(c) create a record ("text voting record") that is stored in the text messaging voting system in respect of each vote cast by a voter by text message that comprises of:




(iv) the date and time of the voter’s vote

(d) if the voter’s vote has been duly cast and recorded, provide the voter with confirmation of this;

(e) prevent any voter from voting after the close of poll.

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The poll

27. Eligibility to vote

27.1 An individual who becomes a member of the corporation on or before the closing date for the receipt of nominations by candidates for the election, is eligible to vote in that election.

28. Voting by persons who require assistance

28.1 The returning officer is to put in place arrangements to enable requests for assistance to vote to be made.

28.2 Where the returning officer receives a request from a voter who requires assistance to vote, the returning officer is to make such arrangements as he or she considers necessary to enable that voter to vote.

29. Spoilt ballot papers and spoilt text message votes

29.1 If a voter has dealt with his or her ballot paper in such a manner that it cannot be accepted as a ballot paper (referred to as a “spoilt ballot paper”), that voter may apply to the returning officer for a replacement ballot paper.

29.2 On receiving an application, the returning officer is to obtain the details of the unique identifier on the spoilt ballot paper, if he or she can obtain it.

29.3 The returning officer may not issue a replacement ballot paper for a spoilt ballot paper unless he or she:

(a) is satisfied as to the voter’s identity; and

(b) has ensured that the completed ID declaration form, if required, has not been returned.

29.4 After issuing a replacement ballot paper for a spoilt ballot paper, the returning officer shall enter in a list (“the list of spoilt ballot papers”):

(a) the name of the voter, and

(b) the details of the unique identifier of the spoilt ballot paper (if that officer was able to obtain it), and

(c) the details of the unique identifier of the replacement ballot paper.

29.5 If a voter has dealt with his or her text message vote in such a manner that it cannot be accepted as a vote (referred to as a “spoilt text message vote”), that voter may apply to the returning officer for a replacement voter ID number.

29.6 On receiving an application, the returning officer is to obtain the details of the voter ID number on the spoilt text message vote, if he or she can obtain it.

29.7 The returning officer may not issue a replacement voter ID number in respect of a spoilt text message vote unless he or she is satisfied as to the voter’s identity.

29.8 After issuing a replacement voter ID number in respect of a spoilt text message vote, the returning officer shall enter in a list (“the list of spoilt text message votes”):

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(a) the name of the voter, and

(b) the details of the voter ID number on the spoilt text message vote (if that officer was able to obtain it), and

(c) the details of the replacement voter ID number issued to the voter.

30. Lost voting information

30.1 Where a voter has not received his or her voting information by the tenth day before the close of the poll, that voter may apply to the returning officer for replacement voting information.

30.2 The returning officer may not issue replacement voting information in respect of lost voting information unless he or she:

(a) is satisfied as to the voter’s identity,

(b) has no reason to doubt that the voter did not receive the original voting information,

(c) has ensured that no declaration of identity, if required, has been returned.

30.3 After issuing replacement voting information in respect of lost voting information, the returning officer shall enter in a list (“the list of lost ballot documents”):

(a) the name of the voter

(b) the details of the unique identifier of the replacement ballot paper, if applicable, and

(c) the voter ID number of the voter.

31. Issue of replacement voting information

31.1 If a person applies for replacement voting information under rule 29 or 30 and a declaration of identity has already been received by the returning officer in the name of that voter, the returning officer may not issue replacement voting information unless, in addition to the requirements imposed by rule 29.3 or 30.2, he or she is also satisfied that that person has not already voted in the election, notwithstanding the fact that a declaration of identity if required has already been received by the returning officer in the name of that voter.

31.2 After issuing replacement voting information under this rule, the returning officer shall enter in a list (“the list of tendered voting information”):

(a) the name of the voter,

(b) the unique identifier of any replacement ballot paper issued under this rule;

(c) the voter ID number of the voter.

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32. ID declaration form for replacement ballot papers (public and patient constituencies)

32.1 In respect of an election for a public or patient constituency an ID declaration form must be issued with each replacement ballot paper requiring the voter to make a declaration of identity as outlined in paragraph 21.

Polling by internet, telephone or text

33. Procedure for remote voting by internet

33.1 To cast his or her vote using the internet, a voter will need to gain access to the polling website by keying in the url of the polling website provided in the voting information.

33.2 When prompted to do so, the voter will need to enter his or her voter ID number.

33.3 If the internet voting system authenticates the voter ID number, the system will give the voter access to the polling website for the election in which the voter is eligible to vote.

33.4 To cast his or her vote, the voter will need to key in a mark on the screen opposite the particulars of the candidate or candidates for whom he or she wishes to cast his or her vote.

33.5 The voter will not be able to access the internet voting system for an election once his or her vote at that election has been cast.

34. Voting procedure for remote voting by telephone

34.1 To cast his or her vote by telephone, the voter will need to gain access to the telephone voting facility by calling the designated telephone number provided in the voter information using a telephone with a touch-tone keypad.

34.2 When prompted to do so, the voter will need to enter his or her voter ID number using the keypad.

34.3 If the telephone voting facility authenticates the voter ID number, the voter will be prompted to vote in the election.

34.4 When prompted to do so the voter may then cast his or her vote by keying in the numerical voting code of the candidate or candidates, for whom he or she wishes to vote.

34.5 The voter will not be able to access the telephone voting facility for an election once his or her vote at that election has been cast.

35. Voting procedure for remote voting by text message

35.1 To cast his or her vote by text message the voter will need to gain access to the text message voting facility by sending a text message to the designated telephone number or telephone short code provided in the voter information.

35.2 The text message sent by the voter must contain his or her voter ID number and the numerical voting code for the candidate or candidates, for whom he or she wishes to vote.

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35.3 The text message sent by the voter will need to be structured in accordance with the instructions on how to vote contained in the voter information, otherwise the vote will not be cast.

Procedure for receipt of envelopes, internet votes, telephone votes and text message votes

36. Receipt of voting documents

36.1 Where the returning officer receives:

(a) a covering envelope, or

(b) any other envelope containing an ID declaration form if required, a ballot paper envelope, or a ballot paper,

before the close of the poll, that officer is to open it as soon as is practicable; and rules 37 and 38 are to apply.

36.2 The returning officer may open any covering envelope or any ballot paper envelope for the purposes of rules 37 and 38, but must make arrangements to ensure that no person obtains or communicates information as to:

(a) the candidate for whom a voter has voted, or

(b) the unique identifier on a ballot paper.

36.3 The returning officer must make arrangements to ensure the safety and security of the ballot papers and other documents.

37. Validity of votes

37.1 A ballot paper shall not be taken to be duly returned unless the returning officer is satisfied that it has been received by the returning officer before the close of the poll, with an ID declaration form if required that has been correctly completed, signed and dated.

37.2 Where the returning officer is satisfied that rule 37.1 has been fulfilled, he or she is to:

(a) put the ID declaration form if required in a separate packet, and

(b) put the ballot paper aside for counting after the close of the poll.

37.3 Where the returning officer is not satisfied that rule 37.1 has been fulfilled, he or she is to:

(a) mark the ballot paper “disqualified”,

(b) if there is an ID declaration form accompanying the ballot paper, mark it “disqualified” and attach it to the ballot paper,

(c) record the unique identifier on the ballot paper in a list of disqualified documents (the “list of disqualified documents”); and

(d) place the document or documents in a separate packet.

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37.4 An internet, telephone or text message vote shall not be taken to be duly returned unless the returning officer is satisfied that the internet voting record, telephone voting record or text voting record (as applicable) has been received by the returning officer before the close of the poll, with a declaration of identity if required that has been correctly made.

37.5 Where the returning officer is satisfied that rule 37.4 has been fulfilled, he or she is to put the internet voting record, telephone voting record or text voting record (as applicable) aside for counting after the close of the poll.

37.6 Where the returning officer is not satisfied that rule 37.4 has been fulfilled, he or she is to:

(a) mark the internet voting record, telephone voting record or text voting record (as applicable) “disqualified”,

(b) record the voter ID number on the internet voting record, telephone voting record or text voting record (as applicable) in the list of disqualified documents; and

(c) place the document or documents in a separate packet.

38. Declaration of identity but no ballot paper (public and patient constituency)1

38.1 Where the returning officer receives an ID declaration form if required but no ballot paper, the returning officer is to:

(a) mark the ID declaration form “disqualified”,

(b) record the name of the voter in the list of disqualified documents, indicating that a declaration of identity was received from the voter without a ballot paper, and

(c) place the ID declaration form in a separate packet.

39. De-duplication of votes

39.1 Where different methods of polling are being used in an election, the returning officer shall examine all votes cast to ascertain if a voter ID number has been used more than once to cast a vote in the election.

39.2 If the returning officer ascertains that a voter ID number has been used more than once to cast a vote in the election he or she shall:

(a) only accept as duly returned the first vote received that was cast using the relevant voter ID number; and

(b) mark as “disqualified” all other votes that were cast using the relevant voter ID number

39.3 Where a ballot paper is disqualified under this rule the returning officer shall:

(a) mark the ballot paper “disqualified”,

(b) if there is an ID declaration form accompanying the ballot paper, mark it “disqualified” and attach it to the ballot paper,

1 It should not be possible, technically, to make a declaration of identity electronically without also submitting a vote.

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(c) record the unique identifier and the voter ID number on the ballot paper in the list of disqualified documents;

(d) place the document or documents in a separate packet; and

(e) disregard the ballot paper when counting the votes in accordance with these rules.

39.4 Where an internet voting record, telephone voting record or text voting record is disqualified under this rule the returning officer shall:

(a) mark the internet voting record, telephone voting record or text voting record (as applicable) “disqualified”,

(b) record the voter ID number on the internet voting record, telephone voting record or text voting record (as applicable) in the list of disqualified documents;

(c) place the internet voting record, telephone voting record or text voting record (as applicable) in a separate packet, and

(d) disregard the internet voting record, telephone voting record or text voting record (as applicable) when counting the votes in accordance with these rules.

40. Sealing of packets

40.1 As soon as is possible after the close of the poll and after the completion of the procedure under rules 37 and 38, the returning officer is to seal the packets containing:

(a) the disqualified documents, together with the list of disqualified documents inside it,

(b) the ID declaration forms, if required,

(c) the list of spoilt ballot papers and the list of spoilt text message votes,

(d) the list of lost ballot documents,

(e) the list of eligible voters, and

(f) the list of tendered voting information

and ensure that complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 are held in a device suitable for the purpose of storage.

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PART 6: COUNTING THE VOTES

41. Interpretation of Part 6

41.1 In Part 6 of these rules:

“ballot document” means a ballot paper, internet voting record, telephone voting record or text voting record.

“continuing candidate” means any candidate not deemed to be elected, and not excluded,

“count” means all the operations involved in counting of the first preferences recorded for candidates, the transfer of the surpluses of elected candidates, and the transfer of the votes of the excluded candidates,

“deemed to be elected” means deemed to be elected for the purposes of counting of votes but without prejudice to the declaration of the result of the poll,

“mark” means a figure, an identifiable written word, or a mark such as “X”,

“non-transferable vote” means a ballot document:

(c) on which no second or subsequent preference is recorded for a continuing candidate,

or

(b) which is excluded by the returning officer under rule 49,

“preference” as used in the following contexts has the meaning assigned below:

(a) “first preference” means the figure “1” or any mark or word which clearly indicates a first (or only) preference,

(b) “next available preference” means a preference which is the second, or as the case may be, subsequent preference recorded in consecutive order for a continuing candidate (any candidate who is deemed to be elected or is excluded thereby being ignored); and

(c) in this context, a “second preference” is shown by the figure “2” or any mark or word which clearly indicates a second preference, and a third preference by the figure “3” or any mark or word which clearly indicates a third preference, and so on,

“quota” means the number calculated in accordance with rule 46,

“surplus” means the number of votes by which the total number of votes for any candidate (whether first preference or transferred votes, or a combination of both) exceeds the quota; but references in these rules to the transfer of the surplus means the transfer (at a transfer value) of all transferable ballot documents from the candidate who has the surplus,

“stage of the count” means:

(a) the determination of the first preference vote of each candidate,

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(b) the transfer of a surplus of a candidate deemed to be elected, or

(c) the exclusion of one or more candidates at any given time,

“transferable vote” means a ballot document on which, following a first preference, a second or subsequent preference is recorded in consecutive numerical order for a continuing candidate,

“transferred vote” means a vote derived from a ballot document on which a second or subsequent preference is recorded for the candidate to whom that ballot document has been transferred, and

“transfer value” means the value of a transferred vote calculated in accordance with rules 47.4 or 47.7.

42. Arrangements for counting of the votes

42.1 The returning officer is to make arrangements for counting the votes as soon as is practicable after the close of the poll.

42.2 The returning officer may make arrangements for any votes to be counted using vote counting software where:

(a) the Board of Directors and the Council of Governors of the corporation have approved:

(i) the use of such software for the purpose of counting votes in the relevant election, and

(ii) a policy governing the use of such software, and

(b) the corporation and the returning officer are satisfied that the use of such software will produce an accurate result.

43. The count

43.1 The returning officer is to:

(a) count and record the number of:

(i) ballot papers that have been returned; and

(ii) the number of internet voting records, telephone voting records and/or text voting records that have been created, and

(b) count the votes according to the provisions in this Part of the rules and/or the provisions of any policy approved pursuant to rule 42.2(ii) where vote counting software is being used.

43.2 The returning officer, while counting and recording the number of ballot papers, internet voting records, telephone voting records and/or text voting records and counting the votes, must make arrangements to ensure that no person obtains or communicates information as to the unique identifier on a ballot paper or the voter ID number on an internet voting record, telephone voting record or text voting record.

43.3 The returning officer is to proceed continuously with counting the votes as far as is practicable.

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44. Rejected ballot papers and rejected text voting records

44.1 Any ballot paper:

(a) which does not bear the features that have been incorporated into the other ballot papers to prevent them from being reproduced,

(b) on which the figure “1” standing alone is not placed so as to indicate a first preference for any candidate,

(c) on which anything is written or marked by which the voter can be identified except the unique identifier, or

(d) which is unmarked or rejected because of uncertainty,

shall be rejected and not counted, but the ballot paper shall not be rejected by reason only of carrying the words “one”, “two”, “three” and so on, or any other mark instead of a figure if, in the opinion of the returning officer, the word or mark clearly indicates a preference or preferences.

44.2 The returning officer is to endorse the word “rejected” on any ballot paper which under this rule is not to be counted.

44.3 Any text voting record:

(a) on which the figure “1” standing alone is not placed so as to indicate a first preference for any candidate,

(b) on which anything is written or marked by which the voter can be identified except the unique identifier, or

(c) which is unmarked or rejected because of uncertainty,

shall be rejected and not counted, but the text voting record shall not be rejected by reason only of carrying the words “one”, “two”, “three” and so on, or any other mark instead of a figure if, in the opinion of the returning officer, the word or mark clearly indicates a preference or preferences.

44.4 The returning officer is to endorse the word “rejected” on any text voting record which under this rule is not to be counted.

44.5 The returning officer is to draw up a statement showing the number of ballot papers rejected by him or her under each of the subparagraphs (a) to (d) of rule 44.1 and the number of text voting records rejected by him or her under each of the sub-paragraphs (a) to (c) of rule 44.3.

45. First stage

45.1 The returning officer is to sort the ballot documents into parcels according to the candidates for whom the first preference votes are given.

45.2 The returning officer is to then count the number of first preference votes given on ballot documents for each candidate, and is to record those numbers.

45.3 The returning officer is to also ascertain and record the number of valid ballot documents.

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46. The quota

46.1 The returning officer is to divide the number of valid ballot documents by a number exceeding by one the number of members to be elected.

46.2 The result, increased by one, of the division under rule 46.1 (any fraction being disregarded) shall be the number of votes sufficient to secure the election of a candidate (in these rules referred to as “the quota”).

46.3 At any stage of the count a candidate whose total votes equals or exceeds the quota shall be deemed to be elected, except that any election where there is only one vacancy a candidate shall not be deemed to be elected until the procedure set out in rules 47.1 to 47.3 has been complied with.

47. Transfer of votes

47.1 Where the number of first preference votes for any candidate exceeds the quota, the returning officer is to sort all the ballot documents on which first preference votes are given for that candidate into sub- parcels so that they are grouped:

(a) according to next available preference given on those ballot documents for any continuing candidate, or

(b) where no such preference is given, as the sub-parcel of non-transferable votes.

47.2 The returning officer is to count the number of ballot documents in each parcel referred to in rule 47.1.

47.3 The returning officer is, in accordance with this rule and rule 48, to transfer each sub-parcel of ballot documents referred to in rule 47.1(a) to the candidate for whom the next available preference is given on those ballot documents.

47.4 The vote on each ballot document transferred under rule 47.3 shall be at a value (“the transfer value”) which:

(a) reduces the value of each vote transferred so that the total value of all such votes does not exceed the surplus, and

(b) is calculated by dividing the surplus of the candidate from whom the votes are being transferred by the total number of the ballot documents on which those votes are given, the calculation being made to two decimal places (ignoring the remainder if any).

47.5 Where at the end of any stage of the count involving the transfer of ballot documents, the number of votes for any candidate exceeds the quota, the returning officer is to sort the ballot documents in the sub-parcel of transferred votes which was last received by that candidate into separate sub-parcels so that they are grouped:

(a) according to the next available preference given on those ballot documents for any continuing candidate, or

(b) where no such preference is given, as the sub-parcel of non-transferable votes.

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47.6 The returning officer is, in accordance with this rule and rule 48, to transfer each sub-parcel of ballot documents referred to in rule 47.5(a) to the candidate for whom the next available preference is given on those ballot documents.

47.7 The vote on each ballot document transferred under rule 47.6 shall be at:

(a) a transfer value calculated as set out in rule 47.4(b), or

(b) at the value at which that vote was received by the candidate from whom it is now being transferred,

whichever is the less.

47.8 Each transfer of a surplus constitutes a stage in the count.

47.9 Subject to rule 47.10, the returning officer shall proceed to transfer transferable ballot documents until no candidate who is deemed to be elected has a surplus or all the vacancies have been filled.

47.10 Transferable ballot documents shall not be liable to be transferred where any surplus or surpluses which, at a particular stage of the count, have not already been transferred, are:

(a) less than the difference between the total vote then credited to the continuing candidate with the lowest recorded vote and the vote of the candidate with the next lowest recorded vote, or

(b) less than the difference between the total votes of the two or more continuing candidates, credited at that stage of the count with the lowest recorded total numbers of votes and the candidate next above such candidates.

47.11 This rule does not apply at an election where there is only one vacancy.

48. Supplementary provisions on transfer

48.1 If, at any stage of the count, two or more candidates have surpluses, the transferable ballot documents of the candidate with the highest surplus shall be transferred first, and if:

(a) The surpluses determined in respect of two or more candidates are equal, the transferable ballot documents of the candidate who had the highest recorded vote at the earliest preceding stage at which they had unequal votes shall be transferred first, and

(b) the votes credited to two or more candidates were equal at all stages of the count, the returning officer shall decide between those candidates by lot, and the transferable ballot documents of the candidate on whom the lot falls shall be transferred first.

48.2 The returning officer shall, on each transfer of transferable ballot documents under rule 47:

(a) record the total value of the votes transferred to each candidate,

(b) add that value to the previous total of votes recorded for each candidate and record the new total,

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(c) record as non-transferable votes the difference between the surplus and the total transfer value of the transferred votes and add that difference to the previously recorded total of non-transferable votes, and

(d) compare:

(i) the total number of votes then recorded for all of the candidates, together with the total number of non-transferable votes, with

(ii) the recorded total of valid first preference votes.

48.3 All ballot documents transferred under rule 47 or 49 shall be clearly marked, either individually or as a sub-parcel, so as to indicate the transfer value recorded at that time to each vote on that ballot document or, as the case may be, all the ballot documents in that sub-parcel.

48.4 Where a ballot document is so marked that it is unclear to the returning officer at any stage of the count under rule 47 or 49 for which candidate the next preference is recorded, the returning officer shall treat any vote on that ballot document as a non-transferable vote; and votes on a ballot document shall be so treated where, for example, the names of two or more candidates (whether continuing candidates or not) are so marked that, in the opinion of the returning officer, the same order of preference is indicated or the numerical sequence is broken.

49. Exclusion of candidates

49.1 If:

(a) all transferable ballot documents which under the provisions of rule 47 (including that rule as applied by rule 49.11) and this rule are required to be transferred, have been transferred, and

(b) subject to rule 50, one or more vacancies remain to be filled,

the returning officer shall exclude from the election at that stage the candidate with the then lowest vote (or, where rule 49.12 applies, the candidates with the then lowest votes).

49.2 The returning officer shall sort all the ballot documents on which first preference votes are given for the candidate or candidates excluded under rule 49.1 into two sub-parcels so that they are grouped as:

(a) ballot documents on which a next available preference is given, and

(b) ballot documents on which no such preference is given (thereby including ballot documents on which preferences are given only for candidates who are deemed to be elected or are excluded).

49.3 The returning officer shall, in accordance with this rule and rule 48, transfer each sub-parcel of ballot documents referred to in rule 49.2 to the candidate for whom the next available preference is given on those ballot documents.

49.4 The exclusion of a candidate, or of two or more candidates together, constitutes a further stage of the count.

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49.5 If, subject to rule 50, one or more vacancies still remain to be filled, the returning officer shall then sort the transferable ballot documents, if any, which had been transferred to any candidate excluded under rule 49.1 into sub- parcels according to their transfer value.

49.6 The returning officer shall transfer those ballot documents in the sub-parcel of transferable ballot documents with the highest transfer value to the continuing candidates in accordance with the next available preferences given on those ballot documents (thereby passing over candidates who are deemed to be elected or are excluded).

49.7 The vote on each transferable ballot document transferred under rule 49.6 shall be at the value at which that vote was received by the candidate excluded under rule 49.1.

49.8 Any ballot documents on which no next available preferences have been expressed shall be set aside as non-transferable votes.

49.9 After the returning officer has completed the transfer of the ballot documents in the sub-parcel of ballot documents with the highest transfer value he or she shall proceed to transfer in the same way the sub-parcel of ballot documents with the next highest value and so on until he has dealt with each sub-parcel of a candidate excluded under rule 49.1.

49.10 The returning officer shall after each stage of the count completed under this rule:

(a) record:

(i) the total value of votes, or

(ii) the total transfer value of votes transferred to each candidate,

(b) add that total to the previous total of votes recorded for each candidate and record the new total,

(c) record the value of non-transferable votes and add that value to the previous non-transferable votes total, and

(d) compare:

(i) the total number of votes then recorded for each candidate together with the total number of non-transferable votes, with

(ii) the recorded total of valid first preference votes.

49.11 If after a transfer of votes under any provision of this rule, a candidate has a surplus, that surplus shall be dealt with in accordance with rules 47.5 to 47.10 and rule 48.

49.12 Where the total of the votes of the two or more lowest candidates, together with any surpluses not transferred, is less than the number of votes credited to the next lowest candidate, the returning officer shall in one operation exclude such two or more candidates.

49.13 If when a candidate has to be excluded under this rule, two or more candidates each have the same number of votes and are lowest:

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(a) regard shall be had to the total number of votes credited to those candidates at the earliest stage of the count at which they had an unequal number of votes and the candidate with the lowest number of votes at that stage shall be excluded, and

(b) where the number of votes credited to those candidates was equal at all stages, the returning officer shall decide between the candidates by lot and the candidate on whom the lot falls shall be excluded.

50. Filling of last vacancies

50.1 Where the number of continuing candidates is equal to the number of vacancies remaining unfilled the continuing candidates shall thereupon be deemed to be elected.

50.2 Where only one vacancy remains unfilled and the votes of any one continuing candidate are equal to or greater than the total of votes credited to other continuing candidates together with any surplus not transferred, the candidate shall thereupon be deemed to be elected.

50.3 Where the last vacancies can be filled under this rule, no further transfer of votes shall be made.

51. Order of election of candidates

51.1 The order in which candidates whose votes equal or exceed the quota are deemed to be elected shall be the order in which their respective surpluses were transferred, or would have been transferred but for rule 47.10.

51.2 A candidate credited with a number of votes equal to, and not greater than, the quota shall, for the purposes of this rule, be regarded as having had the smallest surplus at the stage of the count at which he obtained the quota.

51.3 Where the surpluses of two or more candidates are equal and are not required to be transferred, regard shall be had to the total number of votes credited to such candidates at the earliest stage of the count at which they had an unequal number of votes and the surplus of the candidate who had the greatest number of votes at that stage shall be deemed to be the largest.

51.4 Where the number of votes credited to two or more candidates were equal at all stages of the count, the returning officer shall decide between them by lot and the candidate on whom the lot falls shall be deemed to have been elected first.

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PART 7: FINAL PROCEEDINGS IN CONTESTED AND UNCONTESTED ELECTIONS

52. Declaration of result for contested elections

52.1 In a contested election, when the result of the poll has been ascertained, the returning officer is to:

(a) declare the candidates who are deemed to be elected under Part 6 of these rules as elected,

(b) give notice of the name of each candidate who he or she has declared elected:

(i) where the election is held under a proposed constitution pursuant to powers conferred on Great Ormond Street Hospital for Children NHS Foundation Trust by section 33(4) of the 2006 Act, to the Chair of the NHS Foundation Trust, or

(ii) in any other case, to the Chair of the corporation, and

(c) give public notice of the name of each candidate who he or she has declared elected.

52.2 The returning officer is to make:

(a) the number of first preference votes for each candidate whether elected or not,

(b) any transfer of votes,

(c) the total number of votes for each candidate at each stage of the count at which such transfer took place,

(d) the order in which the successful candidates were elected, and

(e) the number of rejected ballot papers under each of the headings in rule 44.1,

(f) the number of rejected text voting records under each of the headings in rule 44.3,

available on request.

53. Declaration of result for uncontested elections

53.1 In an uncontested election, the returning officer is to as soon as is practicable after final day for the delivery of notices of withdrawals by candidates from the election:

(a) declare the candidate or candidates remaining validly nominated to be elected,

(b) give notice of the name of each candidate who he or she has declared elected to the Chair of the corporation, and

(c) give public notice of the name of each candidate who he or she has declared elected.

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PART 8: DISPOSAL OF DOCUMENTS

54. Sealing up of documents relating to the poll

54.1 On completion of the counting at a contested election, the returning officer is to seal up the following documents in separate packets:

(a) the counted ballot papers, internet voting records, telephone voting records and text voting records,

(b) the ballot papers and text voting records endorsed with “rejected in part”,

(c) the rejected ballot papers and text voting records, and

(d) the statement of rejected ballot papers and the statement of rejected text voting records,

and ensure that complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 are held in a device suitable for the purpose of storage.

54.2 The returning officer must not open the sealed packets of:

(a) the disqualified documents, with the list of disqualified documents inside it,

(b) the list of spoilt ballot papers and the list of spoilt text message votes,

(c) the list of lost ballot documents, and

(d) the list of eligible voters,

or access the complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 and held in a device suitable for the purpose of storage.

54.3 The returning officer must endorse on each packet a description of:

(a) its contents,

(b) the date of the publication of notice of the election,

(c) the name of the corporation to which the election relates, and

(d) the constituency, or class within a constituency, to which the election relates.

55. Delivery of documents

55.1 Once the documents relating to the poll have been sealed up and endorsed pursuant to rule 56, the returning officer is to forward them to the chair of the corporation.

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56. Forwarding of documents received after close of the poll

56.1 Where:

(a) any voting documents are received by the returning officer after the close of the poll, or

(b) any envelopes addressed to eligible voters are returned as undelivered too late to be resent, or

(c) any applications for replacement voting information are made too late to enable new voting information to be issued,

the returning officer is to put them in a separate packet, seal it up, and endorse and forward it to the Chair of the corporation.

57. Retention and public inspection of documents

57.1 The corporation is to retain the documents relating to an election that are forwarded to the chair by the returning officer under these rules for one year, and then, unless otherwise directed by the Board of Directors of the corporation, cause them to be destroyed.

57.2 With the exception of the documents listed in rule 58.1, the documents relating to an election that are held by the corporation shall be available for inspection by members of the public at all reasonable times.

57.3 A person may request a copy or extract from the documents relating to an election that are held by the corporation, and the corporation is to provide it, and may impose a reasonable charge for doing so.

58. Application for inspection of certain documents relating to an election

58.1 The corporation may not allow:

(a) the inspection of, or the opening of any sealed packet containing:

(i) any rejected ballot papers, including ballot papers rejected in part,

(ii) any rejected text voting records, including text voting records rejected in part,

(iii) any disqualified documents, or the list of disqualified documents,

(iv) any counted ballot papers, internet voting records, telephone voting records or text voting records, or

(v) the list of eligible voters, or

(b) access to or the inspection of the complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 and held in a device suitable for the purpose of storage,

by any person without the consent of the Board of Directors of the corporation.

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58.2 A person may apply to the Board of Directors of the corporation to inspect any of the documents listed in rule 58.1, and the Board of Directors of the corporation may only consent to such inspection if it is satisfied that it is necessary for the purpose of questioning an election pursuant to Part 11.

58.3 The Board of Directors of the corporation’s consent may be on any terms or conditions that it thinks necessary, including conditions as to:

(a) persons,

(b) time,

(c) place and mode of inspection,

(d) production or opening,

and the corporation must only make the documents available for inspection in accordance with those terms and conditions.

58.4 On an application to inspect any of the documents listed in rule 58.1 the Board of Directors of the corporation must:

(a) in giving its consent, and

(b) in making the documents available for inspection

ensure that the way in which the vote of any particular member has been given shall not be disclosed, until it has been established –

(i) that his or her vote was given, and

(ii) that Monitor has declared that the vote was invalid.

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PART 9: DEATH OF A CANDIDATE DURING A CONTESTED ELECTION

59. Countermand or abandonment of poll on death of candidate

59.1 If, at a contested election, proof is given to the returning officer’s satisfaction before the result of the election is declared that one of the persons named or to be named as a candidate has died, then the returning officer is to:

(a) publish a notice stating that the candidate has died, and

(b) proceed with the counting of the votes as if that candidate had been excluded from the count so that:

(i) ballot documents which only have a first preference recorded for the candidate that has died, and no preferences for any other candidates, are not to be counted, and

(ii) ballot documents which have preferences recorded for other candidates are to be counted according to the consecutive order of those preferences, passing over preferences marked for the candidate who has died.

59.2 The ballot documents which have preferences recorded for the candidate who has died are to be sealed with the other counted ballot documents pursuant to rule 54.1(a).

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PART 10: ELECTION EXPENSES AND PUBLICITY

Election expenses

60. Election expenses

60.1 Any expenses incurred, or payments made, for the purposes of an election which contravene this Part are an electoral irregularity, which may only be questioned in an application made to Monitor under Part 11 of these rules.

61. Expenses and payments by candidates

61.1 A candidate may not incur any expenses or make a payment (of whatever nature) for the purposes of an election, other than expenses or payments that relate to:

(a) personal expenses,

(b) travelling expenses, and expenses incurred while living away from home, and

(c) expenses for stationery, postage, telephone, internet(or any similar means of communication) and other petty expenses, to a limit of £100.

62. Election expenses incurred by other persons

62.1 No person may:

(a) incur any expenses or make a payment (of whatever nature) for the purposes of a candidate’s election, whether on that candidate’s behalf or otherwise, or

(b) give a candidate or his or her family any money or property (whether as a gift, donation, loan, or otherwise) to meet or contribute to expenses incurred by or on behalf of the candidate for the purposes of an election.

62.2 Nothing in this rule is to prevent the corporation from incurring such expenses, and making such payments, as it considers necessary pursuant to rules 63 and 64.

Publicity

63. Publicity about election by the corporation

63.1 The corporation may:

(a) compile and distribute such information about the candidates, and

(b) organise and hold such meetings to enable the candidates to speak and respond to questions,

as it considers necessary.

63.2 Any information provided by the corporation about the candidates, including information compiled by the corporation under rule 64, must be:

(a) objective, balanced and fair,

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(b) equivalent in size and content for all candidates,

(c) compiled and distributed in consultation with all of the candidates standing for election, and

(d) must not seek to promote or procure the election of a specific candidate or candidates, at the expense of the electoral prospects of one or more other candidates.

63.3 Where the corporation proposes to hold a meeting to enable the candidates to speak, the corporation must ensure that all of the candidates are invited to attend, and in organising and holding such a meeting, the corporation must not seek to promote or procure the election of a specific candidate or candidates at the expense of the electoral prospects of one or more other candidates.

64. Information about candidates for inclusion with voting information

64.1 The corporation must compile information about the candidates standing for election, to be distributed by the returning officer pursuant to rule 24 of these rules.

64.2 The information must consist of:

(a) a statement submitted by the candidate of no more than 250 words, and

(b) if voting by telephone or text message is a method of polling for the election, the numerical voting code allocated by the returning officer to each candidate, for the purpose of recording votes using the telephone voting facility or the text message voting facility (“numerical voting code”).

65. Meaning of “for the purposes of an election”

65.1 In this Part, the phrase “for the purposes of an election” means with a view to, or otherwise in connection with, promoting or procuring a candidate’s election, including the prejudicing of another candidate’s electoral prospects; and the phrase “for the purposes of a candidate’s election” is to be construed accordingly.

65.2 The provision by any individual of his or her own services voluntarily, on his or her own time, and free of charge is not to be considered an expense for the purposes of this Part.

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PART 11: QUESTIONING ELECTIONS AND THE CONSEQUENCE OF IRREGULARITIES

66. Application to question an election

66.1 An application alleging a breach of these rules, including an electoral irregularity under Part 10, may be made to Monitor for the purpose of seeking a referral to the independent election arbitration panel ( IEAP).

66.2 An application may only be made once the outcome of the election has been declared by the returning officer.

66.3 An application may only be made to Monitor by:

(a) a person who voted at the election or who claimed to have had the right to vote, or

(b) a candidate, or a person claiming to have had a right to be elected at the election.

66.4 The application must:

(a) describe the alleged breach of the rules or electoral irregularity, and

(b) be in such a form as the independent panel may require.

66.5 The application must be presented in writing within 21 days of the declaration of the result of the election. Monitor will refer the application to the independent election arbitration panel appointed by Monitor.

66.6 If the independent election arbitration panel requests further information from the applicant, then that person must provide it as soon as is reasonably practicable.

66.7 Monitor shall delegate the determination of an application to a person or panel of persons to be nominated for the purpose.

66.8 The determination by the IEAP shall be binding on and shall be given effect by the corporation, the applicant and the members of the constituency (or class within a constituency) including all the candidates for the election to which the application relates.

66.9 The IEAP may prescribe rules of procedure for the determination of an application including costs.

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PART 12: MISCELLANEOUS

67. Secrecy

67.1 The following persons:

(a) the returning officer,

(b) the returning officer’s staff,

must maintain and aid in maintaining the secrecy of the voting and the counting of the votes, and must not, except for some purpose authorised by law, communicate to any person any information as to:

(i) the name of any member of the corporation who has or has not been given voting information or who has or has not voted,

(ii) the unique identifier on any ballot paper,

(iii) the voter ID number allocated to any voter,

(iv) the candidate(s) for whom any member has voted.

67.2 No person may obtain or attempt to obtain information as to the candidate(s) for whom a voter is about to vote or has voted, or communicate such information to any person at any time, including the unique identifier on a ballot paper given to a voter or the voter ID number allocated to a voter.

67.3 The returning officer is to make such arrangements as he or she thinks fit to ensure that the individuals who are affected by this provision are aware of the duties it imposes.

68. Prohibition of disclosure of vote

68.1 No person who has voted at an election shall, in any legal or other proceedings to question the election, be required to state for whom he or she has voted.

69. Disqualification

69.1 A person may not be appointed as a returning officer, or as staff of the returning officer pursuant to these rules, if that person is:

(a) a member of the corporation,

(b) an employee of the corporation,

(c) a Director of the corporation, or

(d) employed by or on behalf of a person who has been nominated for election.

70. Delay in postal service through industrial action or unforeseen event

70.1 If industrial action, or some other unforeseen event, results in a delay in:

(a) the delivery of the documents in rule 24, or

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(b) the return of the ballot papers,

the returning officer may extend the time between the publication of the notice of the poll and the close of the poll by such period as he or she considers appropriate.

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Annex 5

Additional Provisions – Council of Governors

1. Elected Governors

1.1 A Member of the Public Constituency may not vote at an election for a public Governor unless at the time of voting they have made and returned a declaration in the form specified in Annex 4, paragraph 21, that they are qualified to vote as a Member of the relevant Class/are of the Public Constituency.

1.2 A Member of the Patient and Carer Constituency may not vote at an election for a patient and carer Governor unless at the time of voting they have made and returned a declaration in the form specified in Annex 4, paragraph 21, that they are qualified to vote as a member of the Patient and Carer Constituency.

2. Appointed Governors

2.1 The Trust Secretary, having consulted the Chair and the relevant organisation who is eligible to appoint Governors, are to adopt a process for agreeing with each relevant organisation the appointment of the Governor appointed by it.

For the purposes of this paragraph 2 of this Annex 5 “relevant organisation” shall mean any local authority, university or other partnership organisation who is eligible to appoint a Governor to the Council of Governors.

3. Lead Governor

3.1 The Council of Governors shall elect one of the elected Governors as the Lead Governor in accordance with the conditions of appointment set out in the Lead Governor role description approved by the Council of Governors.

3.2 The Lead Governor shall have the responsibilities, and perform the tasks, set out in the Lead Governor role description.

4. Further provisions as to eligibility to be a Governor

4.1 In addition to paragraph 13 of this Constitution, a person may not become or continue as a Governor if:

4.1.1 they are not a Member;

4.1.2 in the case of a public Governor, or patient and carer Governor, or staff Governor they cease to be a Member of the Constituency or Class from which they were elected;

4.1.3 in the case of an appointed Governor, if the organisation which appointed them terminates that appointment;

4.1.4 they have been required to notify the police of their name and address as a result of being convicted or cautioned under the Sexual Offences Act 2003 or other applicable legislation or their name appears a Barred List as defined in the Safeguarding Vulnerable Groups Act 2006;

4.1.5 they (or an organisation which they were a director of) have been found guilty of an offence under the Modern Slavery Act 2015;

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4.1.6 they (or an organisation which they were a director of) have been found guilty of an offence under the Bribery Act 2010 or any other applicable law relating to fraud, financial crime or terrorist financing;

4.1.7 they are the spouse, partner, parent, child of, or occupant of the same household as a Director or a member of the Council of Governors;

4.1.8 they are a member of a local authority’s Overview and Scrutiny Committee covering health matters;

4.1.9 they are a Director;

4.1.10 they are a Governor, Non-Executive Director (including the chair) or, Executive Director (including the chief executive officer) of another Health Service Body, unless they are appointed by an appointing organisation which is a Health Service Body or the Chair agrees to them becoming, or continuing as, a Governor of the Trust in exceptional circumstances;

4.1.11 they have within the preceding two years been dismissed, otherwise than by reason of redundancy or ill health, from any paid employment with a Health Service Body;

4.1.12 they are a person whose tenure of office as a Chair or as a member or Director of a Health Service Body has been terminated on the grounds that their appointment is not in the interests of the NHS, for non-attendance at meetings, or for non-disclosure of a pecuniary interest;

4.1.13 they have previously been removed as a Governor pursuant to paragraph 5 of this Annex 5;

4.1.14 they have previously been removed by as a Governor from another NHS Foundation Trust by resolution of the Council of Governors of that NHS Foundation Trust;

4.1.15 they have failed to sign and deliver to the Trust Secretary a statement in the form required by the Trust Secretary confirming acceptance of the Code of Conduct for Governors or any required non-disclosure agreement;

4.1.16 they lack capacity within the meaning of the Mental Capacity Act 2005 to carry out all the duties and responsibilities of a Governor;

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4.1.17 they are the subject of a disqualification order made under the Company Directors Disqualification Act 1986;

4.1.18 they have had their name removed from a list maintained under regulations pursuant to sections 91 (Persons performing primary medical services), 106 (Persons performing primary dental services), 123 (Persons performing primary ophthalmic services), or 146 (Persons performing local pharmaceutical services) of the 2006 Act, or the equivalent lists maintained by Local Health Boards in Wales under the National Health Service (Wales) Act 2006, and they have not subsequently had their name included in such a list;

4.1.19 they are deemed a vexatious or persistent complainant or litigant against the Trust without reasonable cause; or

4.1.20 they have failed to repay (without good cause) any amount of monies properly owed to the Trust.

4.2 All non-staff candidates for election to the Council of Governors and prospective appointees to the Council of Governors will undergo Disclosure and Barring Service checks. The Chair will after taking appropriate advice determine instances in which criminal records will preclude election or appointment to the Council of Governors.

4.3 A person holding office as a Governor shall immediately cease to do so if:

4.3.1 they resign by notice in writing to the Trust Secretary;

4.3.2 they become disqualified from office under paragraph 13 of this Constitution or under paragraph 4.1 of this Annex 5;

4.3.3 they fail to attend two meetings of the Council of Governors in a period of one financial year unless the Lead Governor, Chair and Trust Secretary are satisfied that:

4.3.3.1 the absence was due to a reasonable cause; and

4.3.3.2 they will be able to start attending meetings of the Trust again within such a period as they consider reasonable.

4.3.4 they have refused to undertake any training which the Council of Governors requires all Governors to undertake unless the Lead Governor, Chair and Trust Secretary are satisfied that the refusal was due to a reasonable cause; or

4.3.5 they are removed from the Council of Governors by a resolution passed under paragraph 5 below.

4.4 For the purposes of 4.3.3.1 and 4.3.4:

4.4.1 an absence will ordinarily be considered to be due to a reasonable cause if it is due to:

4.4.1.1 a conflict with work or personal commitments in circumstances where the Trust has changed the date of the meeting of the Council of Governors at short notice;

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4.4.1.2 ill health (provided that the Governor in question, or someone on their behalf, has advised the Trust Secretary of such circumstances as soon as reasonably practicable); or

4.4.1.3 a personal or family emergency.

4.4.2 For the avoidance of doubt, work commitments will not be considered a reasonable cause unless the Trust has changed the date of the meeting of the Council of Governors at short notice.

4.4.3 Instances of ill health will be reviewed on a case-by-case basis in consultation between the Lead Governor, Trust Secretary, the Chair and the affected Governor with a view of acting in the best interests of the Trust.

4.5 Where a Governor becomes disqualified for appointment under this paragraph 4 or paragraph 13 of this Constitution, they shall notify the Trust Secretary in writing without delay upon becoming aware the grounds for disqualification. Any failure to notify the Trust Secretary of grounds for disqualification pursuant to this paragraph 4.5 shall result in such individual becoming ineligible to become a Governor at any future point.

4.6 If it comes to the notice of the Trust Secretary that at the time of their appointment or later a Governor is disqualified, they shall immediately declare that the person in question is disqualified and notify them in writing to that effect.

5. Removal of Governor from office

5.1 A Governor may be removed from the Council of Governors by a resolution approved at a meeting of the Council of Governors by not less than three-quarters of the Governors present and voting on the grounds that:

5.1.1 they have committed a serious breach of the Governor Code of Conduct; or

5.1.2 they have acted in a manner detrimental to the interests of the Trust or otherwise bring the Trust into disrepute; or

5.1.3 the Council of Governors consider that it is not in the best interests of the Trust for them to continue as a Governor, for example because:

5.1.3.1 the individual's continuation as a Governor would likely prejudice the ability of the Trust to fulfil its principle purpose or discharge its duties and functions;

5.1.3.2 the individual's continuation as a Governor would likely prejudice the Trust's work with other persons or body within whom it is engaged or may be engaged in the provision of goods and services;

5.1.3.3 the individual's continuation as a Governor would be likely to adversely affect public confidence in the goods and services provided by the Trust;

5.1.3.4 it would not be in the best interests of the Council of Governors for the individual to continue as a Governor / the individual has caused or is likely to cause

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prejudice to the proper conduct of the Council of Governors affairs; or

5.1.3.5 the individual has failed to comply with the values and principles of the NHS, the Trust or this Constitution.

5.2 The Council of Governors will agree a process for investigating complaints against Governors which may lead to a removal of a Governor under this paragraph 5.

6. Vacancies amongst Governors

6.1 Where a vacancy arises on the Council of Governors for any reason other than expiry of term of office, the following provisions will apply.

Appointed Governors

6.2 Where the vacancy arises amongst the appointed Governors, the Trust Secretary shall request that the appointing organisation appoints a replacement to hold office for the remainder of the term of office or to commence a new term of office.

Elected Governors

6.3 Where the vacancy arises amongst the elected Governors, the Council of Governors shall be at liberty either:

6.3.1 to call an election within three months to fill the seat for the remainder of that term of office;

6.3.2 to call an election to fill the seat for a new term of office;

6.3.3 to invite the next highest polling candidate for that seat at the most recent election, who is willing to take office, to fill the seat until the next annual election, at which time the seat will fall vacant and subject to election for any unexpired period of the term of office;

6.3.4 to invite the next highest polling candidate for that seat at the most recent election, who is willing to take office, to fill the seat until the next annual election, at which time the seat will fall vacant and subject to election for a new term of office; or

6.3.5 if the unexpired period of the term of office is less than twelve months, to leave the seat vacant until the next elections are held.

6.4 All decisions taken in good faith at a meeting of the Council of Governors or of any committee shall be valid even if it is discovered subsequently that there was a defect in the calling of the meeting, or in the appointment or election of the Governors attending the meeting.

7. Maximum Tenure

7.1 A Governor may not serve on the Council of Governors for more than 9 years in aggregate during their lifetime. For the avoidance of doubt, this covers all Constituencies such that once a Governor has served for 9 years in any one Constituency or across a mixture of several Constituencies they are no longer eligible to stand for election in any Constituency or be appointed to the Council of Governors.

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Annex 6

Additional Provisions – Board of Directors

1. Disqualification of Directors

1.1 In addition to paragraph 27 of this Constitution, a person may not become or continue as a Director if:

1.1.1 they have been required to notify the police of their name and address as a result of being convicted or cautioned under the Sexual Offences Act 2003 or other applicable legislation or their name appears a Barred List as defined in the Safeguarding Vulnerable Groups Act 2006;

1.1.2 they (or an organisation which they were a director of) have been found guilty of an offence under the Modern Slavery Act 2015;

1.1.3 they (or an organisation which they were a director of) have been found guilty of an offence under the Bribery Act 2010 or any other applicable law relating to fraud, financial crime or terrorist financing;

1.1.4 they are the spouse, partner, parent, child of, or occupant of the same household as a Director or a member of Council of Governors;

1.1.5 they are a member of a local authority’s Overview and Scrutiny Committee covering health matters;

1.1.6 they are a Governor of the Trust;

1.1.7 they are a Governor, Non-Executive Director (including the Chair) or, executive Director (including the chief executive officer) of another Health Service Body, unless:

1.1.7.1 in the case of an executive Director other than the Chief Executive, the Chair, following consultation with the Chief Executive;

1.1.7.2 in the case of the Chief Executive, the Chair, following consultation with the Board of Directors;

1.1.7.3 in the case of a Non-Executive Director other than the Chair, the Chair following consultation with the Council of Governors; or

1.1.7.4 in the case of the Chair, the Senior Independent Director, following consultation with the Board of Directors and the Council of Governors,

agrees to them becoming, or continuing as, a Director;

1.1.8 they are a person whose tenure of office as a Chair or as a member or Director of a Health Service Body has been terminated on the grounds that their appointment is not in the interests of the NHS, for non-attendance at meetings, or for non-disclosure of a pecuniary interest;

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1.1.9 in the case of a Non-Executive Director, they have refused, without reasonable cause, to fulfil any training requirement established by the Board of Directors;

1.1.10 they lack capacity within the meaning of the Mental Capacity Act 2005 to carry out all the duties and responsibilities of a Director;

1.1.11 they are the subject of a disqualification order made under the Company Directors Disqualification Act 1986;

1.1.12 they have had their name removed from a list maintained under regulations pursuant to sections 91 (Persons performing primary medical services), 106 (Persons performing primary dental services), 123 (Persons performing primary ophthalmic services), or 146 (Persons performing local pharmaceutical services) of the 2006 Act, or the equivalent lists maintained by Local Health Boards in Wales under the National Health Service (Wales) Act 2006, and they have not subsequently had their name included in such a list;

1.1.13 they are deemed a vexatious or persistent complainant or litigant against the Trust without reasonable cause;

1.1.14 they have failed to repay (without good cause) any amount of monies properly owed to the Trust; or

1.1.15 they fail to satisfy the fit and proper persons requirements for Directors as detailed in Regulation 5 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as may be amended from time to time.

1.2 Where a Director becomes disqualified for appointment under paragraph 1 of this Annex or paragraph 27 of this Constitution, they shall notify the Trust Secretary in writing of such disqualification.

1.3 If it comes to the notice of the Trust Secretary that at the time of their appointment or later the Director is so disqualified, they shall immediately declare that the Director in question is disqualified and notify them in writing to that effect.

1.4 Where a Director is disqualified his or her tenure of office shall automatically terminate and they shall cease to hold office with immediate effect.

2. Expenses

2.1 The Trust may reimburse executive Directors travelling and other costs and expenses incurred in carrying out their duties at such rates as the Appointments and Remuneration Committee decides. These are to be disclosed in the annual report.

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Annex 7

Further Provisions – Members

1. Restriction on membership

1.1 In addition to paragraph 8 of this Constitution, the following restrictions on Membership apply:

1.1.1 The following will not be eligible to become or continue a Member:

1.1.1.1 they have been required to notify the police of their name and address as a result of being convicted or cautioned under the Sexual Offences Act 2003 or other applicable legislation or their name appears a Barred List as defined in the Safeguarding Vulnerable Groups Act 2006;

1.1.1.2 an individual who exhibits inappropriate conduct (as agreed by a majority of the Governors present and voting at a meeting of the Council of Governors), including those who have been identified as the perpetrators of a serious incident involving violence, assault or harassment against Trust staff; and/or

1.1.1.3 a person who is a deemed a vexatious or persistent complainant or litigant against the Trust without reasonable cause (as agreed by a majority of the Governors present and voting at a meeting of the Council of Governors).

2. Termination of Membership

2.1 A Member shall cease to be a Member if:

2.1.1 they resign by notice in writing to the Trust Secretary;

2.1.2 they cease to be eligible to continue to as a Member under paragraph 1.1.1 of this Annex 7 or paragraph 8 of this Constitution;

2.1.3 they are expelled from Membership under paragraph 1.1 of this Annex 7; or

2.1.4 they die.

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